Impact of health spending on hospitalization rates in Baltic countries: a comparative analysis.

INTRODUCTION: This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020. METHOD: We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita. RESULTS: Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models. CONCLUSIONS: The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts.

The Impact of Raising Alcohol Taxes on Government Tax Revenue: Insights from Five European Countries.

BACKGROUND AND OBJECTIVE: Reducing the affordability of alcoholic beverages by increasing alcohol excise taxation can lead to a reduction in alcohol consumption but the impact on government alcohol excise tax revenue is poorly understood. This study aimed to (a) describe cross-country tax revenue variations and (b) investigate how changes in taxation were related to changes in government tax revenue, using data from Estonia, Germany, Latvia, Lithuania and Poland. METHODS: For the population aged 15 years or older, we calculated the annual per capita alcohol excise tax revenue, total tax revenue, gross domestic product and alcohol consumption. In addition to descriptive analyses, joinpoint regressions were performed to identify whether changes in alcohol excise taxation were linked to changes in alcohol excise revenue since 1999. RESULTS: In 2022, the per capita alcohol excise tax revenue was lowest in Germany (€44.2) and highest in Estonia (€218.4). In all countries, the alcohol excise tax revenue was mostly determined by spirit sales (57-72% of total alcohol tax revenue). During 2010-20, inflation-adjusted per capita alcohol excise tax revenues have declined in Germany (- 22.9%), Poland (- 19.1%) and Estonia (- 4.2%) and increased in Latvia (+ 56.8%) and Lithuania (+ 49.3%). In periods of policy non-action, alcohol consumption and tax revenue showed similar trends, but tax level increases were accompanied by increased revenue and stagnant or decreased consumption. CONCLUSIONS: Increasing alcohol taxation was not linked to decreased but increased government revenue. Policymakers can increase revenue and reduce alcohol consumption and harm by increasing alcohol taxes.

Does higher alcohol consumption affect attitudes towards alcohol control measures in Estonia?

Objectives: To analyze whether higher alcohol consumption is associated with negative attitudes towards stricter alcohol control policy measures in Estonia. Study design: Cross-sectional analysis of nationally representative data from 2022 (n = 2059). Methods: Attitudes towards seven alcohol control measures and their association with high-risk alcohol consumption (>140 g absolute alcohol for men and >70 g for women per week) were analyzed using used descriptive statistics and binary logistic regression using nationally representative data on Estonian 15-74-year-old population. Results: In general, high-risk consumption associated with lower acceptance for alcohol control policies. Although men had higher prevalence of opposing alcohol control measure for every item considered, both men and women with high-risk alcohol consumption were significantly more likely to be against alcohol control measures in general even after accounting for the variation by demographic characteristics. Conclusions: As public opinion is detrimental to the successful implementation of alcohol policies, these findings emphasize the need to communicate alcohol-related harms to the public in order to increase awareness and support for alcohol control policies.

Estonian alcohol control legislation in 1990-2020: A narrative review.

ISSUES: The aim of this narrative review is to provide a detailed, chronological overview on the development of Estonian alcohol control legislation during 1990-2020. APPROACH: Qualitative document review focused on six legislative acts central to Estonian alcohol control policy. Distinguishing four policy areas (availability, advertising, taxation and drink-driving), the review identifies and describes significant changes in these legislative acts and their amendments from 1990 to 2020. KEY FINDINGS: The review identified 51 significant changes in acts regulating either availability, advertising, taxation or drink-driving in Estonia. Majority of these changes (n = 36) relate to Alcohol Excise Duty Act and the Alcohol Act which regulate the taxation, production and sales of alcohol. Although all six key legislative acts were introduced during the 1990s, only a few significant changes to alcohol control policy were made in this decade. In contrast, the 2000s experienced an intense period of new legislation and amendments followed by 2010s when the main emphasis was on alcohol taxation and advertising. IMPLICATIONS: During three decades, Estonian alcohol control legislation has gradually evolved to include most evidence-based measures to reduce the harmful use of alcohol, the effects of the policies on consumption and alcohol-related harms remain relatively modest. CONCLUSION: The liberal and unregulated alcohol control measures in the 1990s have transitioned in the following two decades towards a coherent alcohol policy. While many of the World Health Organization's 'best buys' have been successfully implemented, there are still some recommendations which have not been targeted.

