Thomas Munk Laursen

Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders

BACKGROUND People with mental disorders evince excess mortality due to natural and unnatural deaths. The relative life expectancy of people with mental disorders is a proxy measure of effectiveness of social policy and health service provision. AIMS To evaluate trends in health outcomes of people with serious mental disorders. METHOD We examined nationwide 5-year consecutive cohorts of people admitted to hospital for mental disorders in Denmark, Finland and Sweden in 1987-2006. In each country the risk population was identified from hospital discharge registers and mortality data were retrieved from cause-of-death registers. The main outcome measure was life expectancy at age 15 years. RESULTS People admitted to hospital for a mental disorder had a two- to threefold higher mortality than the general population in all three countries studied. This gap in life expectancy was more pronounced for men than for women. The gap decreased between 1987 and 2006 in these countries, especially for women. The notable exception was Swedish men with mental disorders. In spite of the positive general trend, men with mental disorders still live 20 years less, and women 15 years less, than the general population. CONCLUSIONS During the era of deinstitutionalisation the life expectancy gap for people with mental disorders has somewhat diminished in the three Nordic countries. Our results support further development of the Nordic welfare state model, i.e. tax-funded community-based public services and social protection. Health promotion actions, improved access to healthcare and prevention of suicides and violence are needed to further reduce the life expectancy gap.

Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden.

Background Excess mortality among patients with severe mental disorders has not previously been investigated in detail in large complete national populations. Objective To investigate the excess mortality in different diagnostic categories due to suicide and other external causes of death, and due to specific causes in connection with diseases and medical conditions. Methods In longitudinal national psychiatric case registers from Denmark, Finland, and Sweden, a cohort of 270,770 recent-onset patients, who at least once during the period 2000 to 2006 were admitted due to a psychiatric disorder, were followed until death or the end of 2006. They were followed for 912,279 person years, and 28,088 deaths were analyzed. Life expectancy and standardized cause-specific mortality rates were estimated in each diagnostic group in all three countries. Results The life expectancy was generally approximately 15 years shorter for women and 20 years shorter for men, compared to the general population. Mortality due to diseases and medical conditions was increased two- to three-fold, while excess mortality from external causes ranged from three- to 77-fold. Mortality due to diseases and medical conditions was generally lowest in patients with affective disorders and highest in patients with substance abuse and personality disorders, while mortality due to suicide was highest in patients with affective disorders and personality disorders, and mortality due to other external causes was highest in patients with substance abuse. Conclusions These alarming figures call for action in order to prevent the high mortality.

Life expectancy and cardiovascular mortality in persons with schizophrenia.

Purpose of review To assess the impact of cardiovascular disease on the excess mortality and shortened life expectancy in schizophrenic patients. Recent findings Patients with schizophrenia have two-fold to three-fold higher mortality rates compared with the general population, corresponding to a 10–25-year reduction in life expectancy. Although the mortality rate from suicide is high, natural causes of death account for a greater part of the reduction in life expectancy. The reviewed studies suggest four main reasons for the excess mortality and reduced life expectancy. First, persons with schizophrenia tend to have suboptimal lifestyles including unhealthy diets, excessive smoking and alcohol use, and lack of exercise. Second, antipsychotic drugs may have adverse effects. Third, physical illnesses in persons with schizophrenia are common, but diagnosed late and treated insufficiently. Lastly, the risk of suicide and accidents among schizophrenic patients is high. Summary Schizophrenia is associated with a substantially higher mortality and curtailed life expectancy partly caused by modifiable risk factors.

Life expectancy among persons with schizophrenia or bipolar affective disorder.

CONTEXT Mortality rates among individuals with schizophrenia or bipolar disorder are elevated compared to the general population. OBJECTIVE The objective was to estimate life-expectancy (average age at death) among these persons and make a comparison to people in the general population. METHODS Life-expectancy was calculated by means of survival analysis techniques using the entire Danish population as a cohort. RESULTS Life-expectancy was 18.7 years shorter for schizophrenic men compared to men in the general population. Corresponding numbers for schizophrenic women was 16.3 years, for bipolar men 13.6 years, and for bipolar women 12.1 years. CONCLUSIONS Life-expectancy was much shorter in persons with schizophrenia or bipolar disorder. Excess mortality from physical diseases and medical conditions exerts a far greater influence on the curtailed life-expectancy, when compared against the impact of death by external causes.

