Epidemiology of suicide in Estonia, 2000–2024: Trends, demographic patterns, and implications for the National Suicide Prevention Action Plan

Epidemiology of suicide in Estonia, 2000–2024: Trends, demographic patterns, and implications for the National Suicide Prevention Action Plan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Epidemiology of suicide in Estonia, 2000–2024: Trends, demographic patterns, and implications for the National Suicide Prevention Action Plan Zrinka Laido, Peeter Värnik, Merike Sisask, Käthlin Mikiver, Airi Värnik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9413966/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Suicide remains a significant public health concern in Estonia. Despite a marked decline in mortality since the early 2000s, rates continue to exceed the European Union average, particularly among men. Estonia adopted its first National Suicide Prevention Action Plan (SETK) for 2025–2028, providing a structured framework for evidence-based prevention. Methods A descriptive time-trend study was conducted using data from the Estonian Causes of Death Registry for the period 2000–2024. Suicide deaths coded as ICD-10 X60–X84 and Y87.0 were analysed by year, sex, age group (0–19, 20–39, 40–59, 60–79, 80+), nationality, educational level, and method. Age-standardized rates per 100,000 population were computed. Temporal trends were examined using general linear models (GLM), Pearson correlation, ANOVA, and linear regression. Method-specific trends were assessed using chi-square tests with linear-by-linear association. Results Between 2000 and 2024, 6,188 suicide deaths were registered (79.4% male). Total standardized suicide rates declined by approximately 56%, from the highest suicide rate of 28.8 per 100,000 (N 401) in 2001 to 12.7 (N 175) in 2024. Gender remained the dominant predictor of suicide mortality (partial η² = .904). Hanging (X70) accounted for 75.6% of all deaths. For the period 2000–2024, suicide rates among individuals aged 0–19 showed no significant temporal change. Suicide rates were highest among individuals with basic education, with divergent temporal trends across educational groups. Conclusions Estonia has achieved substantial reductions in suicide mortality, yet persistent gender disparities and evolving method patterns underline the need for targeted, gender-responsive prevention strategies. The findings directly inform implementation of the 2025–2028 National Suicide Prevention Action Plan (SETK) and the broader Mental Health Action Plan 2023–2026. suicide epidemiology Estonia gender disparities suicide methods suicide prevention national suicide prevention action plan Figures Figure 1 Figure 2 1. Introduction Suicide remains a major and largely preventable public health challenge worldwide. According to the World Health Organization (WHO), more than 720,000 people die by suicide each year, and for every suicide death there are many more non-fatal attempts, indicating a substantially wider burden of suicidal behaviour beyond mortality alone ( 1 ). Suicide was the third leading cause of death among individuals aged 15–29 years globally in 2021 ( 1 ). Although global standardized suicide rates have declined since the early 2000s, large disparities persist between countries and regions ( 2 ). In the European Union (EU), suicide represented approximately 0.9% of all deaths in 2021, equating to an average of 10.2 deaths per 100,000 population — a 13% reduction from the 2011 rate of 12.4 per 100,000 ( 3 , 13 ). This decline, however, has been uneven across the continent. Countries in Northern and Eastern Europe have historically borne the greatest burden. Some countries, such as Lithuania and Hungary, have achieved dramatic reductions from very high baselines, while others have shown more modest progress ( 3 , 14 ). Gender differences in suicide mortality are a consistent pan-European finding, with men accounting for approximately 76.7% of all EU suicide deaths in 2021 ( 3 , 13 ). Estonia has historically belonged to the high-burden group within Europe. Long before the post-Soviet transition, Värnik (1991) documented that suicide rates in Estonia averaged 33 per 100,000 between 1965 and 1985, among the highest in Europe at the time, with male rates reaching 55.2 per 100,000 during the Soviet stagnation period ( 4 ). Following a dramatic further surge during the post-Soviet socioeconomic transition of the early 1990s, when rates peaked at among the highest ever recorded on the continent (41.3 per 100,000), the country has made substantial progress ( 4 , 5 ). Nonetheless, Estonia ranked fourth highest in the EU for suicide mortality in 2020 (16.3 per 100,000), behind Lithuania, Hungary, and Slovenia ( 2 , 3 , 5 ). By 2024, the rate had declined further to 12.7 per 100.000, yet still remained well above the EU average of around 10 per 100,000 ( 7 , 13 ). In 2024, 186 suicide deaths were registered, with male rates nearly four times higher than those among females ( 6 , 7 ). Recognizing suicide as a preventable public health issue requiring sustained and coordinated action, Estonia adopted its first National Suicide Prevention Action Plan (SETK) for 2025–2028 ( 11 ). This represented a significant step in the development of the country’s mental health policy framework. It followed the 2021 Green Paper on Mental Health, Estonia’s first comprehensive national mental health policy document, and the subsequent Mental Health Action Plan 2023–2026, adopted by the Ministry of Social Affairs ( 7 ). Important preparatory work had been undertaken earlier by the Mental Health Coalition (VATEK), which in 2016 drafted and submitted the policy document Estonian Mental Health Strategy 2016–2025 to the Ministry of Social Affairs ( 12 ). This document served as a precursor to the Green Paper; however, neither it nor the Green Paper was formally approved as a funded policy document accompanied by an action plan. Taken together, these policy developments indicate an increasing national commitment to strengthening mental health governance and reducing suicide mortality at the population level. The aim of this study is to analyse suicide trends in Estonia during the period 2000–2024, focusing on changes in mortality rates, demographic characteristics, and methods of suicide, and to situate these findings within broader European and international comparisons and the evolving national suicide prevention policy framework. 2. Methods 2.1 Study design and data sources A descriptive time-trend study was conducted using data from the Estonian Causes of Death Registry, maintained by the National Institute for Health Development (Tervise Arengu Instituut; TAI) ( 9 ). For each death, the registry recorded the year, external cause of death according to ICD-10 codes X60–X84 (intentional self-harm) and Y87.0 (sequelae of intentional self-harm), as well as sociodemographic characteristics including sex, age, nationality, and educational attainment. The analyses were based on aggregated data covering the period 2000–2024. Age-standardized mortality rates per 100,000 population were calculated using population denominators obtained from the National Institute for Health Development (TAI). 2.2 Variables Analyses considered year of occurrence, method of suicide (ICD-10 X60–X84), and sociodemographic indicators: sex; five age groups (0–19, 20–39, 40–59, 60–79, 80+); nationality (Estonian, Russian, Other); and educational level (basic, secondary, higher). Suicide methods were grouped into standard injury-epidemiology categories derived from ICD-10 codes for intentional self-harm (X60–X84). 2.3 Statistical analysis Temporal trends and gender differences were examined using a univariate General Linear Model (GLM) with year as a continuous covariate and gender as a fixed factor. Pairwise comparisons were adjusted using the Bonferroni method, and effect sizes were reported as partial η². Within‑gender temporal associations were assessed using Pearson correlation coefficients. Age‑specific trends were evaluated using separate linear regression models for each age group, with year entered as a continuous predictor; the reported F‑statistics reflect the overall model fit for each regression. A full factorial GLM was used to assess the combined effects of gender, age group, and year on suicide rates, including all main effects and interaction terms (Gender × Year, Age_group × Year, Gender × Age_group, and Gender × Age_group × Year). Estimated marginal means were calculated with Bonferroni‑adjusted comparisons, and model assumptions were checked using standard residual diagnostics. Educational and nationality differences were analysed using GLMs with fixed categorical factors (three levels each) and year as a covariate. Adjusted marginal means were estimated at Year = 2012 (midpoint of the study period) using Type III sums of squares. Method distributions were summarised using frequencies and proportions; gender differences were tested with chi‑square statistics and Cramér’s V, with effect sizes reported alongside p‑values. Suicide methods were classified according to ICD‑10 external cause codes (X60–X84). Method distributions were summarised using frequencies and percentages, and gender differences were assessed using chi‑square tests with Cramér’s V reported as the effect size. Temporal changes in method use were evaluated across the 25‑year period using two complementary approaches. First, overall shifts in method distribution were tested using chi‑square analyses across all years. Second, directional (linear) temporal trends were assessed using the Linear‑by‑Linear Association (LLA) statistic to determine whether specific methods increased or decreased over time. Gender‑specific temporal patterns were examined separately using the same procedure. For additional clarity, annual method counts were inspected to identify consistent increases, decreases, or irregular fluctuations. All analyses were conducted in IBM SPSS Statistics v29, and statistical significance was defined as α = .05. 3. Results 3.1 Overall trends in suicide mortality, 2000–2024 Between 2000 and 2024, a total of 6,188 suicides were registered among the Estonian general population. Among these, 4,912 cases were male (79.4%) and 1,276 female (20.6%). The total standardized suicide rate peaked at 28.8 per 100,000 (N 401) in 2001 and declined to 12.7 (N 175) in 2024 (Fig. 1 ), an overall reduction of approximately 56%. The mean total rate across the period was 18.4 (SD = 4.5). Male suicide rates ranged from 48.5 per 100,000 in 2001 to 21.8 in 2024 (mean 31.2, SD 7.9), with a secondary peak occurred in 2009 (35.4) Female rates ranged from 11.8 per 100,000 in 2000 to 4.4 in 2024 (mean 6.8, SD 1.9). Across the full period, male rates were approximately three to five times higher than female rates, mirroring the EU-wide pattern in which men account for around three-quarters of all suicide deaths ( 12 ). A univariate GLM was statistically significant (R² = .917, adjusted R² = .914). A Year showed a significant negative association (B = − 0.574, SE = 0.053, t(71) = − 10.76, p < .001; partial η² = .620). Gender differences were highly significant (F (1, 71) = 334.82, p < .001, partial η² = .904). Pearson correlations confirmed strong negative trends for total (r = − 0.894), males (r = − 0.914), and females (r = − 0.757; all p < .001). 3.2 Age-specific trends In 2024, age-specific suicide rates showed a clear age gradient, with the lowest rate observed in the 0–19 age group (6.5 per 100,000), followed by the 20–39 group (13.2 per 100,000). Rates increased progressively with age, reaching 15.4 per 100,000 among those aged 40–59 and 16.2 per 100,000 in the 60–79 group, with the highest rate recorded among individuals aged 80 and over (20.1 per 100,000), underscoring the elevated suicide risk in the oldest age group. For the period 2000–2024, suicide rates among individuals aged 0–19 showed no significant temporal change (F( 1 , 23 ) = 0.96, p = .337, B = − 0.054). All adult groups demonstrated statistically significant declines: 20–39 years (F( 1 , 23 ) = 42.1, p < .001, B = − 0.536); 40–59 years, the largest reduction (F( 1 , 23 ) = 90.6, p < .001, B = − 1.187); 60–79 years (F( 1 , 23 ) = 52.4, p < .001, B = − 0.516); and 80 + years (F( 1 , 23 ) = 8.4, p = .008, B = − 0.695) (Fig. 2 ). The gender gap varied across age groups (Gender × Age_group: F(4,230) = 14.71, p < .001, partial η² = .204), with the largest male–female difference observed among adults aged 40–59, smaller differences in youth, and substantial gaps persisting in older adults. Temporal trends also differed by gender and age. The three‑way interaction was significant (Gender × Age_group × Year: F(4,230) = 14.81, p < .001, partial η² = .205), indicating that the evolution of suicide rates over time was not uniform across demographic groups. Male rates declined in all age groups, with the steepest decrease in middle‑aged men (B = − 3.093, p < .001) and a smaller decline among younger men (B = − 1.738, p < .001). Female rates remained largely stable across the study period. Consequently, the gender gap narrowed most rapidly in middle age, narrowed moderately in older adults, and remained relatively unchanged among younger cohorts. 