Jan Sundquist

Comorbidities and Mortality in Persons With Schizophrenia: A Swedish National Cohort Study

OBJECTIVE Schizophrenia is associated with premature mortality, but the specific causes and pathways are unclear. The authors used outpatient and inpatient data for a national population to examine the association between schizophrenia and mortality and comorbidities. METHOD This was a national cohort study of 6,097,834 Swedish adults, including 8,277 with schizophrenia, followed for 7 years (2003-2009) for mortality and comorbidities diagnosed in any outpatient or inpatient setting nationwide. RESULTS On average, men with schizophrenia died 15 years earlier, and women 12 years earlier, than the rest of the population, and this was not accounted for by unnatural deaths. The leading causes were ischemic heart disease and cancer. Despite having twice as many health care system contacts, schizophrenia patients had no increased risk of nonfatal ischemic heart disease or cancer diagnoses, but they had an elevated mortality from ischemic heart disease (adjusted hazard ratio for women, 3.33 [95% CI=2.73-4.05]; for men, 2.20 [95% CI=1.83-2.65]) and cancer (adjusted hazard ratio for women, 1.71 [95% CI=1.38-2.10; for men, 1.44 [95% CI=1.15-1.80]). Among all people who died from ischemic heart disease or cancer, schizophrenia patients were less likely than others to have been diagnosed previously with these conditions (for ischemic heart disease, 26.3% compared with 43.7%; for cancer, 73.9% compared with 82.3%). The association between schizophrenia and mortality was stronger among women and the employed. Lack of antipsychotic treatment was also associated with elevated mortality. CONCLUSIONS Schizophrenia patients had markedly premature mortality, and the leading causes were ischemic heart disease and cancer, which appeared to be underdiagnosed. Preventive interventions should prioritize primary health care tailored to this population, including more effective risk modification and screening for cardiovascular disease and cancer.

Cardiovascular risk factors in Mexican American adults: a transcultural analysis of NHANES III, 1988-1994.

OBJECTIVES This study examined the extent to which cardiovascular disease risk factors differ among subgroups of Mexican Americans living in the United States. METHODS Using data from a national sample (1988-1994) of 1387 Mexican American women and 1404 Mexican American men, aged 25 to 64 years, we examined an estimate of coronary heart disease mortality risk and 5 primary cardiovascular disease risk factors: systolic blood pressure, body mass index, cigarette smoking, non-high-density lipoprotein cholesterol, and type 2 diabetes mellitus. Differences in risk were evaluated by country of birth and primary language spoken. RESULTS Estimated 10-year coronary heart disease mortality risk per 1000 persons, adjusted for age and education, was highest for US-born Spanish-speaking men and women (27.5 and 11.4, respectively), intermediate for US-born English-speaking men and women (22.5 and 7.0), and lowest for Mexican-born men and women (20.0 and 6.6). A similar pattern of higher risk among US-born Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors. CONCLUSIONS These findings illustrate the heterogeneity of the Mexican American population and identify a new group at substantial risk for cardiovascular disease and in need of effective heart disease prevention programs.

Comorbidities and Mortality in Bipolar Disorder: A Swedish National Cohort Study

IMPORTANCE Bipolar disorder is associated with premature mortality, but the specific causes and underlying pathways are unclear. OBJECTIVE To examine the physical health effects of bipolar disorder using outpatient and inpatient data for a national population. DESIGN, SETTING, AND PARTICIPANTS National cohort study of 6,587,036 Swedish adults, including 6618 with bipolar disorder. MAIN OUTCOMES AND MEASURES Physical comorbidities diagnosed in any outpatient or inpatient setting nationwide and mortality (January 1, 2003, through December 31, 2009). RESULTS Women and men with bipolar disorder died 9.0 and 8.5 years earlier on average than the rest of the population, respectively. All-cause mortality was increased 2-fold among women (adjusted hazard ratio [aHR], 2.34; 95% CI, 2.16-2.53) and men (aHR, 2.03; 95% CI, 1.85-2.23) with bipolar disorder, compared with the rest of the population. Patients with bipolar disorder had increased mortality from cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), influenza or pneumonia, unintentional injuries, and suicide for both women and men and cancer for women only. Suicide risk was 10-fold among women (aHR, 10.37; 95% CI, 7.36-14.60) and 8-fold among men (aHR, 8.09; 95% CI, 5.98-10.95) with bipolar disorder, compared with the rest of the population. Substance use disorders contributed only modestly to these findings. The association between bipolar disorder and mortality from chronic diseases (ischemic heart disease, diabetes, COPD, or cancer) was weaker among persons with a prior diagnosis of these conditions (aHR, 1.40; 95% CI, 1.26-1.56) than among those without a prior diagnosis (aHR, 2.38; 95% CI, 1.95-2.90; P(interaction) = .01). CONCLUSIONS AND RELEVANCE In this large national cohort study, patients with bipolar disorder died prematurely from multiple causes, including cardiovascular disease, diabetes, COPD, influenza or pneumonia, unintentional injuries, and suicide. However, chronic disease mortality among those with more timely medical diagnosis approached that of the general population, suggesting that better provision of primary medical care may effectively reduce premature mortality among persons with bipolar disorder.

