The United Nations Convention Relating to the Status of Refugees became effective in Denmark as of 1954. Two years later, Denmark received its first refugees after joining the convention, namely, around 1,400 people from Hungary. In the 1950s and 1960s, refugees were primarily people who had escaped from the communist states in Eastern Europe, whereas in the 1970s, the refugees arriving in the country were mainly Asians driven out of Uganda, refugees from Chile and Vietnamese boat refugees . Through the 1980s and 1990s, the refugee group was dominated by people who had escaped from conflicts in the Middle East, Sri Lanka, Somalia and the Balkans . The number of positive asylum applications has fluctuated through the years, but the overall tendency has been a decline in the number of individuals granted protection in the last ten years [3, 4]. In 2010, the largest groups of people seeking asylum in Denmark were from Afghanistan, Syria, Iran and Russia, and approximately 2,124 individuals obtained refugee or similar protection status . In addition, Denmark receives 500 quota refugees per year as part of an agreement entered into with the United Nations High Commissioner for Refugees . The societal discourse and the refugee politics of the Danish government have varied over the years [1, 5]. In 1983, the Danish Aliens Act was changed and was regarded as one of the most humane and liberal alien acts in Europe [1, 6]. It introduced measures such as granting refugees the right to asylum given that they fulfilled the conditions of the law, it extended the refugee concept to include de facto refugees, i.e., individuals who did not meet the requirements of the UN convention were still able to obtain asylum, an appeal authority was established for people who had had their asylum application rejected and refugees were able to claim family reunification. One year later, the world’s first rehabilitation centre for torture survivors was opened in Copenhagen. Though the principles in the asylum system are still the same, it has become more difficult to access Denmark [1, 7]. For instance, the former government implemented changes in the Aliens Act in 2005 implying that the selection of quota refugees to a greater extent should be based on their integration potential assessed through parameters such as age, education, network and motivation  compared to an earlier focus based on who was most in need . Denmark has a tax-financed health care system and the majority of services are offered free of charge . Recognised refugees are enrolled with the National Register of Persons and, thereby, they are entitled to access health care services on the same terms as Danish citizens residing in the country and in the case they are traumatised, they are entitled to cost-free treatment in specialised rehabilitation centres .
Refugees are a particularly vulnerable group in relation to the development of mental illness . Migration can be a stressful event regardless of the circumstances, but refugees are being forced to flee their countries and have often been exposed to events before, during and after migration that can influence their mental health [11–14]. Great variations in the prevalence of mental illness in refugees are reported in different studies, which is most likely due to heterogeneity in choice of study populations and measurement instruments . However, in a meta-analysis of 20 studies, it was reported that approximately one in ten adult refugees settled in Western countries had post-traumatic stress disorder and it was concluded that they may be 10 times more likely to suffer from this disorder than an age-matched general American population. In addition, the results suggest that about one in 20 suffers from major depression and about one in 25 has generalised anxiety disorder. It is likely that many people have comorbid diagnoses in relation to these disorders . In a recent study from Denmark, it was also concluded that refugees have an increased risk of mental illness in comparison with native-born Danes measured by the number of first time contacts with the psychiatric hospital system . In spite of this, a qualitative study by Amnesty International, based on interviews with former asylum seekers having been subjected to torture, showed that this group underutilises psychiatric health care services though a great need exists. It is concluded in the study by Amnesty International that contact with health care services becomes less frequent after asylum seekers leave asylum centres and that referrals to relevant health care services are lacking. Even the former asylum seekers who are in contact with the regular health care system and would benefit from psychiatric treatment have never been in contact with the psychiatric health care system .
Recent studies in Denmark and Norway show that between 45–57.3% of the asylum seekers arriving in these countries have been subjected to torture [19, 20]. However, even asylum seekers who have not experienced torture will often have experienced other traumatic events rendering them particularly vulnerable . Survivors of torture may not easily share their stories on their own initiative . Furthermore, several studies show that general practitioners are uncertain whether a refugee background is of importance in relation to the health of their patients [22–24] and that they are reluctant to initiate conversations about traumatic experiences in relation to the situation in their home countries, their escape and their life in exile .
In summary, refugees are a vulnerable group in relation to mental health problems and the seemingly scarce awareness of this subject on the side of the health professionals should be reason for concern. General practitioners are the gatekeepers for access to much psychiatric treatment, and knowledge of how they experience providing care to refugees is crucial in order to secure adequate treatment for this patient group. The aim of this study was to qualitatively explore issues identified by general practitioners as important in their experiences of providing care for refugees with mental health problems.