This chapter covers the case study of the Prompt Mental Health Care, a low-threshold, free‑of-charge mental health care scheme in Norway. The case study includes an assessment of the Prompt Mental Health Care against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to other OECD and EU27 countries.
Mental Health Promotion and Prevention
Best Practices in Public Health
Abstract
Description: Prompt Mental Health Care (PMHC) is a Norwegian programme that aims to provide low-threshold, free‑of-charge access to mental health care. It is designed to offer short waiting times and allow for access without a general practitioner’s referral. Treatment at PMHC is based on Cognitive Behavioural Therapy (CBT) and is divided into low-intensity treatment (teaching-based courses and guided self-help) and high-intensity treatment (individual psychotherapy).
Best practice assessment:
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Criteria |
Assessment |
|---|---|
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Effectiveness |
PMHC is significantly more effective than treatment as usual in reducing depression and anxiety, increasing recovery rates by 83% at 6‑months, with sustained improvements lasting up to 36 months. The SPHeP-NCD model estimated that by 2050, expanding PMHC would result in:
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Efficiency |
When transferring PMHC to all OECD and EU27 countries, average annual health expenditure savings amount to EUR 4.7 and EUR 3.5 on average per person between 2025 and 2050, for OECD and EU27 countries, respectively, excluding intervention costs. PMHC would be cost saving in eight OECD and EU27 countries and cost-effective in all remaining countries. |
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Equity |
PMHC is a service free at the point of care, easily accessible and does not require a referral, ensuring direct access for individuals aged 16 and older with mild-to-moderate mental health needs. |
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Evidence‑base |
The effectiveness of PMHC is supported by data from a randomised controlled trial study, with long-term benefits shown at 12‑, 24‑, and 36‑month follow-ups. The overall quality of this study was considered as moderate, with strong quality regarding study design, control of cofounders and data collection method, moderate quality regarding selection bias and withdrawal, and poor quality in blinding. |
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Extent of coverage |
75 PMHC teams provide services across 88 municipalities and city districts in Norway, with approximately 23 500 individuals receiving PMHC treatment annually. |
Enhancement options: To enhance effectiveness of PMHC, establishing systematic monitoring and assessment to collect data could improve the quality and effectiveness of the programme. Further use of digital tools could increase the availability and accessibility of the service. To enhance equity, strengthening collaboration with community organisations and primary care providers can also support outreach to populations that are less likely to seek mental health support. To enhance extent of coverage, expanding PMHC services to more municipalities could extend the programmes benefits to a larger portion of the population.
Transferability: PMHC is based on the Improving Access to Psychological Therapies programme in the United Kingdom, and has been adapted in various countries, including Australia, New Zealand, Japan, Canada and Spain. PMHC is highly transferable in nearly 47% of OECD and EU countries with available data (20 out of 43 countries), and intermediately transferable to nine countries.
Conclusion: PMHC is effective in reducing symptoms of anxiety and depression, achieving higher recovery rates and sustained long-term improvements compared to treatment as usual.
Prompt Mental Health Care (PMHC) is a Norwegian initiative that aims to provide low-threshold, free‑of-charge access to mental health care. It is an innovative strategy to increase the access to evidence‑based primary care treatment, such as cognitive behavioural therapy (CBT) (Box 3.1), for individuals above 16 years old with mild-to-moderate symptoms of depression and/or anxiety (Knapstad et al., 2020[1]). PMHC is also accessible for individuals with incipient substance use problems or sleep difficulties (although these are not assessed in this Chapter). PMHC is adapted from the United Kingdom’s Improving Access to Psychological Therapies (IAPT) programme. IAPT was developed by the UK Government in 2008 to improve access to evidence‑based psychological therapies for depression and anxiety disorders after the National Institute for Health and Care Excellence (NICE) guidelines recommended evidence‑based psychological interventions in a stepped care model (Wakefield et al., 2021[2]), and exists under its current form “NHS Talking Therapies”.
Cognitive Behavioural Therapy (CBT) is an evidence‑based talking therapy designed to help individuals manage psychological challenges by identifying and changing unhelpful thoughts, beliefs and behaviours. In CBT, patients work collaboratively with a therapist to address negative thinking patterns and develop coping strategies.
CBT is widely used to treat a variety of mental health conditions but is most commonly used to treat anxiety and depression. Research shows that CBT is effective in reducing symptoms of depression and anxiety, with evidence suggesting associated improvements in overall functioning and well-being.
Source: American Psychological Association (2017[3]), “What is cognitive behavioural therapy?”, https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.pdf; Hofman et al. (2012[4]), “The efficacy of cognitive behavioral therapy: A review of meta‑analyses”, https://doi.org/10.1007/s10608-012-9476-1.
The key characteristics of PMHC in Norway are as follows:
Users can contact and get access to the PMHC service directly, without having to be referred by a general practitioner (GP).
The service is easily accessible and reduces waiting times. The aim is to provide access within 7‑14 days, whereas the national average waiting time for mental health services is 54 days (Helsedirektoratet, 2023[5]).
The service is designed to provide more users with access to treatment, as it involves less therapist contact through “low-intensity treatment” (such as guided self-help and teaching-based courses).
PMHC was initiated by the Norwegian Directorate of Health commissioned by the Ministry of Health in 2012 as a pilot project in 12 pilot sites in different geographical areas of Norway. There are currently 75 PMHC teams registered. These are spread across 88 municipalities, city districts, and inter-municipal co‑operations (NAPHA, 2022[6]). Around 60% of the adult population resides in municipalities where PMHC has been implemented (Smith et al., 2025[7]). The services are organised within municipal healthcare and function as low-threshold programmes, accessible through self-referral or referral from GPs. The programme aims to reduce the gap between the number of people suffering from anxiety and depression and the number of those seeking and receiving treatment, by increasing access to mental health care.
