Strengthening
mental health care
Recommendations for a 10-year action planin Denmark – short version

Strengthening mental health care
Recommendations for a 10-year action plan in Denmark– short version© Sundhedsstyrelsen, 2022
The publication can be cited freely
with clear source reference.
Sundhedsstyrelsen/Danish Health Authority
Islands Brygge 67
DK-2300 Copenhagen S
www.sst.dk/en/English
Electronic ISBN: 978-87-7014-459-9
ISBN of the printed version: 978-87-7014-458-2
Language: English
Version 01
Version date: 13 January 2022
Design and layout: Sundhedsstyrelsen/Danish Health Authority
Model photos: Lars Wittrock for the Danish Health Authority
Published by the Danish Health Authority
January 2022

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STRENGTHENING MENTAL HEALTH CARE – RECOMMENDATIONS FOR A 10-YEAR ACTION PLAN IN DENMARK – SHORT VERSION

1. Background
According to the political agreement, ‘Retfærdig
retning for Danmark’ (A Fair Direction for Denmark)from 2019, the Danish Government declared its
intentions to implement a 10-year action plan for
mental health with political goals for, among otherthings, reducing the number of re-admissions,
reducing waiting times and increasing the average
life expectancy for people with mental disorders.
As part of the agreement on the Finance andAppropriation Act for 2020, it was decided to initiate
the work on a 10-year action plan for mental health
aimed at setting long-term goals for improving
mental health and social care services for people
with mental disorders.
At the same time, it was decided to allocate
DKK 600 million annually from 2020 and onwards
to improve mental health care in Denmark.
The purpose of this publication is to provide
recommendations for an ambitious, long-term
action plan for improving mental health in thegeneral population and for strengthening mental
health and social care services across several public
sectors for people with mental disorders. Thus,
the aim is to form the basis for the Government’s
proposal for a 10-year action plan.

1.1. Preparation of the publication

Board of Social Services. The Danish Health
Authority and the National Board of Social
Services have continuously been advised byseveral expert groups with representation from
authority and administrative level, professional
associations and organisations as well as patientorganisations.
The challenges and recommendations presented
in this publication are largely based on existing
strategies, analyses, publications and action plansfrom national stakeholders, patient organisations,professional organisations and societies. In four
selected areas – mental health and social careservices in primary healthcare, mental health andsocial care services for children and young people,
psychiatric services in hospitals and mental healthand wellbeing in the general population – theexpert groups contributed with expert knowledge
on mental disorders, status of the services andidentification of key challenges in relation tomental health.
Further, experts contributed with possible solutions
to the challenges and recommendations foradvance­ment of mental health and social careservices, in particular in the assessment of how toensure quality and coherence, seen from both auser perspective and from a medical and resource
perspective. Ongoing meetings with experts andwritten hearings have been an integrated part of theprocess to produce this publication.

The Danish Health Authority has prepared thispublication in collaboration with the National32. Challenges and opportunities
Mental health problems are increasing in Denmark.
It is particularly worrying that an increasing numberof children and young people are experiencing poor
mental health with potentially serious consequences
for their health and development.
Mental disorders are very common, and a largepart of the population will suffer from a mental
disorder at some point in their lives. Consequencesof mental disorders might interfere with our ability
to lead fulfilling lives, to realise our full potential
and lead a normal life with family, work andleisure interests. Further, mental disorders result insignificant excess mortality. Nevertheless, people
with mental disorders are not provided with thesame quality of care as people with physicaldiseases. An essential part of recovery is offering
people with mental disorders the right treatment
and support as early as possible.
Mental health and social care services are currently
characterised by a lack of coordination andcooperation, insufficient quality and inadequate
interventions. If we are to eliminate this significant
inequality and make a real difference for people
with mental disorders, ongoing commitment andprioritisation over the next many years is necessary.
This publication describes the inadequacy
and insufficiency of current mental health andsocial care services and the great potential foradvancement in the field. The publication aims
to set a new and ambitious direction for a radical
improvement over the next ten years.
It aims to strengthen multidisciplinary collaborationand set a new standard for quality, coordinationand cooperation in mental health and social
care services as well as promote a more holistic
approach. The objective is to improve the life ofpeople with mental disorders in respect of their own
wishes and choices.

2.1. A public health challenge
Mental health problems are increasing in Denmark,and a growing number of children and young
people, and nearly one in four young women,
are reporting poor mental health.
Both children, young people, adults and elderly
people can suffer from mental disorders. It isestimated that approximately 580,000 people

4

currently suffer from a mental disorder and that,in the course of a lifetime, approximately 40-50% of
the population will be affected by a mental disorder.
Among children and young people, approximately
15% will be diagnosed with a mental disorder before
the age of 18. However, the figures may be higher,
as it is presumed that some people with mental
disorders are not registered in the national registers
or in questionnaire surveys, nor do they necessarily
seek assistance.
Mental disorders have different degrees of severity,and some are very serious. They very often havelarge consequences for both the individual person
and his or her social network, and, from a social
perspective, mental disorders account for 25% of
the total disease burden1.
Mental disorders entail massive costs to society.
After diabetes and ischemic heart diseases, anxiety
disorders are the third most common healthproblem measured by the number of new cases
per year. It is the cause of most new allocationsof early retirement pension and results in thegreatest costs to society in terms of production
loss. Schizophrenia is not so frequent, but, in turn,it is often very serious and is associated with thehighest costs for treatment and care relative toother health problems.
Mental disorders are the cause of approximately
3,500 deaths annually and are thus the fourth mostfrequent cause of death in Denmark. People withmental disorders have significantly shorter lives
and experience more illness than the rest of the
population. Especially people with severe mental
disorders have an up to 15-20 years shorter life
expectancy than the background population andoften also struggle with, for example, substanceabuse and concomitant complex social problems
such as homelessness.
This analysis of the mental health situation showsthat, in just a decade, there has been an increaseof about 30% in the number of patients with mental
disorders treated in hospital. In comparison, thenumber of patients with physical diseases has
only increased by 13% in the same period. At least
Based on the WHO’s data from 2019 when using the standardised
disease burden measure YLD (Years Lost to Disability). Mental
disorders include common mental disorders, substance abuse disorders and certain neurological brain diseases such as dementia
diseases (3). Mental disorders constitute 14% and substance abuse
disorders 4% of the total disease burden.
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STRENGTHENING MENTAL HEALTH CARE – RECOMMENDATIONS FOR A 10-YEAR ACTION PLAN IN DENMARK – SHORT VERSION

500,000 people annually are in contact with generalpractitioners due to mental health problems. The
number of adults with mental disorders referred
to social care services in the form of, for example,
mental health supported housing and home-based
support has increased by just over 11% in only
five years. In child and adolescent psychiatry, thenumber of patients has increased by approximately
50% within a ten-year period. Correspondingly,
there has been a 41% increase in the number ofchildren and young people with mental disorders
who are placed outside their home or who
receive preventive assistance in the municipality,
for example family-oriented services.