Impact of the WHO "best buys" for alcohol policy on consumption and health in the Baltic countries and Poland 2000-2020.

Alcohol use is a major risk factor for burden of disease. This narrative review aims to document the effects of major alcohol control policies, in particular taxation increases and availability restrictions in the three Baltic countries (Estonia, Latvia, and Lithuania) between 2000 and 2020. These measures have been successful in curbing alcohol sales, in general without increasing consumption of alcoholic beverages from unrecorded sources; although for more recent changes this may have been partly due to the COVID-19 pandemic. Moreover, findings from time-series analyses suggest improved health, measured as reductions in all-cause and alcohol-attributable mortality, as well as narrowing absolute mortality inequalities between lower and higher educated groups. For most outcomes, there were sex differences observed, with alcohol control policies more strongly affecting males. In contrast to this successful path, alcohol control policies were mostly dismantled in the neighbouring country of Poland, resulting in a rising death toll due to liver cirrhosis and other alcohol-attributable deaths. The natural experiment in this region of high-income European countries with high consumption levels highlights the importance of effective alcohol control policies for improving population health.

Alcohol-attributable mortality and alcohol control policy in the Baltic Countries and Poland in 2001-2020: an interrupted time-series analysis.

BACKGROUND: The Baltic countries-Lithuania, Latvia and Estonia-are characterized by a high rate of fully alcohol-attributable mortality, compared with Poland. Alcohol control policy measures implemented since 2001 in the Baltic countries included a restriction on availability and an increase in excise taxation, among others. The aim of the current study was to evaluate the relationship between alcohol control policy implementation and alcohol-attributable mortality in the Baltic countries and Poland. METHODS: Alcohol-attributable mortality data for 2001-2020 was defined by codes 100% alcohol-attributable for persons aged 15 years and older in the Baltic countries and Poland. Alcohol control policies implemented between 2001 and 2020 were identified, and their impact on alcohol-attributable mortality was evaluated using an interrupted time-series methodology by employing a generalized additive model. RESULTS: Alcohol-attributable mortality was significantly higher in the Baltic countries, compared with Poland, for both males and females. In the final reduced model, alcohol control policy significantly reduced male alcohol-attributable mortality by 7.60% in the 12 months post-policy implementation. For females, the alcohol control policy mean-shift effect was higher, resulting in a significant reduction of alcohol-attributable mortality by 10.77% in the 12 months post-policy implementation. The interaction effects of countries and policy tested in the full model were not statistically significant, which indicated that the impact of alcohol control policy on alcohol-attributable mortality did not differ across countries for both males and females. CONCLUSIONS: Based on the findings of the current study, alcohol control policy in the form of reduced availability and increased taxation was associated with a reduction in alcohol-attributable mortality among both males and females.

Estonian National Mental Health Study: Design and methods for a registry-linked longitudinal survey.

OBJECTIVES: The Estonian National Mental Health Study (EMHS) was conducted in 2021-2022 to provide population-wide data on mental health in the context of COVID-19 pandemic. The main objective of this paper is to describe the rationale, design, and methods of the EMHS and to evaluate the survey response. METHODS: Regionally representative stratified random sample of 20,000 persons aged 15 years and older was drawn from the Estonian Population Register for the study. Persons aged 18 years and older at the time of the sampling were enrolled into three survey waves where they were invited to complete an online or postal questionnaire about mental well-being and disorders, and behavioral, cognitive, and other risk factors. Persons younger than 18 years of age were invited to fill an anonymous online questionnaire starting from wave 2. To complement and validate survey data, data on socio-demographic, health-related, and environmental variables were collected from six national administrative databases and registries. Additionally, a subsample was enrolled into a validation study using ecological momentary assessment. RESULTS: In total, 5636 adults participated in the survey wave 1, 3751 in wave 2, and 4744 in wave 3. Adjusted response rates were 30.6%, 21.1%, and 27.6%, respectively. Women and older age groups were more likely to respond. Throughout the three survey waves, a considerable share of adult respondents screened positive for depression (27.6%, 25.1%, and 25.6% in waves 1, 2, and 3, respectively). Women and young adults aged 18 to 29 years had the highest prevalence of depression symptoms. CONCLUSIONS: The registry-linked longitudinal EMHS dataset comprises a rich and trustworthy data source to allow in-depth analysis of mental health outcomes and their correlates among the Estonian population. The study serves as an evidence base for planning mental health policies and prevention measures for possible future crises.

