transcription of Sami Pirkola lecture on 10.08.06

Sami Pirkola is a psychiatrist, a researcher and a epidemiologist working in MERTTU -project, Mental Health Group within STAKES (National Research and Development Centre for Welfare and Health). He accepted to give a lecture about some depression statistics from Finland and other countries. Following there is the transcription of the lecture, which was based on a PowerPoint presentation that we are going to post as soon as we would figure out if would there be any way to attach a pdf file.

Thank you, Mireia for inviting me to take part in this project. I don’t know what is going to happen in the future but, anyway, I find this whole idea interesting and that’s why actually I took your call seriously and thought about coming here.

I don’t know anyone of you and I don’t know who are you representing but I don't expect anybody of you as any professional working in the mental scene, I guess. (Smiles confirming that). …Which is quite interesting because I am going to give you a quite typical professional presentation about mental health and its encouraging seeing how is going to be accepted. I am going to fit you with lots of concepts and so on and if it is uncomfortable or you can’t get what I mean, please interrupt or ask anything. You should know that I speak quite fast. I don't think you should try to learn anything. I am only trying to give some concepts and some basic ideas about what Mireia actually is looking for.

This idea about misconception is the point for me too, because in my field these concepts are quite important today, actually at two levels. And you already mentioned something about personal misconceptions about oneself and actually today psychiatric professionals think that a big deal of depression comes from a misconception of oneself: a tendency of seeing oneself in a kind of wrong way. Another misconception is actually the one you are researching. Your project that is going on is exactly what we have in general. In general we have a wrong conception in Europe about how Finnish people are doing and how everybody is doing. Just to present me shortly, I am a psychiatrist, a researcher and an epidemiologist. And if you don’t know anything about epidemiology, it is a science that is studying what is really going on in the population, what sicknesses are there, how much do they cost and what are their risk factors. It’s looking for how are we doing, do we have diseases and what are their costs and so on.

So my view today is quite scientific in a way. I am going to talk about population; how do we Finns do, how Spanish people do and I am going to use some more examples.

But in the beginning I’ll give you some conceptual ideas (he starts showing a PowerPoint presentation that he will comment until the end of his speech).

Mental health: we only have some ideas about what it is and actually any technician is writing about it. Here we see something from the WHO (World Health Organization), which is a general conceptualization about what is mental health. This kind of definition tries to get all the important things in it and tries to define what the general core of mental health is. We can think that mental health is a state of well being. And in such a way, that any individual can perhaps cope and enjoy his or her life. Usually we think that people can work, love and be a bit creative. That’s a kind of a minimum demand for people to somehow function.

There are lots of these kinds of definitions. I don’t know if is there something special about them, but anyway it’s kind of interesting to define what mental health is. Anyone of you can try to define what mental health is, what a good mental health is, what is a bad mental health.

We can conceptualize this definition in a broader way. We can say that it is a state. And on the other hand that it is, in a way, a psychological interaction with his or herself and his or her personal experiences, history and personality. And then we have this social interaction -we are interacting with other people-. We also have a societal context: its policy and its organizations. And at a higher level and the least concrete level are the cultural values that we are facing when we are acting with society. And in this whole context, a good mental health experiences the balance between the individual oneself and the environment.

We got lots of these kinds of conceptualizations, but another one emphasizes more the process, the time process. We can see that mental health comes from somewhere and goes to somewhere: our history, our genetic structure and our childhood experiences make us all what are we today. And we have our mental resources. And we have some reason to live. And our social support. And then we are going somewhere. Our mental health is dealing with where are we going, how are we experiencing and what are we doing: do we feel healthy and are we doing good things to other people?

And well, it's quite complex to conceptualize this, but anyway it is good to understand that mental health is a very broad concept, that doesn’t have only to do with small symptoms and that is also affecting our whole environment.

