Anders Prior

The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study

Multimorbidity is common and is associated with poor mental health and high mortality. Nevertheless, no studies have evaluated whether mental health may affect the survival of people with multimorbidity. We investigated the association between perceived stress and mortality in people with multimorbidity by following a population-based cohort of 118,410 participants from the Danish National Health Survey 2010 for up to 4 years. Information on perceived stress and lifestyle was obtained from the survey. We assessed multimorbidity using nationwide register data on 39 conditions and identified 4,229 deaths for the 453,648 person-years at risk. Mortality rates rose with increasing levels of stress in a dose-response relationship (P-trend < 0.0001), independently of multimorbidity status. Mortality hazard ratios (highest stress quintile vs. lowest) were 1.51 (95% confidence interval (CI): 1.25, 1.84) among persons without multimorbidity, 1.39 (95% CI: 1.18, 1.64) among those with 2 or 3 conditions, and 1.43 (95% CI: 1.18, 1.73) among those with 4 or more conditions, when adjusted for disease severities, lifestyle, and socioeconomic status. The numbers of excess deaths associated with high stress were 69 among persons without multimorbidity, 128 among those with 2 or 3 conditions, and 255 among those with 4 or more conditions. Our findings suggested that perceived stress contributes significantly to higher mortality rates in a dose-response pattern, and more stress-associated deaths occurred in people with multimorbidity.

Depression and risk of hospitalisations and rehospitalisations for ambulatory care-sensitive conditions in Denmark: a population-based cohort study.

Objective Hospitalisations for ambulatory care-sensitive conditions (ACSCs), a group of chronic and acute illnesses considered not to require inpatient treatment if timely and appropriate ambulatory care is received, and early rehospitalisations are common and costly. We sought to determine whether individuals with depression are at increased risk of hospitalisations for ACSCs, and rehospitalisation for the same or another ACSC, within 30 days. Design National, population-based cohort study. Setting Denmark. Participants 5 049 353 individuals ≥18 years of age between 1 January 2005 and 31 December 2013. Measurements Depression was ascertained via psychiatrist diagnoses in the Danish Psychiatric Central Register or antidepressant prescription redemption from the Danish National Prescription Registry. Hospitalisations for ACSCs and rehospitalisations within 30 days were identified using the Danish National Patient Register. Results Overall, individuals with depression were 2.35 times more likely to be hospitalised for an ACSC (95% CI 2.32 to 2.37) versus those without depression after adjusting for age, sex and calendar period, and 1.45 times more likely after adjusting for socioeconomic factors, comorbidities and primary care utilisation (95% CI 1.43 to 1.46). After adjusting for ACSC-predisposing comorbidity, depression was associated with significantly greater risk of hospitalisations for all chronic (eg, angina, diabetes complications, congestive heart failure exacerbation) and acute ACSCs (eg, pneumonia) compared to those without depression. Compared to those without depression, persons with depression were 1.21 times more likely to be rehospitalised within 30 days for the same ACSC (95% CI 1.18 to 1.24) and 1.19 times more likely to be rehospitalised within 30 days for a different ACSC (95% CI 1.15 to 1.23). Conclusions Individuals with depression are at increased risk of hospitalisations for ACSCs, and once discharged are at elevated risk of rehospitalisations within 30 days for ACSCs.

Risk of suicide, deliberate self-harm and psychiatric illness after the loss of a close relative: A nationwide cohort study

