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Mental health problems among Estonia’s adult population

Key message
Data indicate that mental health problems are widespread among the adult population of Estonia. Based on self-reports, one in four adults is at risk of depression, and one in five is at risk of generalised anxiety disorder. Young adults are at significantly higher risk. The risk of depression and anxiety disorders increased during the COVID-19 pandemic. The risk of depression depends on the environment and health behaviours as well as genetic factors, but no single factor is decisive.

Mental health disorders, or mental disorders, may disrupt self-control and coping skills, as well as a person’s capacity for self-realisation, interaction with others, building relationships and contributing to society. Mental health disorders are complex problems arising from the interaction of genetic and environmental factors as well as individual behaviour. Every year, an estimated one in five people worldwide experiences some form of mental health problem, while one in three experiences mental problems sometime during their life (Steel et al. 2014). Individual mental health disorders have a significant economic impact on society as a whole. In Europe, the average total cost of mental disorders is estimated at over 4.1% of the gross domestic produc (OECD 2018). This figure includes direct health care costs (1.3%), the cost of social protection programmes (1.2%) and indirect costs, such as those related to unemployment and lower productivity rates resulting from the disorders (1.6%).

According to Ferrari et al. (2022) , the global prevalence rate of any of the more common mental disorders did not change significantly between 1990 and 2019. Depression, anxiety and eating disorders are more prevalent among women, while attention deficit and hyperactivity and autism spectrum disorders are more common among men. Compared to most other parts of the world, Europe has very high rates of anxiety disorders and attention deficit hyperactivity disorder. These increased by approximately 5% between 1990 and 2019. However, Europe is not more depressed than the rest of the world, and depression rates in Europe decreased slightly from 1990 to 2019.

There is evidence that the rate of mental health disorders has increased worldwide during the COVID-19 pandemic, including an estimated increase of more than 25% in cases of depression or anxiety disorder (Santomauro et al. 2021). It is worth noting that these estimates are primarily based on data from wealthy countries and have been interpolated from self-report surveys. The long-term effects of the COVID-19 pandemic on mental health are still unclear.

The prevalence of mental disorders varies widely across studies. The main methods for determining prevalence are (a) the use of registry data, (b) population-based surveys and (c) clinical interviews. Depending on the method used, studies can either overestimate or underestimate the prevalence of mental disorders. The prevalence rate of depression, for example, can vary by several times depending on the assessment method(Sjöberg et al. 2017) While registry data can underestimate the prevalence of disorders, self-report surveys tend to overestimate it.

Symptoms of depression and generalised anxiety disorder according to the International Classification of Diseases (ICD-10) and the Emotional State Questionnaire (EST-Q-2)

ICD-10 EST-Q-2
Assessment Medical assessment of the symptoms based on a clinical interview and other methods, with cases reflected in the registry data. Self-report questionnaire about the frequency of experiencing the following problems during the past month. Answer options: ‘not at all’, ‘rarely’, ‘sometimes’, ‘often’, ‘constantly’.
DEPRESSION Main symptoms: lowered mood, loss of interest and zest for life, and decreased energy, which contributes to increased weariness and decreased activity.
Additional symptoms: decreased attention and concentration, lowered self-esteem, feelings of guilt and worthlessness, pessimistic outlook on the future, thoughts or actions of self-harm or suicide, disturbed sleep, and decreased appetite.
Sadness, loss of interest, feelings of inferiority, self-blame, repeated thoughts of death or suicide, feeling lonely, hopelessness about the future, and inability to feel joy.
GENERALISED ANXIETY DISORDER The main indicator is generalised and persistent anxiety unrelated to specific environmental conditions.
Frequent complaints include persistent nervousness, tremors, muscle tension, sweating, dizziness, weakness, worrying and negative anticipation.
Irritability or anger, anxiety or fear, tension and inability to relax, excessive worrying, restlessness or impatience, fidgeting, and being easily startled.

This article focuses on three questions. First, what is the prevalence of the most common mental health problems (depression, anxiety disorders, mental exhaustion, sleep disorders and alcohol abuse) based on survey data, and how has it changed during the COVID-19 crisis? Second, what does registry data tell us about the prevalence of mental health disorders? Third, to what extent do genetic and environmental factors contribute to the occurrence of mental health disorders? Our approach to these questions will rely on data from the Estonian National Mental Health Study, the 2019 Estonian Health Interview Survey, the Estonian Genome Centre of the University of Tartu and the Estonian Health Insurance Fund.

Prevalence of mental health disorders in the population

Survey data show that mental health disorders are widespread

We used self-reported data collected for the Estonian National Mental Health Study in the first half of 2021 to estimate the prevalence of depression, anxiety disorders, sleep disorders, mental exhaustion and alcohol abuse (and resulting mental disorders). Depression, anxiety and sleep disorders were assessed using the EST-Q-2 Emotional State Questionnaire (Aluoja et al. 1999) and alcohol abuse was assessed using the AUDIT-C screening test (Bush, Kivlahan, McDonell et al. 1998).

The results of the study indicate a high prevalence of mental health disorders in the adult population. About a fourth of the respondents (28%) were at risk for depression (24% of men and 31% of women), and a fifth (20%) were at risk for anxiety disorder (15% of men and 25% of women). The risk of sleep disorders was found in 39% of the respondents (33% of men and 44% of women). Signs of mental exhaustion were seen in 43% of the respondents (36% of men and 48% of women).