3.3 Educational disparities Educational level had a significant effect on suicide rates (F (2,35) = 5.274, p = .010, partial η² = .231). Suicide rates were highest for those with basic education (mean = 17.8), intermediate for secondary (mean = 15.9), and lowest for higher education (mean = 13.5). The education × year interaction (F(2,35) = 7.113, p = .003) revealed divergent trajectories: rates declined among individuals with basic education (B = − 0.463, p = .001), increased among those with secondary education (B = + 0.217, p = .028), and remained stable for higher education (B = − 0.052, p = .487), indicating to educational inequalities over time. In the joint gender-education model (R² = .929), the gender × education interaction was large (partial η² = .496): men with basic education had the highest suicide rates (mean = 46.4 vs. mean = 12.4 for women), underscoring the compounding effect of male sex and low educational attainment. 3.4 Nationality Nationality had a significant but modest effect (F(2,35) = 3.596, p = .038, partial η² = .170). Adjusted marginal means (estimated at Year = 2012) were highest for those of Other nationality (mean = 16.6), followed by Estonians (mean = 15.7) and Russians (mean = 13.6); only the Other–Russian contrast reached significance (p = .014). Crucially, all three groups exhibited nearly identical negative temporal slopes (B ≈ − 0.426), confirming a common downward trajectory irrespective of nationality. 3.5 Suicide methods Hanging (X70) dominated throughout, accounting for 75.6% of all deaths (n = 4,678) (Table 1 ). Firearms comprised 8.0% (n = 494) and drug poisoning 5.0% (n = 311). Gender differences in method distribution were significant (χ²( 10 ) = 546.93, p < .001, Cramér’s V = .30, indicating a medium-to-large effect) (Table 1 ). The overall method distribution changed significantly over time (χ²(240) = 483.52, p < .001), though without a simple linear trend (LLA = 3.45, p = .063). Among men, the distribution of suicide methods varied significantly across the 25-year period (χ²(240) = 393.84, p < .001), but no overall directional trend was detected (LLA = 0.029, p = .864). Hanging (X70) remained the dominant method throughout, yet its annual counts declined steadily from the early 2000s to the 2020s. Firearms and explosives (X72–X75) consistently represented the second most common method, showing fluctuations but no clear long-term increase or decrease. Other methods, including poisoning (X60–X64), sharp objects (X78–X79), and jumping from height (X80), remained comparatively infrequent and exhibited irregular year-to-year variation without a stable trend. Among women, a significant directional shift occurred (χ²(240) = 335.70, p < .001; LLA = 10.21, p = .001): poisoning (X60–X64) increased steadily across the 25-year period, while hanging (X70) declined consistently from its early-2000s peak. These evolving female method patterns warrant continued monitoring, as they may reflect changes in access to means, prescribing practices, or broader shifts in method availability. Table 1 Suicide methods by gender, Estonia 2000–2024 (N = 6,188) ICD-10 Method Men n (%) Women n (%) Total n (%) X60–X64 Drug poisoning 120 (2.4%) 191 (15.0%) 311 (5.0%) X65 Alcohol poisoning 20 (0.4%) 10 (0.8%) 30 (0.5%) X66–X69 Other poisoning 90 (1.8%) 29 (2.3%) 119 (1.9%) X70 Hanging 3,832 (78.0%) 836 (66.3%) 4,678 (75.6%) X71 Drowning 37 (0.8%) 31 (2.4%) 68 (1.1%) X72–X75 Firearms 478 (9.7%) 16 (1.3%) 494 (8.0%) X76–X77 Explosives 19 (0.4%) 4 (0.3%) 23 (0.4%) X78–X79 Cutting/piercing 123 (2.5%) 35 (2.7%) 158 (2.6%) X80 Jumping from height 131 (2.7%) 100 (8.0%) 231 (3.8%) X81–X82 Jumping/lying before object 30 (0.6%) 4 (0.3%) 34 (0.5%) X83–X84 Other 32 (0.7%) 8 (0.6%) 40 (0.6%) Total 4,912 (100%) 1,276 (100%) 6,188 (100%) 4. Discussion 4.1 Estonia in EU context Estonia’s 56% reduction in suicide mortality between 2000 and 2024 is one of the steepest sustained declines recorded in the region and reflects the cumulative impact of socioeconomic stabilization, healthcare reform, alcohol harm-reduction policies, and growing national investment in mental health. Nevertheless, with a rate of approximately 12–14 per 100,000 population in recent years, Estonia remains well above the EU average of 10.2 per 100,000 ( 3 , 13 , 14 ). By comparison, the EU average suicide rate stood at approximately 12.4 per 100,000 in 2011 and declined to 10.2 in 2021, indicating that, while Estonia’s trajectory of decline has been steeper than the EU average, its suicide rates have consistently remained substantially above the EU mean ( 12 ). In 2020, Estonia ranked fourth-highest among EU member states, behind Lithuania (21.3), Hungary (17.1), and Slovenia (17.0) ( 3 , 15 , 16 ). This positioning underscores both the progress achieved and the distance yet to be covered. The pattern of decline observed in Estonia parallels, and in magnitude surpasses, trends seen across Eastern Europe more broadly. A 2019 analysis of European suicide trends found significant reductions in 15 of 38 European countries between 2011 and 2019, with the greatest declines in Lithuania, Hungary, Latvia, and Poland. These are all countries that, like Estonia, started from historically elevated baselines ( 3 ). Critically, European countries that implemented structured national suicide prevention action plans alongside alcohol harm-reduction and mental health reforms showed the most consistent reductions ( 17 ), supporting the strategic rationale behind Estonia’s National Suicide Prevention Action Plan (SETK) 2025–2028. The gender distribution of suicide deaths in Estonia (79.4% male over 2000–2024) is closely aligned with the EU average (76.7% in 2021) and reflects the well‑documented “gender paradox of suicide,” in which women report higher levels of suicidal ideation and attempts, while men die by suicide at substantially higher rates ( 18 ). However, earlier national evidence suggests that Estonia partly deviates from this pattern: men also exhibit higher rates of suicide attempts, except in the youngest age groups ( 5 ). This reinforces the need for prevention strategies that move beyond clinical pathways to reach men in non‑medical settings, including workplaces, community organizations, and digital platforms. 4.2 Gender, age, and socioeconomic disparities The secondary peak in male suicide rates in 2009, coinciding with the global financial crisis, is consistent with European evidence that economic recessions disproportionately increase suicide risk among men through unemployment, financial hardship, and loss of occupational identity ( 19 ). This finding reinforces the importance of integrating suicide prevention with labor market and social protection policy — an emphasis that is reflected in Goal 6 of the National Suicide Prevention Action Plan (SETK) 2025–2028 (Table 2 ), which calls for the integration of suicide prevention into broader health and social promotion activities. Age-specific declines were most pronounced in the 40–59 years group, consistent with EU patterns where improvements in healthcare access, alcohol policies, and economic stabilization have benefited middle-aged adults most. The absence of a significant declining trend in the youngest age group (0–19 years) is a concern shared across Europe, where deteriorating adolescent mental health has been documented in multiple countries following the COVID-19 pandemic ( 8 ). These age-specific patterns are broadly consistent with EU trends, where improvements in healthcare access and restrictive alcohol policies have contributed most to declines among older age groups, while youth mental health trajectories remain a concern across many EU member states ( 2 , 22 ). In Estonia, approximately 30% of adolescents report feeling depressed on a weekly basis, a figure that has increased over recent years ( 20 ). Strengthening school-based mental health promotion, digital mental health services for young people, and family support interventions is therefore a shared European priority and a specific focus of the Estonian Mental Health Action Plan 2023–2026. Among adults in Estonia, depressive symptoms are also widespread. National health surveys indicate that approximately one in five adults reports moderate or severe depressive symptoms, and these rates have shown a gradual increase over the past decade ( 20 ). Although the prevalence is lower than among adolescents, the adult trend similarly reflects a growing mental‑health burden in the population. These findings underscore the importance of strengthening accessible mental‑health services for adults, including primary‑care–based screening, digital support tools, and community‑level interventions. The educational gradient in suicide mortality documented in this study — with individuals holding basic education bearing a substantially higher burden — is consistent with the socioeconomic patterning of suicide risk observed across Europe ( 2 , 8 ). The divergent trends in different educational groups, points to a reshaping of social vulnerability as socioeconomic transformation continues. These findings highlight the importance of targeting prevention resources toward socioeconomically disadvantaged populations, in line with broader EU health equity goals. This socioeconomic gradient in suicide mortality is consistent with finding from other EU countries, where lower educational attainment is a robust predictor of suicide risk ( 2 , 17 , 18 ). Nationality had a significant but modest effect. These findings contrast with the pattern observed in the early post-independence period, when Russian-speaking populations in Estonia experienced a sharp rise in suicide rates, attributed to their dramatic shift in social status following 1991 ( 21 ). The convergence of trajectories observed in the present data may therefore reflect a gradual stabilisation of social and economic conditions across ethnic groups over the study period. 4.3 Suicide methods and means restriction The predominance of hanging across the entire study period (75.6% of all deaths) is consistent with method patterns documented over the last decades in the Baltic States and other Northern and Eastern European countries, where hanging is typically the most common suicide method and represents a major challenge for prevention due to its high lethality and wide accessibility ( 17 ). Unfortunately, means restriction as an evidence-based method of suicide prevention is not very useful in Estonia, because the primary method is hanging. The significant directional shift among women toward an increase in drug poisoning parallels trends observed in several other EU countries, where strengthened prescription monitoring, safer medication packaging, and restrictions on high‑risk pharmaceuticals have contributed to reductions in poisoning‑related suicides ( 17 ). These experiences suggest that Estonia could benefit from adopting similar measures, particularly for preventing poisoning‑related suicides among women, where regulatory and clinical interventions may be more feasible and effective than for hanging. 