2.2. Previous initiatives andactions plans have not ensured
the necessary improvement
For many years, work has gone into developing andimproving mental health and social care services
for people with mental disorders, and many diverse
measures have been initiated aimed at ensuring
better surroundings, improving capacity andincreasing quality. Many employees and managers
across the field of mental health and social careservices have done and still do great work.
The challenges presented in this publication
are well known, and many of them have been
described in previous publications, studies,
analyses etc. During the past many years, a numberof major and minor initiatives have also beenlaunched in relation to developing and improving
mental health and social care services bothnationally and locally.

Two national action plans have previously
been adopted politically, based on thoroughrecommendations for how to strengthen mental
health and social care services.
All of these previous initiatives have largely been
incoherent and sporadically implemented throughtemporary projects without a joint direction andambition for the field. An action plan successfully
supporting overall general improvement of
mental health is yet to be realised. Likewise, themany recommendations and guidelines as wellas methods and tools developed over the past
many years have often not been systematically
implemented, nor have services been adequately
described and monitored.
As a consequence, there has not been the sameadvancement of mental health and social careservices for people with mental disorders as forpeople with physical illness. At the same time, there
has been a major increase in the number of people
with mental disorders who need support and/or
treatment.

2.3. Current challenges
Current mental health and social care services forpeople with mental disorders are characterised by alack of availability, insufficient quality, limited treatment offers, significant challenges in recruiting andretaining staff, inadequate professional development
and research as well as stigmatisation and lack ofprioritisation. The challenges vary across sectors,
but services in municipalities, the primary healthcare sector and in hospitals must be strengthened.
The main challenges are outlined in Box 1.

Box 1: Main challenges• Insufficient availability, capacity, coordination and cooperation• Insufficient quality and interdisciplinarity in existing mental health and social care services• Inadequate prevention and early interventions• Stigmatisation, lack of prioritisation and equity• Inadequate research, professional development and lack of prestige

5Insufficient availability, capacity, coordinationand cooperation
A major challenge in services aimed at people withmental disorders is insufficient availability, capacity,
coordination and cooperation.
A basic requirement for providing high-quality
mental health and social care services is theavailability of a sufficient number of employees
and managers with the right multidisciplinary andspecialised competences. There are pervasive
and persistent challenges in recruiting andretaining competent staff for mental healthservices aimed at children, young people andadults with mental disorders. At the same time, far
too many children, young people and adults withmental disorders experience incomprehensive
patient pathways with frequent transitions,multiple concurrent types of treatment as well
as different organisation and legislation acrossdifferent sectors.
The lack of availability of mental health and social
care services to people with mental disorders is
also a problem. For example, the need for services
manifests itself when parents contact their generalpractitioner or their child’s school because ofincreasing concern about their child’s well-being
and mental health. Here, current services offeredin the municipalities do not meet the increasingneed for early interventions for children and young
people with mental health problems and withsymptoms of mental disorders. It may also often
take a long time before the child gets the right help,
and it is difficult for families to figure out where
to turn. Current services are aimed at supervisingschool teachers and kindergarten teachers aswell as to prepare pedagogical-psychologicalassessments (PPAs).
Correspondingly, there is a strong need for better
availability, capacity and coherence when it
comes to services for adults. For example, a lackof capacity may result in long waiting times formunicipal mental health supported housing or
home-based support or that sufficient psychiatriccounselling is not provided in relation to mental
health supported housing. The consequence may
be that a patient either remains hospitalised or isdischarged with an increased risk of relapse andre-hospitalisation, and thus additional strain on boththe patient and his or her social network.

6

At the same time, too many people with mental
disorders experience incomprehensive patient
pathways with multiple concurrent interventions
without sufficient coordination. These challenges
are complex and are due to a number of factors,
including different legislation and management
regimes as well as different professional
approaches across sectors.
People with mental disorders and concurrent
substance abuse constitute a particularly vulnerable
group. Their condition is medically complex tohandle, and they often have both mental disorders
and physical diseases. Also, the patient pathway ischaracterised by both acute admissions and many
re-admissions as well as increased use of coercion
during hospitalisation. Due to an unclear distributionof responsibilities, there is also a very fragmented
patient pathway across municipality and hospital,
in which this particular group is unable to navigate.
It is a key requirement for increasing the qualityof care for people with the most severe mental
disorders that there is an unambiguous distributionof responsibilities, and that overall integrated
services, based in the regions, are established forthis group.
Insufficient quality and interdisciplinarity inexisting mental health and social care services
The analysis points to problems with insufficientquality and interdisciplinarity in existing mental
health and social care services.
The quality of psychiatric care in hospitals and social
care services in Danish municipalities is not of a
sufficient quality, which has major consequences
and creates an unacceptable inequality, significantly
shorter life expectancy, increased burden of disease
and lower quality of life. There are several examplesof this.
Firstly, people with mental disorders have asignificant excess mortality rate, due to a higher
occurrence of preventable diseases such as cancer
and cardiovascular diseases and an insufficient
cooperation between psychiatric and physical care.
Secondly, there is a lack of research, evidencebased guidelines as well as updated and welldeveloped quality databases. There are othermedical specialisations and specialist fields with a
far greater scientific tradition and higher prestige,STRENGTHENING MENTAL HEALTH CARE – RECOMMENDATIONS FOR A 10-YEAR ACTION PLAN IN DENMARK – SHORT VERSION

