Systematic reviews have consistently shown that individuals with mental disorders have an increased risk of premature mortality. Traditionally, this evidence has been based on relative risks or crude ...estimates of reduced life expectancy. The aim of this study was to compile a comprehensive analysis of mortality-related health metrics associated with mental disorders, including sex-specific and age-specific mortality rate ratios (MRRs) and life-years lost (LYLs), a measure that takes into account age of onset of the disorder.
In this population-based cohort study, we included all people younger than 95 years of age who lived in Denmark at some point between Jan 1, 1995, and Dec 31, 2015. Information on mental disorders was obtained from the Danish Psychiatric Central Research Register and the date and cause of death was obtained from the Danish Register of Causes of Death. We classified mental disorders into ten groups and causes of death into 11 groups, which were further categorised into natural causes (deaths from diseases and medical conditions) and external causes (suicide, homicide, and accidents). For each specific mental disorder, we estimated MRRs using Poisson regression models, adjusting for sex, age, and calendar time, and excess LYLs (ie, difference in LYLs between people with a mental disorder and the general population) for all-cause mortality and for each specific cause of death.
7 369 926 people were included in our analysis. We found that mortality rates were higher for people with a diagnosis of a mental disorder than for the general Danish population (28·70 deaths 95% CI 28·57–28·82 vs 12·95 deaths 12·93–12·98 per 1000 person-years). Additionally, all types of disorders were associated with higher mortality rates, with MRRs ranging from 1·92 (95% CI 1·91–1·94) for mood disorders to 3·91 (3·87–3·94) for substance use disorders. All types of mental disorders were associated with shorter life expectancies, with excess LYLs ranging from 5·42 years (95% CI 5·36–5·48) for organic disorders in females to 14·84 years (14·70–14·99) for substance use disorders in males. When we examined specific causes of death, we found that males with any type of mental disorder lost fewer years due to neoplasm-related deaths compared with the general population, although their cancer mortality rates were higher.
Mental disorders are associated with premature mortality. We provide a comprehensive analysis of mortality by different types of disorders, presenting both MRRs and premature mortality based on LYLs, displayed by age, sex, and cause of death. By providing accurate estimates of premature mortality, we reveal previously underappreciated features related to competing risks and specific causes of death.
Danish National Research Foundation.
Individuals with mental disorders often develop comorbidity over time. Past studies of comorbidity have often restricted analyses to a subset of disorders and few studies have provided absolute risks ...of later comorbidity.
To undertake a comprehensive study of comorbidity within mental disorders, by providing temporally ordered age- and sex-specific pairwise estimates between the major groups of mental disorders, and to develop an interactive website to visualize all results and guide future research and clinical practice.
This population-based cohort study included all individuals born in Denmark between January 1, 1900, and December 31, 2015, and living in the country between January 1, 2000, and December 31, 2016. The analyses were conducted between June 2017 and May 2018.
Danish health registers were used to identify mental disorders, which were examined within the broad 10-level International Statistical Classification of Diseases and Related Health Problems, 10th Revision, subchapter groups (eg, codes F00-F09 and F10-F19). For each temporally ordered pair of disorders, overall and lagged hazard ratios and 95% CIs were calculated using Cox proportional hazards regression models. Absolute risks were estimated using competing risks survival analyses. Estimates for each sex were generated.
A total of 5 940 778 persons were included in this study (2 958 293 men and 2 982 485 women; mean SD age at beginning of follow-up, 32.1 25.4 years). They were followed up for 83.9 million person-years. All mental disorders were associated with an increased risk of all other mental disorders when adjusting for sex, age, and calendar time (hazard ratios ranging from 2.0 95% CI, 1.7-2.4 for prior intellectual disabilities and later eating disorders to 48.6 95% CI, 46.6-50.7 for prior developmental disorders and later intellectual disabilities). The hazard ratios were temporally patterned, with higher estimates during the first year after the onset of the first disorder, but with persistently elevated rates during the entire observation period. Some disorders were associated with substantial absolute risks of developing specific later disorders (eg, 30.6% 95% CI, 29.3%-32.0% of men and 38.4% 95% CI, 37.5%-39.4% of women with a diagnosis of mood disorders before age 20 years developed neurotic disorders within the following 5 years).