5. Estonia’s National Suicide Prevention Action Plan (SETK) 2025–2028 The adoption of Estonia’s first National Suicide Prevention Action Plan (SETK) for 2025–2028 represents a landmark development in national public health policy. Developed on the foundations of the 2021 Green Paper on Mental Health and informed by the European Joint Action on Implementation of Best Practices in Mental Health (JA ImpleMENTAL), the SETK adopts a whole-of-government and whole-of-society approach consistent with WHO recommendations ( 17 ). Implementation is carried out through the Estonian Ministry of Social Affairs’ annual work plan, with progress reviewed yearly in collaboration with stakeholders covering health, education, social affairs, justice, NGOs, and research sectors through strategic partnership ( 11 ). SETK is structured around eight strategic goals, each corresponding to a distinct pillar of comprehensive suicide prevention (Table 2 ): Table 2 The eight strategic goals of Estonia's National Suicide Prevention Action Plan (SETK) 2025–2028 and their key focus areas ( 11 ) # Strategic Goal Key Focus Areas 1 Awareness & knowledge Public awareness campaigns; destigmatization; gatekeeper training; responsible media reporting (Papageno principles) 2 Early detection & support Suicide risk screening in primary care; training for GPs, nurses, social workers; integration of mental health into primary healthcare; digital e-consultation platforms 3 Intervention for high-risk groups Crisis lines, walk-in crisis centres emergency psychiatric services; targeted programs for prior attempters, severe mental illness, substance misuse, veterans, prisoners, domestic violence victims 4 Postvention/Follow-up after suicide attempts Structured transitional care protocols; case management; coordinated hospital–community outreach; improvement of suicide attempt data quality and completeness 5 Means restriction safer packaging for analgesics and sedatives; safe storage of firearms and medications; physical barriers at high-risk jumping locations; ligature-point reduction in institutional settings 6 Integration with health promotion Alcohol harm reduction; workplace mental health programs; reducing social isolation in older adults and rural populations; school-based health programs 7 Coordination & Governance Cross-sectoral partnerships (MoSA, NGOs, research institutions); postvention support for suicide-bereaved; responsible media guidelines; Estonian Mental Health and Well-being Coalition (VATEK) coordination 8 Monitoring & evaluation Strengthening cause-of-death registration quality; expanding suicide attempt data collection; standardized WHO/EU indicator reporting; research investment in intervention effectiveness The epidemiological findings of this study align closely with the SETK’s strategic priorities. The persistent gender gap and dominance of high-lethality methods among men underscore the urgency of Goals 1, 3, and 5. The emerging shift toward jumping from height among women and the stable youth suicide rate reinforce the relevance of Goals 4 and 8. Educational inequalities in suicide mortality point to the importance of Goals 6 and 7 in engaging intersectoral social policy. Taken together, the SETK provides an evidence-responsive framework for translating this study’s epidemiological findings into sustained preventive action. 6. Mental health interventions in Estonia: system-level context 6.1 Historical background and early prevention efforts The decline in suicide rates observed from 1994 onwards may be partly attributed to early prevention efforts initiated at the start of Estonia's independence. The Estonian-Swedish Mental Health and Suicidology Institute (ERSI) began its work in 1993, introducing professional training, public awareness campaigns, anti-stigma initiatives, and epidemiological research. These efforts were further formalized in 2000 with the development of the Suitsidaalse Käitumise Preventsiooni Tegevuskava ( Action Plan for prevention of suicidal behaviour) , commissioned by the Estonian Health Insurance Fund ( 24 ). However, this action plan lacked sufficient financial resources and institutional support and was therefore never implemented. 6.2 Policy framework Estonia’s approach to mental health has undergone significant transformation since 2020. Important preparatory work had been undertaken earlier by the Mental Health Coalition (VATEK), which in 2016 drafted and submitted the policy document Estonian Mental Health Strategy 2016–2025 to the Ministry of Social Affairs. This strategy served as a precursor to the subsequent 2021 Green Paper on Mental Health, the first comprehensive, cross‑sectoral policy document developed under the national Mental Health Task Force ( 23 ). However, neither the VATEK strategy nor the Green Paper was formally approved as a funded policy document accompanied by an implementation plan. The Green Paper nonetheless provided a shared conceptual framework and laid the groundwork for the more operational Estonian Mental Health Action Plan 2023–2026. The 2021 Green Paper on Mental Health was the country’s first comprehensive national mental health policy document, developed through a cross-sectoral Mental Health Task Force convening stakeholders from health, education, social affairs, criminal justice, academia, and NGOs ( 7 ). Building on this, the Ministry of Social Affairs established a Mental Health Department in 2022, and funding for mental healthcare services more than tripled to €7 million in 2023 ( 3 ). The Mental Health Action Plan 2023–2026 is organized around five pillars: innovation; promotion, prevention and self-care (including suicide prevention); community support and intersectoral integration; improvement of mental health services; and crisis preparedness ( 12 , 15 ). The SETK (2025–2028) represents Estonia's first standalone national suicide prevention policy, signaling a renewed commitment to addressing suicide as a public health priority, implemented through a strategic partnership between the Estonian Ministry of Social Affairs, research institutions, and the NGO sector ( 11 ). The priorities for the first two years focus primarily on universal prevention activities, including promoting responsible media reporting on suicide. In parallel, the Action Plan includes selective measures, such as continuous surveillance and reporting on suicidal behaviour, as well as indicated interventions, including postvention support for the bereaved. A particular emphasis is placed on developing a systematic follow‑up care pathway for suicide attempters after discharge from emergency departments, an area that has historically lacked structured support. 6.3 Service delivery and digital innovation Structural challenges still persist, care pathways remain fragmented, and specialist capacity is constrained. The OECD estimates that mental ill-health costs Estonia approximately 2.8% of GDP annually ( 8 , 25 ). The Mental Health Action Plan 2023–2026 prioritizes strengthening primary care as the first point of mental health contact, expanding community-based services, and clarifying care pathways connecting self-care, primary care, and specialist services ( 16 , 26 ). Several web-based mental-health applications have been developed in Estonia, further strengthening the national digital ecosystem for early recognition and intervention, screening, and prevention. These developments align with broader European initiatives, including MENTBEST (Protecting mental health in times of change; https://mentbest.com/ ) , EAAD (European Alliance Against Depression; https://www.eaad.net/ ) , and iFD (iFightDepression; https://ifightdepression.com/en ), which promote evidence-based community interventions, early-detection strategies, and suicide-prevention practices. In parallel, Estonia has a range of non-governmental organizations that provide crisis support, online counselling, and self-help resources, contributing to a more accessible and integrated prevention infrastructure. 7. Implications for policy and practice The epidemiological findings of this study map directly onto the strategic objectives of the National Suicide Prevention Action Plan (SETK) 2025–2028 and the Mental Health Action Plan 2023–2026. In addition, several points need to be emphasized. Men with basic education represent the highest-risk group and the population most underserved by conventional mental health pathways. Prevention must embed gender-sensitive approaches across all SETK pillars, including male-targeted awareness campaigns, occupational health programs in male-dominated sectors, and crisis services designed to reduce barriers to help-seeking. This mirrors recommendations emerging from EU-level evaluations of gender-responsive prevention strategies ( 2 , 17 , 18 ). The sustained dominance of hanging as the leading method across the study period (75.6% of all deaths) is consistent with patterns observed across the Baltic States and other Northern and Eastern European countries, where hanging is typically the most common suicide method and poses substantial challenges for prevention due to its high lethality and limited opportunities for means restriction ( 17 ). In contrast, the emerging increase in poisoning (X60–X64) among women highlights an area where preventive action is more feasible. Experiences from other EU countries—such as strengthened prescription monitoring, safer medication packaging, and restrictions on high‑risk pharmaceuticals—have contributed to reductions in poisoning‑related suicides and may offer valuable lessons for Estonia. Continued surveillance of poisoning trends is warranted given its historical significance ( 17 ). The stable youth suicide rate and deteriorating adolescent mental health indicators are a shared concern across EU and reinforce the need for sustained investment in school-based programs, digital youth services, and family support interventions. Finally, educational inequalities in suicide mortality call for explicit integration of prevention into social and economic policy frameworks addressing poverty, unemployment, and educational disadvantage, consistent with both the SETK’s Goal 6 and broader EU health equity commitments. 8. Strengths and limitations A major strength of this study is the use of national, registry-based mortality data spanning 25 years, ensuring comprehensive coverage and high reliability. The consistency of Estonia's suicide death registration system throughout the entire observation period further enhances the temporal comparability of findings and reduces the risk of spurious trends arising from changes in classification practices ( 27 ). The long observation period allowed for robust assessment of temporal trends, demographic patterns, and method-specific changes across multiple analytical frameworks including GLM, ANOVA, regression, and chi-square analyses. Several limitations must be acknowledged as well. Analyses were based on aggregated data, limiting examination of individual-level risk factors. Some method categories contained small annual counts among women, reducing statistical power. Possible misclassification of suicide deaths as accidental or undetermined intent / causes may result in underestimation, particularly among older adults. Despite these limitations, the study provides a methodologically rigorous, population-level overview of suicide mortality in Estonia with direct relevance for national prevention policy, and universal, and/or selected, indicated level of interventions. 