And the last one of these is a broadest conceptualization is this division between positive and negative mental health. Is quite obvious and you can even understand it quite easily. Positive mental health is the resources that we have. We need to feel well and to be motivated with the things we want to do and maybe to enjoy our existences, our living. We try to promote a positive mental health. And then we have the concept of negative mental health when we are talking about symptoms, problems and disorders. These are always, almost always, causing suffering problems and they are making life more difficult. And this kind of negative mental health is often reflected in disorders that can drive to diseases or illnesses. And psychiatry that I am representing is diagnosing and treating mental disorders as themselves. These kind of mental disorders are defined in current classifications and they are counted and tried to be evaluated. This can be very useful in some contexts, especially in this context where we are comparing mental health measures in different countries.

Well, there is no more to add to this and we are getting close to the point. This lecture is more about states, its treatments and people that have suffered about mental disorders. Almost a half has suffered from mental disorders during their life. We can have small phobias, anxieties and we can also have more difficult mental disorders like psychotic disorders, long term diseases, substance use disorders and some others. Actually almost the third of us suffers from mental disorders during the last year, which is a quite high percentage. Today I won’t explain them in detail, but the most common of them are depressive disorders and substance use disorders and we have some personality and psychotic disorders. So you have to believe that these kinds of disorders exist and they have been studied and treated quite often.

-Excuse me, how was the research made, how many people got interested or have participated?
-I will show you that in a minute. We have done a couple of very good studies with big populations. And actually all around the world there have been quite many studies. People have been taken and have been interviewed. And this is what has been made. But you will see. It is something about where is a mental disorder. Almost a third of the population, 28% per year, suffers from some kind of mental disorders, but only 8% actually has diagnosis under treatment and a 20%, a fifth of us, has some kind of disorders that are not treated. And at the same time 7% of people have some kind of treatment without having a kind of mental disorder. (Laughs)
It’s quite easy to understand. Mental disorders are a definition, a certain criteria. But one can still have some suffering without being a clear mental disorder that can’t be treated or helped in some way. And at the same time many of these disorders don’t necessarily need immediate treatment. They can get cured by themselves.

Now I am going to explain you what we made for a health care research project in Finland during 2000-2001. It was conducted by the national public institute where I was working too. And more than 8000 subjects were called to the study and examined quite thoroughly. And they were making, as you can see here (he refers to an image from his presentation where we can see a small room that reminds us to a hospital room. We understand that this picture was taken while an examination as we can see 1 person dressed in white with another person in front that is wearing street clothes) many health examinations, blood examinations, distressed tests and measures. As well their eating habits and other common things were evaluated. And at the end, the final examination was a mental health interview that we translated from a German computerized method and it took from twenty minutes to one hour to interview these people. We collected the data whether they had certain depressive disorders, anxiety disorders or alcohol use disorders. We had to leave out a lot of disorders because we didn’t have time to evaluate all the disorders but these where the most common and perhaps the most interesting for public health institute to use.

And, well, it was so that we had a big team. Actually 5 teams were touring around Finland and I was touring between them supervising within the mental health interview. You can see here this room, a mental health examination room. Is not very fashionable but all the interviews were made there and computerized. People were asked a long sequence of questions about whether they felt depressed or not. And if they did so, about their days. In this way was possible to collect data for us to notice. We collected data from 6005 people, which is a big amount of people. And the results we got were not very surprising. Some of them we were expecting from previous literature and they are quite comparable with the international literature. And we were actually quite happy that they seemed so believable and reliably. And we actually have analyzed them later on very extensively, and have been convinced about them.

And these are some of the tasks I do at work: I collect data, I get figures and I show them. These are percentages. So, you can see that out of these 6005 Finnish citizens, 6.5% had some kind of depressive disorder during last year. It’s quite a lot if we think that a depressive disorder can be something serious. And for the most, it is. The 5% of the 6005 had one depressive disorder episode. And for other disorders you must understand panic disorders, agoraphobia, perhaps social phobia, general anxiety disorder: a generalized feeling of worry and continuous anxiety. And these results are quite comparable to the international ones.

If we think in questions of gender, you can see that, not surprisingly, female suffer twice times from depression and male abuse three times more of alcohol. These are very classical and somehow interesting results, but that is how it goes in population. But we won’t discuss this today.

