Potentially traumatic events are common [1]. Approximately 70% of people experience one or more traumatic events, and those exposed report an average of three potentially traumatic events during their lifetime [2]. The most common types of traumatic events are witnessing death or serious injury, experiencing the unexpected death of a loved one, being mugged or assaulted, being in a life-threatening traffic accident, and experiencing a life-threatening illness or injury [3].

Although many people recover naturally from these experiences, a significant proportion will be substantially affected and develop problems [1]. These problems include elevated levels of distress, significant problems in psychological functioning, and development of mental health disorders such as post-traumatic stress disorder (PTSD), complex PTSD (CPTSD), acute stress disorder, adjustment disorder, and complicated grief disorder [4]. The experiences may also impact social and occupational functioning, leading to sick leave, early retirement, or job loss [5][6]. Additionally, people experiencing potentially traumatic events are at risk of developing long-term sequelae such as mental and physical health problems [7], and, consequently, consume a higher number of healthcare benefits and have an elevated risk of early mortality [8].

Due to the elevated risk for developing physical and mental health problems, we wanted to investigate the extent of such problems before the occurrence of exposure to the traumatic or adverse event. It is possible that people who are exposed to trauma and seek help might be challenged by already having physical and/or mental problems and therefore a larger need for treatment than people not suffering from pre-trauma health problems. This aspect is often ignored and tabooed because of fear of victim-blaming—stigmatizing victims who suffer from the trauma exposure.

The Danish Health Care System (DHCS) recognizes the need for treatment after a traumatic or adverse life event and is unique in providing public financial support to people who have had such experiences and fit a set of criteria for receiving treatment [9]. This means that patients can receive psychological treatment after a traumatic or adverse event if their general practitioner gives them a referral, and if they are able to pay 40% of the fee themselves. This study is also step one in a series, where the next step is a study of the overall effects of the subsidized treatment, and the third step will compare the subsidized treatment scheme (STS) after specific events with available register data (e.g., death in the family).

After a two-year pilot period in 1994, a subsidized treatment scheme (STS) between the DHCS and the Danish Association of Psychologists (DAP) was agreed upon. Those who had been exposed to a traumatic or an adverse event could enter psychological treatment shortly after the event with the aim of getting them back to work as quickly as possible, avoiding a worsening of symptoms, and improving their overall quality of life. Seven specific events were listed as referral categories in the agreement; two more were added later [9].

STS began 35 years ago and had a large national impact as a recognition of trauma sequelae, that trauma can be toxic, the state wants to help you, and that you have the right to get proper treatment. The Danish STS is the only broad national trauma treatment scheme that we know of, and we want to examine the possible differences among the various trauma types.

After the introduction of the STS, many other trauma services have emerged. There are now specialized Danish treatment centers for rape victims, incest survivors, victims of stalking and interpersonal violence, and for child maltreatment. In addition, there are counselling services for victims of violence and suicidal people. The treatment centers are situated in the large cities in contrast to the STS that covers the whole country. Several of the centers have long waiting lists. The treatment of these center services is free, although it is sometimes restricted (e.g., 5 sessions for rape victims). The admission to the Child Advocacy Centers depends on the municipality accept and in the involvement of the police. The counselling services are mostly hotlines run by volunteers. There are often problems with access: e.g., in the national suicide hotline, it was recently found that only 25 people use 2/3 of the calls and 1/3 of the total telephone time [10]. Private insurance often covers violence, accidents and loss with a restricted number of sessions (4 - 5 times) and is a fast-growing market (see the Discussion). They usually do not have any waiting time and are served by psychologists.

STS is open for all ages, and the access is based on the occurrence of the specified event and not on symptom level. To receive subsidized psychological treatment, patients need an electronic or written referral from their primary physician (general practitioner) within 12 months after experiencing a potentially traumatic event. Some exceptions are made regarding the time frame for victims of sexual abuse or sexual assault before the age of 18 years. The patients qualifying for a subsidy may receive a maximum of 12 sessions of psychological treatment [11].

Only private practice psychologists with a license under the agreement are eligible to provide psychological treatment. The private practice psychologist offering STS cannot be employed elsewhere for more than 15 hours per week; at the same time, there is also a STS income cap for each psychologist. By April 2024, 900 private practice psychologists had obtained a license under the agreement [12], serving a population of almost 6 million inhabitants [13].

The STS is a unique therapeutic agreement serving trauma survivors and victims of specified, adverse events. Since the initial evaluation of the STS [14], no studies have investigated the patients who receive STS after traumatic or adverse events. In April 2008, the STS was expanded to include individuals suffering mild to moderate depression or anxiety. Research since then has focused on these two categories [15]-[17].

We wish to investigate the subsidized treatment for traumatic and adverse events through two objectives:

1) What are the characteristics of the people using the public subsidy for psychological treatment (i.e., gender, age, area of living, level of education, family type, and income) compared with the general population?