9. Conclusion This study documents a 56% decline of suicide mortality in Estonia between 2000 and 2024. Despite this progress, Estonia’s rates remain above the EU average of approximately 10.2 per 100,000, and substantial disparities persist by gender, age, and socioeconomic status. Men with lower educational attainment continue to face disproportionate risk; hanging remains the overwhelmingly dominant method; and an emerging increase in jumping from height among women signals a shifting prevention landscape. Of particular concern is the stable suicide rate among young people, which contrasts with the declining trends observed in other age groups and aligns with deteriorating adolescent mental‑health indicators. Situated within a European context in which structured national action plans have been associated with the most consistent reductions in suicide mortality, Estonia’s adoption of the National Suicide Prevention Action Plan (SETK) 2025–2028 and the Mental Health Action Plan 2023–2026 provides an evidence‑aligned framework for sustained progress. The eight strategic goals of the SETK—spanning awareness, early detection, crisis intervention, follow‑up care, means restriction, intersectoral integration, governance, and monitoring—directly correspond to the epidemiological priorities identified in this study. Addressing the stagnation in youth suicide rates will require targeted, developmentally appropriate interventions alongside universal and selective measures. Continued investment in community‑based, digital, and gender‑responsive services, underpinned by robust monitoring and cross‑sectoral collaboration, will be essential to closing the gap with the EU average and reducing the human toll of suicide in Estonia. Declarations Consent to participate: It does not apply. The study used aggregated, anonymized mortality registry data and did not involve direct participation of human subjects. Consent to publish: It does not apply. This study did not involve individual-level data or personal information requiring consent to publish. Ethics approval: This study was based on aggregated, suicide mortality data from the Estonian Causes of Death Registry and did not involve human participants directly. Formal ethics committee approval was not required under applicable national regulations. The study was conducted in accordance with the principles of the Declaration of Helsinki. Data availability: The data used in this study are based on aggregated statistics from the Estonian Causes of Death Registry, maintained by the National Institute for Health Development (Tervise Arengu Instituut; TAI). These data are not publicly available in their original form but may be requested directly from TAI. Population denominator data are publicly available from Statistics Estonia (www.stat.ee). Authors contributions : ZL led the study’s conceptualization, data work, methodological development, analysis, preparation of the original manuscript, and revisions. PV provided data‑related assistance, and participated in manuscript writing and editing. MS contributed to methodology, validation, context and editing the content of the manuscript. KM contributed to reviewing and editing the manuscript. AV supervised, supported validation, and supported revisions. All authors approved the final manuscript. Competing Interests: The authors declare no competing interests. Funding Declaration: The authors declare that no funding was received for the conduct of this study or preparation of this manuscript. References World Health Organization. Suicide. WHO Fact Sheet. Geneva: WHO; 2023. World Health Organization. Suicide worldwide in the 21st century. Geneva: WHO; 2022. Giménez A, Fico G et al. Suicide-related mortality trends in Europe 2011–2019. European Congress of Psychiatry; 2023. Available from: https://www.europsy.net Värnik A. Suicide in Estonia. Acta Psychiatr Scand. 1991;84(3):229–32. Värnik P, Sisask M, Värnik A. Enesetappude ja enesetapukatsete epidemioloogiline ülevaade Eestis. Uuringu raport. Kopenhaagen: WHO Euroopa Regionaalbüroo; 2021. Usberg K, Laido Z, Täht T, Ader M, Lepnurm M, Idavain J. Suitsiidide statistika: epidemioloogiline ülevaade Eestis 2000–2023. Tallinn: Tervise Arengu Instituut; 2024. Usberg K, Laido Z, Värnik P, Lepnurm M. Suitsiidide statistika Eestis: 2024. aasta ülevaade. Tallinn: Tervise Arengu Instituut; 2025. OECD. Boosting efforts to improve mental health in Estonia. OECD Ecoscope Blog. May 2025. Available from: https://oecdecoscope.blog/2025/05/19/boosting-efforts-to-improve-mental-health-in-estonia/ Statistics Estonia. Deaths by cause of death, sex and age group. Tallinn: Statistics Estonia; 2024. Baltic Times. Estonia ranks 6th in Europe in terms of suicide figure. 2024. Available from: https://www.baltictimes.com/estonia_ranks_6th_in_europe_in_terms_of_suicide_figure/ Laido Z, Randväli A, Sisask M, Mikiver et al. (2024). Suitsiidiennetuse tegevuskava 2025–2028 . Sotsiaalministeerium. Ministry of Social Affairs (Estonia). Mental Health Action Plan 2023–2026. Tallinn: Ministry of Social Affairs; 2022. Eurostat. Deaths by suicide in the EU down by 13% in a decade. News article. September 2024. Available from: https://ec.europa.eu/eurostat/web/products-eurostat-news/w/edn-20240909-1 Eurostat. Deaths by suicide down by almost 14% in a decade. (2020 data). News article. September 2023. Available from: https://ec.europa.eu/eurostat/web/products-eurostat-news/w/edn-20230908-3 European Observatory on Health Systems and Policies. Estonia adopts its first national suicide prevention action plan. Copenhagen: WHO Regional Office for Europe. 2025. Available from: https://eurohealthobservatory.who.int European Observatory on Health Systems and Policies. Estonia sets to improve mental health outcomes with the Mental Health Action Plan 2023–2026. Copenhagen: WHO Regional Office for Europe; 2023. World Health Organization. Live Life: An implementation guide for suicide prevention in countries. Geneva: WHO; 2021. Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;28(1):1–23. Chang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ. 2013;347:f5239. Estonian HDR. 2023: Mental health and well-being. Tallinn: Estonian Cooperation Assembly; 2023. Värnik A, Kõlves K, Wasserman D. Suicide among Russians in Estonia: database study before and after independence. BMJ. 2005;330(7484):176–7. Laido Z, Voracek M, Till B, Pietschnig J, Eisenwort B, Dervic K, Sonneck G, Niederkrotenthaler T. Epidemiology of suicide among children and adolescents in Austria, 2001–2014. Wien Klin Wochenschr. 2017;129(3–4):121–8. 10.1007/s00508-016-1092-8 . Epub 2016 Oct 14. PMID: 27743176; PMCID: PMC5318485. Government of Estonia. Mental health green paper. Ministry of Social Affairs; 2021. Värnik A, Wasserman D. Examples of how to develop suicide prevention on the five continents: Europe, Estonia. In: Wasserman D, Wasserman C, editors. Oxford Textbook of Suicidology and Suicide Prevention. London: Oxford University Press; 2009. pp. 791–2. Estonian Mental Health. and Well-Being Coalition (VATEK). Available from: https://vatek.ee. EACEA National Policies Platform. Estonia: Mental Health (Chap. 7.5). Available from: https://national-policies.eacea.ec.europa.eu/youthwiki/chapters/estonia/75-mental-health Värnik P, Sisask M, Värnik A, Laido Z, et al. Suicide registration in eight European countries: A qualitative analysis of procedures and practices. Forensic Sci Int. 2010;202(1–3):86–92. https://doi.org/10.1016/j.forsciint.2010.04.032 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9413966","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626274627,"identity":"f885131f-84a7-4829-be12-ce5cc99c73f8","order_by":0,"name":"Zrinka Laido","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYFACxgbGBgYGGQZmBgOGDwwMPGDGAyK0gFUyzoBpSSBoD0glA4MBMw9EAL8W+dmH2x7OqGHg4W9n3vjY5s9hGRDjQUJFbWIDe/MBrDb0JbYbbjjGwCNxmK3YOLftMJhhkHDmeGIDzzGsljHzMLZJPmADOuwwj5l0bsNhHqDzzCQS244lNkjkGGDTwgbW8o+BRx6kxeIPshb59x+waeEBadnYxsBjANLCwAbXUgO0hQer9yVAWmb2SfAYAr1g2NuWDvPLAeM2njSsDpPvYX8m2fPNRk7u/OGND378sbbn7wcyPlTUyfazH36A1RqoZRgihx3b8KjHCursSdUxCkbBKBgFwxYAACD5WESvWr38AAAAAElFTkSuQmCC","orcid":"","institution":"Estonian-Swedish Mental Health and Suicidology Institute","correspondingAuthor":true,"prefix":"","firstName":"Zrinka","middleName":"","lastName":"Laido","suffix":""},{"id":626274629,"identity":"2e474691-61a0-4b44-b7d1-b442f5bf4e35","order_by":1,"name":"Peeter Värnik","email":"","orcid":"","institution":"Estonian-Swedish Mental Health and Suicidology Institute","correspondingAuthor":false,"prefix":"","firstName":"Peeter","middleName":"","lastName":"Värnik","suffix":""},{"id":626274630,"identity":"8e6dedb7-891b-412c-a032-c43f70d2e46f","order_by":2,"name":"Merike Sisask","email":"","orcid":"","institution":"Tallinn University","correspondingAuthor":false,"prefix":"","firstName":"Merike","middleName":"","lastName":"Sisask","suffix":""},{"id":626274633,"identity":"3aefe6bd-1a23-4b79-b9fe-ebdbd93e0b89","order_by":3,"name":"Käthlin Mikiver","email":"","orcid":"","institution":"Tallinn University","correspondingAuthor":false,"prefix":"","firstName":"Käthlin","middleName":"","lastName":"Mikiver","suffix":""},{"id":626274637,"identity":"980cb177-39ce-474b-a300-52010000d7a1","order_by":4,"name":"Airi Värnik","email":"","orcid":"","institution":"Estonian-Swedish Mental Health and Suicidology Institute","correspondingAuthor":false,"prefix":"","firstName":"Airi","middleName":"","lastName":"Värnik","suffix":""}],"badges":[],"createdAt":"2026-04-14 10:09:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9413966/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9413966/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107744671,"identity":"1ec05ec9-af13-40e5-b851-7174a5a79d35","added_by":"auto","created_at":"2026-04-24 15:41:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36796,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStandardized suicide rates by gender, Estonia 2000–2024 (per 100,000 population)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9413966/v1/9b3f156f62ebcfb230c00968.png"},{"id":107744646,"identity":"a1dea432-551b-46b7-883b-4028dae3fd61","added_by":"auto","created_at":"2026-04-24 15:40:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58583,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in age-specific suicide rates, Estonia 2000–2024 (per 100,000 population)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9413966/v1/131eeee9c23931a546bbac9e.png"},{"id":108775459,"identity":"5b37f360-1b9f-4350-86f8-3e814b989131","added_by":"auto","created_at":"2026-05-08 09:13:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":391266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9413966/v1/18e5facd-8ccd-4460-8374-17d57f045907.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiology of suicide in Estonia, 2000–2024: Trends, demographic patterns, and implications for the National Suicide Prevention Action Plan","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSuicide remains a major and largely preventable public health challenge worldwide. According to the World Health Organization (WHO), more than 720,000 people die by suicide each year, and for every suicide death there are many more non-fatal attempts, indicating a substantially wider burden of suicidal behaviour beyond mortality alone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Suicide was the third leading cause of death among individuals aged 15\u0026ndash;29 years globally in 2021 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although global standardized suicide rates have declined since the early 2000s, large disparities persist between countries and regions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the European Union (EU), suicide represented approximately 0.9% of all deaths in 2021, equating to an average of 10.2 deaths per 100,000 population \u0026mdash; a 13% reduction from the 2011 rate of 12.4 per 100,000 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This decline, however, has been uneven across the continent. Countries in Northern and Eastern Europe have historically borne the greatest burden. Some countries, such as Lithuania and Hungary, have achieved dramatic reductions from very high baselines, while others have shown more modest progress (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Gender differences in suicide mortality are a consistent pan-European finding, with men accounting for approximately 76.7% of all EU suicide deaths in 2021 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEstonia has historically belonged to the high-burden group within Europe. Long before the post-Soviet transition, V\u0026auml;rnik (1991) documented that suicide rates in Estonia averaged 33 per 100,000 between 1965 and 1985, among the highest in Europe at the time, with male rates reaching 55.2 per 100,000 during the Soviet stagnation period (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Following a dramatic further surge during the post-Soviet socioeconomic transition of the early 1990s, when rates peaked at among the highest ever recorded on the continent (41.3 per 100,000), the country has made substantial progress (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Nonetheless, Estonia ranked fourth highest in the EU for suicide mortality in 2020 (16.3 per 100,000), behind Lithuania, Hungary, and Slovenia (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). By 2024, the rate had declined further to 12.7 per 100.000, yet still remained well above the EU average of around 10 per 100,000 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In 2024, 186 suicide deaths were registered, with male rates nearly four times higher than those among females (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecognizing suicide as a preventable public health issue requiring sustained and coordinated action, Estonia adopted its first National Suicide Prevention Action Plan (SETK) for 2025\u0026ndash;2028 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This represented a significant step in the development of the country\u0026rsquo;s mental health policy framework. It followed the 2021 Green Paper on Mental Health, Estonia\u0026rsquo;s first comprehensive national mental health policy document, and the subsequent Mental Health Action Plan 2023\u0026ndash;2026, adopted by the Ministry of Social Affairs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Important preparatory work had been undertaken earlier by the Mental Health Coalition (VATEK), which in 2016 drafted and submitted the policy document \u003cem\u003eEstonian Mental Health Strategy 2016\u0026ndash;2025\u003c/em\u003e to the Ministry of Social Affairs (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This document served as a precursor to the Green Paper; however, neither it nor the Green Paper was formally approved as a funded policy document accompanied by an action plan. Taken together, these policy developments indicate an increasing national commitment to strengthening mental health governance and reducing suicide mortality at the population level.