In this study, we explored the burden of mental health-related mortality in Estonia, Latvia, and Lithuania from 2007 to 2018. The aim was to examine the changing pattern of mortality from mental disorders, suicides, alcohol and drug use disorders, and external causes of death. Better understanding what groups of causes of death related to mental health are the most responsible for years of life lost in population is particularly important for the post-soviet countries, where lacking comprehensive scientific evidence coincides with inadequate and/or poorly implemented policies. Such long-lasting contradiction persists despite a striking burden related to excess deaths such as suicides. Although the situation has been improving especially in reducing suicide mortality, the post-soviet region including the Baltic countries, Russia, and Belarus remains a hotspot of suicide mortality in Europe and globally .
Results of our study show that the proportion of ASYR from mental disorders in all three countries was relatively small when compared to other causes of death. However, it was much higher when including suicide, substance use-related causes of death, and external causes of death. Although it is obvious that not all external causes of death are related to mental health, we argue that there is a solid evidence showing a strong association between mental disorders and increased risk of dying from specific external causes such as suicide [12, 26].
We found two clear trends of mortality from mental disorders that are worth discussing. First, it was a clear increase in ASYR from mental disorders both for males and females in Latvia. This trend goes in line with mortality from mental disorder trends in other developed countries like Sweden, Germany or United Kindom . However, there was no such trend in Estonia or Lithuania. On the contrary, Estonia showed a sudden decrease in ASYR from mental disorders starting from 2008, which was caused by reduced mortality from mental disorders due to use of alcohol.
Data from international mortality databases [8, 31, 32] show that mortality indicators from mental disorders (F00-F99) in the Baltic States are still relatively low when compared to other EU countries. For example, standardized mortality rate for mental and behavioural disorders in Lithuania in 2015 was 3 deaths per 100,000 population. While the same indicator in France was 16, Germany – 24, Netherlands – 36 deaths per 100,000 population . Data from France show that majority of causes of death in mental and behavioural disorders group was dementias (F01, F03) which mainly concentrated among 65+ years age group. Such a pattern can be explained by the different overall causes of death structure in Western Europe and post-soviet countries. The Baltic States suffered a long-lasting health crisis which disturbed entering into the cardiovascular revolution that allowed Western Europe to maintain rapid progress in life expectancy . As a result, cardiovascular diseases are still dominant cause of death, especially among elder population in Estonia, Latvia, and Lithuania. Nevertheless, standardized mortality rates for other mental health-related causes of death such as suicide and alcohol-related mortality remains very high in the Baltic States when compared to othe EU countries [8, 32].
Our findings indicate that during 2007-2018, the measurements of the burden of mental health-related mortality showed pronounced differences in patterns and directions of changes across the three seemingly similar countries still suffering from common problems from the soviet past. The trajectories of changes were also diverging for various mental health-related causes of death. ASYR from suicide and external causes of death were decreasing but remained very high in the international context. The proportion of ASYR from suicide when compared to ASYR from all deaths stagnated (in Lithuania) or even increased (in Estonia and Latvia). Lithuania was the only country which showed substantial decrease in ASYR from alcohol and drug use disorders.
Our study suggests about large ASYR disparities in mental health-related causes of death by sex and age group. The burden of mental health-related mortality was concentrated among males, especially of working ages. Findings confirm prior evidence showing large sociodemographic disparities in suicide in three countries [13, 34, 35]. A previous study on determinants of male suicide in Lithuania confirmed that lower educated, unemployed or economically inactive, non-married, residing or being born in rural areas experience a particularly high risk of suicide . The same study also showed that residing in socioeconomically disadvantaged areas has an additional positive effect on increasing male suicide risk which persists even after controlling for major individual-level characteristics. These risk groups and persisting inequalities should be taken into account in planning and implementing mental health policies.
