Denmark occupies an approximated area of 43,000 square kilometers. The country’s population in 2018 was approximately 5.8 million individuals. Life expectancy in Denmark is 76 years for men, while that of women is 81 years ( Terlizzi, 2019 ). According to the World Bank, the country is among the highest-income countries. Denmark's health expenditure expressed as a percentage of the country's domestic product is around 11.9%. The current statistics on suicide rates for men are 17.5% for every 100,000 individuals, while that of women is 6.4 for every 100,000 women (Folke et al., 2020). Mental health disorders in Denmark contribute to approximately 28.8% of disease burden globally.
In 1938, Denmark passed the first mental health act. Another act was also passed in 1989, according to a report released by the country's Ministry of Justice ( European Observatory on Health Systems and Policies, n. d. ). The act focused on protecting the rights of the country’s citizens related to forced admission and treatment of psychiatric problems. Today, many people living in Denmark are affected by mental health issues either because they are suffering from mental health illnesses/disorders, or they have relatives who have mental health problems. The number of people who are suffering from mental health problems in Denmark has significantly risen in the past few years. The Danish National Institute of Public Health statistics indicates that an estimated 20% of the country's population suffers from mental health issues throughout a year ( Terlizzi, 2019 ).
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The provision of mental health services in Denmark is a responsibility of the ministry of health and the ministry of children, gender equality, integration, and social affairs ( Terlizzi, 2019 ). Denmark's ministry of health takes care of hospital psychiatry. Hospital psychiatry is governed by two main acts, which are the health care act and the country's psychiatry act. Services offered under psychiatry include assessments, diagnosis, and treatment. It also conducts procedures for admitting patients. The district psychiatry also forms a part of hospital psychiatry. It provides both outpatient and psychiatric interventions that are interdisciplinary ( Terlizzi, 2019 ). Danish ministry of children, equality, integration, and social affairs is responsible for social psychiatry. It is under the governance of the country’s service act. Different types of social services are provided by social psychiatry at regional and municipality levels.
Governance Structure for Mental Health Services in Denmark
Denmark's mental health care system is dual, and municipalities play a significant role in the system. After political and administrative reforms were conducted in 1970, psychiatric hospitals were placed under the former counties. This led to a reduction in hospital beds and an increase in the use of local community outpatient treatment for mental health. Public services for individuals who have mental illness are offered through a multi-sector partnership between health and social care agencies ( Terlizzi, 2019 ). Regions handle health care services related to psychiatry, while municipalities are responsible for social services for psychiatric patients ( Terlizzi, 2019 ).
There are social psychiatry facilities that are still under the governance of regions but are financed by municipalities ( Terlizzi, 2019 ). As a result of some facilities remaining under the management of regional government but financed by municipalities, there is overlap in the provision of some mental health services. This has led to complications in running an effective system that connects decisions and financing duties ( Terlizzi, 2019 ). To overcome the challenge, Denmark included psychiatry in health agreements that are made between regional governments and municipalities. Denmark has more than 170 private practice psychiatrists. Patients who see them are either referred by a general practitioner financed by the respective region or direct approach by the patient ( Terlizzi, 2019 ).
Community health centers that are established locally offer outpatient care. Interdisciplinary teams are involved in mental health care provision at the centers. The teams comprise physicians, nurses, psychologists, and social workers, among others ( Terlizzi, 2019 ). There are regions in the country where the interdisciplinary groups are locally placed in community health centers. The centers are then linked to a daycare center for mental health patients. Some regions have the teams placed in hospital psychiatry sections. Such regions also have separate mental health services, with some strictly offered to individuals with an illness that is long term and affecting the ability of the sick person to socialize effectively. Others include mental health services for individuals who have mental illness in a short time. For an individual to receive treatment from a community mental health center, a referral is usually required ( Terlizzi, 2019 ).