\u003c/p\u003e \u003cp\u003eThe aim of this study is to analyse suicide trends in Estonia during the period 2000\u0026ndash;2024, focusing on changes in mortality rates, demographic characteristics, and methods of suicide, and to situate these findings within broader European and international comparisons and the evolving national suicide prevention policy framework.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and data sources\u003c/h2\u003e \u003cp\u003eA descriptive time-trend study was conducted using data from the Estonian Causes of Death Registry, maintained by the National Institute for Health Development (Tervise Arengu Instituut; TAI) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). For each death, the registry recorded the year, external cause of death according to ICD-10 codes X60\u0026ndash;X84 (intentional self-harm) and Y87.0 (sequelae of intentional self-harm), as well as sociodemographic characteristics including sex, age, nationality, and educational attainment. The analyses were based on aggregated data covering the period 2000\u0026ndash;2024. Age-standardized mortality rates per 100,000 population were calculated using population denominators obtained from the National Institute for Health Development (TAI).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Variables\u003c/h2\u003e \u003cp\u003eAnalyses considered year of occurrence, method of suicide (ICD-10 X60\u0026ndash;X84), and sociodemographic indicators: sex; five age groups (0\u0026ndash;19, 20\u0026ndash;39, 40\u0026ndash;59, 60\u0026ndash;79, 80+); nationality (Estonian, Russian, Other); and educational level (basic, secondary, higher). Suicide methods were grouped into standard injury-epidemiology categories derived from ICD-10 codes for intentional self-harm (X60\u0026ndash;X84).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eTemporal trends and gender differences were examined using a univariate General Linear Model (GLM) with year as a continuous covariate and gender as a fixed factor. Pairwise comparisons were adjusted using the Bonferroni method, and effect sizes were reported as partial η\u0026sup2;. Within‑gender temporal associations were assessed using Pearson correlation coefficients.\u003c/p\u003e \u003cp\u003eAge‑specific trends were evaluated using separate linear regression models for each age group, with year entered as a continuous predictor; the reported F‑statistics reflect the overall model fit for each regression. A full factorial GLM was used to assess the combined effects of gender, age group, and year on suicide rates, including all main effects and interaction terms (Gender \u0026times; Year, Age_group \u0026times; Year, Gender \u0026times; Age_group, and Gender \u0026times; Age_group \u0026times; Year). Estimated marginal means were calculated with Bonferroni‑adjusted comparisons, and model assumptions were checked using standard residual diagnostics. Educational and nationality differences were analysed using GLMs with fixed categorical factors (three levels each) and year as a covariate. Adjusted marginal means were estimated at Year\u0026thinsp;=\u0026thinsp;2012 (midpoint of the study period) using Type III sums of squares. Method distributions were summarised using frequencies and proportions; gender differences were tested with chi‑square statistics and Cram\u0026eacute;r\u0026rsquo;s V, with effect sizes reported alongside p‑values.\u003c/p\u003e \u003cp\u003eSuicide methods were classified according to ICD‑10 external cause codes (X60\u0026ndash;X84). Method distributions were summarised using frequencies and percentages, and gender differences were assessed using chi‑square tests with Cram\u0026eacute;r\u0026rsquo;s V reported as the effect size. Temporal changes in method use were evaluated across the 25‑year period using two complementary approaches. First, overall shifts in method distribution were tested using chi‑square analyses across all years. Second, directional (linear) temporal trends were assessed using the Linear‑by‑Linear Association (LLA) statistic to determine whether specific methods increased or decreased over time. Gender‑specific temporal patterns were examined separately using the same procedure. For additional clarity, annual method counts were inspected to identify consistent increases, decreases, or irregular fluctuations. All analyses were conducted in IBM SPSS Statistics v29, and statistical significance was defined as α\u0026thinsp;=\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Overall trends in suicide mortality, 2000\u0026ndash;2024\u003c/h2\u003e \u003cp\u003eBetween 2000 and 2024, a total of 6,188 suicides were registered among the Estonian general population. Among these, 4,912 cases were male (79.4%) and 1,276 female (20.6%). The total standardized suicide rate peaked at 28.8 per 100,000 (N 401) in 2001 and declined to 12.7 (N 175) in 2024 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), an overall reduction of approximately 56%. The mean total rate across the period was 18.4 (SD\u0026thinsp;=\u0026thinsp;4.5). Male suicide rates ranged from 48.5 per 100,000 in 2001 to 21.8 in 2024 (mean 31.2, SD 7.9), with a secondary peak occurred in 2009 (35.4) Female rates ranged from 11.8 per 100,000 in 2000 to 4.4 in 2024 (mean 6.8, SD 1.9). Across the full period, male rates were approximately three to five times higher than female rates, mirroring the EU-wide pattern in which men account for around three-quarters of all suicide deaths (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A univariate GLM was statistically significant (R\u0026sup2; = .917, adjusted R\u0026sup2; = .914). A Year showed a significant negative association (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.574, SE\u0026thinsp;=\u0026thinsp;0.053, t(71)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;10.76, p \u0026lt; .001; partial η\u0026sup2; = .620). Gender differences were highly significant (F (1, 71)\u0026thinsp;=\u0026thinsp;334.82, p \u0026lt; .001, partial η\u0026sup2; = .904). Pearson correlations confirmed strong negative trends for total (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.894), males (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.914), and females (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.757; all p \u0026lt; .001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Age-specific trends\u003c/h2\u003e \u003cp\u003eIn 2024, age-specific suicide rates showed a clear age gradient, with the lowest rate observed in the 0\u0026ndash;19 age group (6.5 per 100,000), followed by the 20\u0026ndash;39 group (13.2 per 100,000). Rates increased progressively with age, reaching 15.4 per 100,000 among those aged 40\u0026ndash;59 and 16.2 per 100,000 in the 60\u0026ndash;79 group, with the highest rate recorded among individuals aged 80 and over (20.1 per 100,000), underscoring the elevated suicide risk in the oldest age group. For the period 2000\u0026ndash;2024, suicide rates among individuals aged 0\u0026ndash;19 showed no significant temporal change (F(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;0.96, p = .337, B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.054). All adult groups demonstrated statistically significant declines: 20\u0026ndash;39 years (F(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;42.1, p \u0026lt; .001, B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.536); 40\u0026ndash;59 years, the largest reduction (F(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;90.6, p \u0026lt; .001, B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.187); 60\u0026ndash;79 years (F(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;52.4, p \u0026lt; .001, B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.516); and 80\u0026thinsp;+\u0026thinsp;years (F(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;8.4, p = .008, B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.695) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe gender gap varied across age groups (Gender \u0026times; Age_group: F(4,230)\u0026thinsp;=\u0026thinsp;14.71, p \u0026lt; .001, partial η\u0026sup2; = .204), with the largest male\u0026ndash;female difference observed among adults aged 40\u0026ndash;59, smaller differences in youth, and substantial gaps persisting in older adults. Temporal trends also differed by gender and age. The three‑way interaction was significant (Gender \u0026times; Age_group \u0026times; Year: F(4,230)\u0026thinsp;=\u0026thinsp;14.81, p \u0026lt; .001, partial η\u0026sup2; = .205), indicating that the evolution of suicide rates over time was not uniform across demographic groups. Male rates declined in all age groups, with the steepest decrease in middle‑aged men (B = \u0026minus;\u0026thinsp;3.093, p \u0026lt; .001) and a smaller decline among younger men (B = \u0026minus;\u0026thinsp;1.738, p \u0026lt; .001). Female rates remained largely stable across the study period. Consequently, the gender gap narrowed most rapidly in middle age, narrowed moderately in older adults, and remained relatively unchanged among younger cohorts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Educational disparities\u003c/h2\u003e \u003cp\u003eEducational level had a significant effect on suicide rates (F (2,35)\u0026thinsp;=\u0026thinsp;5.274, p = .010, partial η\u0026sup2; = .231). Suicide rates were highest for those with basic education (mean\u0026thinsp;=\u0026thinsp;17.8), intermediate for secondary (mean\u0026thinsp;=\u0026thinsp;15.9), and lowest for higher education (mean\u0026thinsp;=\u0026thinsp;13.5). The education \u0026times; year interaction (F(2,35)\u0026thinsp;=\u0026thinsp;7.113, p = .003) revealed divergent trajectories: rates declined among individuals with basic education (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.463, p = .001), increased among those with secondary education (B\u0026thinsp;=\u0026thinsp;+\u0026thinsp;0.217, p = .028), and remained stable for higher education (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.052, p = .487), indicating to educational inequalities over time. In the joint gender-education model (R\u0026sup2; = .929), the gender \u0026times; education interaction was large (partial η\u0026sup2; = .496): men with basic education had the highest suicide rates (mean\u0026thinsp;=\u0026thinsp;46.4 vs. mean\u0026thinsp;=\u0026thinsp;12.4 for women), underscoring the compounding effect of male sex and low educational attainment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Nationality\u003c/h2\u003e \u003cp\u003eNationality had a significant but modest effect (F(2,35)\u0026thinsp;=\u0026thinsp;3.596, p = .038, partial η\u0026sup2; = .170). Adjusted marginal means (estimated at Year\u0026thinsp;=\u0026thinsp;2012) were highest for those of Other nationality (mean\u0026thinsp;=\u0026thinsp;16.6), followed by Estonians (mean\u0026thinsp;=\u0026thinsp;15.7) and Russians (mean\u0026thinsp;=\u0026thinsp;13.6); only the Other\u0026ndash;Russian contrast reached significance (p = .014). Crucially, all three groups exhibited nearly identical negative temporal slopes (B\u0026thinsp;\u0026asymp;\u0026thinsp;\u0026minus;\u0026thinsp;0.426), confirming a common downward trajectory irrespective of nationality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Suicide methods\u003c/h2\u003e \u003cp\u003eHanging (X70) dominated throughout, accounting for 75.6% of all deaths (n\u0026thinsp;=\u0026thinsp;4,678) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Firearms comprised 8.0% (n\u0026thinsp;=\u0026thinsp;494) and drug poisoning 5.0% (n\u0026thinsp;=\u0026thinsp;311). Gender differences in method distribution were significant (χ\u0026sup2;(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;546.93, p \u0026lt; .001, Cram\u0026eacute;r\u0026rsquo;s V = .30, indicating a medium-to-large effect) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The overall method distribution changed significantly over time (χ\u0026sup2;(240)\u0026thinsp;=\u0026thinsp;483.52, p \u0026lt; .001), though without a simple linear trend (LLA\u0026thinsp;=\u0026thinsp;3.45, p = .063). Among men, the distribution of suicide methods varied significantly across the 25-year period (χ\u0026sup2;(240)\u0026thinsp;=\u0026thinsp;393.84, p \u0026lt; .001), but no overall directional trend was detected (LLA\u0026thinsp;=\u0026thinsp;0.029, p = .864). Hanging (X70) remained the dominant method throughout, yet its annual counts declined steadily from the early 2000s to the 2020s. Firearms and explosives (X72\u0026ndash;X75) consistently represented the second most common method, showing fluctuations but no clear long-term increase or decrease. Other methods, including poisoning (X60\u0026ndash;X64), sharp objects (X78\u0026ndash;X79), and jumping from height (X80), remained comparatively infrequent and exhibited irregular year-to-year variation without a stable trend. Among women, a significant directional shift occurred (χ\u0026sup2;(240)\u0026thinsp;=\u0026thinsp;335.70, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001; LLA\u0026thinsp;=\u0026thinsp;10.21, \u003cem\u003ep\u003c/em\u003e = .001): poisoning (X60\u0026ndash;X64) increased steadily across the 25-year period, while hanging (X70) declined consistently from its early-2000s peak. These evolving female method patterns warrant continued monitoring, as they may reflect changes in access to means, prescribing practices, or broader shifts in method availability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSuicide methods by gender, Estonia 2000\u0026ndash;2024 (N\u0026thinsp;=\u0026thinsp;6,188)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e ICD-10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX60\u0026ndash;X64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrug poisoning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e191 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e311 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlcohol poisoning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX66\u0026ndash;X69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther poisoning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e119 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHanging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,832 (78.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e836 (66.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,678 (75.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrowning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX72\u0026ndash;X75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirearms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e478 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e494 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX76\u0026ndash;X77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplosives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX78\u0026ndash;X79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCutting/piercing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e158 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJumping from height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e231 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX81\u0026ndash;X82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJumping/lying before object\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eX83\u0026ndash;X84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4,912 (100%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1,276 (100%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e6,188 (100%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Estonia in EU context\u003c/h2\u003e \u003cp\u003eEstonia\u0026rsquo;s 56% reduction in suicide mortality between 2000 and 2024 is one of the steepest sustained declines recorded in the region and reflects the cumulative impact of socioeconomic stabilization, healthcare reform, alcohol harm-reduction policies, and growing national investment in mental health. Nevertheless, with a rate of approximately 12\u0026ndash;14 per 100,000 population in recent years, Estonia remains well above the EU average of 10.2 per 100,000 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). By comparison, the EU average suicide rate stood at approximately 12.4 per 100,000 in 2011 and declined to 10.2 in 2021, indicating that, while Estonia\u0026rsquo;s trajectory of decline has been steeper than the EU average, its suicide rates have consistently remained substantially above the EU mean (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In 2020, Estonia ranked fourth-highest among EU member states, behind Lithuania (21.3), Hungary (17.1), and Slovenia (17.0) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This positioning underscores both the progress achieved and the distance yet to be covered.\u003c/p\u003e \u003cp\u003eThe pattern of decline observed in Estonia parallels, and in magnitude surpasses, trends seen across Eastern Europe more broadly. A 2019 analysis of European suicide trends found significant reductions in 15 of 38 European countries between 2011 and 2019, with the greatest declines in Lithuania, Hungary, Latvia, and Poland. These are all countries that, like Estonia, started from historically elevated baselines (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Critically, European countries that implemented structured national suicide prevention action plans alongside alcohol harm-reduction and mental health reforms showed the most consistent reductions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), supporting the strategic rationale behind Estonia\u0026rsquo;s National Suicide Prevention Action Plan (SETK) 2025\u0026ndash;2028.\u003c/p\u003e \u003cp\u003eThe gender distribution of suicide deaths in Estonia (79.4% male over 2000\u0026ndash;2024) is closely aligned with the EU average (76.7% in 2021) and reflects the well‑documented \u0026ldquo;gender paradox of suicide,\u0026rdquo; in which women report higher levels of suicidal ideation and attempts, while men die by suicide at substantially higher rates (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, earlier national evidence suggests that Estonia partly deviates from this pattern: men also exhibit higher rates of suicide attempts, except in the youngest age groups (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This reinforces the need for prevention strategies that move beyond clinical pathways to reach men in non‑medical settings, including workplaces, community organizations, and digital platforms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Gender, age, and socioeconomic disparities\u003c/h2\u003e \u003cp\u003eThe secondary peak in male suicide rates in 2009, coinciding with the global financial crisis, is consistent with European evidence that economic recessions disproportionately increase suicide risk among men through unemployment, financial hardship, and loss of occupational identity (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This finding reinforces the importance of integrating suicide prevention with labor market and social protection policy \u0026mdash; an emphasis that is reflected in Goal 6 of the National Suicide Prevention Action Plan (SETK) 2025\u0026ndash;2028 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which calls for the integration of suicide prevention into broader health and social promotion activities.\u003c/p\u003e \u003cp\u003eAge-specific declines were most pronounced in the 40\u0026ndash;59 years group, consistent with EU patterns where improvements in healthcare access, alcohol policies, and economic stabilization have benefited middle-aged adults most. The absence of a significant declining trend in the youngest age group (0\u0026ndash;19 years) is a concern shared across Europe, where deteriorating adolescent mental health has been documented in multiple countries following the COVID-19 pandemic (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These age-specific patterns are broadly consistent with EU trends, where improvements in healthcare access and restrictive alcohol policies have contributed most to declines among older age groups, while youth mental health trajectories remain a concern across many EU member states (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In Estonia, approximately 30% of adolescents report feeling depressed on a weekly basis, a figure that has increased over recent years (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Strengthening school-based mental health promotion, digital mental health services for young people, and family support interventions is therefore a shared European priority and a specific focus of the Estonian Mental Health Action Plan 2023\u0026ndash;2026. Among adults in Estonia, depressive symptoms are also widespread. National health surveys indicate that approximately one in five adults reports moderate or severe depressive symptoms, and these rates have shown a gradual increase over the past decade (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Although the prevalence is lower than among adolescents, the adult trend similarly reflects a growing mental‑health burden in the population. These findings underscore the importance of strengthening accessible mental‑health services for adults, including primary‑care\u0026ndash;based screening, digital support tools, and community‑level interventions.\u003c/p\u003e \u003cp\u003eThe educational gradient in suicide mortality documented in this study \u0026mdash; with individuals holding basic education bearing a substantially higher burden \u0026mdash; is consistent with the socioeconomic patterning of suicide risk observed across Europe (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The divergent trends in different educational groups, points to a reshaping of social vulnerability as socioeconomic transformation continues. These findings highlight the importance of targeting prevention resources toward socioeconomically disadvantaged populations, in line with broader EU health equity goals. This socioeconomic gradient in suicide mortality is consistent with finding from other EU countries, where lower educational attainment is a robust predictor of suicide risk (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNationality had a significant but modest effect. These findings contrast with the pattern observed in the early post-independence period, when Russian-speaking populations in Estonia experienced a sharp rise in suicide rates, attributed to their dramatic shift in social status following 1991 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The convergence of trajectories observed in the present data may therefore reflect a gradual stabilisation of social and economic conditions across ethnic groups over the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Suicide methods and means restriction\u003c/h2\u003e \u003cp\u003eThe predominance of hanging across the entire study period (75.6% of all deaths) is consistent with method patterns documented over the last decades in the Baltic States and other Northern and Eastern European countries, where hanging is typically the most common suicide method and represents a major challenge for prevention due to its high lethality and wide accessibility (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Unfortunately, means restriction as an evidence-based method of suicide prevention is not very useful in Estonia, because the primary method is hanging. The significant directional shift among women toward an increase in drug poisoning parallels trends observed in several other EU countries, where strengthened prescription monitoring, safer medication packaging, and restrictions on high‑risk pharmaceuticals have contributed to reductions in poisoning‑related suicides (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These experiences suggest that Estonia could benefit from adopting similar measures, particularly for preventing poisoning‑related suicides among women, where regulatory and clinical interventions may be more feasible and effective than for hanging.