Number Of Excess Deaths Research Articles

S39-02 - Mortality in serious mental illness

IntroductionThere is evidence that patients with bipolar disorder have an increased mortality from somatic causes of death, including coronary heart disease and myocardial infarction. However, present mortality ratios and mortality trends over time are not known.AimTo analyze relative mortality and mortality trends for patients with bipolar disorder in relation to the population for cerebrovascular disease, coronary heart disease and myocardial infarction.MethodsAll patients in Sweden with a clinical diagnosis of bipolar disorder from the introduction of ICD-10 (1987–2006) found in the National Swedish Patient Register were followed-up in the Cause of death register. Mortality rate ratios (MRR) for different cardiovascular diseases and different age groups were calculated, as well as numbers of excess deaths, relative to the population. Also, admission rate ratios (ARR) and yearly mortality rates for bipolar patients versus the population were calculated for the same time period.ResultsFrom all causes of death, there were 5,471 deaths for bipolar patients. MRR was 2.58 (95% CI: 2.51–2.65). For cerebrovascular disease MRR was 2.19 (95% CI: 2.01–2.40), and for coronary heart disease MRR was 2.10 (95% CI: 1.98–2.2.24). In the subgroup of acute myocardial infarction MRR was 1.97 (95% CI: 1.81–2.14). In cerebrovascular disease, ARR was increased to 1.47 (95% CI: 1.35–1.59), while in coronary heart disease ARR was 1.06 (95% CI: 0.98–2.24), and in acute myocardial infarction 1.09 (95% CI: 0.0.98–1.22). Yearly mortality rates for these causes of death decreased both among patients and the population, without indication of a decreasing gap.ConclusionsIn patients with bipolar disorder, mortality from cerebrovascular disease and coronary heart disease with its subgroup acute myocardial infarction was doubled during 1987–2006. In contrast, admission rates for coronary heart disease and acute myocardial infarction were not increased. Yearly mortality rates decreased both for the patients and the population, but there were no indications of a decreasing gap.KeywordsBipolar disorder; Register study; Cerebrovascular disease; Coronary heart disease; Acute myocardial infarction; Mortality rate ratios; Admission rate ratios.

Disease-specific mortality may underestimate the total effect of prostate cancer screening

To study the difference between the disease-specific and excess mortality rate in the European Randomized Study of Screening for Prostate Cancer section Rotterdam. A total of 42,376 men were randomized to systematic screening or usual care. The excess number of deaths was defined as the difference between the observed number of deaths in the prostate cancer (PC) patients and the expected number of deaths up to 31 December 2006. The expected number was derived from mortality of all study participants before a possible diagnosis with PC. The disease-specific mortality rate was based on the number of men who died from PC. The excess mortality rate based on the arm-specific excess number of deaths and the disease-specific mortality rate were compared between the two study arms. The overall mortality rate was not significantly different between the intervention and the control arms of the study: RR 1.02 (95% CI 0.98-1.07). The disease-specific mortality rate was 0.42 men per 1000 person-years in the intervention and 0.48 men per 1000 person-years in the control arm: RR 0.86 (95% CI 0.64-1.17). The excess mortality rate was 0.40 per 1000 person-years in the intervention arm and 0.61 men per 1000 person-years in the control arm, and the RR for excess mortality was 0.66 (95% CI 0.39-1.13). In contrast to the disease-specific mortality rates an increased difference in the excess mortality rates was observed between the two arms. This observation may be due to a systematic underestimation of the disease-specific deaths, and/or an additional disease-related mortality that is measured by an excess mortality analysis but not by a disease-specific mortality.