Somatic Hospital Contacts, Invasive Cardiac Procedures, and Mortality From Heart Disease in Patients With Severe Mental Disorder

CONTEXT Excess mortality from heart disease is observed in patients with severe mental disorder. This excess mortality may be rooted in adverse effects of pharmacological or psychotropic treatment, lifestyle factors, or inadequate somatic care. OBJECTIVES To examine whether persons with severe mental disorder, defined as persons admitted to a psychiatric hospital with bipolar affective disorder, schizoaffective disorder, or schizophrenia, are in contact with hospitals and undergoing invasive procedures for heart disease to the same degree as the nonpsychiatric general population, and to determine whether they have higher mortality rates of heart disease. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort of 4.6 million persons born in Denmark was followed up from 1994 to 2007. Rates of mortality, somatic contacts, and invasive procedures were estimated by survival analysis. MAIN OUTCOME MEASURES Incidence rate ratios of heart disease admissions and heart disease mortality as well as probability of invasive cardiac procedures. RESULTS The incidence rate ratio of heart disease contacts in persons with severe mental disorder compared with the rate for the nonpsychiatric general population was only slightly increased, at 1.11 (95% confidence interval, 1.08-1.14). In contrast, their excess mortality rate ratio from heart disease was 2.90 (95% confidence interval, 2.71-3.10). Five years after the first contact for somatic heart disease, the risk of dying of heart disease was 8.26% for persons with severe mental disorder (aged <70 years) but only 2.86% in patients with heart disease who had never been admitted to a psychiatric hospital. The fraction undergoing invasive procedures within 5 years was reduced among patients with severe mental disorder as compared with the nonpsychiatric general population (7.04% vs 12.27%, respectively). CONCLUSIONS Individuals with severe mental disorder had only negligible excess rates of contact for heart disease. Given their excess mortality from heart disease and lower rates of invasive procedures after first contact, it would seem that the treatment for heart disease offered to these individuals in Denmark is neither sufficiently efficient nor sufficiently intensive. This undertreatment may explain part of their excess mortality.

Risk for schizophrenia and schizophrenia-like psychosis among patients with epilepsy: population based cohort study.

Abstract Objectives To investigate whether age at onset of epilepsy, type of epilepsy, family history of psychosis, or family history of epilepsy affect the risk of schizophrenia or schizophrenia-like psychosis among patients with epilepsy. Design Comparison of population based data. Setting Danish longitudinal registers. Subjects The cohort comprised 2.27 million people. Main outcome measures Epilepsy, psychosis, personal birth data. Results We found an increased risk of schizophrenia (relative risk 2.48, 95% confidence interval 2.20 to 2.80) and schizophrenia-like psychosis (2.93, 2.69 to 3.20) in people with a history of epilepsy. The effect of epilepsy was the same in men and in women and increased with age. Family history of psychosis and a family history of epilepsy were significant risk factors for schizophrenia and schizophrenia-like psychosis, and the effect of epilepsy, both in cases and families, was greater among people with no family history of psychosis. In addition, the increased risk for schizophrenia or schizophrenia-like psychosis did not differ by type of epilepsy but increased with increasing number of admissions to hospital and, particularly, was significantly greater for people first admitted for epilepsy at later ages. Conclusions There is a strong association between epilepsy and schizophrenia or schizophrenia-like psychosis. The two conditions may share common genetic or environmental causes.

Excess Early Mortality in Schizophrenia

Schizophrenia is often referred to as one of the most severe mental disorders, primarily because of the very high mortality rates of those with the disorder. This article reviews the literature on excess early mortality in persons with schizophrenia and suggests reasons for the high mortality as well as possible ways to reduce it. Persons with schizophrenia have an exceptionally short life expectancy. High mortality is found in all age groups, resulting in a life expectancy of approximately 20 years below that of the general population. Evidence suggests that persons with schizophrenia may not have seen the same improvement in life expectancy as the general population during the past decades. Thus, the mortality gap not only persists but may actually have increased. The most urgent research agenda concerns primary candidates for modifiable risk factors contributing to this excess mortality, i.e., side effects of treatment and lifestyle factors, as well as sufficient prevention and treatment of physical comorbidity.