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Estonia’s National Suicide Prevention Action Plan (SETK) 2025–2028","content":"\u003cp\u003eThe adoption of Estonia\u0026rsquo;s first National Suicide Prevention Action Plan (SETK) for 2025\u0026ndash;2028 represents a landmark development in national public health policy. Developed on the foundations of the 2021 Green Paper on Mental Health and informed by the European Joint Action on Implementation of Best Practices in Mental Health (JA ImpleMENTAL), the SETK adopts a whole-of-government and whole-of-society approach consistent with WHO recommendations (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Implementation is carried out through the Estonian Ministry of Social Affairs\u0026rsquo; annual work plan, with progress reviewed yearly in collaboration with stakeholders covering health, education, social affairs, justice, NGOs, and research sectors through strategic partnership (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). SETK is structured around eight strategic goals, each corresponding to a distinct pillar of comprehensive suicide prevention (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe eight strategic goals of Estonia's National Suicide Prevention Action Plan (SETK) 2025\u0026ndash;2028 and their key focus areas (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrategic Goal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Focus Areas\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAwareness \u0026amp; knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic awareness campaigns; destigmatization; gatekeeper training; responsible media reporting (Papageno principles)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEarly detection \u0026amp; support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuicide risk screening in primary care; training for GPs, nurses, social workers; integration of mental health into primary healthcare; digital e-consultation platforms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIntervention for high-risk groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrisis lines, walk-in crisis centres emergency psychiatric services; targeted programs for prior attempters, severe mental illness, substance misuse, veterans, prisoners, domestic violence victims\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePostvention/Follow-up after suicide attempts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStructured transitional care protocols; case management; coordinated hospital\u0026ndash;community outreach; improvement of suicide attempt data quality and completeness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMeans restriction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003esafer packaging for analgesics and sedatives; safe storage of firearms and medications; physical barriers at high-risk jumping locations; ligature-point reduction in institutional settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIntegration with health promotion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlcohol harm reduction; workplace mental health programs; reducing social isolation in older adults and rural populations; school-based health programs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCoordination \u0026amp; Governance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectoral partnerships (MoSA, NGOs, research institutions); postvention support for suicide-bereaved; responsible media guidelines; Estonian Mental Health and Well-being Coalition (VATEK) coordination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMonitoring \u0026amp; evaluation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthening cause-of-death registration quality; expanding suicide attempt data collection; standardized WHO/EU indicator reporting; research investment in intervention effectiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe epidemiological findings of this study align closely with the SETK\u0026rsquo;s strategic priorities. The persistent gender gap and dominance of high-lethality methods among men underscore the urgency of Goals 1, 3, and 5. The emerging shift toward jumping from height among women and the stable youth suicide rate reinforce the relevance of Goals 4 and 8. Educational inequalities in suicide mortality point to the importance of Goals 6 and 7 in engaging intersectoral social policy. Taken together, the SETK provides an evidence-responsive framework for translating this study\u0026rsquo;s epidemiological findings into sustained preventive action.\u003c/p\u003e"},{"header":"6. Mental health interventions in Estonia: system-level context","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e6.1 Historical background and early prevention efforts\u003c/h2\u003e \u003cp\u003eThe decline in suicide rates observed from 1994 onwards may be partly attributed to early prevention efforts initiated at the start of Estonia's independence. The Estonian-Swedish Mental Health and Suicidology Institute (ERSI) began its work in 1993, introducing professional training, public awareness campaigns, anti-stigma initiatives, and epidemiological research. These efforts were further formalized in 2000 with the development of the \u003cem\u003eSuitsidaalse K\u0026auml;itumise Preventsiooni Tegevuskava\u003c/em\u003e (\u003cem\u003eAction Plan for prevention of suicidal behaviour)\u003c/em\u003e, commissioned by the Estonian Health Insurance Fund (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, this action plan lacked sufficient financial resources and institutional support and was therefore never implemented.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e6.2 Policy framework\u003c/h2\u003e \u003cp\u003eEstonia\u0026rsquo;s approach to mental health has undergone significant transformation since 2020. Important preparatory work had been undertaken earlier by the Mental Health Coalition (VATEK), which in 2016 drafted and submitted the policy document \u003cem\u003eEstonian Mental Health Strategy 2016\u0026ndash;2025\u003c/em\u003e to the Ministry of Social Affairs. This strategy served as a precursor to the subsequent 2021 Green Paper on Mental Health, the first comprehensive, cross‑sectoral policy document developed under the national Mental Health Task Force (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, neither the VATEK strategy nor the Green Paper was formally approved as a funded policy document accompanied by an implementation plan. The Green Paper nonetheless provided a shared conceptual framework and laid the groundwork for the more operational Estonian Mental Health Action Plan 2023\u0026ndash;2026.\u003c/p\u003e \u003cp\u003eThe 2021 Green Paper on Mental Health was the country\u0026rsquo;s first comprehensive national mental health policy document, developed through a cross-sectoral Mental Health Task Force convening stakeholders from health, education, social affairs, criminal justice, academia, and NGOs (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Building on this, the Ministry of Social Affairs established a Mental Health Department in 2022, and funding for mental healthcare services more than tripled to \u0026euro;7\u0026nbsp;million in 2023 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The Mental Health Action Plan 2023\u0026ndash;2026 is organized around five pillars: innovation; promotion, prevention and self-care (including suicide prevention); community support and intersectoral integration; improvement of mental health services; and crisis preparedness (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The SETK (2025\u0026ndash;2028) represents Estonia's first standalone national suicide prevention policy, signaling a renewed commitment to addressing suicide as a public health priority, implemented through a strategic partnership between the Estonian Ministry of Social Affairs, research institutions, and the NGO sector (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The priorities for the first two years focus primarily on universal prevention activities, including promoting responsible media reporting on suicide. In parallel, the Action Plan includes selective measures, such as continuous surveillance and reporting on suicidal behaviour, as well as indicated interventions, including postvention support for the bereaved. A particular emphasis is placed on developing a systematic follow‑up care pathway for suicide attempters after discharge from emergency departments, an area that has historically lacked structured support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e6.3 Service delivery and digital innovation\u003c/h2\u003e \u003cp\u003eStructural challenges still persist, care pathways remain fragmented, and specialist capacity is constrained. The OECD estimates that mental ill-health costs Estonia approximately 2.8% of GDP annually (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The Mental Health Action Plan 2023\u0026ndash;2026 prioritizes strengthening primary care as the first point of mental health contact, expanding community-based services, and clarifying care pathways connecting self-care, primary care, and specialist services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Several web-based mental-health applications have been developed in Estonia, further strengthening the national digital ecosystem for early recognition and intervention, screening, and prevention. These developments align with broader European initiatives, including MENTBEST (Protecting mental health in times of change; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mentbest.com/\u003c/span\u003e\u003cspan address=\"https://mentbest.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, EAAD (European Alliance Against Depression; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.eaad.net/\u003c/span\u003e\u003cspan address=\"https://www.eaad.net/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, and iFD (iFightDepression; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ifightdepression.com/en\u003c/span\u003e\u003cspan address=\"https://ifightdepression.com/en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), which promote evidence-based community interventions, early-detection strategies, and suicide-prevention practices. In parallel, Estonia has a range of non-governmental organizations that provide crisis support, online counselling, and self-help resources, contributing to a more accessible and integrated prevention infrastructure.\u003c/p\u003e \u003c/div\u003e"},{"header":"7. Implications for policy and practice","content":"\u003cp\u003eThe epidemiological findings of this study map directly onto the strategic objectives of the National Suicide Prevention Action Plan (SETK) 2025\u0026ndash;2028 and the Mental Health Action Plan 2023\u0026ndash;2026. In addition, several points need to be emphasized.\u003c/p\u003e \u003cp\u003eMen with basic education represent the highest-risk group and the population most underserved by conventional mental health pathways. Prevention must embed gender-sensitive approaches across all SETK pillars, including male-targeted awareness campaigns, occupational health programs in male-dominated sectors, and crisis services designed to reduce barriers to help-seeking. This mirrors recommendations emerging from EU-level evaluations of gender-responsive prevention strategies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe sustained dominance of hanging as the leading method across the study period (75.6% of all deaths) is consistent with patterns observed across the Baltic States and other Northern and Eastern European countries, where hanging is typically the most common suicide method and poses substantial challenges for prevention due to its high lethality and limited opportunities for means restriction (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In contrast, the emerging increase in poisoning (X60\u0026ndash;X64) among women highlights an area where preventive action is more feasible. Experiences from other EU countries\u0026mdash;such as strengthened prescription monitoring, safer medication packaging, and restrictions on high‑risk pharmaceuticals\u0026mdash;have contributed to reductions in poisoning‑related suicides and may offer valuable lessons for Estonia. Continued surveillance of poisoning trends is warranted given its historical significance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe stable youth suicide rate and deteriorating adolescent mental health indicators are a shared concern across EU and reinforce the need for sustained investment in school-based programs, digital youth services, and family support interventions. Finally, educational inequalities in suicide mortality call for explicit integration of prevention into social and economic policy frameworks addressing poverty, unemployment, and educational disadvantage, consistent with both the SETK\u0026rsquo;s Goal 6 and broader EU health equity commitments.