PMHC is organised around a mixed-care model where the information from an initial assessment carried out by a CBT-therapist and the preferences of the patient are combined to determine the choice of treatment. The right treatment at the appropriate level is decided between the user and the therapist based on the severity of symptoms, the mental health problems, the situation, and the resources. An initial assessment is conducted when the user first contacts the PMHC centre, which determines their suitability for PMHC treatment. Users who are not considered suitable, such as those with severe depression or other severe mental health disorders, are supported in accessing other appropriate services, including referrals to their GP or other specialised services appropriate to their needs (NAPHA, 2022[6]).
Treatment and follow-up in PMHC are provided by multidisciplinary teams of independent therapists, with at least one psychologist in each team. PMHC staff have at least three years of relevant higher education related to mental health. In addition, all personnel are required to complete a mandatory training programme in CBT, which has been developed as part of the PMHC programme and is funded by the Norwegian Directorate of Health (NAPHA, 2022[6]). Although GP referral is not required for PMHC treatment, the PMHC teams aim to work closely with GPs and other primary or secondary services.
Treatment in PMHC is based on CBT and is divided into low- and high-intensity care. Low-intensity care consists of teaching-based courses and guided self-help, while more high-intensity care consists of treatment groups and individual face‑to-face psychotherapy (Knapstad et al., 2020[1])(Box 3.2). Because PMHC uses a mixed-care approach, the user does not necessarily start with low-intensity training but can also start with higher-intensity. This contrasts to the stepped care model used in IAPT, where users start with low-intensity training. In PMHC, the type and the intensity of treatment is decided between the user and the therapist.
PMHC offers four types of treatment. The type and the intensity of treatment depend on user’s needs evaluated by the CBT-therapist and user’s preferences. All the treatment offered are guided by a therapist and can be provided either in-person or virtually.
Teaching-based courses in PMHC have a fixed content, are led by course instructors, and can involve 8 to 40 participants. Users participate in four group sessions. Each session generally lasts two hours and consists of 25 participants.
Guided self-help is offered to the user with weekly structured guidance from the same therapist. It usually consists of six guiding sessions of approximately 20 minutes. The user works with a programme over a set period to acquire knowledge and techniques to cope with various psychological problems. Online self-help programmes or self-help books are often used.
Treatment groups usually consist of 6‑10 people who meet for 6‑8 sessions of 2.5 hours each. In the group, they discuss their experiences, receive education about mental health, and are assigned various exercises to do between sessions.
Individual psychotherapy has a fixed structure and works towards the goals of the treatment through talking therapy. Users usually attend six sessions, but this can vary from two to 15 sessions. Each session lasts for 45 minutes.
Source: NAPHA (2022[6]), “RPH-håndboka: anbefalinger baser på nasjonale retningslinjer og ti års erfaringer med rask psykisk helsehjelp”.
This section analyses PMHC against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 3.3 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.
Effectiveness
PMHC demonstrates significantly greater effectiveness than treatment as usual (i.e. usual services available to the target population, such as general practitioners or private psychologists) with large effects in reducing depression (d = ‑0.88) and anxiety (d = ‑0.60).
PMHC increases recovery by 83% at six‑month follow-up compared to treatment as usual.
Improvements in depression and anxiety symptoms are sustained over long-term follow-ups at 12, 24 and 36 months.
The SPHeP-NCD model estimated that by 2050, scaling-up and transferring PMHC would result in a cumulative gain of about 46 000 disability-adjusted life years (DALYs) for Norway; and an average of 35 and 33 DALYs per 100 000 population per year in OECD and EU27 countries, respectively.
Efficiency
When scaled up across the whole of Norway, it is estimated that PMHC will lead to cumulative health expenditure savings of EUR 240 per person by 2050, excluding the intervention cost.
When transferring PMHC to all OECD and EU27 countries, average annual health expenditure savings – excluding the intervention cost – amount to EUR 4.7 and EUR 3.5 on average per person between 2025 and 2050, for OECD and EU27 countries, respectively.
PMHC would be cost saving in eight OECD and EU27 countries and cost-effective in all remaining countries.
Transferring PMHC intervention would save OECD countries up to EUR 3.8 per person per year in labour market costs (EUR 3.5 in EU27 countries).
Equity
PMHC is a service that is free at the point of care easily accessible and that does not require a doctor’s referral, ensuring direct access for individuals aged 16 and older with mild-to-moderate mental health needs.
PMHC is more often utilised by women, individuals with higher education, and non-immigrants, though user demographics vary by municipality.
Evidence‑base
The evidence for the effectiveness of PMHC is based on data from a randomised controlled trial study.
The overall quality of this study was considered as moderate, with strong quality regarding study design, control of cofounders and data collection method, moderate quality regarding selection bias and withdrawal, and poor quality in blinding.
The long-term benefits of PMHC have been assessed through follow-up studies at 12, 24 and 36 months.
Extent of coverage
As of March 2023, 75 PMHC teams operate in 88 municipalities and city districts across Norway, with approximately 23 500 individuals receiving PMHC treatment annually.
Note: d refers to Cohen’s d effect size and is generally interpreted as small (0.20), medium (0.50) and large (0.80).