Comorbidity within mental disorders is pervasive, and the risk persists over time. This study provides disorder-, sex-, and age-specific relative and absolute risks of the comorbidity of mental disorders. Web-based interactive data visualization tools are provided for clinical utility.
Many countries have used the new ANACONDA (Analysis of Causes of National Death for Action) tool to assess the quality of their cause of death data (COD), but no cross-country analysis has been done ...to verify how different or similar patterns of diagnostic errors and data quality are in countries or how they are related to the local cultural or epidemiological environment or to levels of development. Our objective is to measure whether the usability of COD data and the patterns of unusable codes are related to a country's level of socio-economic development. We have assessed the quality of 20 national COD datasets from the WHO Mortality Database by assessing their completeness of COD reporting and the extent, pattern and severity of garbage codes, i.e. codes that provide little or no information about the true underlying COD. Garbage codes were classified into four groups based on the severity of the error in the code. The Vital Statistics Performance Index for Quality (VSPI(Q)) was used to measure the overall quality of each country's mortality surveillance system. The proportion of 'garbage codes' varied from 7 to 66% across the 20 countries. Countries with a high SDI generally had a lower proportion of high impact (i.e. more severe) garbage codes than countries with low SDI. While the magnitude and pattern of garbage codes differed among countries, the specific codes commonly used did not. There is an inverse relationship between a country's socio-demographic development and the overall quality of its cause of death data, but with important exceptions. In particular, some low SDI countries have vital statistics systems that are as reliable as more developed countries. However, in low-income countries, where most people die at home, the proportion of unusable codes often exceeds 50%, implying that half of all cause-specific mortality data collected is of little or no use in guiding public policy. Moreover, the cause of death pattern identified from the data is likely to seriously under-represent the true extent of the leading causes of death in the population, with very significant consequences for health priority setting. Garbage codes are prevalent at all ages, contrary to expectations. Further research into effective strategies deployed in these countries to improve data quality can inform efforts elsewhere to improve COD reporting systems.
The nature and prevalence of combinations of mental disorders and their associations with premature mortality have never been reported in a comprehensive way. We describe the most common combinations ...of mental disorders and estimate excess mortality associated with these combinations. We designed a population‐based cohort study including all 7,505,576 persons living in Denmark at some point between January 1, 1995 and December 31, 2016. Information on mental disorders and mortality was obtained from national registers. A total of 546,090 individuals (10.5%) living in Denmark on January 1, 1995 were diagnosed with at least one mental disorder during the 22‐year follow‐up period. The overall crude rate of diagnosis of mental disorders was 9.28 (95% CI: 9.26‐9.30) per 1,000 person‐years. The rate of diagnosis of additional mental disorders was 70.01 (95% CI: 69.80‐70.26) per 1,000 person‐years for individuals with one disorder already diagnosed. At the end of follow‐up, two out of five individuals with mental disorders were diagnosed with two or more disorder types. The most prevalent were neurotic/stress‐related/somatoform disorders (ICD‐10 F40‐F48) and mood disorders (ICD‐10 F30‐F39), which – alone or in combination with other disorders – were present in 64.8% of individuals diagnosed with any mental disorder. Mortality rates were higher for people with mental disorders compared to those without mental disorders. The highest mortality rate ratio was 5.97 (95% CI: 5.52‐6.45) for the combination of schizophrenia (ICD‐10 F20‐F29), neurotic/stress‐related/somatoform disorders and substance use disorders (ICD‐10 F10‐F19). Any combination of mental disorders was associated with a shorter life expectancy compared to the general Danish population, with differences in remaining life expectancy ranging from 5.06 years (95% CI: 5.01‐5.11) to 17.46 years (95% CI: 16.86‐18.03). The largest excess mortality was observed for combinations that included substance use disorders. This study reports novel estimates related to the “force of comorbidity” and provides new insights into the contribution of substance use disorders to premature mortality in those with comorbid mental disorders.