2) Are there social, somatic, and psychiatric differences between the people from each of the nine referral categories compared with the general population?

All individuals receiving STS between 2014-2023 (N = 361,152) were compared with the full Danish population, which increased from 5,632,466 to 5,944,001 during the decade (equaling 57,509,964 person years). We presuppose that the trauma exposure happens in the year of referral, unless for childhood sexual abuse. There is a general 12-month time limit from exposure to referral—see AppendixA2.

Data was obtained from: 1) the five regions of Denmark that administer the STS. In addition, 2) the national medical and social longitudinal registers provided data both for the STS sample and for the rest of the population.All Danes are assigned a unique civil registry number (CPR), which can be used to link information within and across the administrative Danish registers. The 10-digit CPR number was used to retrieve and merge individual data. The legal office at the University of Southern Denmark has approved that the study (#12,242) complies with the General Data Protection Regulation (GDPR) and Danish legislation.

Demographic data (i.e., gender, age, area of living, and family status) was obtained from the Population register in Statistics Denmark. Area of living covers five categories based on the degree of urbanization. Level of education was obtained from Education Statistics. Information regarding income was obtained from the Income Statistics Register.

Somaticand psychiatric disease information from all hospital treatment was provided from the Danish National Patient Registry (DNPR) [18]. The somatic disorders covered cardiovascular, endocrinological, musculoskeletal, chronic obstructive pulmonary disease, and cancer. The psychiatric diagnoses included ten disorders: organic disorders, substance use disorders, schizophrenic disorders, mood disorders, neurotic disorders, eating disorders, personality disorders, bipolar affective disorders, depression, and PTSD. In addition, suicide attempts were also included. The demographic and disease information is based on the three years before the referral for each individual (see AppendixA1 for ICD-10 codes).

Referral categories: To qualify for the subsidy, the patient must have been exposed to an event in at least one of the following nine (see AppendixA2 for details):

Category 1: Victims of robbery, violence, or rape.

Category 2: Victims of traffic accidents and other accidents.

Category 3: Relatives of severely mentally ill individuals.

Category 4: Individuals suffering from a severely disabling disease or illness.

Category 5: Relatives of individuals suffering from a severely disabling disease or illness.

Category 6: Bereaved individuals.

Category 7: Individuals who have attempted suicide.

Category 8: Individuals who have undergone an abortion past week 12 of their pregnancy.

Category 9: Victims of sexual abuse or sexual assault prior to the age of 18 years (CSA).

We first explored the characteristics of people and degree of utilization within each category using descriptive statistics. We then compared service users to the remaining general population regarding age, gender, family type, income, educational level, and area of living using descriptive statistics. To answer the second aim, we investigated possible predictors for use of the subsidized treatment through nine four-step hierarchical logistic regression analyses, one for each category of events, controlling for varying levels of covariates. We applied hierarchical logistic regressions in order to explore the impact of different covariates separately. Step 1 includes demographic factors (age, gender, family type), while step 2 adds salient socioeconomic features: income, area of living, and educational level. Further, steps 3 and 4 include somatic and psychiatric comorbidity from hospital records: In Step 3, diagnoses of five somatic diseases up to three years prior to the use of the STS are added, while Step 4 includes suicide attempts and ten psychiatric disorders up to three years before using the subsidy. While there may be some redundancy in steps 3 and 4 due to overlapping diseases, we considered the use of hospital diagnoses to be the most precise adjustment for comorbidity. Alternatively, the presence of hospital-treated disease could have been included as dichotomous variables, thus overlooking the specific significance of, inter alia, suicide attempts.

Psychiatric diseases that have been diagnosed at Danish hospitals [28] (present/not present):

 Organic disorders (DF00 - DF09)

 Substance use disorders (DF10 - DF19)

 Schizofrenic disorders (DF20 - DF29)

 Mood disorders, (DF30 - DF39), including separate analysis of bipolar affective disorder and depression

 Neurotic disorders (DF40 - DF48), including separate analysis of PTSD

 Eating disorders (DF50)

 Personality disorders (DF60)

Suicide attempt (data from the Register for Suicide attempts)

Chronic somatic disorders (present/not present):

 Cardio vaskular (codes DI20 - DI25; DI150; DI160 - DI164)

 Endocrinological, including type 2 diabetes (codes DE00-DE90, type 2 diabetes: DE11)

 Musculoskeletal (codes: DM54, DM15 - DM19)

 Chronic obstructiv pulmonary disease, code DJ44.

 Cancer codes (DC15 - DC26; DC30 - DC39; DC50; DC00 - DC14), as these codes refer to cancer types that can be related to health behavior.