Heat-related mortality in residents of nursing homes

in population-based studies, age and morbidity were associated with heat-related mortality. The nursing home population reveals both factors and may represent a highly vulnerable subgroup. Therefore, temperature-mortality relationship was examined in residents of nursing homes. the association between daily ambient maximum temperature and mortality was analysed in 95,808 nursing home residents in southwest Germany between 2001 and 2005. Time series analyses were applied across age groups, sex and functional abilities. In addition, excess mortality was determined for the 2003 heat wave. mortality risk was lowest at maximum temperatures between 16 and 25.9 degrees Celsius. Risk increased by 26 and 62% at days of 32.0-33.9 and 34 degrees Celsius and more, respectively. In August 2003, heat caused >400 additional deaths in the observed population and was followed by only a moderate mortality displacement in the following months. The excess number of deaths during the heat wave was particularly high in residents aged > or = 90 years and in residents with higher care needs. high ambient temperature was associated with an increased mortality risk in all analysed subgroups of the nursing home population. Medical competence and supervision are available in nursing homes and should, therefore, be favourable preconditions for the implementation of preventive measures.

Poor Progress in Breast Cancer Control in the Elderly in the UK.

Abstract Background:In 1998 England introduced a national cancer target, to reduce cancer mortality in the under 75 year olds from 1996 to 2010 by 20%. This might potentially lead to inequalities between younger and elderly cancer patients. In this study we assessed progress in breast cancer control in the elderly in the UK by comparing cancer mortality rates in the elderly with younger age groups in the UK and by comparing the elderly in the UK with other similar countries.Material and Methods:Mortality data for the UK, USA, Northern Europe (Denmark, Finland, Iceland, Sweden and Norway) and Western Europe (Germany, Netherlands, Luxembourg, Austria, France Switzerland) was obtained from the WHO mortality database. Age specific cancer mortality rates for the age bands 55-64, 65-74, 75-84 and 85 plus were calculated for the different geographies for the three year periods 1995-97 and 2003-05. Change in the differences between the age bands was assessed as the ratio between the youngest age group 55-64, which was set to 1, and the older age groups. The number of excess deaths in the UK was calculated by applying the lowest rate observed in each age band to the UK population, assuming that the UK could achieve the same rate.Results:Compared to other countries the UK had the highest breast cancer mortality rates in all age bands in 1995-07 and 2003-05 and rates were statistically significantly higher in 2003-05 at the 95% Confidence interval limit. In the younger age groups (55-64 and 65-74) the UK had the biggest decrease from 1995-97 to 2003-05 and is decreasing the gap to the other countries. In contrast the UK was the only geography with an increase in mortality rates in the over 85 year olds and only ranked second after the USA in the 75 to 84 year olds. If the UK had the same mortality rates as the lowest observed in each age band 681 breast cancer deaths could be prevented in the 55 to 74 year olds and 1590 in the over 75 year olds each year. The UK also had the greatest increase in the ratio between the 55-64 year olds and 85plus year olds, with and increase of a 100% from 3.5 to 4.5 from 1995-97 to 2003-05. The USA had the lowest rates in each age group.Conclusion:Little progress has been made in decreasing breast cancer mortality rates in the elderly in the UK. The gap in breast cancer mortality in the elderly compared to the younger age groups as well as the other countries is increasing. The gap with other countries will be closed only if there is a marked decrease in death rates in the over 75s. Future analysis should also look at the causes of higher mortality in the UK, taking the USA as the gold standard. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2059.