Introduction and Aims
The gender difference in alcohol use seems to have narrowed in the Nordic countries, but it is not clear to what extent this may have affected differences in levels of harm. We ...compared gender differences in all‐cause and cause‐specific alcohol‐attributed disease burden, as measured by disability‐adjusted life‐years (DALY), in four Nordic countries in 2000–2017, to find out if gender gaps in DALYs had narrowed.
Design and Methods
Alcohol‐attributed disease burden by DALYs per 100 000 population with 95% uncertainty intervals were extracted from the Global Burden of Disease database.
Results
In 2017, all‐cause DALYs in males varied between 2531 in Finland and 976 in Norway, and in females between 620 in Denmark and 270 in Norway. Finland had the largest gender differences and Norway the smallest, closely followed by Sweden. During 2000–2017, absolute gender differences in all‐cause DALYs declined by 31% in Denmark, 26% in Finland, 19% in Sweden and 18% in Norway. In Finland, this was driven by a larger relative decline in males than females; in Norway, it was due to increased burden in females. In Denmark, the burden in females declined slightly more than in males, in relative terms, while in Sweden the relative decline was similar in males and females.
Discussion and Conclusions
The gender gaps in harm narrowed to a different extent in the Nordic countries, with the differences driven by different conditions. Findings are informative about how inequality, policy and sociocultural differences affect levels of harm by gender.
Background
The provision of different types of mortality metrics (e.g., mortality rate ratios MRRs and life expectancy) allows the research community to access a more informative set of health ...metrics. The aim of this study was to provide a panel of mortality metrics associated with a comprehensive range of disorders and to design a web page to visualize all results.
Methods and findings
In a population-based cohort of all 7,378,598 persons living in Denmark at some point between 2000 and 2018, we identified individuals diagnosed at hospitals with 1,803 specific categories of disorders through the International Classification of Diseases-10th Revision (ICD-10) in the National Patient Register. Information on date and cause of death was obtained from the Registry of Causes of Death. For each of the disorders, a panel of epidemiological and mortality metrics was estimated, including incidence rates, age-of-onset distributions, MRRs, and differences in life expectancy (estimated as life years lost LYLs). Additionally, we examined models that adjusted for measures of air pollution to explore potential associations with MRRs. We focus on 39 general medical conditions to simplify the presentation of results, which cover 10 broad categories: circulatory, endocrine, pulmonary, gastrointestinal, urogenital, musculoskeletal, hematologic, mental, and neurologic conditions and cancer. A total of 3,676,694 males and 3,701,904 females were followed up for 101.7 million person-years. During the 19-year follow-up period, 1,034,273 persons (14.0%) died. For 37 of the 39 selected medical conditions, mortality rates were larger and life expectancy shorter compared to the Danish general population. For these 37 disorders, MRRs ranged from 1.09 (95% confidence interval CI: 1.09 to 1.10) for vision problems to 7.85 (7.77 to 7.93) for chronic liver disease, while LYLs ranged from 0.31 (0.14 to 0.47) years (approximately 16 weeks) for allergy to 17.05 (16.95 to 17.15) years for chronic liver disease. Adjustment for air pollution had very little impact on the estimates; however, a limitation of the study is the possibility that the association between the different disorders and mortality could be explained by other underlying factors associated with both the disorder and mortality.
Conclusions
In this study, we show estimates of incidence, age of onset, age of death, and mortality metrics (both MRRs and LYLs) for a comprehensive range of disorders. The interactive data visualization site (
https://nbepi.com/atlas
) allows more fine-grained analysis of the link between a range of disorders and key mortality estimates.