which have better opportunities and resources
for maintaining and developing high-quality
assessment and treatment of patients.
Thirdly, there are insufficiently binding systematic
descriptions of the entire patient pathway, including
clear agreements on referral, distribution of
responsibilities, cooperation and interdisciplinarity.
There is an insufficiently holistic approach to patientsensuring that all relevant elements of treatment
and care are included, including pharmacologicaltreatment, psychotherapy, environmental therapy,
occupational therapy, physiotherapy etc. Highquality multidisciplinary services throughout thepatient pathway require professionals with theright competences and the best possible use ofcompetences of all professions involved. Manydifferent professions are typically involved in theoverall patient pathway, including nurses, social andhealthcare assistants, psychologists, physicians,
occupational therapists, physiotherapists, social
workers, residential social workers etc. In addition
to interdisciplinarity, there is a great potential indigital solutions being disseminated and used in asystematic and evidence-based manner.
Fourthly, we still face major challenges with theuse of coercion in psychiatric wards. For a numberof years and especially since 2014, hospitals haveworked to reduce the use of coercion in psychiatricwards, but although the use of mechanical restraint
has been reduced, the overall use of coercion
remains too high. This also highlights a mental
health system without the capacity and resources
needed to ensure adequate quality and targeted
services, and where patients should be met byattentive professionals and services based on theirindividual needs. Correspondingly, in the past ten
years, Denmark has failed to reduce the numberof suicides and suicide attempts and is the OECD
country with the highest suicide rate among
inpatients.
Fifthly, social care services are of varying
quality. Furthermore, there is a lack of sufficiently
specialised services for people with severe mental
disorders who are discharged from hospitaltreatment. In addition, a very high proportion of theemployees are unskilled. Descriptions of quality
standards for social care services are needed,
including how services can be more targeted andsystematic , for example by strengthening anddocumenting quality and ensuring that services

have similar content and quality. At the sametime, there are still major challenges associatedwith patient safety at mental health supported
housing, especially in relation to handling residents'
medicine, and managers in social care services
demand more healthcare competences in thesocial care services offered.
Overall, there are currently no systematic, multidisciplinary, holistic and evidence-based services
for people with mental disorders, which is a pre­requisite for ensuring that more people recover andexperience greater quality of life.
Inadequate prevention and early interventions
Inadequate prevention and early interventions are amajor cause of excess mortality and morbidity.
Much of the excess mortality seen in people
with mental disorders is caused by physicaldiseases. People with mental disorders are justas interested as others in leading a healthy life,
but there is insufficient attention paid to offering
health promoting and preventive services such as
smoking cessation, dietary advice and exercise forpeople with mental disorders. Furthermore, we are
not doing enough to offer support for participationin routine examinations such as health checks,
screening examinations or preventive visits to thedentist. Again, people with the most severe mental
disorders are those who are most affected, because
they are also those most in need of a helping handand awareness of their state of health.
Another cause of the excess mortality is suicide.
People who have been admitted due to a mental
disorder have an approximately 20 times higher
suicide rate than the background population.
Especially in connection with admission anddischarge, people with mental disorders are
particularly vulnerable, in particular if they are notsupported by adequate follow-up or if they aredischarged before they are ready for it. In the firstweek after discharge, the risk of suicide is over 200
times higher than for the background population.
At the same time, many people do not receive
help early enough. There are currently not uniform
services avaliable in general practice. At the sametime, general practitioners lack an overview of outof-hospital services to which they can refer when
there is no need for hospital treatment. Too often,7the consequence of this is that children, young
people and their families are sent around between
different types of services in the primary sector
and in the municipality. It is not easy to find thenecessary help – often because the right type ofservices are not available. At the same time, there ismuch too often a lack of cross-sectoral cooperation
and a lack of focus on systematic screening anddetection of mental disorders in the municipalities.
Stigmatisation, lack of prioritisation and equity
The most fundamental challenges concern
stigmatisation and lack of prioritisation and equity.
Although mental disorders are common, they arestill associated with taboo, guilt and shame. People
distance themselves from mental disorders and find
it difficult to understand why they occur and what
they mean.
Many people find it easier to talk about andshare the fact that they have a physical disease
compared to a mental disorder. Most people know
how common mental disorders are, and this issue
should be dealt with openly and without prejudice.
Stigmatisation has extensive consequences
for people with mental disorders in the form of
discrimination, self-stigmatisation and social
exclusion. Stigmatisation and discrimination insociety, at work, at school and among colleagues
etc. are important for the individual person’s
possibilities of regaining or establishing their placein society and of obtaining the same access tohelp, support and treatment, and it can therefore
enhance inequality.
The widespread stigmatisation also contributes
to far less political and public attention andprioritisation compared to physical diseases. Mental
health is quite simply not given the attention andpriority that it should be getting based on the
disease burden.
The stigmatisation and lack of prioritisation alsomean that the mental health system does nothave the same terms and resources for developing
the quality of services. Many years of temporary
projects and lack of resources mean that no overall
direction has been set for the development of themental health system.

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Inadequate research, professional development
and lack of prestige
Lack of prioritisation of research and professional
development results in a lack of prestige andchallenges in relation to retention and recruitmentof health professionals.
Mental health is not prioritised to the same degree
as corresponding disease areas and is not granted
the same amount of research resources. Within
the psychiatric specialisations, there has not been
the same tradition for developing evidence-based
guidelines as in other medical specialisations.
Likewise, there is limited professional development
and documentation of the services for people withmental disorders in municipalities and the primary
health care sector.
The limited documentation, development andresearch result in insufficient knowledge about
mental disorders and about the efficacy of services
as well as limited implementation of effective
services.
The limited resources for professional development
and research means that psychiatry is often
considered a less attractive field relative to otherdisease areas. There is no doubt that the many
employees working in the mental health system dogreat and dedicated work and also perceive theirwork as both meaningful and attractive. But seen
across a number of specialisations in the healthcare
system, there are large differences indicating that,at the structural level, psychiatry has not received
the attention and recognition that it deserves. Thisshould also be seen in relation to the importanceof this field for both the people affected by mental
disorders and for society as a whole, as well as thefact that many people with mental disorders canactually recover if given the right help.
Recruitment and retention of professionals inmental health care and social care throughstrengthened research and professional
development are therefore also a key challenge
which must be met in the coming years.