\u003c/p\u003e"},{"header":"8. Strengths and limitations","content":"\u003cp\u003eA major strength of this study is the use of national, registry-based mortality data spanning 25 years, ensuring comprehensive coverage and high reliability. The consistency of Estonia's suicide death registration system throughout the entire observation period further enhances the temporal comparability of findings and reduces the risk of spurious trends arising from changes in classification practices (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The long observation period allowed for robust assessment of temporal trends, demographic patterns, and method-specific changes across multiple analytical frameworks including GLM, ANOVA, regression, and chi-square analyses.\u003c/p\u003e \u003cp\u003eSeveral limitations must be acknowledged as well. Analyses were based on aggregated data, limiting examination of individual-level risk factors. Some method categories contained small annual counts among women, reducing statistical power. Possible misclassification of suicide deaths as accidental or undetermined intent / causes may result in underestimation, particularly among older adults. Despite these limitations, the study provides a methodologically rigorous, population-level overview of suicide mortality in Estonia with direct relevance for national prevention policy, and universal, and/or selected, indicated level of interventions.\u003c/p\u003e"},{"header":"9. Conclusion","content":"\u003cp\u003eThis study documents a 56% decline of suicide mortality in Estonia between 2000 and 2024. Despite this progress, Estonia\u0026rsquo;s rates remain above the EU average of approximately 10.2 per 100,000, and substantial disparities persist by gender, age, and socioeconomic status. Men with lower educational attainment continue to face disproportionate risk; hanging remains the overwhelmingly dominant method; and an emerging increase in jumping from height among women signals a shifting prevention landscape. Of particular concern is the stable suicide rate among young people, which contrasts with the declining trends observed in other age groups and aligns with deteriorating adolescent mental‑health indicators.\u003c/p\u003e \u003cp\u003eSituated within a European context in which structured national action plans have been associated with the most consistent reductions in suicide mortality, Estonia\u0026rsquo;s adoption of the National Suicide Prevention Action Plan (SETK) 2025\u0026ndash;2028 and the Mental Health Action Plan 2023\u0026ndash;2026 provides an evidence‑aligned framework for sustained progress. The eight strategic goals of the SETK\u0026mdash;spanning awareness, early detection, crisis intervention, follow‑up care, means restriction, intersectoral integration, governance, and monitoring\u0026mdash;directly correspond to the epidemiological priorities identified in this study. Addressing the stagnation in youth suicide rates will require targeted, developmentally appropriate interventions alongside universal and selective measures. Continued investment in community‑based, digital, and gender‑responsive services, underpinned by robust monitoring and cross‑sectoral collaboration, will be essential to closing the gap with the EU average and reducing the human toll of suicide in Estonia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eIt does not apply. The study used aggregated, anonymized mortality registry data and did not involve direct participation of human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003eIt does not apply. This study did not involve individual-level data or personal information requiring consent to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis study was based on aggregated, suicide mortality data from the Estonian Causes of Death Registry and did not involve human participants directly. Formal ethics committee approval was not required under applicable national regulations. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe data used in this study are based on aggregated statistics from the Estonian Causes of Death Registry, maintained by the National Institute for Health Development (Tervise Arengu Instituut; TAI). These data are not publicly available in their original form but may be requested directly from TAI. Population denominator data are publicly available from Statistics Estonia (www.stat.ee).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eZL led the study\u0026rsquo;s conceptualization, data work, methodological development, analysis, preparation of the original manuscript, and revisions. PV provided data‑related assistance, and participated in manuscript writing and editing. MS contributed to methodology, validation, context and editing the content of the manuscript. KM contributed to reviewing and editing the manuscript. AV supervised, supported validation, and supported revisions. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e The authors declare that no funding was received for the conduct of this study or preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Suicide. WHO Fact Sheet. Geneva: WHO; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Suicide worldwide in the 21st century. Geneva: WHO; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGim\u0026eacute;nez A, Fico G et al. Suicide-related mortality trends in Europe 2011\u0026ndash;2019. European Congress of Psychiatry; 2023. 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Estonia sets to improve mental health outcomes with the Mental Health Action Plan 2023\u0026ndash;2026. Copenhagen: WHO Regional Office for Europe; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Live Life: An implementation guide for suicide prevention in countries. Geneva: WHO; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;28(1):1\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang SS, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ. 2013;347:f5239.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEstonian HDR. 2023: Mental health and well-being. Tallinn: Estonian Cooperation Assembly; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026auml;rnik A, K\u0026otilde;lves K, Wasserman D. Suicide among Russians in Estonia: database study before and after independence. BMJ. 2005;330(7484):176\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaido Z, Voracek M, Till B, Pietschnig J, Eisenwort B, Dervic K, Sonneck G, Niederkrotenthaler T. Epidemiology of suicide among children and adolescents in Austria, 2001\u0026ndash;2014. Wien Klin Wochenschr. 2017;129(3\u0026ndash;4):121\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00508-016-1092-8\u003c/span\u003e\u003cspan address=\"10.1007/s00508-016-1092-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Oct 14. PMID: 27743176; PMCID: PMC5318485.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovernment of Estonia. Mental health green paper. Ministry of Social Affairs; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026auml;rnik A, Wasserman D. Examples of how to develop suicide prevention on the five continents: Europe, Estonia. In: Wasserman D, Wasserman C, editors. Oxford Textbook of Suicidology and Suicide Prevention. London: Oxford University Press; 2009. pp. 791\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEstonian Mental Health. and Well-Being Coalition (VATEK). Available from: https://vatek.ee.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEACEA National Policies Platform. Estonia: Mental Health (Chap. 7.5). Available from:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://national-policies.eacea.ec.europa.eu/youthwiki/chapters/estonia/75-mental-health\u003c/span\u003e\u003cspan address=\"https://national-policies.eacea.ec.europa.eu/youthwiki/chapters/estonia/75-mental-health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026auml;rnik P, Sisask M, V\u0026auml;rnik A, Laido Z, et al. Suicide registration in eight European countries: A qualitative analysis of procedures and practices. Forensic Sci Int. 2010;202(1\u0026ndash;3):86\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.forsciint.2010.04.032\u003c/span\u003e\u003cspan address=\"10.1016/j.forsciint.2010.04.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"suicide epidemiology, Estonia, gender disparities, suicide methods, suicide prevention, national suicide prevention action plan","lastPublishedDoi":"10.21203/rs.3.rs-9413966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9413966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuicide remains a significant public health concern in Estonia. Despite a marked decline in mortality since the early 2000s, rates continue to exceed the European Union average, particularly among men. Estonia adopted its first National Suicide Prevention Action Plan (SETK) for 2025\u0026ndash;2028, providing a structured framework for evidence-based prevention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive time-trend study was conducted using data from the Estonian Causes of Death Registry for the period 2000\u0026ndash;2024. Suicide deaths coded as ICD-10 X60\u0026ndash;X84 and Y87.0 were analysed by year, sex, age group (0\u0026ndash;19, 20\u0026ndash;39, 40\u0026ndash;59, 60\u0026ndash;79, 80+), nationality, educational level, and method. Age-standardized rates per 100,000 population were computed. Temporal trends were examined using general linear models (GLM), Pearson correlation, ANOVA, and linear regression. Method-specific trends were assessed using chi-square tests with linear-by-linear association.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBetween 2000 and 2024, 6,188 suicide deaths were registered (79.4% male). Total standardized suicide rates declined by approximately 56%, from the highest suicide rate of 28.8 per 100,000 (N 401) in 2001 to 12.7 (N 175) in 2024. Gender remained the dominant predictor of suicide mortality (partial η\u0026sup2; = .904). Hanging (X70) accounted for 75.6% of all deaths. For the period 2000\u0026ndash;2024, suicide rates among individuals aged 0\u0026ndash;19 showed no significant temporal change. Suicide rates were highest among individuals with basic education, with divergent temporal trends across educational groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEstonia has achieved substantial reductions in suicide mortality, yet persistent gender disparities and evolving method patterns underline the need for targeted, gender-responsive prevention strategies. The findings directly inform implementation of the 2025\u0026ndash;2028 National Suicide Prevention Action Plan (SETK) and the broader Mental Health Action Plan 2023\u0026ndash;2026.\u003c/p\u003e","manuscriptTitle":"Epidemiology of suicide in Estonia, 2000–2024: Trends, demographic patterns, and implications for the National Suicide Prevention Action Plan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 15:40:31","doi":"10.21203/rs.3.rs-9413966/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4806a4d6-fc2b-4caf-9cdd-f54cc813a4ba","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-08T09:03:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T18:55:13+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T05:59:22+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T09:12:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 15:40:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9413966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9413966","identity":"rs-9413966","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}