Mental health problems and suicide rates have been rising – long before the COVID-19 pandemic caused explosive growth. In 2018, the trend led Denmark’s healthcare system to start a pilot scheme eliminating the co-payment - user charges - for psychologist treatment for people 18–20 years old with anxiety or depression. Researchers have now found a remarkable effect of this initiative – 25% fewer suicide attempts, especially among women from high-income families and men from low-income areas.
Stress, anxiety and depression are increasing in modern society – and especially among young people. Globally, an estimated one seventh of 10- to 19-year olds experience these mental disorders, but most of those with these disorders are undiagnosed and untreated. According to WHO, 62,000 adolescents died from self-harm in 2016 and suicide is the third most common cause of death among older adolescents. These data and other events led politicians in Denmark to initiate a pilot scheme in the healthcare system in 2018.
“Adolescents previously had a 40% co-payment for psychologist treatment. The hope was that eliminating the co-payment could prevent more mental disorders at an early stage. The scheme has also doubled the use of psychologist treatment. Nevertheless, we did not find, as we had hoped, a decline in the use of outpatient mental health services or the use of antidepressants, but the really important and good finding is that the scheme seems to have prevented one in four suicide attempts,” explains the lead author, Marie Kruse, Danish Centre for Health Economics, University of Southern Denmark, Odense.
Can increase equal access to healthcare
Many healthcare systems have higher co-payments for mental healthcare than somatic healthcare, which leads to inadequate treatment of people with mental disorders in many cases. Research has shown that people 15–29 years old are especially mentally vulnerable. Data from Denmark from 2006 show that attempted suicide was the most common cause of hospitalisation among 15- to 34-year-olds and that suicide was one of the most common causes of death in this age group.
“Until 2018, Denmark required a 40% co-payment from adults older than 18 years for psychologist treatment for anxiety and depression. Since previous studies indicate that people use less healthcare when co-payments increase, this was a unique opportunity to investigate what actually happens when co-payments are eliminated for specific people for a specific service for a period of time,” says Marie Kruse.
In 2018, an opportunity arose to be able to monitor a natural experiment in Denmark, when Denmark’s healthcare system implemented a pilot scheme that enabled 18-to 20-year olds to get psychologist treatment if their general practitioner assessed that they had mild to moderate anxiety or depression. The researchers used Denmark’s health registries to access nationwide data on about 1.2 million individuals 18–20 years old and age-matched controls, which provided 51 million person-months of observation.
“We found that eliminating co-payments almost doubled the use of psychologist treatment, and the largest increase was among 18- to 20-year olds from low-income families, indicating that eliminating co-payments may actually increase equality in access to healthcare, even though some general practitioners may be reluctant to issue referrals,” explains Marie Kruse, adding that:
The results show that these young people may be extra vulnerable to co-payments because they either have low income or still depend on their parents for financial support.
45% decline in suicide among men from low-income areas
Denmark’s politicians had hoped that the free psychologist treatment might result in spillover savings later in mental healthcare services or in antidepressant prescriptions.
“The spillover effect is at best the opposite of what was expected, so even though the scheme may have identified some people before their anxiety or depression really developed, this seems to be cancelled out by many more young people accessing the mental healthcare services,” says Marie Kruse.
According to the researchers, the lack of spillover should not be considered a failure given the main result: 25% fewer suicide attempts among 18- to 20-year-olds, with several significant nuances.
“In this age group, suicide attempts declined by 20% among high-income women, who are often ambitious and excel in the education system, and account for the most suicide attempts. Even more marked is a 45% decline in suicide attempts among men from low-income areas,” explains Marie Kruse.
COVID-19 pandemic may have increased the need
In addition to finances being an obstacle to seeking psychologist treatment, the researchers think that mental health problems can often be linked to stigma, which can be more pronounced among young adults.
However, the study also indicates that general practitioners have a key role as gatekeepers: referring young adults for psychologist treatment.
“We found a huge difference – partly geographically, with doctors in some regions being more reluctant to refer patients when there are co-payments, probably because the doctor knows that the young adults themselves or their parents will have difficulty paying – and partly related to some doctors’ reluctance to refer young people to a psychologist or not recognize the severity of their anxiety or depression,” says Marie Kruse.
Marie Kruse is pleased that the study shows that general practitioners who are reluctant to refer increase their number of referrals when the financial barriers are reduced. This especially happened when Denmark’s politicians decided to expand the scheme to people 18–24 years old and made it permanent in 2021 so that those with anxiety and depression can continue to receive psychologist treatment free of charge.
“Our study clearly indicates that improving access to mental healthcare for young adults may positively affect their mental health and well-being. We will continue our research in two directions. One will focus on how the COVID-19 pandemic has changed and probably reinforced the need for psychologist treatment. The second will focus on differences in general practitioners’ referral policies, which leads to differences in the treatment of young adults with anxiety or depression,” concludes Marie Kruse.