Mental health care offered by community health centers is often criticized because of providing treatment that is not sufficient. This is, in most cases, associated with a reduced number of hospital beds without, at the same time adding more resources for outpatient care. Almost the whole of the country receives mental health care from the community psychiatry hospitals. The country has been focusing on quality enhancement and execution of new treatment methods and guidelines. While municipalities are responsible for social psychiatry, regional authorities' responsibility is to provide the services that need exclusive competence. There are more than 2,061 day-centers throughout Denmark and 3,256 in both day and night centers for accommodating mentally ill patients. It is the responsibility of municipalities to govern local nursing homes. They also provide temporary accommodation and home care services to mental illness patients. The organizational structure and governance of the psychiatry department allow the treatment of patients with mental illnesses in their homes. There are fieldwork teams within the psychiatry department whose responsibility is to provide psychiatric health care services to patients such as young patients who have schizophrenia and those with psychosis ( Terlizzi, 2019 ). The two groups of patients are the most challenging to handle, and it is essential to ensure that they receive appropriate and adequate treatment.
The government and parliament are responsible for the formation, execution, and amendment of laws related to mental health care and services in the country. Since the 1980s, part of the Danish parliament and the government agenda has been mental health ( Health systems in transition, Denmark: health system, n. d. ). The country’s legislation gives regions and municipalities some significant freedom in organizing and managing mental health care services ( Terlizzi, 2019 ). Treatment of mental health patients in psychiatric facilities is governed by law. The laws cover areas such as the rights of patients, denial of patient's freedom, and application of force in the provision of psychiatric care. The existing legislation found in the health act changed the 1938 law and emphasize more on the rights of mentally ill patients ( Health systems in transition, Denmark: health system, n. d. ). The current legislation requires health authorities to provide hospital stay, offer psychiatric treatment that complies with the established standards, and provide personnel. Also, health authorities have an obligation to determine the likelihood of stay outside a mental health care facility, provision of activity services such as education, and occupational therapy. However, the national government has more influence on the way different regions and municipalities manage psychiatry. The state executes the authority via economic and psychiatry agreements entered into during negotiations about budget and expenses, which happen every year ( Health systems in transition, Denmark: health system, n. d. ).
The mental health act controls how restraint is applied in psychiatry. The law requires the treatment process to be a collaboration between the patient and the health care provider. The statute further states that a treatment plan should be developed and executed within seven days after a patient is admitted to a facility. According to the act which is executed by the state government, a patient should be made aware of the components of the treatment plan and give informed consent ( European Observatory on Health Systems and Policies, n. d. ). Patients are also provided with a list of advocates who can help them file a complaint when restraint is used on them. An advocate who is appointed for a patient assists in starting and implementing a complaint. Even though the use of restraint is still prevalent in other countries, it is widespread in Denmark compared to most other countries. The act on mental health indicates that the application of restraint should be recorded and presented to the state board of health.
Mental Health System Financing
The mental health system is part of the comprehensive health care system in Denmark. The country's mental health system is financed through federal and local taxes collected for the health care system. One my not opt-out of the health care taxes, but some expenses are deductible. Taxes finance approximately 84 percent of the total costs in the health care system. Co-payments in Denmark are moderate and make sixteen percent of the entire health care expenses. The co-payments are mainly from medicine costs, physiotherapy, dental care, and glasses for the elderly and children below the age of sixteen. Municipalities generate revenue from income taxes and block grants provided by the state government ( Terlizzi, 2019 ). Mental health services under the governance of municipalities are financed through taxes and block grants. Municipalities set their tax rates from a formal perspective but, in reality, are set according to the limits agreed upon with the national government ( European Observatory on Health Systems and Policies, n. d. ). Regions/states responsible for services provided by hospitals, psychologists, and GPs among receive funding from the national government and municipalities
Since taxes fund the Danish health care system, it is delivered for free for primary and secondary care. However, treatment by a psychologist is not free at delivery but subsidized ( Terlizzi, 2019 ). General practitioners play the role of a gatekeeper, and care from a specialist is only given free when a GP refers one. Mental health treatment form a psychologist is subsidized for clients referred by a general practitioner for some conditions. The mental health conditions that are subsidized in referral cases include those that result from certain traumatic situations, depression at the mild and moderate stages for those between the ages of 18 and 38 years ( Health systems in transition, Denmark: health system, n. d. ). Besides, mild and moderate anxiety problems are treated by a psychologist at a subsidized cost. For a psychologist to be subsidized, special authorization given by the supervisory board of psychological practice is required ( Health systems in transition, Denmark: health system, n. d. ). Medicines are offered free for all patients who are admitted to hospitals across Denmark.