Socio-demographic and regional differences in unmet healthcare needs among migrants in Europe.

BACKGROUND: Different barriers that hinder migrants' access to healthcare may have detrimental effect on health but also contribute to health inequalities. Given the lack of evidence on unmet healthcare needs among European migrant population, the study aimed to analyse the demographic, socio-economic and health-related patterning of unmet healthcare needs among migrants in Europe. METHODS: European Health Interview Survey data from 2013-2015 covering 26 countries was used to analyse associations of individual-level factors and unmet healthcare needs among migrants (n = 12,817). Prevalences and 95% confidence intervals for unmet healthcare needs were presented for geographical regions and countries. Associations between unmet healthcare needs and demographic, socio-economic, and health indicators were analysed using Poisson regression models. RESULTS: The overall prevalence of unmet healthcare needs among migrants was 27.8% (95% CI 27.1-28.6) but the estimate varied substantially across geographical regions in Europe. Unmet healthcare needs due to cost or access were patterned by various demographic, socio-economic, and health-related indicators but higher prevalence of UHN were universally found for women, those with the lowest income, and poor health. CONCLUSIONS: While the high level of unmet healthcare needs illustrate migrants' vulnerability to health risks, the regional variations in the prevalence estimates and individual-level predictors highlight the variations in national policies regarding migration and healthcare legislations and differences in welfare-systems across Europe in general.

Alcohol control policies reduce all-cause mortality in Baltic Countries and Poland between 2001 and 2020.

Alcohol consumption in the Baltic countries and Poland is among the highest globally, causing high all-cause mortality rates. Contrary to Poland, the Baltic countries have adopted many alcohol control policies, including the World Health Organization (WHO) "best buys". The aim of this study was to evaluate the impact of these policies, which were implemented between 2001 and 2020, on all-cause mortality. Monthly mortality data for men and women aged 20+ years of age in Estonia, Latvia, Lithuania, and Poland were analysed for 2001 to 2020. A total of 19 alcohol control policies, fulfilling an a-priori defined definition, were implemented between 2001 and 2020 in the countries of interest, and 18 of them could be tested. Interrupted time-series analyses were conducted by employing a generalized additive mixed model (GAMM) for men and women separately. The age-standardized all-cause mortality rate was lowest in Poland and highest in Latvia and had decreased in all countries over the time period. Taxation increases and availability restrictions had short-term effects in all countries, on average reducing the age-standardized all-cause mortality rate among men significantly (a reduction of 2.31% (95% CI 0.71%, 3.93%; p = 0.0045)). All-cause mortality rates among women were not significantly reduced (a reduction of 1.09% (95% CI - 0.02%, 2.20%; p = 0.0554)). In conclusion, the alcohol control policies implemented between 2001 and 2020 reduced all-cause mortality among men 20+ years of age in Baltic countries and Poland, and thus, the practice should be continued.

Classifying alcohol control policies enacted between 2000 and 2020 in Poland and the Baltic countries to model potential impact.

AIMS: The study's aim is to identify and classify the most important alcohol control policies in the Baltic countries (Estonia, Latvia and Lithuania) and Poland between 2000 and 2020. METHODS: Policy analysis of Baltic countries and Poland, predicting potential policy impact on alcohol consumption, all-cause mortality and alcohol-attributable hospitalizations was discussed. RESULTS: All Baltic countries implemented stringent availability restrictions on off-premises trading hours and different degrees of taxation increases to reduce the affordability of alcoholic beverages, as well as various degrees of bans on alcohol marketing. In contrast, Poland implemented few excise taxation increases or availability restrictions and, in fact, reduced stipulations on prior marketing bans. CONCLUSIONS: This classification of alcohol control policies in the Baltic countries and Poland provides a basis for future modeling of the impact of implementing effective alcohol control policies (Baltic countries), as well as the effects of loosening such policies (Poland).

Do alcohol control policies have the predicted effects on consumption? An analysis of the Baltic countries and Poland 2000-2020.

