The severity of the current economic crisis has hit Spain far harder than other European countries, with the possible exceptions of Portugal, Greece and Cyprus . The recession has had a significant impact on conditions and levels of employment and on poverty rates in Spain as a whole, although with considerable differences between Autonomous Communities. In this respect, in a prior study comparing regions, Zapata states “Spain is currently a natural laboratory for exploring how negative macroeconomic changes affect health” .
As regards limitations, Parmar  states that the majority of studies on crises and health are subject to biases, pointing above all to reverse causality or not taking possible prior trends into account. In this study, in the first place, we have used a short period to study the impact of the crisis with two cut-off points and therefore it is quite possible that mental health has continued getting worse. It was not possible to measure the trend, since in previous years the Health Survey has not measured psychic morbidity. In the second place, given the cross-sectional nature the possible existence of reverse causality cannot be overlooked. There may be some uncontrolled confusion bias given that other variables are not taken into account (some gathered in surveys and others not) which may or may not have an effect on state of mental health. Yet in spite of these limitations, our study is the first of its kind to analyse a multilevel design to investigate the impact of contextual variables during the recession in Spain and its possible consequences on mental health.
The socio-economic factors linked to mental health were healthcare spending per capita and percentage of temporary workers. Estimating the contribution of factors which can affect the health of the population is a complex and inexact task . What does seem clear is that a robust health system can level out inequalities, since it enables support to be given to the most vulnerable sectors of the population . By contrast, a weaker health system (with lower spending) would leave the most vulnerable less protected and these groups are the most exposed in the recession and therefore at higher risk of worse mental health.
Although Spain has a national health system which provides (almost) universal coverage, there is considerable variation in healthcare spending and services from one Autonomous Community to another . It is difficult to find reliable data on healthcare spending specifically for mental health, since budges are not broken down by medical fields. However, it is not unreasonable to believe that it may have suffered the same fate as spending as a whole, at least as regards the most general figures and trends. Inequalities in healthcare spending have a two-pronged effect: a) differences in resource allocation for service provision in different regions (the territorial perspective) and b) differences in public health insurance contributions by individuals or families (the personal perspective) . There is an additional area as regards provision of mental health services which professional associations for mental health have condemned for years: Spain is still bringing up the rear in comparison with other European countries in terms of numbers of mental health practitioners, as shown by official WHO figures .
The link between worse mental health and percentage of temporary workers can be understood given that economic recessions can have a direct effect on people who keep their jobs. These individuals face situations of stress and anxiety caused by possible reduction in income, greater employment insecurity and increased workload. Recessions can likewise have a disproportionate negative impact on subgroups in the vulnerable population such as persons with a pre-existing mental disorder, or a low socio-economic level, or the unemployed .
The literature shows contradictory results for the relationship between unemployment and mental health. Some studies have found that unemployment is associated with poorer mental health, particularly amongst women , whilst others have found that during recessions or in cases of higher regional unemployment when the number of unemployed people increases and unemployment becomes a status, the psychological cost and stigma of being unemployed diminishes and the subjective well-being of the unemployed improves . Taking into consideration the context variables found in our study, these differences would be nuanced by factors such as per capita healthcare spending or percentage of temporary workers.
In the light of these findings, one might think that different political responses to economic crises would give rise to different mental health outcomes among the population. For example in Spain, unemployment levels in the 70’s and 80’s were accompanied by a corresponding increase in risk of suicide. In Sweden, however, the banking crisis of 1990 left a lot of people unemployed but the suicide rate dropped, even during this period. This marked difference has been attributed to the protection provided by the Swedish welfare state [38, 39].
As regards the measures which should be taken during economic crises to palliate effects on mental health, Kentikelenis and Papanicolas [40, 41] state the need to safeguard programmes for vulnerable groups such as the mentally ill and drug addiction rehabilitation programmes; to increase the number of general practitioners working in rural areas; to taken on the cost of non-medical illnesses among patients; and to prescribe a higher proportion of generic drugs in order to make savings in spending on drugs.
Other studies have highlighted the effectiveness of policies such as active programmes to incentivise the labour market, which have a significant impact on reducing suicide rates . Policies which aim to prevent individuals from taking on too much debt and for making it easier to pay off debts could be beneficial for people whose excessive levels of debt cause them stress . Similarly, policies or initiatives such as financial mediators have huge potential for mitigating the effects of recession .
As regards health centres, it has been found that health initiatives for exploring the subjective perception of aloneness can be effective in improving mental health and should focus particularly on individuals in poor health and the unemployed ; similarly effective are programmes which support the role of primary care professionals in detecting persons at risk of suicide or other psychological problems .
Therefore, instead of making cutbacks in healthcare and social welfare, there should be higher spending on measures for social protection during times of recession and increased support for mental health programmes in the health sector, particularly in primary care [44, 45]. Additionally, there should be more comprehensive and cooperative consolidation of the mental health network within healthcare (social services, primary care, specialised care, and social rehabilitation and reintegration) which takes into account the specific needs of the individuals which this healthcare sector focuses on .