Effectiveness
A randomised controlled trial (RCT) of the PMHC programme was used to assess the effectiveness of PMHC compared to a control group that received treatment as usual (TAU) (Knapstad et al., 2020[1]). The study included 681 participants from two PMHC pilot sites (Kristiansand and Sandnes) above 18 years old with mild-to-moderate symptoms of depression and anxiety, who were randomly assigned to the PMHC group (n=463) or to the TAU group (n=218). The follow-up period was six months. TAU included all standard services available to the target population, typically involving follow-up by a GP, or alternatively by private psychologists or occupational services. Individuals in the TAU group received a letter encouraging them to contact their GP for further follow-up as well as references to publicly available self-help resources, such as websites and books. Change in symptoms of depression was assessed using the Patient Health Questionnaire (PHQ‑9, range 0‑27) and the change in symptoms of anxiety was assessed using the Generalised Anxiety Disorder scale (GAD‑7, range 0‑21). Threshold values for PHQ‑9 and GAD‑7 are presented in Box 3.4 In this study, recovery was defined as users scoring above the threshold on the PHQ‑9 (≥10) and/or GAD‑7 (≥8) at the beginning of the treatment and below the threshold on both measures at six‑month follow-up. The reliable recovery rate was used as a measure of sufficient reduction in symptom severity, accounting for measurement error (Knapstad et al., 2020[1]).
This box presents two widely used scales, the Patient Health Questionnaire (PHQ‑9) and the Generalised Anxiety Disorder (GAD‑7) scale, for the assessment of depression and anxiety severity. The PHQ‑9 scale presents a series of nine questions to assess the severity of depressive symptoms. Each question aims to rate the frequency of symptoms over the past two weeks on a scale from 0 to 3. The total score ranges from 0 to 27, with higher score indicating greater severity of symptoms. Likewise, the GAD‑7 scale presents seven questions, each scoring from 0 to 3, with a total score ranging from 0 to 21. The score cut-offs are shown in Table 3.1.
People with severe symptoms of depression or anxiety are typically not eligible for treatment in PMHC and are directed to alternative services, such as referral to their GP, secondary services, or other relevant healthcare providers.
Source: Kroenke et al. (2001[8]), “The PHQ‑9: Validity of a brief depression severity measure”, https://doi.org/10.1046/j.1525-1497.2001.016009606.x; Spitzer et al. (2006[9]), “A brief measure for assessing generalized anxiety disorder: the GAD‑7”.
The study shows that PMHC is significantly more effective than TAU in reducing the depression and anxiety scores. The estimated mean score for PHQ‑9 was reduced from 15.72 to 7.45 in the PMHC group and from 15.57 to 11.15 in the TAU group over six months, resulting in a between-group effect size1 d=‑0.88 (with 95% confidence intervals (CI) ranging from ‑1.23 to ‑0.43) in favour of the PMHC group. Over the same period, the GAD‑7 mean score was reduced from 13.13 to 5.88 in the PMHC group and from 12.85 to 8.27 in the TAU group, resulting in a between-group effect size d=‑0.60 (95% CI ‑0.90 to ‑0.30) (Knapstad et al., 2020[1]). In addition, PMHC increases recovery at six‑month follow-up by 83% compared to TAU. The reliable recovery rate observed in the PMHC group was 58.5% compared to 31.9% in the TAU group at six‑month follow-up, giving a between-group effect size of 0.61 (95% CI 0.37 to 0.85, p < 0.001). Finally, PMHC treatment shows greater improvement in functional status (d=‑0.39), health-related quality of life (d=‑0.46), and mental well-being (d=0.65) with medium between-group effect sizes.
PMHC also produces long-lasting improvements in symptoms of depression and anxiety. Studies suggest that PMHC is an effective treatment programme for people with mild-to-moderate depression and anxiety, and that these effects are maintained over time. Results from a 12‑month post-treatment evaluation of PMHC show substantial reductions in symptoms from the baseline to the 12‑month follow-up for both measures of depression (PHQ‑9) (d=‑0.98) and anxiety (GAD‑7) (d=‑0.94). These observed improvements were largely sustained 12 months after the treatment (Sæther et al., 2019[10]). It has also been shown that for individuals assigned to PMHC treatment, the observed improvements in symptoms are sustained or further improved at 24‑ and 36‑month follow-ups (Smith et al., 2022[11]).
The OECD’s Strategic Public Health Planning for non-communicable diseases (SPHeP-NCDs) microsimulation model was used to estimate the health and economic impact of expanding PMHC across Norway, and across all OECD and non-OECD European countries, assuming that 3% of the target population received the intervention. Details on the model are in Annex A, while the list of model assumptions are in Annex 3.A at the end of this Chapter.
The rest of this section presents results for Norway, followed by remaining OECD and non-OECD European countries.
Norway
The OECD’s SPHeP-NCD micro-simulation model estimates that 46 000 disability-adjusted life years (DALYs) would be gained between 2025‑2050 in Norway (Figure 3.1).
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Early intervention programmes that treat mild and moderate symptoms of anxiety and depression and reduce scores for PHQ‑9 and GAD‑7, such as PMHC, are expected to have large impact on anxiety and depressive disorders. If PMHC was scaled up in Norway, the number of anxiety and depressive disorders cases would fall by 78 000 and 59 000 cases, respectively, between 2025 and 2050 (Figure 3.2).
Note: NS = non-significant. The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
OECD and non-OECD European countries
Transferring PMHC to all OECD and EU27 countries is estimated to result in 35 and 33 DALYs gained per 100 000 people, respectively, on average per year between 2025 and 2050. This ranges from 11 in Bulgaria to 53 in Iceland (Figure 3.3).
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Overall, PMHC is expected to have the greatest impact on anxiety and depression. In gross terms, between 2025 and 2050, it is estimated that PMHC will reduce anxiety disorder cases by 14.4 million in OECD countries and by 4.4 million in EU27 countries (Figure 3.4). PMHC is also estimated to reduce depressive disorder cases by 11.3 million in OECD countries and by 35 million in EU27 countries. This represents about 0.6% and 1.4% of all cases of anxiety and depression across OECD and EU27 countries.