Mental Health Care State in Denmark
Mental Health Treatment Rates
The number of individuals under psychiatric care in Denmark has significantly increased between 2009 and 2018 (). This indicates that the number of those seeking treatment has increased dramatically. However, approximately half of Denmark's citizens with severe mental disorders are the only ones who seek treatment. Also, a third of those suffering from moderate mental disorders seek treatment too. Treatment from a health care provider who is not a specialist in mental health is estimated at 50% of all treatments for individuals with severe mental illness and two-thirds for the ones with moderate disorders ( Health systems in transition, Denmark: health system, n. d. ). This indicates that under-treatment of mental illnesses is likely to be high in Denmark. This is a major concern for the country.
Mental Health Workforce
Denmark has inadequate psychiatry capacity, and this has placed significant pressure on the mental health care system (Packness, 2018). As a result, social workers who work in municipalities or hospitals have turned into key players in the mental health services field. In addition, just like most countries throughout the world, general practitioners bear much of the weight because they act as gatekeepers to professionals in the mental health system and also offer the first or the only treatment for most mental health patients. Eighty percent of the GPs in Denmark offer psychotherapy treatment to mentally ill patients. The number of psychologists in the country is adequate, but most of them work outside the health care system (Packness, 2018). Denmark has more than 800 university graduate psychologists who have contracts with different regions in the country. As a result of the shortage in the number of psychiatrists, there are considerable waiting lists for patients in need of psychiatric services. The number of practicing psychiatrists in the country is approximately 125 for an estimated 50,000 patients every year. This means that each psychiatrist should attend to 400 patients. The total number of psychiatrists in all healthcare facilities lies between 700 and 800. As a result, psychiatric nurses, GPs, psychologists, and social workers bear a lot of weight in the county's mental health system (Packness, 2018).
Mental Health Service System Gap
Despite reduced rates of suicides resulting from mental illness, the mortality rate related to mental illness in Denmark is till high (OECD, 2017). The mortality rates are below the OECD average of 12. The high mortality associated with mental illness indicates lower access to and utilization of mental health services and reduced mental health care quality (World Health Organization, 2017). This is a key gap in the Danish mental health care system. Reasons for the low use of mental health services can be linked to stigma and mental health system problems such as access, among others. It is, therefore, crucial to address the gap to reduce mortality rates associated with mental disorders in Denmark.
Strategies to Address the Gap and Recommendations
Improving care coordination between mental health specialists and other health care providers can be an effective strategy in addressing the gap. Care coordination aims to enhance the health status and function of individuals suffering from mental health disorders (Falkoner et al., 2018). In coordinated care, there is an active organization of the individual suffering from mental illness. Also, information is shared among all the care providers. Collaboration in care provision has been found by researchers to be effective in improving patient outcomes and fulfillment with the treatment provided (Falkoner et al., 2018). Making mental health care for mild and moderate mental health problems such as depression widely available is also an effective strategy. In Denmark, severe mental health problems are given priority, while the moderate and mild conditions are not accorded the care and attention they deserve. According to them, appropriate care would also prevent progression into severe levels. Another strategy would be to incorporate mental health services into employment and ensure that the current social and labor reforms put into consideration people who are suffering from mental health problems. However, implementation of the recommended strategies would face a major challenge, which is the overlapping of mental health services offered by municipalities and the state government.
Conclusion
Although Denmark is categorized as one of the happiest countries, mental health problems are common in the country. The health system has made considerable efforts to address the issue, but still, some areas require improvements in the mental health system. The Danish government finances the mental health care system in collaboration with municipalities and regions. The different levels of the Danish government have different responsibilities in the mental health care system. Denmark is currently has a shortage of psychiatrists, and this has resulted in long waiting lines for patients in need of the services. This has contributed to the problem of access to mental health care services. The main gap in Denmark's mental health care system is high mortality rates related to mental problems despite a decrease in suicide rates. Implementing strategies such as care coordination among health care providers can help address the gap and ensure access to mental health services by all.
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