Background
It is important to understand the effects of population ageing on disease burden and explore conditions that drive poor health in later life to prevent or manage these. We examined the ...development of disease burden and its components for major disease groups among older adults in Europe over the last 30 years.
Methods
Using data from the Global Burden of Disease 2019 Study, we analyzed burden of disease trends between 1990 and 2019 measured by years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALYs) among older adults (65+ years) in Western, Central and Eastern Europe using cause groups for diseases and injuries.
Results
Between 1990 and 2019, the crude numbers of DALYs for all causes increased substantially among older Western Europeans. In Eastern Europe, the absolute DALYs also increased from 1990 to 2005 but then decreased between 2006 and 2013. However, DALY rates declined for all European regions over time, with large differences in the magnitude by region and gender. Changes in the YLL rate were mainly driven by the contribution of cardiovascular diseases.
Conclusions
This study found an increased overall absolute disease burden among older Europeans between 1990 and 2019. The demographic change that has taken place in Eastern European countries implies a potential problem of directed resource allocation to the health care sector. Furthermore, the findings highlight the potential health gains through directing resources to health promotion and treatment to reduce YLDs and to prevent YLLs, primarily from cardiovascular diseases.
Background: While the system of registration of mortality and cause of death (COD) in Greenland was established several decades ago, reporting procedures follow a complicated administrative process. ...Timely and reliable reporting on mortality and COD is of high importance for the usability of the collected data for research, health planning and decision making. Methods: COD data collected by the Chief Medical Office in Greenland from 2006 to 2015 (4490 registered deaths) were analysed with the software Analysis of National Causes of Death for Action (ANACONDA) v4.0. Unusable or insufficiently specified ICD codes are identified. The Vital Statistics Performance Index for Quality (VSPI(Q)) is estimated for the overall quality conclusions of the register’s usability. Results: Sixty-eight per cent of the input data for Greenland was coded with a usable underlying COD, 24% with an unusable cause and 8% of deaths with an insufficiently specified cause. Almost 700 deaths were coded to an unusable code of ‘very high impact’. The most prevalent unusable underlying causes were other ill-defined and unspecified causes, including no death certificate available, followed by senility, heart failure, sepsis and shock and cardiac arrest. The VSPI(Q) score was 66%, representing medium quality. Conclusions: In the 10 years’ worth of data analysed, the true underlying COD in many cases was unknown. Several likely explanations for this include lack of systematic COD training for physicians, logistic and capacity challenges in Greenland that potentially could reduce the quality of the collected data and its usability in providing essential information about the true pattern of mortality in Greenland.
Background
General medical conditions (GMCs) often co-occur with mental and substance use disorders (MSDs).
Aims
To explore the contribution of GMCs to the burden of disease in people with MSDs, and ...investigate how this varied by age.
Method
A population-based cohort of 6 988 507 persons living in Denmark during 2000–2015 followed for up to 16 years. Danish health registers were used to identify people with MSDs and GMCs. For each MSD, years lived with disability and health loss proportion (HeLP) were estimated for comorbid MSDs and GMCs, using a multiplicative model for disability weights.
Results
Those with any MSD lost the equivalent of 43% of healthy life (HeLP = 0.43, 95% CI 0.40–0.44) after including information on GMCs, which was an increase from 25% before including GMCs (HeLP = 0.25, 95% CI 0.23–0.27). Schizophrenia was associated with the highest burden of disease (HeLP = 0.77, 95% CI 0.68–0.85). However, within each disorder, the relative contribution of MSDs and GMCs varied. For example, in those diagnosed with schizophrenia, MSDs and GMCs accounted for 86% and 14% of the total health loss; in contrast, in those with anxiety disorders, the same proportions were 59% and 41%. In general, HeLP increased with age, and was mainly associated with increasing rates of pulmonary, musculoskeletal and circulatory diseases.
Conclusions
In those with mental disorders, the relative contribution of comorbid GMCs to the non-fatal burden of disease increases with age. GMCs contribute substantially to the non-fatal burden of disease in those with MSDs.
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