A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson's disease

Subthalamic nucleus deep brain stimulation improves motor symptoms and quality of life in advanced Parkinson's disease. As after other life-altering surgeries, suicides have been reported following deep brain stimulation for movement disorders. We sought to determine the suicide rate following subthalamic nucleus deep brain stimulation for Parkinson's disease by conducting an international multicentre retrospective survey of movement disorder and surgical centres. We further sought to determine factors associated with suicide attempts through a nested case-control study. In the survey of suicide rate, 55/75 centres participated. The completed suicide percentage was 0.45% (24/5311) and attempted suicide percentage was 0.90% (48/5311). Observed suicide rates in the first postoperative year (263/100,000/year) (0.26%) were higher than the lowest and the highest expected age-, gender- and country-adjusted World Health Organization suicide rates (Standardized Mortality Ratio for suicide: SMR 12.63-15.64; P < 0.001) and remained elevated at the fourth postoperative year (38/100,000/year) (0.04%) (SMR 1.81-2.31; P < 0.05). The excess number of deaths was 13 for the first postoperative year and one for the fourth postoperative year. In the case-control study of associated factors, 10 centres participated. Twenty-seven attempted suicides and nine completed suicides were compared with 70 controls. Postoperative depression (P < 0.001), being single (P = 0.007) and a previous history of impulse control disorders or compulsive medication use (P = 0.005) were independent associated factors accounting for 51% of the variance for attempted suicide risk. Attempted suicides were also associated (P < 0.05) with being younger, younger Parkinson's disease onset and a previous suicide attempt. Completed suicides were associated with postoperative depression (P < 0.001). Postoperative depression remained a significant factor associated with attempted and completed suicides after correction for multiple comparisons using the stringent Bonferroni correction. Mortality in the first year following subthalamic nucleus deep brain stimulation has been reported at 0.4%. Suicide is thus one of the most important potentially preventable risks for mortality following subthalamic nucleus deep brain stimulation for Parkinson's disease. Postoperative depression should be carefully assessed and treated. A multidisciplinary assessment and follow-up is recommended.

Socioeconomic position and excess mortality during the heat wave of 2003 in Barcelona

The objective of this study is to determine whether the excess of mortality which occurred in Barcelona during the summer of 2003 was dependent on age, gender and educational level. We included all deaths among Barcelona residents 20 years of age and older that occurred in the city during the months of June, July and August of 2003 and also during the same months of the five preceding years. Poisson regression models were fitted to obtain the risk of death in 2003 with respect to the period 1998-2002. The relative risk (RR) of mortality during the summer of 2003, compared to the summers of the previous 5 years, was higher for women than for men and among older ages. Although an increase among women was observed in all educational groups, in some age groups the increase was larger for people with less than primary education. The excess number of deaths was higher for those with less education. These results suggest that age, gender and educational level were important determinants of excess mortality in the 2003 Barcelona heat wave.

Message From the Immediate Past President of SOPHE: Inaugural SOPHE Summit on Eliminating Health Disparity

It has been 20 years since the 1985 Secretary’s Task Force Report on Black and Minority Health was released by the U.S. Department of Health and Human Services (1985). That report concluded that there was an excess of 60,000 deaths among Blacks and other minorities that could have been avoided had the playing fields been even. Subsequent publications have indicated that the number of excess deaths among African Americans has increased to 80,000 (Heisler, Rust, Pattillo, & Dubois, 2005). The disparities in diseases and death tell a story of persistent inequity in society. The focus on excess death has resulted in a focus on clinical intervention to prevent death. Although such a focus is warranted, a critical area of inequity that has yet to receive the same level of attention as clinical intervention is the social environment that creates conditions that promote vulnerability to diseases that account for excess deaths. This negligence in not focusing on the social environmental factors contributing to persistent health disparities among racial and ethnic minorities in the United States was the impetus for the SOPHE Inaugural Summit on Health Disparities in August 2005. Eleven years ago in 1995, SOPHE published its first Research Agenda in Health Education (Clark & McLeroy, 1995). The goal of that document was to help the health education profession frame its research priority for the future. The 2005 SOPHE summit marked 20 years after the Secretary’s Task Force Report on Black and Minority Health and 10 years after the publication of SOPHE’s first research agenda. These two research documents derived from two historical moments of health education and public health inquiry and converged to guide the profession to reframe an agenda for future research in health education in order to optimize the impact that the field has on reducing health disparities. In 2005, SOPHE invited some 85 researchers and practitioners to its Inaugural Summit to Eliminate Racial and Ethnic Health Disparities. The SOPHE summit represented a historical trajectory for affirming and recommitting ourselves to a research agenda for the profession. Although the summit focused our attention on those disparities relating to racial and ethnic minorities, this agenda actually

Summary of the mortality impact assessment of the 2003 heat wave in France

France experienced a record-breaking heat wave between 2 and 15 August 2003. All the French regions were affected by this heat wave, which resulted in an excess of 14 800 deaths between 1 and 20 August. The increase in the number of excess deaths followed the same pattern as the increase in temperatures. No deviance from the normal death rate was observed in the month of August during the last third of the month, nor during the following three months. There was a clear discrepancy in the impact of the heat wave from city to city. If the effect of duration of consecutive days with high minimal temperatures and deviance with the seasonal normal temperature was patent, this could not explain all of the observed variability of the death incidence. The victims were mainly elderly women older than 75 years. In terms of relative risk and contribution to the global toll, deaths linked to heat were the most important. Based on these results, the French government developed a Heat Health Watch Warning System and set up a preventive action plan for each region in 2004.

