8.7 Discussion
8.7.3 The Nordic countries: An epidemiologist’s paradise?
This metaphor contained in this title is sometimes presented by non-Nordic scientists – without the question mark. In real world, hard work, data processing, methodological skills and teamwork are needed for successful register-based studies.
Nordic registers at best are population-based and achieve high levels of ascertainment. They are ideal for epidemiological purposes, as the biases common to many epidemiological surveys (such as information bias) are minimal, and loss to follow-up occurs only through emigration or death. Explana- tory variables and outcome data are collected prospectively and the number of cases can be large, so that it is possible to investigate rare exposure events, for example specific birth complications, with rare outcomes, for example schizophrenia.
The authors are most familiar with the Finnish register system; we acknowledge that our aim to review all Nordic countries in a balanced way may not have been successful. The current review did not include Iceland (population of 0.3M), which also has nationwide registers that have been used in psychiatric research. The current focus is on the anonymous Icelandic Healthcare Database, which has been constructed by a private company, deCODE Genetics. This database has opened up unique pos- sibilities for modelling disease risk as a function of genetic and environmental factors and has resulted in the identification of risk genes for several disorders, including schizophrenia [103, 104].
For administrative and also ethical reasons, some registers are not yet available for research purposes or for linkage to other register data. The introduction of new registers will nevertheless make it possible to study many topics more reliably.
More extensive outpatient registers, for instance, will make it possible to identify more subjects with less severe psychiatric disorders. Until recent years, outpatient registers have often been kept locally, or else nationwide registers have limited coverage. The accumulating medication data should be used in the
future to carry out observational, population-level, phase IV efficacy, effectiveness and safety studies on psychoactive drugs. Register data could also be more commonly used together with data collected from interviews. In the future, increasing interna- tional collaboration and the combining of different registers within and between countries would give further possibilities for studying novel topics.
Acknowledgements
This work has been supported by the Academy of Finland (#125 853, J.M.; #129 434, JS; #110 143, M.I.), NARSAD: Brain and Behavior Research Fund (J.M., J.S., M.I.), and the Sigrid Jus´elius Foundation (J.S., M.I.).
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9 An introduction to mental health services research
Anna Fern ´andez,
1Alejandra Pinto-Meza,
2Antoni Serrano-Blanco,
3Jordi Alonso
4and Josep Maria Haro
51Research and Development Unit, Sant Joan de D´eu-SSM, Fundaci ´o Sant Joan de D´eu, Barcelona, Spain, Red de Investigaciones en Actividades de Prevenci ´on y Promoci ´on de la Salud (REDIAPP)
2Research and Development Unit, Sant Joan de D´eu-SSM, Fundaci ´o Sant Joan de D´eu, Barcelona, Spain, Red de Investigaciones en Actividades de Prevenci ´on y Promoci ´on de la Salud (REDIAPP)
3Research and Development Unit, Sant Joan de D´eu-SSM, Fundaci ´o Sant Joan de D´eu, Barcelona, Spain, Red de Investigaciones en Actividades de Prevenci ´on y Promoci ´on de la Salud (REDIAPP)
4Head, Health Services Research Unit (IMIM-Hospital del Mar), CIBER Epidemiolog´ıa y Salud P ´ublica (CIBERESP), Spain, Master’s Program in Public Health (UPF-UAB), Carrer del Doctor Aiguader, Barcelona, Spain
5Research and Development Unit, Sant Joan de D´eu-SSM, Fundaci ´o Sant Joan de D´eu, Barcelona, Spain, CIBER Salud Mental (CIBERSAM)