In this room we have the interviews that you (Mireia) have made and I have to say that many studies have been made using personal interviews, as is the most common interview or instrument that we have. Here we can see some from USA, Netherland, Germany and many all around Europe. And we can see how many people have been studied. In the USA 8000, Australia 10.000 and so on until 6005 in Finland. And you can see that these frequencies range between 4 and 8. These are actually not very huge differences, so they don’t differ that much. Generally I can say that there are no major differences between the countries results. In our results we had surprisingly a little less social phobia than other countries. I expected that we would have gotten a high social phobic rate, but it was the other way round. And we didn’t have more depression than in other countries.

Here we can see another review, very nice review from last year from Wittchen and Jacobi. If anyone is interested in it, I can offer it. Twenty seven studies were collected from Europe and at the small marks tell from almost 0% to 10% about how diagnoses are going between the different studies. They do distribute, but not that far, so you can realize that all the studies get the similar kind of results. I am not a statistician, but statistical people think that this result is quite reliable. Taking into account, little evidences seem to exist for considerable country variations.

-Excuse me, what is social phobia?
-Is a kind of syndrome when one is absolutely phobic about social situations; gets typical panics like attacks and… I can’t explain in detail but one can’t attend to typical social situations and it causes suffering and disability.

-Is it a part of panic symptom?
-Well, they are different but they are quite near. The symptoms are quite the same, but social phobia are triggered by social situations. Panic symptoms come out form the blue with no triggers and so on.

Okay, the disorder part was there. And there is another part that I am going to explain, but if is there somebody else that wants to make a question....

-I would like to ask how these 6005 people were contacted to make the tests and if were they paid.
-That’s a very good question. We look for a representative population for this kind of study, so we actually selected them from the national census register. A letter was sent to them and as well they received a phone call. And the Finnish people are quite well known for their willingness of participating. Finnish people, let’s say, trust researchers and authorities. So we got quite a nice participating response. First we sent them questionnaires and then they had an appointment questionnaire. So they came there; they got paid for the trip but nothing else more.

-So they did they get remunerated only for the trip?
-Yes, often they had to negotiate with their employers and usually that was ok. And as a kind of salary they got some blood test and other health information and so on, some kind of feedback.

Actually 8000 were selected and 6005 were participating. To conclude our results, most of them represented the general population in Finland quite nicely and we found no major differences between the regions. In the northern Finland they were slightly more depressive disorders and in Helsinki and Uusimaa area slightly more alcohol use problems, but nothing very remarkable.

But I can give you another data. In Europe, the EU that we all love so much, is twice per year conducting a survey. They ask to European people what do they think about things: what do they think about politics and their work and would they like to have a tree in their yard, how do they want to eat their cucumbers and so on. And in the year 2000 they were asking for mental health in order to know how people are doing in Europe. And that is usually done through face to face interviews. National interviewers go to people’s homes and interview them. Then they come back to the office and translate the results to another language. And in this particular survey I was analyzing the data and writing this report. We got the data from the EU, which was ready-collected. So we only analyzed it statistically and wrote about it. There were 16.000 participants from 15 countries and 2 regions. In this mental health section (of the research) were already chosen few easy established instruments. Mental health problems where measured through the MHI section of this SF-36. It doesn’t sound very interesting. (Laughs). This SF-36 is a very big questionnaire and it has a small mental health section, this MHI. It has another section of this positiveness: the energy and vitality scale. These are established scales that are comparable with other studies from other countries and from before and so on. And the third questionnaire was concerning social support: how many close friends the person has is he or she will have problems, how many he or she would contact to ask for help. They need to give figures and classify and measure. I haven’t seen the measures in this case, but I will show you the results.

The worst thing in this data is that response rate has a lot to do and actually is quite low. And this is the most important aspect in this kind of data, so that’s why I am not giving a very big emphasis on this study. But the results are quite interesting anyway. You can see that only a fourth of the population answered and usually in these kind of studies has to be around the 60% of response to be able to rely on the results, but anyway we can check these results; at least for fun. Actually I heard that recently a replication of this study has been published but I haven’t found it in internet. Mireia found this one, but if you find the newer one, please check it. The results might differ from these that I am going to show you.