The loss of a close relative is a common event, yet it is associated with increased risk of serious mental health conditions. No large‐scale study has explored up to now the importance of the bereaved persons relation to the deceased while accounting for gender and age. We performed a nationwide Danish cohort study using register information from 1995 through 2013 on four sub‐cohorts including all persons aged ≥18 years exposed to the loss of a child, spouse, sibling or parent. We identified 1,445,378 bereaved persons, and each was matched by gender, age and family composition to five non‐bereaved persons. Cumulative incidence proportions were calculated to estimate absolute differences in suicide, deliberate self‐harm and psychiatric illness. Cox proportional hazard regression was used to calculate hazard ratios while adjusting for potential confounders. Results revealed that the risk of suicide, deliberate self‐harm and psychiatric illness was increased in the bereaved cohorts for at least 10 years after the loss, particularly during the first year. During that year, the risk difference was 18.9 events in 1,000 persons after loss of a child (95% CI: 17.6‐20.1) and 16.0 events in 1,000 persons after loss of the spouse (95% CI: 15.4‐16.6). Hazard ratios were generally highest after loss of a child, in younger persons, and after sudden loss by suicide, homicide or accident. One in three persons with a previous psychiatric diagnosis experienced suicide, deliberate self‐harm or psychiatric illness within the first year of bereavement. In conclusion, this study shows that the risk of suicide, deliberate self‐harm and psychiatric illness is high after the loss of a close relative, especially in susceptible subgroups. This suggests the need for early identification of high‐risk persons displaying adjustment problems after loss of a close family member, in order to reduce the risk of serious mental health outcomes.

The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study

Objective Multimorbidity (MM) is more prevalent among people of lower socioeconomic status (SES), and both MM and SES are associated with higher mortality rates. However, little is known about the relationship between SES, MM, and mortality. This study investigates the association between educational level and mortality, and to what extent MM modifies this association. Methods We followed 239,547 individuals invited to participate in the Danish National Health Survey 2010 (mean follow-up time: 3.8 years). MM was assessed by using information on drug prescriptions and diagnoses for 39 long-term conditions. Data on educational level were provided by Statistics Denmark. Date of death was obtained from the Civil Registration System. Information on lifestyle factors and quality of life was collected from the survey. The main outcomes were overall and premature mortality (death before the age of 75). Results Of a total of 12,480 deaths, 6,607 (9.5%) were of people with low educational level (LEL) and 1,272 (2.3%) were of people with high educational level (HEL). The mortality rate was higher among people with LEL compared with HEL in groups of people with 0–1 disease (hazard ratio: 2.26, 95% confidence interval: 2.00–2.55) and ≥4 diseases (hazard ratio: 1.14, 95% confidence interval: 1.04–1.24), respectively (adjusted model). The absolute number of deaths was six times higher among people with LEL than those with HEL in those with ≥4 diseases. The 1-year cumulative mortality proportions for overall death in those with ≥4 diseases was 5.59% for people with HEL versus 7.27% for people with LEL, and 1-year cumulative mortality proportions for premature death was 2.93% for people with HEL versus 4.04% for people with LEL. Adjusting for potential mediating factors such as lifestyle and quality of life eliminated the statistical association between educational level and mortality in people with MM. Conclusion Our study suggests that LEL is associated with higher overall and premature mortality and that the association is affected by MM, lifestyle factors, and quality of life.

Post-Stroke Mortality, Stroke Severity, and Preadmission Antipsychotic Medicine Use – A Population-Based Cohort Study

Background and Purpose It has been suggested that antipsychotic medication may be neuroprotective and may reduce post-stroke mortality, but studies are few and ambiguous. We aimed to investigate the post-stroke effects of preadmission antipsychotic use. Methods We conducted a nationwide, population-based cohort study of 81,143 persons admitted with stroke in Denmark from 2003–2010. Using Danish health care databases, we extracted data on preadmission use of antipsychotics and confounding factors. We examined the association between current, former, and never use of antipsychotics and stroke severity, length of hospital stay, and 30-day post-stroke mortality using logistic regression analysis, survival analysis, and propensity score matching. Results Current users of antipsychotics had a higher risk of severe or very severe stroke on The Scandinavian Stroke Scale than never users of antipsychotics (adjusted odds ratios, 1.43; 95% CI, 1.29–1.58). Current users were less likely to be discharged from hospital within 30 days of admission than never users (probability of non-discharge, 27.0% vs. 21.9%). Antipsychotics was associated with an increased 30-day post-stroke mortality among current users (adjusted mortality rate ratios, 1.42; 95% CI, 1.29–1.55), but not among former users (adjusted mortality rate ratios, 1.05; 95% CI, 0.98–1.14). Conclusions Preadmission use of antipsychotics was associated with a higher risk of severe stroke, a longer duration of hospital stay, and a higher post-stroke mortality, even after adjustment for known confounders. Antipsychotics play an important role in the treatment of many psychiatric conditions, but our findings do not support the hypothesis that they reduce stroke severity or post-stroke mortality.