Risks and Predictors of Readmission for a Mental Disorder During the Postpartum Period

CONTEXT It has been suggested that the risk of inpatient psychiatric readmissions is elevated during the postpartum period. To our knowledge, no prior study has compared mothers and nonmothers to determine whether the risk of readmission differs between these 2 groups of women. OBJECTIVES To compare mothers and nonmothers to assess whether childbirth increases the risk for psychiatric readmission and to identify predictors of psychiatric readmission during the postpartum period. DESIGN A population-based cohort study merging data from the Danish Civil Registration System and the Danish Psychiatric Central Register. SETTING The population of Denmark. PARTICIPANTS Two partly overlapping study populations included a total of 28 124 women, 10 218 of whom were mothers, who were followed up from January 1, 1973, through June 30, 2005. Main Outcome Measure Readmission rates to psychiatric hospitals during the 12 months after childbirth (first live-born child). RESULTS The period of highest risk of psychiatric readmission in new mothers was 10 to 19 days post partum (relative risk [RR], 2.71; 95% confidence interval [CI], 1.68-4.37), and the period of lowest risk was during pregnancy (0.54; 0.43-0.69). Childbirth was associated with an increased risk of readmission during the first postpartum month, after which risk for readmission was higher among nonmothers (RR, 1.53; 95% CI, 1.31-1.80). A previous diagnosis of bipolar affective disorder was the strongest predictor of readmissions 10 to 19 days post partum (RR, 37.22; 95% CI, 13.58-102.04). In all, 26.9% of mothers with this diagnosis were readmitted within the first postpartum year. CONCLUSIONS Mothers with mental disorders have lower readmission rates compared with women with mental disorders who do not have children. However, the first month after childbirth is associated with increased risk of psychiatric readmission, and women with a history of bipolar affective disorder are at particular risk of postpartum psychiatric readmissions.

Severe Mental Disorders in Offspring With 2 Psychiatrically Ill Parents

BACKGROUND Studies of couples of psychiatric patients with children allow us to calculate the effects of double predispositions on morbid risk in the offspring, which is of interest for molecular genetic research and for genetic counseling. OBJECTIVE To determine the risks in offspring of receiving a diagnosis of schizophrenia, bipolar disorder, unipolar depressive disorder, or any diagnosis from parents who both have received a diagnosis of schizophrenia or bipolar disorder. DESIGN National register-based cohort study. SETTING Denmark. PARTICIPANTS A population-based cohort of 2.7 million persons born in Denmark, alive in 1968 or born later than 1968, with a register link to their mother and father and aged 10 years or older in 2007. MAIN OUTCOME MEASURE Risk of schizophrenia or bipolar disorder, calculated as cumulative incidences by age 52 years. RESULTS The risk of schizophrenia in 270 offspring of 196 parent couples who were both admitted to a psychiatric facility with a diagnosis of schizophrenia was 27.3% (increasing to 39.2% when schizophrenia-related disorders were included) compared with 7.0% in 13 878 offspring from 8006 couples with only 1 parent ever admitted for schizophrenia and 0.86% in 2 239 551 offspring of 1 080 030 couples with neither parent ever admitted. The risk of bipolar disorder was 24.9% in 146 offspring of 83 parent couples who were ever admitted with bipolar disorder (increasing to 36.0% when unipolar depressive disorder was included) compared with 4.4% in 23 152 offspring from 11 995 couples with only 1 parent ever admitted and 0.48% in 2 239 553 offspring of 1 080 030 couples with neither parent ever admitted. Risks of schizophrenia and bipolar disorder in offspring of couples with 1 parent with schizophrenia and the other with bipolar disorder were 15.6% and 11.7%, respectively. The maximal risks of any psychiatric disorders in the offspring of parents both with schizophrenia or both with bipolar disorder were 67.5% and 44.2%, respectively. CONCLUSIONS Derived risks may be informative for counseling. Patterns of transmission may support evolving assumptions about genetic overlap for traditional categories.

Life expectancy and death by diseases of the circulatory system in patients with bipolar disorder or schizophrenia in the Nordic countries.

Objective Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler’s method. Results The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter. Conclusion Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years.