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25 February 2025 | Country Update
Estonia adopts its first national suicide prevention action plan -
01 April 2024 | Country Update
Improving access to mental health services close to home -
25 March 2024 | Policy Analysis
Estonia sets to improve mental health outcomes with the Mental Health Action Plan 2023–2026
5.11. Mental health care
For decades, mental health has been undervalued, underfinanced and understaffed. Recent changes in the political agenda have brought much needed attention to the field. The core issues range from the fragmentation of services and their availability in different regions to the lack of person-centredness and cooperation between service providers, as well as scarcity of home and community-based mental health support. Roles within the health and social sectors have been poorly defined among various mental health service providers, which has contributed to the further fragmentation over the years.
In recent years, starting from the COVID-19 pandemic, the whole Estonian society, including politicians and NGOs, have acknowledged the importance of mental health. This societal shift has created a platform for systemic changes in the field.
In cooperation with different stakeholders, the MoSA prepared, and the Estonian Government approved in 2021, the Green Paper on Mental Health – the first comprehensive policy document covering both positive (well-being, prevention and promotion of mental health) and negative (support, counselling and services for those who already have mental health problems) mental health (see section 6.1.7 Elevating the importance of mental health in the political agenda). The document describes a comprehensive intersectoral and multi-level approach to the optimal mix of services in the mental health pyramid. It sets objectives and actions needed in the field based on this model (Ministry of Social Affairs, 2021b).
In response to the COVID-19 pandemic, the Minister of Social Protection initiated the Mental Health Task Force, which brought together policy-makers from different sectors (health, education, social affairs, criminal justice), scientists, NGOs and start-ups. The Task Force met weekly from March to June 2021 and monthly in the second half of the year. As a result of this work, the MoSA established a Mental Health Department within its Health Sector in early 2022. Subsequently, a Mental Health Action Plan 2023–2026 was presented as a result of co-creation work with an extensive list of stakeholders in the field. The plan provides specific lines of action for the MoSA and other actors in the development of mental health policy in the coming years.
Estonia has implemented a variety of mental health interventions and prevention programmes, including school-based initiatives and parenting programmes, such as “The Incredible Years”, (https://tarkvanem.ee). In addition, there are programmes like the “Good Behaviour Game”, which supports teachers in creating a socially healthy environment (NIHD, 2023g) and “KiVa”, an anti-bullying programme (Kiusamisvaba Kool, 2023), both implemented in schools. However, not everyone has access to these interventions. Although schools are required to provide a range of services to support children’s mental health, including school psychologists, school nurses and special educational needs support, the quality and accessibility of these services can vary widely.
Mental health prevention for adults is mainly community-based. Local governments play a key role in the provision of supportive services and activities within communities. Better results can be achieved if more systematic attention and resources are allocated to services and activities at the local level (see section 2.2.2 Local governments). At the national level, evidence-based prevention tools and guidelines are developed and promoted, and awareness-raising activities are supported through strategic partnerships. Additionally, there is a need for significant development of mental health prevention in the workplace.
The MoSA selects NGOs for strategic partnership in the field of mental health advocacy, suicide prevention and treatment of gambling and digital dependence. These NGOs form the Estonian Mental Health and Well-being Coalition (ECA, 2023).
In addition to the Health Insurance Act and the Health Services Organization Act, the 1997 Mental Health Act (last amended in 2022) regulates the organization of mental health care and defines the financial obligations of the state and municipalities in the organization of such care. The Mental Health Act defines procedures and conditions for the provision of mental health care and involuntary treatment. It applies to all psychiatric patients and follows the 1991 United Nations’ principles on protecting the rights of those with mental health disorders. Local governments must ensure the accessibility of necessary social services for persons with mental disorders. The provision of specialized social care, such as 24-hour care with medical supervision in a social care home, is organized at the national level and mostly financed from the state budget. These social care homes are distributed throughout the country.
Diagnosis and treatment of mental health disorders is part of primary and specialized medical care. Mental health treatment is provided by family physicians, nurses (including mental health nurses), psychiatrists and clinical psychologists. To access mental health treatment, a patient may turn directly to a specialist for an outpatient consultation without a family physician’s referral. Mental health treatment is provided in both outpatient and inpatient settings, the latter is mostly used for short-term crises or for solving complex differential diagnostic and treatment problems. Based on the Mental Health Act and the Penal Code, compulsory treatment of a person with a mental disorder can be ordered by the court if (1) the person has a severe mental disorder that limits their ability to understand or control their behaviour; (2) without the inpatient treatment, the person endangers the life, health or safety of themselves or others; and/or (3) other psychiatric care is not sufficient.
There are two specialized psychiatric hospitals in Estonia. In addition, psychiatric units are integrated into larger multi-specialty 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 per 100 000 in 2004 and has since stabilized. At the same time, treatment has gradually shifted to outpatient settings and, in recent years, daily follow-up of mental health problems such as mild depression has also shifted to PHC. By the end of 2016, a new integrated concept for child mental health services had been developed with grant funding from the Norway and the 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 (see section 3.6.2 External sources of funds).
During the past years, the Estonian Government has increased funding for mental health services. This includes additional funding to cover one-year clinical training for psychologists to become clinical psychologists, psychologist–counsellors and school psychologists, and funding to strengthen local governments in organizing community-based support services and activities in the field of mental health. The latter includes measures to enable local governments and primary health centres to receive financial support from the state to provide psychological help to their residents.