STRENGTHENING MENTAL HEALTH CARE – RECOMMENDATIONS FOR A 10-YEAR ACTION PLAN IN DENMARK – SHORT VERSION

2.4. An action plan with ambitious
goals
The major disease burden, significant inequality andinadequate services call for an extensive professional improvement of services across sectors.
The publication therefore describes the needs andopportunities for the advancement of mental healthand social care services over the next 10 years.
The ambition is high and the intended outcome isthat people with mental disorders in Denmark havebetter and longer lives, be included and acceptedin society and receive treatment and services thatare commensurate with the best in the world andwith respect for the individual person’s wishes
and choices.
Therefore, it is also essential that, as part of a 10-year
action plan, ambitious goals are set for achieving abetter life and having the opportunity for inclusion
in society on an equal footing and in accordancewith the individual person’s own wishes and choices.
The goals must set the direction for initiatives andprovide a basis for continuous follow-up on whether

the development is going in the right direction andwhether the implemented services make a difference
to people with mental disorders and to the mental
health of the population in general. In addition toincreasing well-being and quality of life, building
up the field will help reduce socio-economic costsin the form of lower costs for sickness benefits,
occupational injuries, early retirement pension etc.
This publication provides proposals for professional
goals which should be qualified further in a coming
10-year action plan.
The proposed goals are based on the individual
person’s opportunities to lead a good and meaning­
ful life. The goals focus on mental health, mental
health problems and improved services for people
with light, moderate and severe mental disorders.
The goals extend across social care services, theprimary healthcare system and mental health care,and it is a requirement for meeting the goals thateveryone works together across sectors and acrosscivil society, municipalities, regions and national
level, and that everyone works in the same direction.

Box 2: An action plan with ambitious goals for the overall mental health andsocial care services for children, young people and adults• The mental health of children and young people has improved• People with mental disorders live longer lives with less illness• People with mental disorders are included and accepted in society to a higher degree• People with mental disorders are retained in jobs, school and education and more often get an
education and a job• People with early signs of or at risk of developing mental disorders receive early preventive intervention• People with mental disorders experience high quality, care, involvement, coordination andcooperation in the services.
• People with mental disorders are subjected to less coercion and use of force• People with mental disorders and concurrent substance abuse receive more cohesive and effective
treatment and more of them succeed in quitting their abuse• Fewer people with mental disorders are sentenced for a crime• Family and friends are more often given the support they need and their resources are used more
actively in treatment

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The goals should have a central position in asystematic follow-up on the coming 10-year action
plan. Learning from both the cancer plans and, forexample, the Norwegian Psychiatry Plan showsthat it is absolutely essential to ensure systematicand continuous follow-up on the implementationof services.
Follow-up should happen with broad representationof stakeholders from across all the relevant professions that can monitor services and support closeand continuous quantitative and qualitative coordination and follow-up and advise on challenges andneeds in connection with the 10-year action plan.

2.5. Prerequisites for successful
improvement

mental health and social care services. This requires
structured, gradual and long-term build-up of
the field. Structured in terms of clear, uniform andcohesive frameworks for services, and requirements
based on evidence or best knowledge where there
is still a lack of evidence and where evidence needs
to be developed. Gradual because services must
be built up in line with the framework being present
and as prerequisites for an extensive improvement
are established. And long-term because there isa need to do away with temporary projects andpools and instead establish an overall professional
development for the whole field.
To be able to achieve this, a large number ofstakeholders in the field point at some absolutely
essential prerequisites which must be present.

If the ambitions are to be achieved, there is a needfor fundamental professional improvement of

Box 3: Fundamental prerequisites• A gradual, strategic and long-term capacity improvement to meet the need for services andtreatment, including more employees across both social and healthcare services• Better recruitment and retention of competent employees across professional groups andcompetence improvement• More flexible task management• A clearer distribution of responsibilities and better coordination and cooperation across sectors

As the most important measure, the necessary­capacity should gradually be built up in areas inwhich current services are inadequate, and it should
be ensured that sufficiently qualified health professionals are available for these services. The improvement should be gradual in line with the national professional frameworks being described and relevant
competences being recruited and developed.
A basic requirement for providing the necessary
capacity is to establish a better framework forrecruitment and retention of competent employees.
Throughout the 10-year period, work should
be done to ensure sustainable solutions for theextensive challenges of recruitment and retention,for example through a gradual establishment of
attractive jobs with opportunities for professional

10

development, and through more flexible task
management and coincidence of the services
across the professional groups in this field.
It is also essential that the organisationalframeworks help support and ensure better
coordination and cooperation in services forpeople with mental disorders. It is necessary
to have binding cooperation with a moreshared understanding across stakeholders inmunicipalities, the primary health care sector andhospitals, with a clear distribution of responsibilities
and closer collaboration on the performance ofthe tasks. It is also necessary to ensure that social,healthcare, school, education and labour legislation
provides the necessary framework to support
multidisciplinary collaboration and cooperation.