Association between perceived stress, multimorbidity and primary care health services: a Danish population-based cohort study

Objectives Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental–physical multimorbidity. Design Population-based cohort study. Setting Primary healthcare in Denmark. Participants 118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers. Outcome measures General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers. Results Perceived stress levels were associated with primary care activity in a dose–response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services. Conclusion Persons with high stress levels generally had higher use of primary healthcare, 4–6 times higher use of mental health-related services (most often in the form of psychotropic drug prescriptions), but less timely use of chronic care services.

Perceived Stress, Multimorbidity, and Risk for Hospitalizations for Ambulatory Care–sensitive Conditions: A Population-based Cohort Study

Background: Psychiatric disorders are associated with an increased risk for ambulatory care–sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population. Objectives: To determine whether perceived stress is associated with ACSC-related hospitalizations and rehospitalizations, and posthospitalization 30-day mortality. Research Design and Measures: Population-based cohort study with 118,410 participants from the Danish National Health Survey 2010, which included data on Cohen’s Perceived Stress Scale, followed from 2010 to 2014, combined with individual-level national register data on hospitalizations and mortality. Multimorbidity was assessed using health register information on diagnoses and drug prescriptions within 39 condition categories. Results: Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91, 2.38) versus being in the lowest stress quintile after adjusting for age, sex, follow-up time, and predisposing conditions. The associated risk attenuated to 1.48 (95% CI, 1.32, 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless of multimorbidity status. Being in the highest stress quintile was associated with a 1.26-times insignificantly increased adjusted risk (95% CI, 0.79, 2.00) for ACSC rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13, 1.81) of mortality within 30 days of admission. Conclusions: Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis.

Prevalence of persons contacting general practice for psychological stress in Denmark

Abstract Objective: The prevalence of psychological stress has previously been estimated based on self-reported questionnaires. This study aimed to investigate the prevalence of persons who contact the general practitioner (GP) for psychological stress and to explore associations between psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. Design: Cross-sectional computer assisted journal audit. Setting: General practice in the Region of Southern Denmark. Subjects: Patients aged 18–65 years with a consultation during a six-month period that was classified with a stress-related diagnosis code. Main outcome measures: Six months prevalence of GP-assessed psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. Results: Fifty-six GPs (7% of the invited) identified 1066 patients considered to have psychological stress among 51,422 listed patients. Accordingly, a 2.1% six months prevalence of psychological stress was estimated; 69% of cases were women. High prevalence of psychological stress was associated with female sex, age 35–54 years, high education level and low population density in the municipality, but not with unemployment in the municipality or household income in the postal district. GP female sex and age <50 years, few GPs in the practice and few patients per GP were also associated with a higher prevalence of psychological stress. Conclusions: A total of 2% of the working-age population contacted the GP during a six-month period for psychological stress. The prevalence of psychological stress varies with age, sex and characteristics of both the regional area and the GP. Key points   Psychological stress is a leading cause of days on sick leave, but its prevalence has been based on population surveys rather than on assessment by health care professionals.   • This study found that during six months 2.1% of all working-age persons have at least one contact with the GP regarding psychological stress.   • The six months prevalence of psychological stress was associated with patient age and sex, GP age and sex, practices’ number of GPs and patients per GP, and area education and urbanization level.