Category1: Victims of robbery, violence, or rape

A person may qualify if they are the primary victim of a robbery, violence, or rape. Relatives to victims may also qualify if they have experienced real danger either physically or psychologically (towards the quality of life, development, or general well-being). People who assist victims during an event may also qualify, but witnesses to an event do not. The perpetrators also do not qualify. In this category, both physical and psychological violence are included, and there is no minimum requirement of the level of abusiveness of violence. An incident of domestic violence also qualifies, unless the violence has occurred for more than 12 months. Encompassed and qualifying in this category is also rape, as well as other sexual assaults or attempts of sexual assaults. There are no requirements of police reports or convictions of the robbery, violence, or rape necessary to qualify for this category [29].

Category2: Victims of traffic accidents and other accidents

This category includes those who are directly or indirectly involved in an accident, regardless of who caused it. Any incidents other than traffic accidents are also included in this category under the definition of “other accidents”. However, completely trivial accidents with only minor injuries are not covered by the agreement [29].

Category3: Relatives of severely mentally ill individuals

The term “relatives” covers the immediate family, made up of the spouse/partner, siblings, parents, and children. Typically, half-siblings and stepparents will also be included. As a result, under the agreement, both biological parents and stepparents of the same child will be eligible for subsidized treatment. In-laws and more distant relatives will normally not be covered, unless they are the only family [29].

The phrase “severely mentally ill” suggests that the mental disorder must be one that significantly affects the individual’s behavior and level of functioning and does not refer to a specific diagnosis. The determining criteria are whether the consequences of the mental disorder influence the behavior and interpersonal relations of the individual suffering from the disorder. To ascertain if the individual’s relatives qualify, each case is evaluated individually by the GP. The 12-month limit for the STS is not calculated from the diagnosis of a mental disorder but takes effect from the time when the relative starts being affected [29].

Category4: Individuals suffering from a severely disabling disease or illness

A severely disabling disease or illness encompasses more than just situations in which a person is rendered instantly and severely disabled; it also includes conditions where a diagnosis might trigger a crisis for an individual. Illness covers diagnoses such as AIDS, cancer, stroke, joint arthritis, sclerosis, muscular dystrophy, and similar. The 12-month time frame usually begins when the individual is diagnosed. If an individual has previously received a subsidy in the same category, they may still be eligible for additional treatment if the diagnosis is new (e.g., two separate illnesses) or if the illness worsens or moves to a different location (e.g., recurrence of cancer after a period of recovery). If the illness progresses in severity but it is expected (e.g., a cancer patient enters a terminal stage) the individual does not qualify for additional subsidized treatment [29].

Category5: Relatives of individuals suffering from a severely disabling disease or illness

Relatives are defined the same way as in Category 3. A severely disabling disease or illness is defined as in Category 4 [29].

Category6: Bereaved individuals

The individuals qualifying for a subsidy in this category are relatives, as defined in Category 3. Parents of a stillborn child or parents suffering a miscarriage past week 19 of the pregnancy may also qualify under this category [29].

Category7: Individuals having attempted suicide

In this category, individuals who have attempted suicide are qualified for a subsidy [29].

Category8: Individuals who have undergone an abortion past week12of their pregnancy

The subsidized treatment may start before the abortion takes place, as soon as permission for the procedure has been granted [29]. Before 2025, a woman needed a permission to be granted abortion after week 12. Recently, this limit has been pushed to week 18. In many cases, the embryo has a serious illness or genetic defect.

Category9: Victims of sexual abuse or sexual assault prior to the age of18years(CSA)

The 12-month timeframe does not apply in this category. A person may be referred to psychological treatment at any point in their lifetime, although the incident must have happened in childhood before the age of 18 [29].

Table A1.Four-step hierarchical regression analysis for Category 1 (Robbery, violence and rape¹) (N² = 5,881,313).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.001.

Table A2.Four-step hierarchical regression analysis for Category 2 (Traffic and other accidents¹) (N² = 5,860,548).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.0010.

Table A3. Four-step hierarchical regression analysis for Category 3 (Relatives of severely mental ill individuals¹) (N² = 5,889,959).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.001.

Table A4. Four-step hierarchical regression analysis for Category 4 (Individuals suffering from a severely disabling disease or illness¹) (N² = 5,905,918).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.001.

Table A5. Four-step hierarchical regression analysis for Category 5 (Relatives of individuals suffering from a severely disabling disease or illness¹) (N² = 5,899,110).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.0010.

Table A6. Four-step hierarchical regression analysis for Category 6 (Bereaved individuals¹) (N² = 5,907,700).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.0010.

Table A7. Four-step hierarchical regression analysis for Category 7 (Individuals having attempted suicide¹) (N² = 5,855,238).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.0010.

Table A8.Four-step hierarchical regression analysis for Category 8 (Abortion past week 12 of the pregnancy¹) (N² = 5,854,183).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.0010.

Table A9.Four-step hierarchical regression analysis for Category 9 (Sexual abuse or sexual assault prior to the age of 18 years¹) (N² = 5,859,944).

Note: ¹Sample size of the category—see Table 1. ²Total N refers to the number of person years from the full population not using the STS. * = p < 0.05, ** = p < 0.01, *** = p < 0.001.