112.6. Gradual improvement over a
10-year period
In this publication, nine themes have been selected
for in-depth analysis, involving a large number ofstakeholders and professionals.
The first two themes concern fundamental
initiatives essential for ensuring extensive longterm profes­sional improvement. These themes are
Equity and anti-stigmatisation as well as Knowledge,
development and strong professional environments.
The other themes cover Mental health promotion
and the overall patient pathway for people withmental disorders, including the services for Children
and young people, Early interventions for adults,
Analysis and treatment, Forensic psychiatry andSocial care services. Finally, the correlation between
services and sectors is examined in the theme on
Coordination and cooperation.
Together, the recommendations constitute a
broad improvement of the overall services acrossmental health and social care services and havebeen described so they can be prioritised andimplemented in steps.
A clear prioritisation is outlined in this publication.
The priority areas are those where the needis greatest, most urgent and of fundamental
importance to ensuring a long-term development.
The prioritised recommendations and services arepresented in Box 4.
Firstly, it is essential to improve services aimed atchildren, young people and those with the most
severe disorders.
An increasing number of children and young people
have mental health problems and suffer frommental disorders. At the same time, more children
are diagnosed with mental disorders earlier in life.
Services available to children and young people
are currently inadequate. This means that too many
children and their families are left on their own
and that mental health and social care services
for children and adolescents and the municipal
services for children and young people are under
great pressure. Concurrently, there is a needfor strengthened cross-sectoral cooperation onscreening and detection of especially children with
developmental disorders, where far too many cases12

are today discovered too late. The lack of services
has major consequences for the child and his or her
family and leaves deep marks far into adulthood forthe individual person.
People with severe mental disorders are anothergroup currently receiving fragmented andinadequate services. The consequences are asignificantly shorter life expectancy, long courses
of illness and greater risk of homelessness. At
the same time, the people with the most severe
disorders are most often exposed to coercion,
most frequently take their own lives and are mostfrequently sentenced to psychiatric treatment,
which could have been avoided with the righttreatment. There is a need to improve the quality
across mental health and social care services for
adults as well as for children and young people.
There is also a need for cohesive, multidisciplinaryand holistic services based on evidence and clear
pathways for people with mental disorders.
Secondly, there is a need to ensure that the very
fundamental foundations are in place so that theservices can be built up over the next ten years.
The main elements in an extensive professional
improvement of services are breaking down
stigmatisation, increasing prestige andstrengthening research and multidisciplinary
cooperation to increase the evidence basis
for services. Anti-stigmatisation and quality
improvement are also absolutely essential tosuccessful recruitment and retention of sufficient
staff across mental health and social care services
in the coming years.
After commencement of the prioritised recommen­
dations in the initial period of a 10-year action plan,an evaluation should be made of the recommenda­
tions and a status report should be prepared. The
evaluation should be done in order to make a new
professional assessment and prioritisation of therecommendations for the subsequent numberof years. A clear multi-phase prioritisation helps
support a strategic and targeted professional
improvement of the overall field. In the past,
standalone recommendations and short-term
projects have been implemented sporadically andhave thus not supported an overall professional
improvement. The next section provides an
overview of all the recommendations in the
publication for the 10-year action plan.

STRENGTHENING MENTAL HEALTH CARE – RECOMMENDATIONS FOR A 10-YEAR ACTION PLAN IN DENMARK – SHORT VERSION

Box 4: Prioritised recommendations
1.

Establishing easily accessible high-quality services in the municipalities for children andyoung people with mental health problems
This can be ensured through the establishment of single-entry municipal services basedon a national professional framework. Services must include the possibility of assessmentand easier access to treatment. At the same time, services must support cross-sectoral andmultidisciplinary cooperation between municipalities, general practice and child and adolescent
psychiatry regarding services for children and young people with mental health problems
and mental disorder symptoms. This includes early screening, detection and assessment ofespecially children and young people with developmental disorders as well as children andyoung people in high-risk groups (see Recommendation 11).

2.

Strengthened treatment and care for people with severe mental disorderThis can be ensured through well-described quality standards and requirements for thepatient pathway and for the collaboration between professionals and sectors involved during
the entire pathway (see Recommendation 20). Based on these descriptions, specialised
emergency services offered in both psychiatry and child and adolescent psychiatry can be
developed further (see Recommendations 21 and 12). For the most severely ill patients withacute and long-term needs for hospitalisation, an evaluation and assessment can be made of
the intensive care capacity and a framework can be created for a new type of rehabilitating
beds (see Recommendation 18). In addition, quality and capacity of social care services canbe improved through a number of measures. These include a national development strategy
for quality improvement and the establishment of temporary and acute municipal services for
adults who, for example, are waiting for mental health supported housing after hospitalisation(see Recommendations 28 and 31) .

3.

Anti-stigmatisation of mental disorders
This can be ensured through a long-term action plan and framework for anti-stigmatisation
initiatives. As a first measure, a national knowledge centre can be established to support
services aimed at both the broad population and employees across the social and healthcare
services area (see Recommendation 1).

4.

Strengthened multidisciplinary and professional environments
This can be ensured through the establishment of multidisciplinary and cross-sectoral groups(with inspiration from the cancer area) aimed at supporting long-term professional development
and continuous quality improvement in the overall services for people with mental disorders
across the primary health care sector, municipalities and hospitals. This includes preparation of
professional guidelines and dissemination of evidence-based and documented efficient services(see Recommendation 6).

5.

Research and development
This can initially be ensured through implementation of the multidisciplinary and cross-sectoral
research strategy from 2015 (see Recommendation 5).

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3. Overall recommendations
In the following, nine selected themes are presented
together with recommendations for better mental
health and strengthened services for people withmental disorders. The themes are:• Equity and anti-stigmatisation• Knowledge, development and strong
professional environments• Mental health promotion• Children and young people• Early interventions for adults• Assessment and treatment• Forensic psychiatry• Social care services• Coordination and cooperation

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The recommendations cover high-priority initiatives
that can be implemented in the short term (theseare highlighted with an asterisk (*)), as well as
initiatives that can be implemented gradually overthe full 10-year period.
The individual recommendations are described indetail in the extended publication in Danish together
with supplementary recommendations for gradual
implementation. Some of the recommendations
can be implemented immediately, whereas,for others, the conditions for delivering a given
service or initiative should be in place before therecommendation can be implemented.

3.1. Equity and anti-stigmatisation
A basic prerequisite for achieving greater equity for people with mental disorders is to counter
prejudices. It is therefore recommended to implement long-term and persistent, nationalanti-stigmatisation initiatives. It is also of central importance that the increased morbidity
and excess mortality among people with mental disorders is reduced This should be done
through improved disease prevention and access to treatment for physical diseases as well as
implementation of a national action plan on suicide prevention.

