Elsebeth Stenager

Suicide and multiple sclerosis: an epidemiological investigation.

In a nationwide investigation the risk of death by suicide for patients with multiple sclerosis (MS) was assessed using records kept at the Danish Multiple Sclerosis Registry (DMSR) and the Danish National Register of Cause of Death. The investigation covers all MS patients registered with DSMR with an onset of the disease within the period 1953-85, or for whom MS was diagnosed in the same period. Fifty three of the 5525 cases in the onset cohort group committed suicide. Using the figures from the population death statistics by adjustment to number of subjects, duration of observation, sex, age, and calendar year at the start of observation, the expected number of suicides was calculated to be nearly 29. The cumulative lifetime risk of suicide from onset of MS, using an actuarial method of calculation, was 1.95%. The standard mortality ratio (SMR) of suicide in MS was 1.83. It was highest for males and for patients with onset of MS before the age of 30 years and those diagnosed before the age of 40. The SMR was highest within the first five years after diagnosis.

A population-based study of neuromyelitis optica in Caucasians

Background: Epidemiologic studies have suggested different prevalence of neuromyelitis optica (NMO) in different ethnic groups. However, data on the incidence and prevalence of NMO in Caucasians are scarce. Objective: To estimate the incidence and prevalence of NMO in a predominantly Caucasian population based on the Wingerchuk 2006 criteria. Methods: The study was a population-based retrospective case series with longitudinal follow-up. Patients with multiple sclerosis (MS), optic neuritis (ON), acute transverse myelitis (TM), and NMO from the 4 neurology and 3 ophthalmology departments in the Region of Southern Denmark having been diagnosed between 1998 and 2008 were investigated. Patients were included based on 1) episodes of ON or TM and 2) an initial brain MRI not diagnostic for MS. An immunofluorescence assay was used to determine aquaporin-4 (AQP-4) antibodies. Results: A total of 477 patients with MS, TM, or ON were evaluated: 163 fulfilled the inclusion criteria, 42 (26%) qualified for the diagnosis of NMO, 26 (62.0%) of these were AQP4 antibody positive. All except one were Caucasian, the female:male ratio was 2.8:1, and mean age at onset was 35.6 years (range 15–64 years). The clinical presentation was heterogeneous including TM, longitudinally extensive TM, ON, and brainstem syndromes. The yearly incidence rate of NMO in the population was estimated to be 0.4 per 105 person-years (95% confidence interval [CI] 0.30–0.54) and the prevalence was 4.4 per 105 (95% CI 3.1–5.7). Conclusions: Despite being a rare disease, NMO is more common in a Caucasian population than earlier believed.

Concordance for multiple sclerosis in Danish twins: an update of a nationwide study

The occurrence of multiple sclerosis (MS) in twins has not previously been studied in complete nationwide data sets. The existence of almost complete MS and twin registries in Denmark ensures that essentially unbiased samples of MS cases among twins can be obtained. In this population-based study, virtually all Danish MS cases among twins born before 1983 with onset of MS after 1948 and diagnosis before 1 January 1997 were identified. Of 13 286 MS cases, 178 were twins and, of these 164 twin pairs were discordant and seven were concordant. We found significantly higher proband-wise concordance among monozygotic twins than dizygotic twins, with estimated proband-wise concordances of 24% (95% confidence interval (CI): 5-39%) for monozygotic and 3% (95% CI: 0-8%) for dizygotic twins. Thus, a monozygotic twin whose co-twin has MS has a 24% risk of developing the disease, while the corresponding risk for a dizygotic twin is only 3%. Our results largely confirm previously published concordance estimates and indicate that genetic factors are of importance in susceptibility to MS.

Suicide among Danes with multiple sclerosis

Objective: To compare the suicide risk among Danish citizens with multiple sclerosis with that of the general population, and to evaluate changes over 45 years. Methods: The study was based on linkage of the Danish Multiple Sclerosis Registry to the Cause of Death Registry. It comprised all 10 174 persons in whom multiple sclerosis was diagnosed in the period 1953 to 1996. The end of follow up was 1 January 1999. Standardised mortality ratios (SMRs) were calculated for various times after diagnosis and for age and calendar period of diagnosis. Results: In all, 115 persons (63 men, 52 women) had taken their own lives, whereas the expected number of suicides was 54.2 (29.1 men, 25.1 women). Thus the suicide risk among persons with multiple sclerosis was more than twice that of the general population (SMR = 2.12). The increased risk was particularly high during the first year after diagnosis (SMR = 3.15). Conclusions: The risk of suicide in multiple sclerosis was almost twice as high as expected more than 20 years after diagnosis. The excess suicide risk has not declined since 1953.

The risk of multiple sclerosis in bereaved parents A nationwide cohort study in Denmark

Background: Previous studies have suggested that psychological stress may play a role in the risk of multiple sclerosis (MS), but the evidence is very limited. Objective: To examine the association between MS and a well-defined major stressful life event: the death of a child. Methods: In this follow-up study based on nationwide and population-based registers, all 21,062 parents who lost a child younger than 18 years from 1980 to 1996 in Denmark were included in the exposed cohort and 293,745 matched parents who did not lose a child in the unexposed cohort. The two cohorts were followed for incident MS from 1980 to 1997. Hazard ratios (HR) with 95% CI were calculated as the measure of association between the exposure and MS, using the Cox proportional hazards regression model. Results: Two hundred fifty-eight MS patients were identified (28 in the exposed cohort and 230 in the unexposed cohort). The exposed parents had an increased risk of MS (HR 1.56, 95% CI 1.05 to 2.31), which is significant only when follow-up was at least 8 years. The HR for definite/probable MS was 1.42 (95% CI 0.90 to 2.24). Parents who lost a child unexpectedly had an HR of 2.13 (95% CI 1.13 to 4.03) for all MS, which is higher than that for other bereaved parents (HR 1.33; 95% CI 0.81 to 2.16). Conclusion: Psychological stress may play a role in the development of MS.