BACKGROUND: Many population-based alcohol control policies are postulated to work via changes in adult alcohol per capita consumption (APC). However, since APC is usually assessed on a yearly basis, often there are not enough data to conduct interrupted time-series or other controlled analyses. The current dataset, with 21 years of observation from four countries (Estonia, Latvia, Lithuania, and Poland), had sufficient power to test for average effects and potential interactions of the World Health Organization's (WHO) three "best buys" for alcohol control: taxation increases leading to a decrease in affordability; reduced availability (via a decrease in opening hours of at least 20 %); and advertising and marketing restrictions. We postulated that the former two would have immediate effects, while the latter would have mid- to long-term effects. METHODS: Linear regression analysis. RESULTS: Taxation increases and availability reductions in all countries were associated with an average reduction in APC of 0.83 litres (ℓ) of pure alcohol per year (95 % confidence interval: -1.21 ℓ, -0.41 ℓ) in the same year, with no significant differences between countries. Restrictions on advertising and/or marketing had no significant immediate associations with APC (average effect 0.04 ℓ per year; 95 % confidence interval: -0.65 ℓ, 0.73 ℓ). Several sensitivity analyses corroborated these main results. CONCLUSIONS: The WHO "best buy" alcohol control policies of taxation increases and availability restrictions worked as postulated in these four northeastern European Union countries.

Health-Related Quality of Life and Its Socio-Demographic and Behavioural Correlates during the COVID-19 Pandemic in Estonia.

The aim of the study was to analyse health-related quality of life (HRQoL) among the Estonian general population and its socio-demographic and behavioural correlates during the COVID-19 pandemic. Longitudinal data on 1781 individuals from an Estonian rapid-assessment survey on COVID-19 were used. HRQoL was assessed with the EQ-5D-3L in June 2020 (baseline) and in May 2021 (follow-up). The HRQoL index score and its socio-demographic and behavioural variations were analysed using paired t-tests and Tobit regression modelling. Statistically significant declines in mean EQ-5D index scores were observed for all socio-demographic and behavioural variables considered. Most of these changes were due to increased reporting of problems in the pain/discomfort and anxiety/depression health domains. Older age, being unemployed or economically non-active and having financial difficulties were significantly associated with lower HRQoL in both baseline and follow-up measurements. In the follow-up data, women had significantly lower HRQoL compared to men, whereas higher education proved to be the only protective factor regarding HRQoL. Unhealthy dietary habits and low physical activity had a negative impact on the HRQoL score in the follow-up data. These results indicate that the COVID-19 pandemic has had a substantial impact on HRQoL in the Estonian population.

Socio-economic and demographic patterns of mental health complaints among the employed adults in Estonia.

BACKGROUND: Mental health problems follow a distinct socio-economic gradient and contribute to the health inequalities. The study aims to analyse the socio-economic and demographic factors of self-reported mental health complaints (stress, depressiveness, overtiredness, suicidal thoughts) among employed adult population in Estonia. METHODS: Data on 4041 employed respondents (2064 men and 1977 women) aged 20-64 years from nationally representative health surveys from years 2016 and 2018 in Estonia were used for the study. Dependent variables included self-reported stress, depressiveness, overtiredness, and suicidal thoughts. Descriptive statistics and both log-binomial and Poisson regression analysis were used to describe the socio-economic and demographic variations in these mental health complaints. RESULTS: More than half of the respondents had either stress, depressiveness, overtiredness or suicidal thoughts with 25% reporting two or more of mental health complaints. Lower personal income was associated with higher rates of all mental health complaints (stress, depressiveness, overtiredness, and suicidal thoughts) among employed adults in Estonia. Additionally, lower education was associated with higher prevalence of depressiveness and lower job skills predicted higher prevalence of suicidal thoughts. Higher prevalence ratios for depressiveness and overtiredness were found for women compared to men whereas Estonians had higher prevalence ratios for stress and suicidal thoughts compared to non-Estonians. All mental health complaints were more frequently reported at younger ages (compared to 50-64-year olds) and by not married or cohabiting respondents. CONCLUSION: High prevalence of mental health complaints and their socio-economic and demographic patterning refer to considerable inequalities in mental health among employed adults. Policy actions targeting especially younger adults and those with financial difficulties are needed to address these early manifestations of mental health problems.

Perceived Stress During the First Wave of COVID-19 Outbreak: Results From Nationwide Cross-Sectional Study in Estonia.