Ethnicity, acculturation, and self reported health. A population based study among immigrants from Poland, Turkey, and Iran in Sweden

Study objective: To analyse the association between ethnicity and poor self reported health and explore the importance of any mediators such as acculturation and discrimination. Design: A simple random sample of immigrants from Poland (n = 840), Turkey (n = 840), and Iran (n = 480) and of Swedish born persons (n = 2250) was used in a cross sectional study in 1996. The risk of poor self reported health was estimated by applying logistic models and stepwise inclusion of the explanatory variables. The response rate was about 68% for the immigrants and 80% for the Swedes. Explanatory variables were: age, ethnicity, educational status, marital status, poor economic resources, knowledge of Swedish, and discrimination. Main results: Among men from Iran and Turkey there was a threefold increased risk of poor self reported health than Swedes (reference) while the risk was five times higher for women. When socioeconomic status was included in the logistic model the risk decreased slightly. In an explanatory model, Iranian and Turkish women and men had a higher risk of poor health than Polish women and men (reference). The high risks of Turkish born men and women and Iranian born men for poor self reported health decreased to non-significance after the inclusion of SES and low knowledge of Swedish. The high risks of Iranian born women for poor self reported health decreased to non-significance after the inclusion of low SES, low knowledge of Swedish, and discrimination. Conclusions: The strong association between ethnicity and poor self reported health seems to be mediated by socioeconomic status, poor acculturation, and discrimination.

Gestational Age at Birth and Mortality in Young Adulthood

CONTEXT Preterm birth is the leading cause of infant mortality in developed countries, but the association between gestational age at birth and mortality in adulthood remains unknown. OBJECTIVE To examine the association between gestational age at birth and mortality in young adulthood. DESIGN, SETTING, AND PARTICIPANTS National cohort study of 674,820 individuals born as singletons in Sweden in 1973 through 1979 who survived to age 1 year, including 27,979 born preterm (gestational age <37 weeks), followed up to 2008 (ages 29-36 years). MAIN OUTCOME MEASURES All-cause and cause-specific mortality. RESULTS A total of 7095 deaths occurred in 20.8 million person-years of follow-up. Among individuals still alive at the beginning of each age range, a strong inverse association was found between gestational age at birth and mortality in early childhood (ages 1-5 years: adjusted hazard ratio [aHR] for each additional week of gestation, 0.92; 95% CI, 0.89-0.94; P < .001), which disappeared in late childhood (ages 6-12 years: aHR, 0.99; 95% CI, 0.95-1.03; P = .61) and adolescence (ages 13-17 years: aHR, 0.99; 95% CI, 0.95-1.03; P = .64) and then reappeared in young adulthood (ages 18-36 years: aHR, 0.96; 95% CI, 0.94-0.97; P < .001). In young adulthood, mortality rates (per 1000 person-years) by gestational age at birth were 0.94 for 22 to 27 weeks, 0.86 for 28 to 33 weeks, 0.65 for 34 to 36 weeks, 0.46 for 37 to 42 weeks (full-term), and 0.54 for 43 or more weeks. Preterm birth was associated with increased mortality in young adulthood even among individuals born late preterm (34-36 weeks, aHR, 1.31; 95% CI, 1.13-1.50; P < .001), relative to those born full-term. In young adulthood, gestational age at birth had the strongest inverse association with mortality from congenital anomalies and respiratory, endocrine, and cardiovascular disorders and was not associated with mortality from neurological disorders, cancer, or injury. CONCLUSION After excluding earlier deaths, low gestational age at birth was independently associated with increased mortality in early childhood and young adulthood.

Neighborhood environment and self-reported health status : A multilevel analysis

OBJECTIVES This study examined whether neighborhood socioeconomic environment helps to explain the proportion of community members with self-reported poor health status. METHODS A random sample of 9240 persons aged 25 to 74 years were interviewed during 1988 and 1989. The socioeconomic environment of each respondents neighborhood was measured with the Care Need Index (CNI) and the Townsend score. The data were analyzed with a multilevel model adjusted for the independent variables. The second-level variables were the 2 neighborhood scores. RESULTS There was a clear gradient for poor health and education within every CNI interval so that with an increasing CNI (indicating more deprivation), the prevalence of poor health increased in all 3 education groups (P = .001). In the full model, decreasing educational level, obesity, length and frequency of smoking, physical inactivity, and increasing CNI were associated with poor health. Persons living in the most deprived neighborhoods had a prevalence ratio of 1.69 (95% confidence interval = 1.44, 1.98) for poor health compared with those living in the most affluent areas. CONCLUSIONS Both neighborhood socioeconomic environment and individual educational status are associated with self-reported poor health.

Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden.