The prevalence of mental health disorders in the Estonian adult population is high: 28% are at risk of depression, 20% are at risk of anxiety disorder, 39% are at risk of sleep disorders and 43% are at risk of mental exhaustion.

A closer look at the data by gender and age group (Table 1.4.1), reveals that the group most at risk of experiencing these disorders were young adults (18-to-24-year-olds). Similar to previous research, the study found that in all age groups, women had a higher risk of depression and anxiety disorders than men. While there were no statistically significant gender differences in the risk of sleep disorders, the risk was shown to increase with age.

Alcohol abuse was indicated in 17% of women and 34% of men. However, there were no gender differences in the prevalence of alcohol abuse in the younger age groups (18–34) (Table 1.4.1). From the age of 35, alcohol abuse was significantly more frequent among men, affecting as much as 49% of male respondents aged 35 to 44.

Table 1.4.1. Prevalence of mental health problems (%) by gender and age group based on data from self-reports (EST-Q-2, AUDIT-C) in the Estonian National Mental Health Study
Tabel 1.4.1 - Vaimse tervise probleemide esinemine (%) soo ja vanuserühmade lõikes  RVTU andmetel enesekohaste hinnangute põhjal (EEK-2, AUDIT-C)

Source: table by the authors, based on data from the first wave of the Estonian National Mental Health Study conducted in January–February 2021 (depression, generalised anxiety, mental exhaustion and insomnia; N = range 5,336–5,484) and the second wave conducted in May–June 2021 (alcohol abuse; N = 3,607)
NOTE: * Statistically significant difference between men and women, p < 0,05.

The prevalence of mental health disorders increased during the COVID-19 pandemic

The COVID-19 pandemic led to a significant increase in mental health problems,

During the COVID-19 pandemic, there was a significant increase in mental health problems and a significant decrease in wellbeing.

in all EU member states (WHO 2022). According to data from the first wave of the Estonian National Mental Health Study, 15% of men and 20% of women felt that their mental health had significantly deteriorated during the COVID-19 crisis. The share of people with deteriorated mental health was significantly higher among younger people. For example, 28% of men aged 18–29 felt that their mental health had deteriorated, while the same was true for only 7% of middle-aged men (45–59) and 10% of older men (60–85+). Forty percent of women aged 18–29 rated their mental health as worse than before the pandemic, while only 18% of middle-aged women and 12% of older women felt this way.

Comparing depression, anxiety disorder and mental exhaustion indicators in the Estonian National Mental Health Study data and the Estonian Health Interview Survey data collected in 2019 shows similar results for the prevalence of mental health disorders during the pandemic. The results indicate that during the pandemic, the risk of depression and generalised anxiety disorder, as well as signs of mental exhaustion, increased significantly among people aged 18 to 44 (Figure 1.4.1). Mental health problems were most common among 18-to-24-year-olds even before the pandemic. During the pandemic, the share of young people at risk of depression further increased. In older people, on the other hand, self-reports indicated no differences in the risk of depression between the time before and during the pandemic.

Figure 1.4.1. Prevalence of mental health problems (depression, generalised anxiety, mental exhaustion) by age group based on self-reports


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Source: figure by the authors, based on data from the first wave of the Estonian National Mental Health Study (Jan–Feb 2021) and from online respondents of the 2019 Estonian Health Interview Survey

The prevalence of mental health disorders is significantly lower according to treatment cases in registry data

Due to Estonia’s high rate of coverage (about 95% of the population has medical insurance), registry data from the Estonian Health Insurance Fund treatment bills database provide a good overview of the number of diagnosed mental disorders in the population. The following describes the prevalence of all mental disorders (ICD-10 sections F00–F99) among the Estonian population aged 15 and older, with a special focus on anxiety disorders (F40–F41), depression (F32–F33), alcohol-related mental and behavioural disorders (F10) and sleep disorders (F51). This is done using data on treatment bills for 2016–2020 from the Health Insurance Fund database. The rates presented here as prevalence (and their 95% confidence intervals) have been found based on the number of people with a corresponding treatment bill and the average population of the year by gender and five-year age groups.

On average, almost 142,000 people per year had a mental disorder cited as either the primary or concomitant diagnosis on their treatment bill. From 2016 to 2020, the number of cases of treating mental disorders increased by an average of 1% per year (from 139,470 in 2016 to 144,738 in 2020). The number of cases of treating diagnosed mental disorders did not decrease in 2020, despite the partial suspension of planned treatment in response to the COVID-19 pandemic.

Patients being treated for mental disorders are more likely to be women than men. In 2020, women made up 57% of all medically insured persons aged 15 and over. Meanwhile, they accounted for 63% of the people treated for mental disorders. Gender differences in the distribution of mental health treatment cases also stand out in the comparison of age groups (Figure 1.4.2), where the prevalence of mental disorders among women is higher by almost a fifth than among men in people aged 15–34 and by almost a fourth in people aged 35 and older. Between 2016 and 2020, an average of 10% of men and 15% of women had treatment bills that included a diagnosis of a mental disorder. The prevalence of registered cases of mental disorders increased with age in both men and women, with the highest rates in the oldest age group.

Figure 1.4.2. Prevalence and 95% confidence interval of all cases for treating mental and behavioural disorders in Estonian residents aged 15 and older, by gender and five-year age group