Mortality in patients with Parkinson's disease

Introduction– After the introduction of L‐dopa the mortality rate in Parkinsons disease (PD) patients has changed, but is still higher than in the background population. Material & methods– Mortality, age at death and cause of death in a group of PD patients compared with the background population were studied. The diagnosis on the death certificate were registered. The material consisted of 458 patients who in a period 1.4.1973–31.10.1991 were registered as having PD. Results– Death in the period amounted to 253 patients. Median age of death was 77.29 years for men and 79.11 years for women. In the background population the median age at death was 80.69 years for men and 84.37 years for women. The SMR for men was 1.92 and for women 2.47. Infections, in particular lung infections, and heart diseases were the most common causes of death. Seventy percent of the death certificates had PD as a diagnosis. Conclusion– It is likely that several factors can influence the changed mortality of PD: more effective treatment, changing diagnostic practice, and inter‐disease competition.

Suicide in patients with Parkinson's disease : an epidemiological study

The purpose of this study was to estimate the risk of suicide for patients with Parkinsons disease (PD) in Denmark compared with that in the background population. The study involved 458 patients with a PD diagnosis, 226 men and 232 women. The follow‐up period to either death or end of follow‐up on December 31, 1990 was 0 to 17 years, mean 5.7 years. Deaths in the follow‐up period amounted to 254, 135 men and 119 women. Two women committed suicide. The number of expected suicides was 1.06 for men and 0.55 for women, a total of 1.62. Neither for men nor for women was the difference between expected and observed suicides statistically significant.

Attempted Suicide, Depression and Physical Diseases: A 1-Year Follow-Up Study

In the period January 1, 1990 to March 31, 1991 a sample of suicide attempters admitted to the Department of Psychiatry, Odense University Hospital, underwent a structured interview. In the study 52% of the patients interviewed were found to suffer from a somatic disease, and 21% were daily on analgesics for pain. Patients that suffered from a somatic disease differed from other suicide attempters in depression score, age, pain and the presence of psychosis. Fewer of the somatically ill suicide attempters had a psychosis. Patients complaining of pain were more often depressed and abused medicine. Statistically, the risk of repetition of parasuicide for patients with a somatic disease but without depression was significantly less. The 7 patients committing suicide were older and a tendency was found towards painful somatic diseases and depression as risk factors for suicide.

Suicides in men with IDDM.

OBJECTIVE To investigate the occurrence of suicide in men with insulin-dependent diabetes mellitus (IDDM). RESEARCH DESIGN AND METHODS A cohort of all Danish men born between 1949 and 1964 (including 1964) who were diagnosed with IDDM before age 20 (n = 1,682) was ascertained earlier. Follow-up from diagnosis to death or 1 January 1991 was based on record linkage with the Danish Civil Registration System and was supplemented with information from death certificates obtained from the Danish National Registry of Deaths. From published vital statistics, cause-specific standardized mortality ratios (SMRs), adjusted for age and calendar time, were calculated. RESULTS Among the 168 deaths recorded during follow-up, 15 took place in connection with the onset of IDDM and have been excluded. Of the remaining 153 deaths, 12 were officially classified as suicides (SMR 12/7.48 = 1.6, 0.05 < P < 0.1); as for the age-group of 20-24 years, SMR was 2.98, P < 0.05. Furthermore, all deaths officially classified as attributable to unknown causes (n = 28) and accidents (n = 22) were reviewed with respect to unrecognized suicides; as for deaths of unknown causes, three could be reclassified as probable suicides and two as possible suicides, whereas one of the deaths caused by accident could be reclassified as possible suicide. CONCLUSIONS Young men with IDDM may confer a higher risk of suicide than expected. Furthermore, suicide may represent an underestimated cause of death among patients with IDDM.

Risk Factors for Suicide in Multiple Sclerosis

BACKGROUND The purpose of the present study was to identify risk factors for suicide in patients with multiple sclerosis (MS). METHODS The study is based on available information about MS patients identified in the Danish MS Registry (DMSR) with onset in the period 1950-1985. We compared the MS suicides with the 1950-1985 onset cohort patients in the DSMR as to distribution of age at onset, presenting symptoms, and time from onset to diagnosis. We reviewed sociodemographic data, age of onset, the course of the disease, recent deterioration, type of deterioration, Kurtzke Disability Status Scale (DSS) score, previous mental disorder, type of mental disorder, previous suicide attempts, expression of suicidal intentions, circumstances at suicide, and suicide method for all MS patients who had committed suicide. In order to characterize MS suicides with respect to risk factors, comparisons were made for male and female suicides and for various groups of MS suicides according to disability status. RESULTS The male suicide patients were characterized by a tendency to commit suicide in the age interval 40-49 years, by the use of a violent suicide method, by previous suicidal behaviour, by a previous mental disorder, by recent deterioration of MS, and by a moderate disability. For women the characteristics were less distinct. Patients with a severe course of MS had been subjected to more risk factors before the suicide than patients with a moderate course of the disease. CONCLUSION Careful counselling and good information on all aspects of the disease, especially in the first stages and at time of progression, could be an instrument of prevention of suicides in MS patients. Furthermore, recognition and treatment of depression and pain is important.