Objective: To study the population-level mental health responses during the first wave of coronavirus disease 2019 (COVID-19) outbreak in Estonia and analyze its socio-demographic, behavioral, and health-related variations among general population. Methods: This study used nationally representative data on 4,606 individuals, aged 18-79 years from a rapid-response cross-sectional survey conducted in April 2020. Point prevalence and mutually adjusted prevalence rate ratios for perceived stress from log-binomial regression analysis were presented for socio-demographic, behavioral, and health-related variables. Results: This study found that 52.2% of population aged 18-79 reported elevated stress levels in relation to COVID-19 outbreak. Higher levels of perceived stress were found in women, in younger age groups, in Estonians, and in those with higher self-perceived infection risk, presence of respiratory symptoms, and less than optimal health, according to self-reports. Conclusion: Although, the potential long-term health effects of the current crisis are yet unknown, the alarmingly high stress levels among people indicate that the COVID-19 pandemic might have had a widespread effect on people's mental health.

Age, Period and Cohort Effects On Alcohol Consumption In Estonia, 1996-2018.

AIMS: To analyse the independent effects of age, period and cohort on estimated daily alcohol consumption in Estonia. METHODS: This study used data from nationally representative repeated cross-sectional surveys from 1996 to 2018 and included 11,717 men and 16,513 women aged 16-64 years in total. The dependent variables were consumption of total alcohol and consumption by types of beverages (beer, wine and strong liquor) presented as average daily consumption in grams of absolute alcohol. Mixed-effects negative binomial models stratified by sex were used for age-period-cohort analysis. RESULTS: Alcohol consumption was highest at ages 20-29 years for both men and women and declined in older ages. Significant period effects were found indicating that total alcohol consumption and consumption of different types of beverages had increased significantly since the 1990s for both men and women. Cohort trends differed for men and women. Men born in the 1990-2000s had significantly lower daily consumption compared to earlier cohorts, whereas the opposite was found for women. CONCLUSION: While age-related patterns of alcohol consumption are aligned with life course stages, alcohol use has increased over the study period. Although the total daily consumption among men is nearly four times higher than among women, the cohort trends suggest convergence of alcohol consumption patterns for men and women.

Long-term trends in the body mass index and obesity risk in Estonia: an age-period-cohort approach.

OBJECTIVES: To analyse the age, period and cohort effects on the mean body mass index (BMI) and obesity over the past two decades in Estonia. METHODS: Study used data from nationally representative repeated cross-sectional surveys on 11,547 men and 16,298 women from 1996 to 2018. The independent effects of age, period and cohort on predicted mean BMI and probability of obesity (BMI ≥ 30 kg/m2) were modelled using hierarchical age-period-cohort analysis. RESULTS: Curvilinear association between age and mean BMI was found for men, whereas the increase in mean BMI was almost linear for women. The predicted mean BMI for 40-year-old men had increased by 6% and probability of obesity by 1.8 times over 1996-2018; the period effects were slightly smaller for women. Men from the 1970s birth cohort had higher mean BMI compared to the average, whereas no significant cohort effects were found for obesity outcome. CONCLUSIONS: Population-level BMI changes in Estonia during 1996-2018 were mostly driven by period rather than cohort-specific changes.

E-Cigarette Use by Smoking Status in Estonia, 2012-2018.

Abstract: Background: In the context of declining smoking rates in Estonia, this study aims to analyze the recent trends in e-cigarette use and its associations with smoking status and sociodemographic factors. Methods: Nationally representative data from biennial cross-sectional health surveys in 2012-2018 (n = 9988) were used to describe the prevalence of smoking and e-cigarette use by smoking status in Estonia. Multivariate logistic regression analysis was used to describe the sociodemographic patterns of e-cigarette use in three subgroups: the general population, smokers, and ex-smokers. Results: The prevalence of current smoking decreased from 45.4% in 2012 to 31.5% in 2018 among men and from 26.6% to 20.0% among women. At the same time, e-cigarette use in the general population had increased to 3.7% among men and to 1.2% among women. The increase in the prevalence of e-cigarette use was statistically significant among men in the general population, smokers, and ex-smokers, but non-significant among women. In addition to period effects, e-cigarette use was patterned by age, gender, and education. Conclusion: In 2002-2018, the e-cigarette use had increased but smoking had decreased in Estonia. A timely and targeted tobacco policy may alleviate the harm of e-cigarette use from the public health perspective.

The Cost-Effectiveness of Abdominal Aortic Aneurysm Screening in Estonia.