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Efficiency
Similar to “Effectiveness”, this section presents results for Norway followed by remaining OECD and non-OECD European countries. It presents the potential impact of the intervention on healthcare expenditure and a cost-effectiveness analysis assuming programme costs as reported in Annex 3.A at the end of this Chapter.
Norway
By decreasing symptoms of anxiety and depression and scores for PHQ‑9 and GAD‑7, PMHC can reduce healthcare costs by preventing symptoms from escalating and avoiding GP consultations and hospitalisations. Over the modelled period of 2025‑2050, the OECD’s SPHeP-NCD model estimates that PMHC would lead to cumulative health expenditure savings of EUR 240 per capita by 2050 (Figure 3.5).
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
OECD and non-OECD European countries
Average annual health expenditure (HE) savings amount to EUR 4.7 and EUR 3.5 on average per person between 2025 and 2050, for OECD and EU27 countries, respectively (Figure 3.6). Results may be explained by country-specific characteristics such as the proportion of individuals with mild-to-moderate symptoms, treatment cost, and the level of access to treatment by country (see treatment coverage by country in Chapter 2). For instance, Norway and the United States have higher levels of treatment coverage compared to other countries, resulting in higher potential economic savings. In contrast, Bulgaria and Mexico have lower treatment coverage.
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Table 3.2 provides information on intervention costs, total health expenditure savings and the cost per DALY gained in local currency for OECD and non-OECD European countries. PMHC is cost-saving in eight countries (Croatia, Denmark, Germany, Luxembourg, the Netherlands, Norway, Sweden and the United States). In all other countries, PMHC is considered cost effective with the cost per DALY far below the average cost-effectiveness threshold applied in European countries (i.e. EUR 50 000 based on (Vallejo-Torres et al., 2016[12])).
Note: * Cost per DALY gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2025‑2050.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
The reduction in anxiety and depression resulting from PMHC has, in turn, impacts on the labour market participation and productivity (see Chapter 2). PMHC is expected to lead to an increase in employment and a reduction in absenteeism, presenteeism and early retirement. Converting these labour market outputs into full-time equivalent (FTE) workers, it is estimated that OECD and EU27 countries will gain 7.8 and 8 FTE per 100 000 persons, for working-age people per year between 2025 and 2050, respectively. In monetary terms, this translates into average per capita increase in labour market production of EUR 3.8 and EUR 3.5 for OECD and EU27 countries, respectively (Figure 3.7).
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Equity
PMHC is a free‑of-charge, easily accessible service (without a GP referral) for people over the age of 16 who need treatment for mild-to-moderate depression or anxiety. Specifically, there is no need for a GP referral, so the public can find and contact the service themselves. For individuals with more severe mental health problems, such as indications of psychosis, personality disorder, bipolar disorder, suicide risk or severe drug abuse, PMHC serves as a gateway to secondary healthcare services or to GPs (NAPHA, 2022[6]).
In Norway, there is no national system in place for collecting and reporting user data from various low-threshold municipal services. Additionally, there is no national reporting of service data from PMHC teams, which means that information on the characteristics of individuals receiving PMHC treatment is not readily available. Despite the lack of a national reporting system in place, some studies conducted on PMHC have provided information on the characteristics of PMHC users, as indicated below.
PMHC services are more likely to be sought by women, people with higher education and non-immigrants. Knapstad and colleagues (2020[1]) found that baseline demographics and characteristics were generally similar between the PMHC group and the TAU group. Overall, 66.5% of the participants were female, 41.6% had higher education (compared to 37% in the general Norwegian population) and 11.5% reported an immigrant background (16% in the general Norwegian population) (SSB, 2023[13]; SSB, 2022[14]). Likewise, a survey based on 32 PMHC teams in 2020 confirmed that most PMHC users were female (between 55% and 80% of users in different PMHC teams), aged between 30 and 50, and were highly educated (Oslo Economics, 2020[15]), although the characteristics varied between municipalities.
The effectiveness of PMHC programme may be influenced by individual characteristics. A study, based on the 12 initial pilot sites of PMHC in Norway, found that some user groups tended to improve less during treatment than others. Although all groups of users showed substantial improvement, the strongest predictors of poorer treatment response were having an immigrant background, being unemployed at baseline, taking antidepressant medication and reporting bullying as the cause of their problems (Knapstad, Nordgreen and Smith, 2018[16]). Men, older people, those with lower education and those with an immigrant background were under-represented among the study participants. In contrast, findings from an RCT suggest that PMHC is equally effective as treatment-as-usual across a wide range of potential moderators such as sociodemographic, lifestyle, social, and cognitive variables (Sæther et al., 2022[17]). This suggests that, despite earlier indications, the overall effectiveness of PMHC may not be significantly moderated by individual characteristics.
Evidence‑base
The results for the effectiveness of PMHC are based on data from a RCT study. The results from the study have been published in a journal article (Knapstad et al., 2020[1]) and the details of the study design are described in the study protocol.
The RCT study included 681 participants (aged ≥ 18 years) randomly assigned (70:30 ratio, n=463 to PMHC, n=218 to TAU). Participants were assessed at baseline and six‑month follow-up and were compared in terms of recovery rates and changes in symptoms of depression (PHQ‑9) and anxiety (GAD‑7). The PHQ‑9 has shown good psychometric properties, and the Cronbach’s alpha2 for the sample was 0.80. The GAD‑7 has shown good reliability and validity for measuring generalised anxiety and other anxiety disorders, and the Cronbach’s alpha for the sample was 0.83 (Knapstad et al., 2020[1]).