Excess Deaths Associated With Underweight, Overweight, and Obesity

As the prevalence of obesity increases in the United States, concern over the association of body weight with excess mortality has also increased. To estimate deaths associated with underweight (body mass index [BMI] <18.5), overweight (BMI 25 to <30), and obesity (BMI > or =30) in the United States in 2000. We estimated relative risks of mortality associated with different levels of BMI (calculated as weight in kilograms divided by the square of height in meters) from the nationally representative National Health and Nutrition Examination Survey (NHANES) I (1971-1975) and NHANES II (1976-1980), with follow-up through 1992, and from NHANES III (1988-1994), with follow-up through 2000. These relative risks were applied to the distribution of BMI and other covariates from NHANES 1999-2002 to estimate attributable fractions and number of excess deaths, adjusted for confounding factors and for effect modification by age. Number of excess deaths in 2000 associated with given BMI levels. Relative to the normal weight category (BMI 18.5 to <25), obesity (BMI > or =30) was associated with 111,909 excess deaths (95% confidence interval [CI], 53,754-170,064) and underweight with 33,746 excess deaths (95% CI, 15,726-51,766). Overweight was not associated with excess mortality (-86,094 deaths; 95% CI, -161,223 to -10,966). The relative risks of mortality associated with obesity were lower in NHANES II and NHANES III than in NHANES I. Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category. The impact of obesity on mortality may have decreased over time, perhaps because of improvements in public health and medical care. These findings are consistent with the increases in life expectancy in the United States and the declining mortality rates from ischemic heart disease.

Cause-specific mortality differences across socioeconomic position of municipalities in Japan, 1973-1977 and 1993-1998: increased importance of injury and suicide in inequality for ages under 75

Socioeconomic inequality in health has been a major concern in public health. This study examined socioeconomic inequality in regional mortality and the impact on inequality by cause of deaths in 1973-1977 and 1993-1998 using municipal statistics in Japan. The municipalities across the country (N = 3244 in 1973-1977 and 3334 in 1993-1998) were classified into quintiles according to the index of socioeconomic position (SEP) obtained by principal component analysis of municipal indicators related to income and education. Mortality gradient by SEP for selected major causes of death in the population aged 0-74 years was examined using standardized mortality ratio by quintile and rate ratio of mortality across quintiles. As a measure of cause-specific impact on inequality, the number of excess deaths from each cause in the lower four SEP quintiles compared with the highest quintile was calculated. Mortality gradient by SEP and excess deaths in the lower SEP quintiles due to injury and suicide markedly increased from 1973-1977 to 1993-1998 for both males and females. In contrast, stroke, especially cerebral haemorrhage, showed a decrease in mortality gradient and excess deaths. For females in 1993-1998, a negative gradient of mortality by SEP was found, and cancer contributed the higher all-cause mortality in the higher SEP quintile. The relative importance of socioeconomic inequality in regional mortality of stroke decreased, while that of injury and suicide increased. The prevention of injury and suicide, in addition to stroke, in socioeconomically disadvantaged regions, and cancer in urban areas with higher SEP should be given priority.

New vaccines for old diseases: trivalent cold-adapted influenza vaccine.