We found a substantial decrease in ASYR from alcohol and drug use-related causes of death for both males and females in Lithuania. It is notable that the observed decrease in this group of causes of death was mainly driven by a notable reduction in alcohol-related mortality. It is a noteworthy that the progress in reducing alcohol-related mortality from 2007 was an important contributor to increase in life expectancy . This improvement was associated with important alcohol control policy measures implemented in 2007-2018 [22, 36]. During the reference period, Lithuania introduced several comprehensive alcohol control measures: banned alcohol advertising, shortened retail hours, raised excise tax, introduced criminal charges for drunk driving, reduced the blood alcohol concentration permitted for novice drivers, banned alcohol sales in petrol stations, increased legal age of drinking to 20 years [22, 37]. This evidence indicates a strong potential of further reduction of the mortality burden of mental health-related causes of death by reducing the harm of alcohol .
Current literature stresses the threat of growing importance of drug-related epidemics leading to notable mortality increases in some countries such as the US and Canada [39,40,41]. Although, with an exception of the UK, there is no significant evidence about similar scale crisis in Europe, there are some warning signs, including transient peaks in opioid-related consumption, poisoning, and mortality in the three Baltic countries . We have included accidental poisoning by drugs (X42) which includes opioids, cocaine, etc. in our analysis. However, number of deaths due to alcohol poisoning was higher when compared to drug poisoning.
Mental health-related mortality had significant impact to overall mortality in the Baltic states. The total number of ASYR from suicide and substance use disorders decreased in all three countries for both males and females. However, in Estonia and Latvia, the share of the burden of these deaths in the total ASYR remained high and even increased. Thus, we suggest that improvement in suicide and substance use-related mortality lagged behind the improvement in overall mortality in Estonia and Latvia. However, that was not the case in Lithuania, which showed a significant decrease in substance use-related mortality. Both the total number of ASYR and share in overall mortality significantly decreased during the reference period.
Our study has several limitations which have to be mentioned. First of all, there are a few important methodological limitations related to the list of causes of death we used. It should be noted that results of previous studies and meta-analyses have shown that alcohol and illicit drug use is related to many causes of death and its groups [43, 44]. However, in this study, we have used a short list of the most numbered substance use-related causes of death such as alcohol or drug poisoning, alcohol liver disease, and others. Therefore, the total burden of substance use-related mortality could be underestimated in our study.
We also included external causes of death in our analyses dedicated to examining the burden of mental illness and substance use-related mortality. On one hand, it is very difficult to estimate the exact fraction of external causes of death related to alcohol use or mental health problems. Moreover, it is often difficult to determine causal relationships between specific mental disorders and specific external causes of death. On the other hand, there are numerous studies showing the relationship between substance use and external causes of death [24, 43, 44]. For example, the Lithuanian autopsy data show, that 56.8% of blood samples taken from the persons who died from external causes of death contained alcohol in blood . In Estonia, alcohol in blood was found in 48.7% of males who died from suicide in 1981–1992 . The most recent data on persons who died from external causes of death in Lithuania  shows that the share of positive blood samples remains very high (54.7%).
Mental health-related disorders such as substance use-related illnesses may lead to death. On the contrary, many health conditions increase the risk for a mental disorder or lengthen episodes of mental illness . Therefore, the burden of mental health-related mortality is often underestimated by including only mental disorders and substance use-related mortality [1, 4]. Previous studies show that a large proportion of suicides are related to mental disorders [46, 47] and alcohol abuse . Moreover, meta-analyses and population-based studies reported that mental disorders are independently associated with a substantial excess in all-cause mortality risk .
Recent two decades have been marked by important changes in the field of mental health globally. On one hand, there was increasing agreement that mental health and mental healthcare are obvious priorities for health policies . On the other hand, there was increasing evidence that investments in the prevailing biomedical model do not result in expected outcomes. Important documents by World Health Organization , UN Human Rights Council , and other international, regional organizations have urged goverments and other stakebolders to move to such mental health policies and services that are fully in line with human rights-based approach and evidence.
The region of the Baltic States has seen a respectable development during the two most recent decades. However, further progress is needed in the areas of human rights and community services. Historically, mental health systems in the region have been affected for many decades by the legacy of institutionalization, social exclusion, over-medicalization, and discrimination. Thirty years of democracy and independence have not fully abandoned the effects of that legacy. Political will is needed to invest more not just in existing infrastructure and technology, but to change the system so that mental health policies and services are liberated from a legacy of discrimination.