The main strength of this study is the study design, as a RCT study is considered to provide the most reliable evidence on the effectiveness of interventions while also minimising the risk of confounding factors influencing the results (Akobeng, 2005[18]). On the other hand, a couple of limitations of the study have been pointed out. First, missing outcome data could be a source of potential bias. Almost a third of the participants had missing data on the primary outcomes at the 6‑month follow-up. However, all sensitivity analyses pointed in the same direction with effect sizes of similar magnitude, suggesting that selection bias is unlikely to have significantly influenced the estimated effects of PMHC. Second, the study design did not allow for blinding, meaning both users and therapists were aware of their group assignments.
The Quality Assessment Tool for Quantitative Studies rates the overall quality of this study as moderate, with strong study design, strong control of cofounders and strong data collection method, moderate quality regarding selection bias and withdrawal, and poor quality in blinding (see Table 3.3).
Source: Effective Public Health Practice Project (1998[19]) “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14; Knapstad et al. (2020), “Effectiveness of Prompt Mental Health Care, the Norwegian Version of Improving Access to Psychological Therapies: A Randomized Controlled Trial”, https://doi.org/10.1159/000504453.
Extent of coverage
Based on available estimates provided by PMHC’s owner, approximately 23 500 individuals receive PMHC treatment in Norway each year. As of March 2023, there were 75 PMHC teams providing services in a total of 88 municipalities and city districts across the country. This shows an increase from the 62 teams that were established in 2020. In Oslo, there is a PMHC team in each city district, while some other municipalities work together to provide services through a joint team in inter-municipal co‑operation.
The Norwegian Association for Cognitive Therapy has been responsible for the educational training of PMHC therapists since the beginning of the PMHC service. There are currently no national figures of the number of therapists working in PMHC. However, based on estimates of those who have completed the educational training and those who are currently in training, there are approximately 450 therapists working with PMHC.
Enhancing effectiveness
Establishing systems for monitoring and assessment would improve the quality and effectiveness of PMHC
PMHC services are organised using a decentralised system where each municipality is responsible for how it organises mental health care. There is no standard practice across PMHC centres in the different municipalities, and therefore, it is challenging to monitor the quality for the service as a whole. In addition, there is limited evidence on the effectiveness of PMHC treatment across the municipalities.
A monitoring system that can collect data in a systematic and standardised way can improve the quality and effectiveness of PMHC. For instance, IAPT in England established an outcome monitoring system that ensures that symptom scores are obtained from 98% of the users. Outcome monitoring of IAPT showed that there is a wide variation in the performance of individual IAPT services (Clark et al., 2018[20]). Such monitoring system and the systematic use of the collected data would also be essential for the assessment of the extent to which PMHC contributes to achieving treatment goals, and could contribute to increase the effectiveness of the services and further develop PMHC. In addition, user feedback can ensure the quality of the treatment, increase user engagement, and prevent dropout from the treatment (NAPHA, 2022[6]).
The use of recognised assessment tools can help to monitor the evolution of symptoms of depression and anxiety. Using assessment tools, both at the start of treatment and during treatment, can track symptom progression and guide treatment accordingly. Assessment tools can help evaluate a person’s condition and to guide treatment. Tools such as the PHQ‑9 scale to measure the level of depressive symptoms and GAD‑7 to measure the level of anxiety are recommended for this type of use (NAPHA, 2022[6]). Other tools or measures may be used for more specific mental health problems, such as for specific anxiety disorders.
Digital tools can increase the availability and accessibility of PMHC and offer cost-effective alternatives
Digital treatment can increase the availability and accessibility to healthcare. In PMHC, the CBT-based treatment can also be delivered via video communication, which may offer several advantages such as increased availability and accessibility, and lower dropout. Specifically, a report from the Norwegian Resource Centre for Community Mental Health (NAPHA) suggests that several users have reported that the use of video communication in PMHC has worked well. Some users reported that the use of video in PMHC has made treatment more accessible, as they have saved valuable time by not having to travel back and forth to the service, thus reducing geographical barriers to treatment. Some have also appreciated being able to sit at home in a safe environment and talk about difficult issues (NAPHA, 2022[6]). In addition, many PMHC teams have had lower dropout rates when using digital treatment issues (NAPHA, 2022[6]), since users can follow the treatment regardless of where they are located without it affecting the continuity of the treatment.
Guided internet-based CBT treatment is a cost-effective alternative to other forms of treatment for individuals struggling with anxiety and depression. CBT is well suited to online delivery through video communication. A systematic review shows that internet-based CBT – where therapists guide patients by providing feedback, support and encouragement through online messages rather than scheduled appointments or live video – is just as effective as traditional face to face CBT (Hedman-Lagerlöf et al., 2023[21]), confirming earlier findings (Carlbring et al., 2018[22]). The flexibility and accessibility of guided internet-based treatment, along with its reduced time commitment when compared with face‑to-face treatment, makes it a cost-effective solution. The Norwegian Directorate of Health piloted guided internet-based treatment in collaboration with six PMHC teams across 11 municipalities, using tools from “Assistert Selvhjelp”. The results show that although statistical non-inferiority to standard therapy could not be confirmed, both approaches led to significant improvement, with recovery rates of over 50%. Clients were satisfied with the digital treatment, which required half the therapist time, suggesting that it is a promising option within PMHC (Knapstad et al., 2025[23]).
There are, however, potential barriers to the use of digital tools in mental health treatment. A systematic review found that although technology can offer flexibility and facilitate anonymity, technical issues and privacy concerns are common barriers to user engagement (Borghouts et al., 2021[24]). People’s literacy in understanding mental health and using technology can also affect their ability to use digital tools. Low digital health literacy and negative experiences with mental health services can be barriers to engagement with digital tools and digital mental health interventions (Borghouts et al., 2021[24]).
