This study was carried out at the Department of Mental and Alcohol Research of the National Public Health Institute, Helsinki, and the Primary Health Care Organization of the City of Vantaa, Finland during the years 2001-2008. For providing excellent working facilities in the National Public Health Institute I wish to thank both former and present President of the National Public Health Institute, Professor Jussi Huttunen and Professor Pekka Puska. I am also deeply grateful to former Deputy Mayor Urpo Alanko and Risto Ihalainen former Director of Health Services at the Social Welfare and Health Department at the City of Vantaa and Medical Director Christer Carlson in Myyrmäki Health Centre, Vantaa for their trust on my work and encouraging attitude towards research in primary care; I also wish to thank them for providing me with opportunity of conducting this research in the health centres of the City of Vantaa.
I am deeply grateful to Professor Jouko Lönnqvist for the privilege of working at the Department of Mental Health and Alcohol Research with all the skilled members of its staff. I have enjoyed the many instructive discussions with you about the development of mental health work in primary care.
My warmest thanks are due to my supervisor Professor Erkki Isometsä for his enthusiasm and unfailing support. He has guided me with care, and given me freedom in the choice of scientific topics. Although extremely busy, he always made time for my questions. His profound knowledge and understanding of the field of mood disorders has been invaluable.
It is a privilege to work with you! Your ability to fathom what I am trying to say, even before I know it myself, is admirable.
I am deeply grateful to my co-author Tarja Melartin, M.D., PhD., who has shared the joys and sorrows of research work with me for years, as well as the same interests in clinical work. You did not spare your time when introducing me to the world of research. You were always willing to help, to discuss any ideas, and answer any questions I posed. I regard your timely and thorough reviews of our manuscript highly. Whenever I needed encouragement I got it from you.
I am indebted to the reviewers of this work, Professor Kaisu Pitkälä and Professor Heimo Viinamäki, for fruitful criticism and for their most flexible and positive attitude toward the tight time limit.
I am deeply grateful to all the patients that participated in this study. I admire your patience and positive attitude for the time-consuming interviews during one and a half years and for the numerous question forms, all of which you meticulously fulfilled. I also acknowledge the financial support that I have received from Finnish Medical Society Duodecim.
I wish to thank Medical Director Anita Korhonen for her support and trust in me at the beginning of my research career; without her I would never have started this project. I am also most grateful to former head of the Psychiatric Department of HUCH Peijas Hospital, Juhani Solantaus, for his inspiring ideas in developing mental health services in primary care. My present superior, Health Care Director Timo Aronkytö has provided me with the opportunities of integrating the results of my research in the clinical work in primary care settings, for which I am thankful. I also want to thank Professor Kathryn Rost and Outi Poutanen M.D., Ph.D. for helpful advice during the research process.
The caring, optimistic, and ever helpful atmosphere at the Myyrmäki Health Centre, both the reception and department of radiography there, at Hakunila Health Centre and at Länsimäki Health Centre helped me to carry on with recruiting the patients in the study.
Marjatta Lyly, Arto Nuorento, Marja Jormanainen, Birgitta Rajavaara, and so many others spared no efforts in helping me. All the primary care doctors in 2002 participated willingly in the recruiting process. A warm thank you to you all.
I am also more than grateful to Marjut Schreck for the competent data formation and for her layout in this thesis and for all the other help I received for governing the timetable. I applaud Olli Kiviruusu for his patience and willingness to help with various problems concerning computer programs. I am thankful to the library personnel at the National Public Health Institute, especially Jukka Lindeman, who advised me with the End-Note-program. I am most thankful to Eevaliisa Orelma for the invaluable help in many practical questions concerning the patient recruitment. I also want to thank Matthew D.
Grainger for revising the language of my thesis, as well as Richard Burton and Ann-Mari Pelli for revising the texts in my articles. I am indebted for the practical help received from Sirkka Laakso, Tiina Hara, Tuula Koski and other friendly personnel at the Department of Mental and Alcohol Research of the National Public Health Institute.
I warmly thank all my other collaborators. Special thanks are owed to Kirsi Riihimäki, who is fully engaged continuing my work with the patient cohort of this study; she also shares with me the interest in research on primary care psychiatry. Thanks are rightfully due to researchers in the Vantaa Depression Study: Heikki Rytsälä − co-author in one of the articles, Ulla Leskelä, Petteri Sokero as well as Irina and Mikael Holma for sharing the joys and sorrows of research. I have also had the pleasure of working with other inspiring
researchers on mood disorders: Petri Arvilommi, Outi Mantere, Kirsi Suominen, Hanna Valtonen, Tuula Kieseppä, Tiina Paunio, Pia Soronen and Annamari Tuulio-Henriksson to name a few. With Linnea and Hasse Karlsson I have had numerous interesting discussions and projects concerning depression in primary care. I want to thank you all. A special thanks to Pekkä Jylhä for important practical last minute advice.
For support, I am indebted to all my friends. Kari provided me with an atmospheric photograph for the cover of this volume; Auri helped me with the Finnish language, and my sister-in law Liisa with my stepdaughters Eeva, Maija and Leena with the English language.
My daughter-in-law Kirsi provided me with the figures and tables for the manuscript. My co-workers Outi and Lauri gave me a hand in organizing the dissertation party. Thank you all. My friends Mikko and Taina deserve extra credit for their invaluable help and support in both numerous practical questions during the process of this thesis as well as in encouraging me through unavoidable times of disbelief. Even more than any help I received from you, I value your friendship. I am also greatly indebted to all other friends for their friendship and support.
I thank my parents Liva and Simo for fostering me, for their support and love, and for steering me towards an academic career. My dear brother Kristian, my hiking mate since early childhood, my warm-hearted thanks for the numerous interesting discussions of other aspects of life and for all your, and your wife Päivi’s support and caring. Thanks are also due to my brother Kai for his encouraging attitude to academic research work, as well as to my mother-in-law Brita, for her warm and supporting attitudes towards me. I am grateful to all other relatives as well for providing me with support and joy.
My most heartfelt thanks belong to my family. My greatly beloved sons, Niku, Otso and Lasse, you have shown me that an unprejudiced mind and courage are the driving forces in life. My step-children Jussi, Eeva, Maija and Leena you are an integral part of my life and my heart. My step- grand-children Tuisku, Topias and Olivia, you are a constant source of joy to me. You always bring the sunshine with you. I am grateful for your being there.
Without the care of my loving husband, Jukka, this thesis would not have been possible. As all should know, there are no words beautiful enough to thank you.
Helsinki, April 2008