BACKGROUND Some autoimmune disorders have been linked to venous thromboembolism. We examined whether there is an association between autoimmune disorders and risk of pulmonary embolism. METHODS We followed up all individuals in Sweden without previous hospital admission for venous thromboembolism and with a primary or secondary diagnosis of an autoimmune disorder between Jan 1, 1964, and Dec 31, 2008, for hospital admission for pulmonary embolism. We obtained data from the MigMed2 database, which has individual-level information about all registered residents of Sweden. The reference population was the total population of Sweden. We calculated standardised incidence ratios (SIRs) for pulmonary embolism, adjusted for individual variables, including age and sex. FINDINGS 535,538 individuals were admitted to hospital because of an autoimmune disorder. Overall risk of pulmonary embolism during the first year after admission for an autoimmune disorder was 6·38 (95% CI 6·19-6·57). All the 33 autoimmune disorders were associated with a significantly increased risk of pulmonary embolism during the first year after admission. However, some had a particularly high risk--eg, immune thrombocytopenic purpura (10·79, 95% CI 7·98-14·28), polyarteritis nodosa (13·26, 9·33-18·29), polymyositis or dermatomyositis (16·44, 11·57-22·69), and systemic lupus erythematosus (10·23, 8·31-12·45). Overall risk decreased over time, from 1·53 (1·48-1·57) at 1-5 years, to 1·15 (1·11-1·20) at 5-10 years, and 1·04 (1·00-1·07) at 10 years and later. The risk was increased for both sexes and all age groups. INTERPRETATION Autoimmune disorders are associated with a high risk of pulmonary embolism in the first year after hospital admission. Our findings suggest that these disorders in general should be regarded as hypercoagulable disorders. FUNDING Swedish Research Council, Swedish Council for Working Life and Social Research, Swedish Research Council Formas, Region Skåne.

Self reported poor health and low educational level predictors for mortality: a population based follow up study of 39,156 people in Sweden.

OBJECTIVE: To analyse the relative risk (RR) of mortality for people who reported poor health or had low educational level. SETTING: Sweden. DESIGN: A random sample of 39156 people was interviewed face to face by Statistics Sweden from 1979-85. The dependent variable was total mortality. Independent variables were sex, age, marital status, and socioeconomic position, defined as educational level, type of housing tenure, and health status. This study was designed as a follow up study ranging from 1 January 1979 to 31 December 1993. Information on the dependent variables was obtained from the central cause of death register. Respondents were linked to the register by the Swedish personal registration number. Person-years at risk were calculated from the date of the interview until death, or for those who survived, until the end of the follow up period. Data were analysed in relation to gender and age (25-29 years and 60-74 years) in a proportional hazard model in order to estimate RR. RESULTS: During follow up 2656 men and 1706 women died. Men and women in both age groups who reported poor health status at the interview had a strongly increased risk of dying during the follow up period (RR = 2.05 (95% confidence interval 1.72, 2.31) and RR = 1.91 (1.74, 2.10) for men, and RR = 2.34 (1.94, 2.83) and RR = 1.80 (1.61, 2.02) for women for the younger and older age groups respectively) when simultaneously controlled for age, marital status, education, and housing tenure. Living alone, renting an apartment, and low educational level (< or = 9 years) were also associated with increased mortality risks for men and women in both age groups. CONCLUSION: Poor self reported health was a strong predictor for total mortality. Furthermore, in Sweden, a country well known for the equality of its income distribution, there are inequalities in health with higher total mortality risks for people with a low educational level and those who are not owner-occupiers.

Neighborhood deprivation and cardiovascular disease risk factors: Protective and harmful effects

Aims: To determine whether neighborhood-level deprivation is independently associated with cardiovascular disease (CVD) health behaviors/risk factors in the Swedish population. Methods: Pooled cross-sectional data, Swedish Annual Level of Living Survey (1996—2000) linked with indicators of neighborhood-level (i.e. Small Area Market Statistics areas) deprivation (1997), to examine the association between neighborhood-level deprivation and individual-level smoking, physical inactivity, obesity, diabetes, and hypertension among women and men, aged 25—64 (n=18,081). Data were analyzed with a series of logistic regression models that adjusted for individual-level age, gender, marital status, immigration status, urbanization, and a comprehensive measure of socioeconomic status (SES). Interactions were tested to determine whether neighborhood effects varied by SES or length of neighborhood exposure. Results: Living in a neighborhood with low deprivation was protective (i.e. lower odds) for smoking, while living in a neighborhood with high deprivation was harmful (i.e. higher odds) for smoking, physical inactivity, and obesity (compared with living in a neighborhood with moderate deprivation). These associations were significant after adjustment for individual-level characteristics. There was no evidence that the neighborhood deprivation associations varied by individual-level SES or length of neighborhood exposure. Conclusions: Neighborhood-level deprivation exerted important protective and harmful associations with health behaviors/ risk factors related to CVD. The significance to public health is substantial because of the number of persons at risk as well as the serious health consequences of CVD. These results suggest that interventions focusing on changing contextual aspects of neighborhoods, in addition to changing individual behaviors, may have a greater impact on CVD than a sole focus on individuals.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden.

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovskys sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over ones life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.