Enhancing efficiency
One potential way to enhance the efficiency of PMHC is to encourage the use of low-intensity treatment approaches wherever appropriate. Evidence suggests that such approaches, including guided self-help and group-based treatment, are effective in treating anxiety and depression, and can achieve outcomes that are comparable to individual therapy (Sæther et al., 2022[17]). This approach has the potential to result in cost savings and optimised resources. By promoting the use of low-intensity treatment options, resources can be allocated more efficiently, allowing a greater number of people to access and benefit from PMHC. To enhance the efficiency of PMHC, it is therefore recommended to further utilise low-intensity forms of treatment, such as guided self-help and group courses, along with workplace‑focussed CBT (NAPHA, 2022[6]). The expansion of the use of these approaches could more effectively achieve the goals of PMHC, ensuring better access and timely support for people in need.
Enhancing equity
Men, older people, those with lower education and those with an immigrant background were under-represented among the study participants (Knapstad et al., 2020[1]). To enhance equity, targeted outreach strategies, culturally adapted materials and models of care that are responsive to the needs of diverse groups can help close these gaps. Strengthening collaboration with community organisations and primary care providers can also support outreach to populations that are less likely to seek mental health support.
Enhancing the evidence‑base
PMHC has a strong evidence base with a RCT used to evaluate the effectiveness of the programme. Long-term studies have also been conducted, suggesting that long-term symptom improvement is maintained at 12‑, 24‑ and 36‑month intervals.
As a part of the development of the PMHC models and the research into the impact of interventions and programmes at the municipal level, the Norwegian Directorate of Health is investigating the possibility of creating a national electronic collection of outcome data. These data would be used by all PMHC teams to measure the impact before, during and after treatment, with the possibility of further strengthening the evidence base of PMHC with a large number of user data (Helsedirektoratet, 2021[25]).
Enhancing extent of coverage
Improving geographical accessibility
The extend of PMHC coverage is limited due to restricted geographical accessibility. While people living in a municipality where PMHC is implemented can access the services, those who do not have access to the programme in their municipality may face barriers to receiving the care they need. Expanding the reach of PMHC to additional municipalities could help bridge this gap and extend the benefits of the programme to a larger population. The Norwegian health authorities are encouraging municipalities to expand PMHC services and establish new PMHC teams.
Preventing dropout from therapy
Dropout of treatment is common in PMHC. A study found a dropout rate of 25%, indicating that one out of four users end their treatment early without clarifying this with their therapist (Hanevik and Røvik, 2022[26]). The results also showed that users dropped out most frequently between the first and second treatment session. This emphasises that early prevention of dropout is important already in the assessment phase (i.e. first session). Dropout is costly to the service and can be demotivating for both the users and the therapists. There are a number of measures that can be implemented to prevent dropout, including providing users with an estimate of the treatment duration and enabling them to influence and take part in the treatment process (NAPHA, 2022[6]). PMHC can also benefit from routine tracking of PMHC site outcomes, making systematic monitoring of dropout rates possible.
Certain user groups are more likely to drop out of PMHC treatments. A study found that being younger, having limited social support, and having lower levels of educations were associated with disengagement in PMHC (Hanevik and Røvik, 2022[26]). Therapists should therefore be encouraged to pay particular attention to these groups. If aware of the increased risk of dropping out for these groups, therapists can adopt a more proactive and flexible approach in their work with them. For individuals with lower levels of education and weak social networks, co‑operation with other services can be considered. Services such as the Norwegian Labour and Welfare Organisation can help users to improve their socio-economic status, and co‑operation between services can be beneficial for certain individuals (NAPHA, 2022[6]).
This section explores the transferability of PMHC and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policymakers interested in transferring PMHC.
Previous transfers
There are several models that are similar to the PMHC programme, many of which originated from the IAPT model in England, including initiatives in Spain, Australia, Canada, Japan and New Zealand.
The Improving Access to Psychological Therapies (IAPT) programme was launched in England in 2007. The programme focussed on providing treatment for common mental health disorders in the general population through the use of CBT in a primary care setting. IAPT has shown good results in providing access to broadly effective, evidence‑based psychological therapies for a large number of users, further reducing disability, social care and healthcare costs (Wakefield et al., 2021[2]).
In Spain, the PsicAP programme was launched by the General Council of Psychology and Psicofundación (Spanish Foundation for the Promotion and Development of Scientific and Professional Psychology), following the precedent programme set by the IAPT. The programme aimed to compare psychological therapy with TAU for the treatment of common mental disorders (Cano-Vindel et al., 2022[27]). PsicAP was a clinical trial designed to validate the efficacy of a group transdiagnostic treatment (TD) in Spanish primary care centres. The transdiagnostic approach focusses on treating the common factors involved in many emotional disorders. The results supported the inclusion of psychological treatment, particularly a transdiagnostic approach, in a primary care setting (Cano-Vindel et al., 2022[28]).
NewAccess is an Australian low-intensity cognitive behavioural therapy service that was developed in 2013 based on IAPT. Coaches are recruited and trained to deliver the programme and it is targeted at people who are not currently accessing mental health services (Cromarty et al., 2016[29]). This includes groups that are hard to reach, such as rural communities with lower access to mental health services and men. Results from NewAccess have shown improved recovery rates for both depression and anxiety. NewAccess is an appropriate and effective model to address mild-to-moderate depression and anxiety in an Australian context (Baigent et al., 2020[30]).
In Canada, publicly funded programmes have focussed on improving access to CBT for common mental health disorders. In Ontario, free internet-based CBT services such as LifeWorks AbilitiCBT and MindBeacon Therapist-Guided iCBT, are available via self-referral. Evaluations have reported reductions in symptoms of anxiety and depression among programme participants (Khan et al., 2024[31]).
