-
03 January 2023 | Country Update
Estonian Government approves Green Paper on Mental Health
5.11. Mental health care
The Estonian system of mental health services has improved considerably since the early 1990s when independent Estonia had inherited a system based on institutional provision of care. Physical and mental disability was considered a taboo subject, and most disabled people were taken into an institutionalized care setting even when they could have lived in the community with only modest assistance. Since that time, the system has transformed into a more humane system in which the provided services primarily aim to improve the patient’s quality of life. In the 1990s, a new concept of social services was developed with the intention of reducing and restructuring institutional care and developing a system of community care.
Mental health care in Estonia is regulated by several laws and regulations. In addition to the Health Insurance Act and the Health Services Organization Act, the 1997 Psychiatric Care Act (last amendment in 2016) regulates the organization of mental health care and defines the financial obligations of the state and local governments in the organization of such care. The Psychiatric Care Act also defines procedures and conditions for mental health care provision and involuntary treatment. It applies to all psychiatric patients and basically follows the 1991 United Nations’ principles on protecting the rights of those with mental health disorders. Financial resources from the state budget for social services are allocated to the county governments based on the number of people who need welfare services, and these allocations also take into consideration the extent of services provided within the counties. Local governments must guarantee the accessibility of necessary social services for people with mental disorders. Provision of specialized social care such as 24-hour care with medical surveillance in a social care home is organized on the national level and mostly financed from the state budget. These social care homes are distributed throughout the country.
Mental health care in Estonia is seen as part of specialized medical care and includes the diagnosis, treatment, rehabilitation and prevention of mental disorders. Mental health care is provided mainly by psychiatrists, psychiatric nurses, nurses and psychologists. To access mental health care, a patient may turn directly to a specialist for an outpatient consultation without a family doctor’s referral, while for most disease areas family doctors perform a gatekeeping function. Mental health care is provided both in outpatient and inpatient settings; the latter is mostly used in the event of short-term crises or for solving complex differential diagnostic and treatment problems. Based on the Psychiatric Care Act and the Penal Code, compulsory treatment of a person with a mental disorder is possible in court-ordered cases if all the following circumstances coincide:
- the person has a severe mental disorder which restricts her/his ability to understand or control her/his behaviour;
- without inpatient treatment, the person endangers the life, health or safety of herself/himself or others; and
- other psychiatric care is not sufficient.
There are no specialized psychiatric hospitals and psychiatric beds are integrated into larger multispecialty hospitals. As part of the overall trend, the number of psychiatric beds decreased from 185.8 per 100 000 population in 1990 to 52.6 in 2004 and has stabilized since then. At the same time, treatment was gradually shifted into outpatient settings and in recent years daily follow-up for mental health problems such as mild depression has also been shifted towards primary health care. By the end of 2016, a new integrated child mental health service delivery concept had been developed using grant funding from the Norway and European Economic Area scheme and as a result four regional child mental health centres (in regional and central hospitals) with four regional satellites have become operational.
Finally, it has to be noted that there is no specific mental health plan. The NHP (Ministry of Social Affairs, 2008) also covers mental health care and there is a development plan for a psychiatric specialty. In 2012 a new Estonian Mental Health and Well-Being Coalition (VATEK) was established by the initiative of the Estonian–Swedish Mental Health and Suicidology Institute and with support of the Ministry of Social Affairs. By 2016 over 40 different organizations related to mental health have joined the network. The biggest outcome of the VATEK is the new Mental Health Strategy for 2016–2025. However, the current status of the strategy and any implementation plans are unclear.
The government approval of the Green Paper on Mental Health in April 2021 shows the shift towards a higher prioritization of mental health and the importance of its maintenance across individual, community and state levels. Estonia was one of the few European countries that did not have a national mental health policy framework document, and its absence was an obstacle to cross-disciplinary development. The preparation of the Green Paper on Mental Health was based on the main goal set in the National Health Plan 2020–2030, which is extending the healthy lives of Estonian people by reducing premature mortality and morbidity. The Green Paper on Mental Health was prepared in cooperation with numerous experts and professionals in the field. It outlines the existing organization of mental health care, summarizes the problem areas, and makes proposals for future development in the field. The paper addresses the importance of prevention, early detection of mental health issues and timely availability of high-quality care throughout Estonia. Specific measurable activities and resources are described in follow-up documents. The Green Paper laid a foundation for the development of the mental health action plan, which shall be published by the end of 2022, and the creation of a separate suicide prevention action plan. This will be developed by 2024 in cooperation with EU Joint Action ImpleMental.
Authors
References
Green Paper on Mental Health: https://sm.ee/media/2132/download (in Estonian)
Eesti Rahvusringhääling (ERR News): https://news.err.ee/1608189940/government-approves-green-paper-on-mental-health
JA on Implementation of Best Practices in the area of Mental Health. Summary: https://webgate.ec.europa.eu/chafea_pdb/health/projects/101035969/summary
JA on Implementation of Best Practices in the area of Mental Health. General objectives of the Project: https://ja-implemental.eu/about/