OBJECTIVE: To assess the cost-effectiveness of population-based abdominal aortic aneurysm (AAA) screening in Estonia. METHODS: A Markov cohort model was used to evaluate the cost-effectiveness of population-based AAA screening compared with no screening. A hypothetical cohort of 6000 men aged 65 was followed for 35 years. Data for disease transition probabilities and quality of life outcomes were obtained from published literature; costs were calculated based on Estonian data. Analysis followed the healthcare payer's perspective using an annual discount rate of 5% for costs and effects. The model evaluated the number of avoidable AAA ruptures and AAA-related deaths and the differences in costs and quality-adjusted life-years (QALYs). RESULTS: The AAA screening would have prevented 10 AAA ruptures and 6 AAA-related deaths among the cohort of 6000 men, resulting in 23 QALYs gained (0.000378 QALYs per individual). The additional cost of the screening and treatment was €39 429 (€65.4 per individual) with the incremental cost-effectiveness ratio for screening compared with no screening being €17 303 per QALY gained. Although results were sensitive to assumptions regarding health-related quality of life and the models' time horizon, screening was found to be cost-effective with a 99% probability at a willingness-to-pay threshold of €30 000 per QALY. CONCLUSION: Population-based AAA screening of elderly men is likely to be a cost-effective measure in reducing the AAA-related disease burden. Given the increase in the overall costs, the actual policy decisions regarding implementing an AAA screening program in Estonia are likely to be influenced by availability of resources as well.

Factors associated with improving diet and physical activity among persons with excess body weight.

BACKGROUND: As overweight and obesity are highly prevalent in Eastern Europe, the study examined the trends and factors associated with self-reported weight reducing behaviours among individuals with excess body weight in Estonia. METHODS: Study used nationally representative cross-sectional data from 2006 to 2016 including 4302 men and 3627 women aged 20-64 years with excess body weight (BMI ≥ 25). Trends in the prevalence of changing eating habits and physical activity and their sociodemographic and health-related correlates were studied using descriptive statistics and multivariable logistic regression. RESULTS: Among overweight or obese respondents, 41% of men and 48% of women reported improvements in dietary habits and 19% of men and women reported increase in physical activity during the past 12 months in 2016. Positive trend for 2006-2016 regarding both outcomes was observed for men whereas no statistically significant differences were found for women. Women and those with lower than tertiary education had higher odds for reporting change in eating habits whereas older age and smoking or excessive alcohol consumption reduced the odds. Improvement in physical activity was more likely among younger respondents, women, ethnic Estonians and those with tertiary education, whereas poorer health and smoking reduced the odds. Weight-related advice from health professionals or family had strong effect on both outcomes. CONCLUSION: Socio-demographic and health profiles differentiate the self-reported behavioural change among persons with excess body weight. Advice from either health professionals or family may have a potential to facilitate positive changes in eating habits and physical activity among those individuals.

Economic fluctuations and long-term trends in depression: a repeated cross-sectional study in Estonia 2004-2016.

BACKGROUND: In the 2000s, the Baltic countries experienced unprecedented credit-driven economic growth that was followed by a deep recession. This study examined the impact of profound macroeconomic changes on population mental health in Estonia in 2004-2016. METHODS: Data on 17 794 individuals in the 20-64 age group were obtained from seven nationally representative cross-sectional surveys. The prevalence of past 30-day depression was calculated for men and women further stratified by sociodemographic characteristics. Multivariable regression analysis was used to assess whether these characteristics were associated with the yearly variation in depression. RESULTS: In 2006, the adjusted prevalence ratio for depression was 0.77 (95% CI 0.64 to 0.93) for men and 0.85 (95% CI 0.74 to 0.97) for women as compared with 2004; in 2010, the prevalence ratio as compared with 2008 for both men and women was 1.22 (95% CIs 1.04 to 1.43 and 1.09 to 1.37, respectively). Among men, the increase in the prevalence of depression in 2008-2010 was statistically significant for 35-64 year olds, ethnic Estonians, those who were married, mid-educated or were employed, whereas among women, a significant increase was observed in 50-64 year olds, Estonians and non-Estonians, those who were not-married, were highly educated or mid-educated, in the mid-income group or were employed. CONCLUSIONS: Population mental health is responsive to macroeconomic changes. In less wealthy high-income countries, the greater impact of recession on depression among advantaged groups may relate to a higher debt burden coupled with job insecurity.