Recommendations
1. Long-term anti-stigmatisation initiatives including implementation of a national
knowledge centre, an ambassador corps and action plan *Long-term national anti-stigmatisation initiatives should be implemented acrosssectors over the next 10 years. The initiatives must be implemented in cooperation with
regions, municipalities, civil organisations and national authorities.
2. Better prevention of risk factors for physical diseases among people with mental
disorders
Municipalities and regions will ensure preventive services as part of the services forpeople with mental disorders. This includes that relevant professional staff have thenecessary knowledge, multidisciplinary competences and tools to systematically
identify and prevent known risk factors and to motivate and support people with mental
disorders in changing their health behaviours. These services should be delivered bysocial care services, the general practitioners, and the psychiatric care facilities.
3. Strengthened assessment and treatment of physical diseases among people withmental disorders
Regions and municipalities must ensure that people with mental disorders receive
relevant, timely and qualified assessment and treatment for physical diseases including
medical assistance, screening and health examinations. This also includes review of
medication and screening for side effects as well as support for dental care.
4. A national action plan on prevention of suicide and suicide attempts
There is a need for a systematic and long-term improvement of the suicide prevention
services through a national action plan with ambitious targets for reduction of suicideand suicide attempts. The action plan should address, for example, prevention,screening and detection, early intervention, follow-up after suicide attempts as well as
involvement of the patient and their social network.

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3.2. Knowledge, development and strong professional environments
To strengthen evidence-based knowledge and development across professional areas andsectors, it is recommended that research on mental disorders be strengthened throughimplementation of the existing research strategy. In addition, improved access to and useof data should be prioritised. At the same time, strong professional environments should be
developed to support uniform professional development and documentation of services
through guides, guidelines and databases on quality of care.

Recommendations
5. Implementation of the existing national research strategy*
A widely recognised national research strategy was prepared in 2015. This strategy
should be implemented continuously over the coming years to strengthen knowledge
and evidence and establish strong research networks and traditions.
6. Establishing multidisciplinary groups to support professional development andquality improvement *Inspired by the DMCGs (Danish Multidisciplinary Cancer Groups), multidisciplinary andcross-sectoral groups for the overall health and social care services will be establishedtargeting people with mental disorders to support long-term professional development
and continuous quality improvement.

3.3. Mental health promotion
To address the increase in poor mental health, it is recommended to implement mental healthawareness initiatives focusing on the importance of, for example, civil society and participationin active communities. The initiatives will be targeted at both the general population andworkplaces. The development among children and young people is particularly worrying,
and a special action plan is recommended to stop this trend. Likewise, systematic initiatives
should be put in place for mental health promotion for people with mental disorders who are
hospitalised or receive support in the social care services.

Recommendations
7. Strengthening mental health promotion in prenatal care, childcare institutions
and schools
Mental health promotion for children and young people is strengthened through anaction plan for childcare institutions, schools and youth education programmes, and theexisting recommendations in relation to early intervention will be fully implemented.
8. Mental health awareness initiatives in the population and at workplaces
Through information initiatives, awareness about mental health will be disseminatedas will knowledge on the best ways to promote and protect mental health in the
population. In addition, information and advisory activities will be initiated in relation
to mental health and stress prevention at workplaces.
9. Systematic initiatives for mental health promotion for people with mental
disorders receiving hospital-based care and social care services
Initiatives aimed at supporting mental health promotion among people with mental
health disorders will be disseminated, and the opportunities for entering meaningfulactivities and positive communities will be improved.

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3.4. Children and young people
Services for children and young people with mental health problems and early signs ofmental disorder are inadequate, and too many children and young people are assessed
too late, especially for developmental disorders such as ADHD and autism. There is a needof strengthened screening and early detection in primary schools and among children
and young people at increased risk of developing mental disorders through improved
implementation of validated screening tools. It is also essential to establish easily accessible
services with one entry point for easier access to treatment in all municipalities. At the sametime, the quality of treatment of children and young people with the most severe disorders
should be increased through development of multidisciplinary outgoing teams, models forcross-sectoral cooperation as well as description and implementation of patient pathways.
To support services before, during and after treatment in child and adolescent mental healthcare, specialised social care services should be established for children and young people
with severe mental disorders and concomitant complex social problems.

Recommendations
10. Screening and early detection of children and young people with mental healthproblems and mental disorders
Services must support systematic screening and detection of children and young
people with mental health problems and symptoms of mental disorders. There is aneed for increased knowledge on mental disorders and competences in handlingthem for professionals working closely with children and young people. Evidence fromexisting trials on systematic screening and detection using validated screening tools
should be used as a basis.
11. Establishing easily accessible high-quality services in the municipalities forchildren and young people with mental health problems*Based on national frameworks a general, easily accessible service will be tested andsubsequently disseminated. The service will have one entry point and clear standards
targeted at children and young people with mental health problems and emotional
symptoms such as anxiety or depression. Services must include the possibility ofassessment and easier access to treatment. It is necessary to clarify who is responsiblefor delivering the service, for example municipal family services, and to establish which
legislation provides the legal basis for this service.
12. Increased quality of treatment for children and young people with severe
mental disorders through multidisciplinary, outgoing functions and descriptionsof patient pathways*
There is a need to ensure high-quality treatment for children and young people
receiving treatment at either child and adolescent mental health services or apracticing specialist in child and adolescent psychiatry to assure that more children
and young people with severe mental disorders are offered good and cohesive
treatment of the same quality across Denmark.
13. Establishing or extending existing specialised social care services for children
and young people with severe mental disorders
Specialised social care services are identified, and, where necessary, specialised social
care services are established for children and young people with complex problems,
including children and young people with mental disorders, who also have serious
problems with crime, substance abuse, self-harming behaviour, eating disorders, etc.
These may be by establishing new services or by extending existing services.

173.5. Early interventions for adults
There is a need to establish easily accessible, evidence-based services for young people andadults with mental health problems which has a single entry point across all municipalities.
Frameworks and requirements for the services are described in a national model fororganisation and contents. In addition, screening and detection of people with mental
disorders must be strengthened through screening and detection tools and rapid psychiatricassessment. This also relates to people with co-existing mental disorders and complex social
problems, who struggle with treatment adherence in existing services.