Over the past decade, the following changes have been made to improve mental health services provision: (1) from 2013, the EHIF started covering the costs of family physicians having more than one nurse, one of whom can specialize on mental health issues; (2) PHC physicians can use e-consultation for mental health diagnosis and treatment; (3) from 2021, psychiatric help became available for minors without needing consent from a legal representative; and (4) clinical psychologists, speech therapists and physiotherapist can start providing services as independent health care providers from October 2023.
Estonian has launched its first Suicide Prevention Action Plan for 2025–2028, aiming to comprehensively reduce the number of suicides [1]. Developed based on the foundations laid in the Green Paper on Mental Health [2] and through the activities within the Joint Action on Implementation of Best Practices in the area of Mental Health (JA ImpleMENTAL), this plan adopts a whole-of-government and society-wide approach.
The framework of the plan follows main principles of suicide prevention and is structured around eight strategic goals:
- awareness raising and knowledge;
- support and treatment through early detection;
- intervention to support people with high suicide risk;
- follow-up intervention;
- limiting access to suicide means;
- integrating suicide prevention to other health promotion activities;
- coordination and management; and
- monitoring and evaluation.
Implementation of the plan will be carried out through the Ministry of Social Affairs’ annual work plan, with progress reviewed yearly in collaboration with relevant stakeholders.
Authors
With the goal of improving access to mental health care, in February 2024, the Ministry of Social Affairs opened application rounds for grants to finance mental health services close to home. These grants are designated for two purposes:
- to enable local governments to provide mental health services at the community level, with a total funding of EUR 1 million, and
- to assist primary health care centres and local governments in covering salaries and providing guidance support for psychologists, with a total allocation of EUR 500 000.
The total budget for the grants is EUR 1.5 million. Self-financing for the activity must be a minimum of 30%. These grants should allow local governments not only to increase their capacity to deliver mental health services but also to widen the range of services, such as psychological counselling, creative and family therapy, and support groups. The aim of this mechanism is to enhance the availability of mental health services and psychological help at the local level, thereby promoting psychosocial well-being and mental health. Similar financial support was provided to local governments and primary health care centres in 2021, 2022 and 2023. There is no evaluation of whether the access to services has been improved or how services are reaching those in need.
Authors
References
https://sm.ee/uudised/avanevad-kodulahedaste-vaimse-tervise-teenuste-toetuste-taotlusvoorud
Vaimse tervise teenuse toetus kohalikule omavalitsusele 2023. aastal–Riigi Teataja https://www.riigiteataja.ee/akt/107072023005
Psühholoogi palga- ja juhendamistoetus kohalikule omavalitsusele ja esmatasandi tervisekeskusele 2023. aastal–Riigi Teataja https://www.riigiteataja.ee/akt/107072023006
The COVID-19 pandemic significantly impacted mental health in Estonia. For example, the first Estonian National Mental Health Study in 2022 revealed that one in four adults faced a risk of depression following the pandemic. It also highlighted a stark contrast in depression risks between income groups: 45.5% in the lowest income quartile versus 19.6% in the highest.
Anticipating these issues, policymakers started prioritizing mental health in their political agendas already during the late stages of the COVID-19 pandemic. Thus, the Ministry of Social Affairs (MoSA) initiated the Mental Health Task Force in 2021, collaborating with stakeholders from various sectors, including health, education, social affairs, criminal justice, scientists, NGOs, and startups. This led to the creation of the Green Paper on mental health, Estonia's first comprehensive policy document on the subject. Consequently, in early 2022, MoSA established a Mental Health Department within its Health Sector and by the end of the year, drafted the Mental Health Action Plan for 2023–2026. The development of the action plan had a form of collaborative process, which involved numerous working sessions with stakeholders.
The Mental Health Action Plan outlines expected changes in the field of mental health, focusing on the MoSA’s role in achieving these changes. It aligns with the WHO’s fundamental principles, emphasizing universal health coverage, human rights, evidence-based practice, a life course approach, a multisectoral approach, and empowerment for those persons with mental disorders and psychosocial disabilities. The plan is structured along the mental health services pyramid with promotion, prevention and self-care at its base, followed by the community-based support services and PHC services, ambulatory psychiatric aid and counselling, and psychiatric services in hospitals.
The plan’s five main action lines are:
- Development and innovation in mental health, focusing on evaluation tools and a monitoring system.
- Promotion, prevention, and self-help, including suicide prevention and reducing stigma.
- Community support, integrating mental health activities in various policies, focusing on workplace mental health, and engaging older adults.
- Improvement of mental health services, ensuring equitable access, clarifying care paths, and maintaining adequate professional staffing.
- Organizing mental health and psychosocial support in emergencies, emphasizing access to support, central coordination, and training for first responders.
The action plan, a dynamic document reviewed annually, is designed to establish priority directions for MoSA’s mental health policy through 2026. It acknowledges that resolving problems in the mental health field requires more actions than currently outlined and feasible within the plan’s timeframe, considering political priorities and resource allocation. However, the plan’s adaptability can allow for adjustment in response to evolving needs and priorities in mental health care.
Actions needed to implement the Mental Health Action Plan include linking the MoSA’s annual work plan and proposals for funding actions in the national budget process; annual evaluation of progress made under the plan; and strengthening the link with the National Development Plan.
Authors
References
Full text of the mental health action plan is available (in English): https://www.sm.ee/media/3386/download
Estonian National Mental Health Survey (2022) Final Report of the Population Health Survey. Tallinn, Tartu: National Institute for Health Development, University of Tartu. Available at: https://tai.ee/sites/default/files/2022-06/Eesti%20rahvastiku%20vaimse%20tervise%20uuring.pdf