In Canada, publicly funded programmes have focussed on improving access to CBT for common mental health disorders. In Ontario, free internet-based CBT services such as LifeWorks AbilitiCBT and MindBeacon Therapist-Guided iCBT, are available via self-referral. Evaluations have reported reductions in symptoms of anxiety and depression among programme participants (Khan et al., 2024[31]).
Japan adapted the IAPT model in the Chiba CBT, a Japanese training course for clinicians in Chiba. The model focussed on individual CBT for obsessive‑compulsive disorder, bulimia nervosa, or social anxiety disorder. The results demonstrated statistically significant reductions in symptom severity for all three disorders (Kobori et al., 2014[32]).
New Zealand implemented the Piki Pilot Project to increase access to mental health and well-being support for young people aged 18‑25, following the IAPT model (Dowell et al., 2019[33]).
Transferability assessment
This section outlines the methodological framework to assess transferability followed by analysis results.
Methodological framework
A few indicators to assess the transferability of PMHC were identified (see Table 3.4). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Results
The main findings of the transferability assessment are summarised below (see Table 3.5 for results at the country level):
a) In terms of access to mental health care, 7% reported consulting mental health care or rehabilitative care professionals in Norway, compared to around 6% on average across OECD countries. Norway is among the best performers in the Healthcare Access and Quality index, with a rate higher than the OECD average. More than two‑thirds of OECD countries have a score over 80%.
b) In Norway, the number of psychologists (1.4) and mental health nurses (0.66) per 100 000 is higher than in most other OECD countries.
c) In Norway, talking therapy is provided by all primary care providers, which is more than most other OECD countries. In most OECD countries, including Norway, patients can access mental health care without the need of a referral.
d) Policies and programmes for enabling self-care for people experiencing mental health conditions are implemented or underway in 72% of countries (28 out of 39), including in Norway. The majority of countries (79%) have policies and programmes in place to enable mental health promotion, prevention and treatment of mental health care conditions in primary healthcare.
e) As in Norway, the vast majority of countries (90%) have a strategy or action plan to guide the implementation of mental health policy. A majority of countries (88%) also have policies and programmes to improve mental health awareness and literacy – including Norway.
f) Norway has a lower level of prevention spending as a percentage of GDP, compared to other countries (0.27% vs. 0.40% for the median in OECD and EU countries). Countries with higher spending on prevention would be more likely to have economic support for the transfer of PMHC.
A darker shade indicates PMHC is more suitable for transferral in that particular country
Note: n/a = no available data. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details). The full names and details can be found in Table 3.4.
Source: OECD/WHO Regional Office for Europe, (2023[37]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes for enabling self-care and self-management for people experiencing mental health conditions; OECD/WHO Regional Office for Europe (2023[38]), Mental Health Systems Capacity Questionnaire 2023 – Policies and programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary health care; OECD/WHO Regional Office for Europe (2023[39]), Mental Health Systems Capacity Questionnaire 2023 – Strategy or action plan that guide implementation of the mental health policy; OECD/WHO Regional Office for Europe (2023[40]), Mental Health Systems Capacity Questionnaire 2023 – Policies and programmes to improve mental health awareness and literacy; OECD (2024[41]), “OECD Data Explorer - Prevention spending as a percentage of GDP”, http://data-explorer.oecd.org/s/1nl; Eurostat (2022[34]), Self-reported consultations of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level, https://doi.org/10.2908/HLTH_EHIS_AM6E; IHME (2017[35]), Global Burden of Disease Study 2015 (GBD 2015) Healthcare Access and Quality Index Based on Amenable Mortality 1990–2015, https://ghdx.healthdata.org/record/ihme-data/gbd-2015-healthcare-access-and-quality-index-1990-2015; OECD (2021[36]), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, https://doi.org/10.1787/4ed890f6-en.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 3.5. Countries in clusters with more positive values have the greatest transfer potential. While this analysis provides a high-level overview assuming some simplifications, it is important to note that countries in lower-scoring clusters may also have the capacity to adopt the intervention successfully. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the clusters are below with further details in Figure 3.8 and Table 3.6:
Countries in cluster one has population, sector specific, political and economic arrangements in place to facilitate the transfer of PMHC. Overall, these countries are less likely to experience issues in implementing and operating PMHC in their local context. This group includes 20 countries.
Countries in cluster two might face moderate issues in population and sector-specific contexts, and more significant challenges in political context. The economic context for these countries is close to the dataset mean. These countries might struggle with PMHC implementation due to political barriers. This group includes 9 countries.
Countries in cluster three might experience barriers in population, sector-specific, and political contexts, despite having the economic support in place. These countries might have difficulties to translate economic resource into effective PMHC implementation due to shortcomings in other areas. This group includes 14 countries.
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD analysis.
Source: OECD analysis.
New indicators to assess transferability
Data from publicly available datasets alone is not ideal to assess the transferability of public health interventions. Box 3.5 outlines several new indicators policymakers could consider before transferring PMHC.
In addition to the indicators within the transferability assessment, policymakers are encouraged to collect information for the following indicators:
Population context
What are the main barriers to accessing to mental health care services?
What is the level of mental health literacy in the population?
What proportion of individuals would seek professional help for mental health concerns?
Sector specific context
Is there a monitoring system in place to collect data of PMHC services?
What are the proportion of trained professionals available to deliver CBT-based interventions?
Political context
Does the country or region have national or regional mental health strategies that prioritise early intervention and low-threshold services?
Economic context
What is the cost per patient treated in the PMHC model compared to other mental health care services?
What are the estimated costs of scaling PMHC to new regions?