And now these percentages, these figures: look at it; it is like the Eurovision song contest. Finland was absolutely the best. In most of these measures the lower the score is, the better you are doing in terms of mental health. They were measuring mental health symptoms and Finnish people had absolutely the lowest scores in this.

In terms of vital index, the higher the better. And we were the winners again.

But I don’t take all this too serious, but it is a nice addition to this Finns being depressive discussion. But something not surprising happened with the social support. If we look at the strong column, we were the worst in reporting getting strong social support. It could be that we conceptualize social support differently. And in this we lost if we want to, somehow, compete with the other figures.

Well, the last figures I am going to show you are about suicide rates, which are particularly interesting for Finland. Finland has had among the highest suicide rates in the world. During the 90’s our suicide rates have been falling until a third, which is a quite big decreasing. Still it is at the higher end in the world, but anyway something has happened in the last 10 years and we should keep going on. Especially males had the highest rate.

Recent Europe statistics show that actually young males from 20 to 34 tent to have still high suicides. But the subpopulation of younger males started worrying about the situation.

And to conclude there are no major differences in mental health measures in European cultures. It depends on the measures, but when we use comparable measurements and instruments we get these kinds of results. And although Finnish people have increased their drinking quite much, a four-fold increase from the sixties, Finnish people are still doing quite well. Drinking increases comes mostly from the wine and soft drinks that have come in addition to the traditional strong dinks. General suicide rate has decreased but it is still the highest at international level.

And as general conclusions, these misconceptions that we are today talking about may have some other known functions. They may have other purposes for society: somehow support order or togetherness, keep similarities or keep our identity and stuff like that. I don’t know exactly what; perhaps this project will bring more ideas about that; or where these misconceptions come from.

he debate starts about the suicide rates and I comment the case of Ira Tirinen and her brother (you can check her story called Sinisyys).
-Suicide is a very tough talk. There are many causes and we can not show one reason only. The most common are anyway trough mental disorders, quite often depression but there are many mixed disorders, like some will have as well some psychotic symptoms or so. But of course this high suicide rate has to have some influence and we need to look for an answer from the society too. To continue mentioning, this fast shift to urban society could be a reason and another reason might be the heavy drinking. When you are very drunk you feel scared to do things that in another situation you would not do.

-Is this a problem of young man and 40 years old women?
-Yes, but actually the male suicides are more highly prevalent. But anyway, males have a peak in the younger age and female peak is later. Some mental disorders come during the young age and substance abuse can influence. And young people start using substances already quite early and they might then face several disorders at the same time. For middle age people is very often a question about depression, substance abuse problems and recent adverse happenings: bankrupts, unemployment, divorces and so on. This is just to simplify, but every suicide is an individual process, but they have something very deep, of course.

-I am living near the railway station and there are lots of them there
-I can talk about this for hours, and actually this method of suicide thing is very interesting. The availability of methods may affect, too.
-But isn’t it strange that when you take this percentage in Europe, Finland is the country that has by one hand the lowest depression rate and by the other hand the highest suicide rate. Doesn’t it sound that there is a gap in this research?
-Yes, there is a gap. It is a very difficult question. Depression is not the only suicide risk. It is also this substance abuse problem, this kind of specific changes we have in society and some others. We do not have one answer. I am not saying that Finnish are less depressive, as I would not rely on these Eurobarometer results. What I am saying is that there are not major differences between the countries and that Finnish people absolutely are no more depressive than other Europeans, but probably we are in the same level about than the others.

-How was all that data gathered exactly?
-There are to dates. The last one was facilitated by EU. In Finland the data was collected by Suomen Gallup, which is a professional agency. The first one I showed was collected by the National Public Health Institute, where I was working in. It was an epidemiologist study (then he repeats the same info that he did at the beginning explaining about how they interview was made to the 6005 people). (…)