Australians tend to group the Nordic countries together when thinking about public policy, but their approaches to the COVID-19 pandemic have not been uniform.
At a recent webinar, one of an ongoing series on which mental health policy expert Sebastian Rosenberg has been reporting for Croakey, Danish psychiatrist Mikkel Rasmussen took the opportunity to explain some of these differences and the outcomes for populations.
He also outlined his mental health service’s approach to care of their patients in a crisis that has consumed acute health care, emphasising that planning is needed for both current and future needs.
Sebastian Rosenberg writes:
This is a short report summarising the fourth in a series of e-presentations about the international impact of COVID-19 on mental health, jointly hosted by The Centre for Mental Health Research (CMHR) at the Australian National University and ConNetica Consulting.
This webinar, held on 9 April, featured a presentation from Dr Mikkel Rasmussen, physician, psychiatric consultant, and mental health advocate, Denmark. Rasmussen is from the Central Health Region of Denmark.
Denmark appears to have had some success in limiting the spread and impact of COVID-19.
Is this true and if so, what lessons can be drawn?
Comparing Nordic nations
Scandinavian countries often adopt similar approaches to policy problems but their responses to COVID-19 have been somewhat different.
Denmark and Norway have adopted Australian style limitations on gatherings and enforced social distancing. Outings are limited to essential activities.
By contrast Sweden has taken a more relaxed approach. For example, Sweden’s borders are still open, as are its restaurants. Gatherings have been limited, but to 50 people.
This makes Nordic countries an interesting comparison in public health approaches.
Sweden’s government is placing a great deal of responsibility on individuals and has given high priority to maintaining economic activity. Sweden is a country with less population density than Denmark and citizens are accustomed to keeping their distance.
Sweden’s rate of growth of deaths due to COVID-19 is currently comparable to that of the US, considerably faster than either Denmark or Norway. Its rate of deaths per million of the population is markedly higher (see excerpted figures from COVID-19 worldometer below)
US President Trump suggested Sweden was not doing much to prevent the spread or impact of COVID-19, with a view to establishing ‘herd immunity’ swiftly.
While this assertion was rejected by the Swedish Government, there is clear disagreement between Sweden and other Nordic countries about the best or most appropriate public health response to COVID-19. Sweden’s neighbours are concerned the Swedish Government’s decisions will have serious consequences.
Rasmussen stated that there were several important ‘protective factors’ aiding the Danish response to COVID-19, including:
- a high degree of bipartisan political consensus
- A solid and well organised welfare system
- A high level of public trust in and support for government processes and systems
- A culture of public order and obedience
- A strong sense of public altruism, to help others
- A strong and well organised health sector.
As in Australia, COVID-19 largely came to Denmark from abroad. There is significant regional variation in COVID-19 infection, mirroring population density. Cases are across all age ranges.
Danes lifting restrictions
The number of COVID-19 deaths in Denmark had declined over the week before the seminar, as had the number of people in ICU and requiring ventilation.
The overall number of virus-related hospital admissions had also declined.
The success the Danes have had controlling COVID-19 has encouraged them to lift some of the lockdown measures they imposed. Specifically, schools are re-opening for kids up to 11 years of age. Restaurants, bars and churches remain closed, gatherings banned.
Impact on mental health services
Rasmussen’s Central Denmark Region provides mental health care to 1.3 million people, with five hospitals, eight specialised services and thirty supported accommodation services. There are also ‘non-specialised’ services, including primary care, addiction services, rehabilitation and so on.
Overall the service employs 5,000 people, 3,000 providing mental health services and 2,000 providing social services. Staff are regarded as all working for the same service.
A critical first part of the mental health response to COVID-19 was for mental health services to be recognised as a critical function for the operation of society. The Government did this and provided consistent information through official channels about services and changes. This provided a level of public calm.
The mental health service aimed to deliver the same level of inpatient and outpatient care to all existing clients and prevent the worsening of conditions and admissions to hospital.
Inpatient admissions were minimised given the need for hospitals to prepare for an influx of COVID-19 patients. Mental health beds in Emergency Departments were also given up.
At the time of the webinar there had been no COVID-19 admissions of mental health clients, but a designated ward had been readied in anticipation of this requirement. There has been concern that psychiatrists and other mental health professionals have been poorly prepared or trained to respond to emergency situations such as this.
Face to face interactions with mental health clients has been replaced with telephone services and there has been a 1,000 percent increase in the use of telepsychiatry services.
Staff working administration and many in residential services were sent home. Visitors to mental health services have been banned, creating further isolation for both clients and families. There is increased use of phone support wherever possible.
Home visits by mental health teams still occur but there has been concern about lack of access to personal protective equipment and necessary training. Visits occur while maintaining social distance, sometimes in the garden of the house rather than inside.
Rasmussen said there had been decreased access to mental health care in aged care facilities, and that homeless people and people with severe mental illness will also have experienced a decline in access to services. A job bank was established to encourage additional volunteer capacity to the health sector.
Denmark had prepared well for COVID-19 and had a strong understanding of its resources and capacity. This made modelling and planning for better decision-making possible.
Overall demand for mental health services has dropped considerably. Rasmussen’s inpatient unit normally has 130 percent bed occupancy but is now running at 60 percent. It is unclear if this is because of reduced need or because people are afraid to present.
Either way, there is considerable concern in Denmark at the prospect of a rebound – an explosion of demand for mental health care as soon as it is safe to seek it.
This explosion would include not only existing clients but also those newly affected by isolation and the social and economic dislocation arising from COVID-19. There is concern about increased suicidality.
A key concern in Denmark now is to begin planning how best to meet this possible surge in demand for mental health care. No strategy yet exists, with the main concern being COVID-19 itself and the economy. Rasmussen stated that while this may be reasonable now, Denmark cannot afford to ignore the mental health of the community.
Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He is Head of the Mental Health Policy Unit at the Centre for Mental Health Research at ANU and holds a position as Senior Lecturer at the Brain and Mind Centre, University of Sydney.
The virtual meeting described above is one of a series of meetings that The Centre for Mental Health Research at the Australian National University and ConNetica Consulting are jointly hosting with mental health leaders around the world to better understand responses to COVID-19. A recording of the presentations and discussions is available here.