PMHC is a Norwegian programme that provides low-threshold, free mental health care to individuals aged 16 and older with mild-to-moderate symptoms of depression and/or anxiety. With treatment grounded in evidence‑based CBT, PMHC offers two types of treatment: low-intensity (teaching-based courses and guided self-help) and high intensity (individual psychotherapy).
PMHC has proven highly effective in reducing depression and anxiety symptoms, compared to treatment as usual (including usual services such as general practitioners or private psychologists). It achieves an 83% increase in recovery rate at six months and demonstrates sustained improvements over 12, 24 and 36 months. It is estimated that transferring PMHC to all OECD and EU27 countries would be cost saving in eight OECD and EU27 countries and cost-effective in all remaining countries.
Currently, 75 PMHC teams operate across 88 municipalities and city districts in Norway, providing care to approximately 23 500 individuals annually. PMHC is based on IAPT in the United Kingdom (currently known as “NHS Talking Therapies”), and similar services or programmes exists in countries such as Australia, New Zealand, Japan and Spain. PMHC is highly transferable in nearly 47% of OECD and EU countries with available data (20 out of 43 countries), and intermediately transferable to nine countries. All countries have the opportunity to tailor mental health prevention strategies according to their specific needs, resources and context.
Box 3.6 outlines next steps for policymakers and funding agencies.
Next steps for policymakers and funding agencies to enhance PMHC are listed below:
Extend the reach of PMHC to more municipalities, regions or potentially nationwide.
Develop and implement a monitoring system that can collect data in a systematic and standardised way.
Improve the ability of PMHC to attract and support traditionally underserved groups, such as gender and sexual minorities, minority ethnic groups or those with low socio-economic status.
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The effectiveness of PMHC was evaluated using data from a randomised controlled trial (RCT) (Knapstad et al., 2020[1]) and using a Difference‑in-Difference (DiD) analysis to estimate the relative impact of PMHC compared to Treatment as Usual (TAU). The RCT showed that PMHC was significantly more effective than TAU in reducing symptoms of depression and anxiety:
PHQ: Mean scores decreased from 15.72 to 7.45 in the PMHC group, compared to 15.57 to 11.15 in the TAU group over six months, resulting in a between-group effect size of ‑0.88.
GAD: Mean scores decreased from 13.13 to 5.88 in the PMHC group, compared to 12.85 to 8.27 in the TAU group, with a between-group effect size of ‑0.60.
EQ‑5D: Mean scores decreased from 10.93 to 8.20 in the PMHC group, compared to 10.86 to 9.59 in the TAU group, with a between-group effect size of ‑0.46.
A DiD analysis was used to measure the change in outcomes over time for the PMHC group relative to the TAU group while accounting for baseline differences and trends unrelated to the intervention. The study included both the PMHC and the TAU group with before‑and-after research design:
) – ()
Where is the mean score in the PMHC group at six months, the mean score in the PMHC group at baseline, is the mean score in the TAU group at six months, and the mean score in the TAU group at baseline.
The standard error (SE) of the DiD estimator was calculated following the methods detailed in Xiao et al. (2019[42]) and using the formula:
Where is the estimate of the pooled standard deviation (SD) of the PMHC and TAU groups.
Where is the sample size of the PMHC group and is the sample size of the TAU group.
The time to maximum effectiveness of PMHC was assumed to be six months (Smith et al., 2022[11]). The maximum effect was assumed to have been maintained for three years, based on evidence showing sustained improvements up to 36 months (Smith et al., 2022[11]). From three years to four years, the effect was assumed to diminish linearly, returning to baseline levels.
PMHC targets individuals aged 16 years and older with mild-to-moderate symptoms of depression and/or anxiety. The inclusion criteria for the modelling were based on clinical thresholds for PHQ and GAD scores:
Individuals with a PHQ‑9 score between 5 and 14, indicating mild-to-moderate depression.
Individuals with a GAD‑7 score between 5 and 14, indicating mild-to-moderate anxiety.
It is estimated that 2.9% of the target population currently receive PMHC in Norway. Based on information provided by PMHC owner, approximately 23 500 individuals receive PMHC treatment in Norway each year. Given the size of the population aged 16 and over in Norway (4 507 271 people, as of 2023, according to Statistisk Sentralbyrå (Statistisk sentralbyrå, 2023[43])), and given that 18% of this group has mild or moderate symptoms of depression or anxiety (according to data from the European Health Interview Survey 2019), it is assumed that 2.9% of the target population receives the intervention (23 418 / (18%*4 507 271) = 2.9%).
There are no figures available for the dropout rate of PMHC in real life, but the dropout rate in the RCT study was 23.1%. Another study looking at user predictors of dropout from PMHC services found a dropout rate of 25% (Hanevik and Røvik, 2022[26]).
Based on this evidence, and assuming a higher coverage, it is assumed that 4% of the target population will receive the intervention in the model (higher than the estimated 2.9% to reflect a scale‑up scenario). Of those receiving the intervention, 75% will take up the full programme (dropout rate of 25%). Therefore, the exposure rate is 3% (4%x75%).
A study estimated that the average cost per PMHC patient is EUR 1 825 (NOK 17 054) (Smith et al., 2025[7]). This is based on data provided by the participating municipalities and the Norwegian Association for Cognitive Therapy.
← 1. Between-group effect sizes (Cohen’s d) were calculated by dividing the mean difference in estimated change scores from baseline to six months by the standard deviation at baseline. Generally, the effect size is interpreted as small (0.20), medium (0.50), and large (0.80).
← 2. Cronbach’s alpha is a way of assessing reliability by comparing the amount of shared variance among the questions in the instrument to the amount of overall variance (Collins, 2007[44]).