Recommendations
14. Establishing easily accessible high-quality services in the municipalities foryoung people and adults with mental health problems
Based on national frameworks, one-entry point services will be established in eachmunicipality for young people and adults with mental health problems. Young people
and adults will be able to contact these services themselves or can be referred by for
instance their general practitioner. The service should, as a minimum, include services
that have been effective in treating people who struggle with life crises, stress, anxiety
and depression, and the service should include an overview of the overall services
offered by the municipality. There may be a need to clarify which legislation will
provide the legal basis for the services.
15. Systematic and targeted screening and detection of people with mental
disorders in general practice and municipalities
Living with an untreated mental disorder may have large consequences in relation toexperiences of exacerbation, sequelae as well as social and mental health problems.
Therefore, validated tools for early screening and identification of risk groups are to bedisseminated in general practice and municipalities. It will be assured that these tools
have a special focus on groups with concurrent substance abuse.

3.6. Assessment and treatment
Assessment and treatment of people with mental disorders must be holistic and cohesiveacross sectors. In addition, both the patients and their social network must be involved
throughout the course of treatment. Therefore, it is recommended to prepare national patient
pathways for children, young people and adults with mental disorders, which describe
professional frameworks for services and initiatives delivered across municipalities andregions. At the same time, there is a need to address significant challenges regarding capacityand quality of services for people with the most severe disorders. It is therefore recommended
to establish additional acute psychiatric services and capacity in the specialised care services
as well as national initiatives aimed at reducing the use of coercion. At the same time, it isessential to find a solution for the patients with mental disorders and concurrent substanceabuse and who do not receive integrated and cohesive services today. For better utilisationof resources, it is also essential that digital solutions become widespread in use and areused systematically and based on evidence. In addition, it is recommended to establish
more outgoing services as well as easily accessible services for adults with light to moderatemental disorders.

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Recommendations
16. Easy and rapid access to acute psychiatric services for people with acute or
acutely exacerbated mental disorder and strengthening of outgoing acute functions
It is recommended to strengthen organisation and capacity in acute care services andto assure that services offered are similar and based on the Danish Health Authority’s
recommendations for organisation of healthcare services in psychiatric emergency
care. For instance, it can be relevant to facilitate a widespread use of outgoing acuteservices and joint referral systems in relation to psychiatric emergency care. In addition,
trials evaluating citizen-oriented psychiatric hotlines can be conducted in relation tosuicide prevention but also other mental health problems.
17. Preparation and systematic implementation of new guidelines for medical
specialisations shall improve the quality of care for the most severely ill and mostcomplex patients in psychiatric hospital care
The national guidelines for medical specialisations regarding psychiatry and child andadolescent psychiatry are systematically revised and implemented to ensure adequateorganisation and high quality of care in psychiatric hospital care. There will be focus on
both broad and specialised areas of hospital care.
18. Better organisation of specialised treatment for the most severely ill patients
through extension of differentiated and specialised psychiatric in-patient capacity *To ensure better quality, coordination and cooperation in care, differentiated treatments
will be developed for both the acute and rehabilitation phases of care for patients withsevere mental disorder who need intensive or long-term rehabilitation.
19. Giving national priority to and assuring high quality of digital solutions andservices for people with mental disorders
COVID-19 has highlighted the potential of digital care services and the potential benefit
from developing more and better digital solutions. In addition, the increase in people
with mild mental health problems proves the need to develop innovative solutions inorder to ensure the capacity of care services. At the same time, this development mustbe supported by clear national frameworks for digital solutions and services for people
with mental disorders to ensure accessibility and patient-experienced quality.
20. Development and implementation of national patient pathways are to improve
the overall quality of services and initiatives *National patient pathways for people with mental disorders must support evidencebased and uniform healthcare and social service services in assessment, treatment andrehabilitation/recovery across all sectors, and must be prepared in conjunction with
the national guidelines in the social service area (see Recommendation 31).
21. Dissemination of outgoing specialised, multidisciplinary services for people
with severe mental disorders *As part of the descriptions of patient pathways, specialised, multidisciplinary outgoingteams will be established throughout Denmark based on inspiration from evidencebased services such as OPUS and ACT. This is to support intensive outpatient andmultidisciplinary treatment services for people with onset of severe mental disorders
and for people with severe and/or complex mental disorders with a need for integrated
and flexible multidisciplinary services. In relation to onset of severe mental disorders,
early interventions should be implemented for all patients with onset of psychosis
spectrum disorders or bipolar affective disorder.
... to be continued

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... continued

22. Ambitious objectives for reducing the use of coercion and strengthening quality
and prevention of coercion through a national knowledge centre and mobile units
The use of coercive measures in psychiatric wards must be reduced to an absolute
minimum. This requires a strong focus both nationally and locally. A general capacityand quality improvement in psychiatric care should therefore be supported by new
objectives for reducing coercion, close monitoring and a national focus on learningand knowledge sharing.
23. A quality improvement of services for people with mental disorders andconcurrent substance abuse through integrated treatment
People with concurrence of mental disorders and substance abuse often experiencea complex and severe disease course, and there is a great need to strengthen thecoordination and cooperation and professional quality of services targeting this group.
It would be beneficial to establish integrated, high-quality services, delivered by theregions to ensure concurrent and coordinated treatment of both the mental disorder,
substance abuse and possible physical diseases.
24. Establishing easily available, evidence-based treatment for adults with mild tomoderate mental disorders
Relevant, accessible, timely and qualified services for people with mild to moderatemental disorders must be established in the primary health care sector based on both
Danish and international experiences with systematic and early treatment. These
services can be based on national, evidence-based, professional frameworks andexisting experiences with documented services in the primary health care sector
and existing cooperation structures such as practice collective agreements, healthagreements or the coming health clusters.
25. Strengthened support for and involvement of family and other immediate
relatives of people with mental disorders
Family and immediate relatives of people with mental disorders must be offeredsupport, and their resources must be used more actively, systematically and uniformly
in both municipal and regional services. This applies to children, young people andadults who have relatives with mental disorders in the immediate family.

3.7. Forensic psychiatry
In recent years, there has been a significant increase in the number of people sentenced to
psychiatric treatment. This development is worrying, and there is a need for reviewing thelegislation in this area to ensure that the right group of people are sentenced to psychiatrictreatment. In addition, there is a need to strengthen the framework for correct referral, forinstance through revision of the existing guidelines.

Recommendations
26. A review of the legislation governing forensic psychiatry will be conducted,
including the provisions of the Danish Criminal CodeIn order to support cooperation and coordination across authorities in a forensic patient
pathway, a review of the legislation governing the field will be conducted, including
an assessment of case law in relation to the requirements for being sentenced to
psychiatric treatment.
... to be continued

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... continued

27. Strengthened professional frameworks for the services targeting forensic
psychiatric patients to assure correct treatment referrals
It should be assessed whether there is an appropriate organisation of the forensic
psychiatric care services. This includes acquiring knowledge about and discussing
matters of importance to organisation and capacity of the field.

3.8. Social care services
There is a great need to improve capacity, quality and competences in the social care services.
Therefore, a national development strategy for quality of care focusing on recovery-oriented
rehabilitation should be implemented together with a wide competence boost. In addition,
the quality of the administrative case handling of adult patients should be strengthened inorder for people with mental disorders to receive the right and specialised treatment. It is also
recommended to ensure increased specialisation of social care services as well as to assure amore widespread implementation of outgoing services at street level to reach people with themost severe and most complex problems. A very central recommendation is to disseminate
the availability of flexible and acute services for people who are awaiting mental healthsupported housing after being discharged from hospital. Finally, it is recommended to review
the provisions on adults in the Danish Social Services Act (Serviceloven) in relation to whether
they effectively support people with mental disorders in their recovery, and it is recommended
that a management review of social care services be performed.

Recommendations
28. Establishing and reorganising the capacity in social care services to ensurethat adequate and available knowledge-based services are provided and that
there is a dissemination of flexible services meeting the varying needs of people
with mental disorders. *The capacity building must ensure that the individual person receives the rightand documented effective social care services at the right time. Experiences withestablishment of easily accessible, flexible and round-the-clock staffed temporary
services or self-referring services will also be disseminated to provide better help
for those in need of a temporary service. Also, more services of this type, including
temporary transitional services, will be established.
29. The quality of administrative case handling in relation to adult patients will bestrengthened, so that people with mental disorders receive social care services
providing them with the best support to recover.
It should be ensured that people with mental disorders are offered the right services
and experience a recovery-oriented and rehabilitating approach to the assessment of
their need for support. Therefore, a mapping and dissemination of knowledge about
the quality of the administrative case handling of adults will be carried out. In addition,a more systematic implementation of the Adult Assessment Method (VUM) 2.0 will be
initiated in the municipalities, so that the method is used on all relevant target groups
in the social care services and uniformly across municipalities.
... to be continued

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... continued

30. A review of the provisions on adults in the Danish Social Services Act will be
initiated in relation to whether they effectively support the recovery of people withmental disorders.
The Danish Social Services Act sets out the regulatory framework for the organisationof social care services as well as referrals to these services. There is a need to assess
whether the current legislation adequately supports recovery-oriented rehabilitationand creates adequate frameworks for flexible and easily accessible services inaccordance with the needs of people with mental disorders.
31. A broad and uniform quality improvement of the entire social care services area
through a national development strategy*
A national strategy will be prepared for continued development and reorganisationof social care services towards a recovery-oriented and rehabilitating approach, sothat all people with mental disorders across Denmark will receive relevant, timely andhigh-quality services. The existing knowledge and experience will be disseminatedmore systematically to all the municipalities of Denmark – this in relation to boththe strategic management level, among caseworkers as well as among managers,
employees and in relation to the individual person.
32. Improvement in the level of education and competencies in the social careservices and strengthened recruitment
There is a need to raise the education and competence level among managers andemployees in social care services. Moreover, it is necessary to strengthen recruitment
and retention of competent professionals in social care services.
33. Increased specialisation of social care services is recommended for people withthe most severe and most complex problems
People with severe mental disorders and possibly complex social problems must be
met by employees who are qualified to handle their special needs. This requires thatthe employees have sufficient specialised knowledge and specialised competences.
34. Development and dissemination of outgoing services at street level in relation topeople with the most severe mental disorders and complex social problems
People with severe mental disorders and complex social problems must receive
outreaching and advanced services that are provided on the individual person’s
own terms.

223.9. Coordination and cooperation
A lack of coordination and cooperation is one of the main challenges in current services.
The frameworks, and the organisation and culture needs to support multidisciplinary andcross-sectoral cooperation based on the individual person’s wishes and needs. Therefore, it isrecommended to improve coordination and cooperation at a structural level through a better
linkage between the Danish Social Services Act and the Danish Health Act (Sundhedsloven).
Coordination and cooperation is best supported in practice through systematic implementationof permanent contact persons in all sectors. To strengthen cooperation, it must be possible toshare data across sectors, and better digital support of cohesive treatment should therefore
be ensured.

Recommendations
35. Establishing a strong cooperation between public authorities that supports
cohesive services for people with mental disorders
Binding cooperation agreements will be established across authorities in the fields ofhealth, social care services, education and employment. This cooperation will support
the development and implementation of targeted services and increased focus on
optimal support for people with mental disorders, for example in education andwork contexts.
36. Strengthened coordination of the patient pathway for people with mental
disorders using permanent contact persons and coordinators in all sectors
A number of people with mental disorders have long patient pathways across sectors
and municipal administrations. Therefore, binding cooperation structures should beestablished and implemented across social care services, specialised social careservices (for children and young people), the field of employment, mental healthcare, physical health care and general practice. It can be beneficial to establish thiscooperation under the auspices of the upcoming health clusters.
37. Better digital support for integrated patient pathways
At a national level, digital solutions are prepared in existing systems together with better
opportunities for data sharing across sectors and administrations, as this is a basic
prerequisite for creating integrated patient pathways. The digital solutions must support
a number of measures, including cross-sectoral sharing of master data and plans.

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