Schoolchildren regularly have the highest influenza attack rates. Schoolchildren also are accessible for vaccination; school-based vaccine clinics can facilitate delivery of vaccine to a high proportion of children in a short period of time. CAIV-T has advantages for immunization of this group due to the effectiveness of a single dose, ease of administration, and ready acceptance by children. Modeling of control for an influenza epidemic by Longini et al. has shown vaccination of 70% of school children would dampen epidemics and significantly reduce the exposure of vulnerable people in the community. The goal of the central Texas trial is to demonstrate this effect in the field. Universal childhood immunization could be an important supplement to current control efforts. Vaccine coverage with TIV has leveled off since 1997; no progress toward the Healthy People 2010 goals of 90% coverage has been made after 4 years in the new decade. The number of excess deaths is expected to double within the next 25 years if control methods are not intensified. CAIV-T may become an important adjunct to control measures and can facilitate influenza pandemic preparedness.

Increased excess deaths in urban areas: quantification of geographical variation in mortality in Japan, 1973–1998

To quantify the magnitude of geographical health inequality by sex and age group, and to observe the change in regional distribution of health disadvantage, this study estimated excess deaths attributable to the mortality variation among municipalities across Japan from 1973 through 1998. The municipalities ( N=3340 in 1995) were divided into quintiles according to standardized mortality ratio (SMR). Using the mortality of the lowest SMR quintile as the standard, the number of excess deaths (ED) and its ratio to observed deaths (EDR) were estimated by sex, age group (total population and under 65-year population) and regional block in 1973–1977, 1978–1982, 1983–1987, 1988–1992 and 1993–1998. Total annual ED in 1993–1998 was estimated as 47,124 for males and 46,562 for females, representing EDR of 9.9 and 11.6%, respectively. The under 65-year population had a higher EDR than the total population. Rural regions showed a marked decrease in EDR in contrast to the increase in urban regions over time. The present study suggests that the reduction of a large number of deaths, especially premature deaths, is expected by elimination of geographical health inequality, and that health policies for urban residents are prioritized.

Preventing mother-to-child HIV transmission in the new millennium: the challenge of breast feeding.

Short courses of antiretroviral drugs have greatly enhanced the prospect of reducing mother-to-child HIV transmission. Yet transmission by breast feeding clouds hopes for this seemingly simple intervention. We revisit mathematical models to assess the competing risks associated with feeding by breast vs. formula. These indicate that, in the less developed world where the HIV epidemic predominates, neither option, unmodified, offers a reasonable choice for HIV-positive women. Where infant mortality rates are greater than about 40 per 1000 live births, if formula were made available to HIV-infected women only, the excess number of deaths that would result from formula use would be approximately the same or greater than the number of HIV infections that might be prevented. Only at lower infant mortality rates, less than about 40 per 1000, is the risk greater on the breast. There are thus no good grounds for the total avoidance of breast feeding under all conditions. Research to develop and test safer infant feeding alternatives is an urgent priority. On the one hand, ways to reduce HIV transmission while preserving breast feeding, as exclusive breast feeding could do, need to be fully tested. On the other hand, ways to reduce non-HIV morbidity and mortality associated with formula feeding, as educational or sanitary interventions could do, equally need testing. With either approach, a necessary foundation for implementing all the core components of preventing mother-to-child HIV transmission is competent counselling for mothers. Innovative approaches are needed to mobilise and train effective counsellors among health care workers and, as appropriate, community members.

The molecular biologist against infectious disease: Infectious diseases, in both the developing and the developed world, still pose considerable challenges to biomedical research. But science alone is clearly not sufficient to overcome the burden of disease in the world

The molecular biologist against infectious disease: Infectious diseases, in both the developing and the developed world, still pose considerable challenges to biomedical research. But science alone is clearly not sufficient to overcome the burden of disease in the world

The molecular biologist against infectious disease. Infectious diseases, in both the developing and the developed world, still pose considerable challenges to biomedical research. But science alone is clearly not sufficient to overcome the burden of disease in the world.

Infectious disease is one aspect of worldwide public health in which molecular biologists could bring about real change and improve the overall quality of life for many people. There are identified targets—be they viruses, bacteria or other agents—that are sufficiently different from the human body for specific intervention. And, indeed, major achievements show that this is possible: the big killers of the past—including smallpox, cholera and typhoid fever—have been eliminated from the globe, or at least from the developed world, and families do not need to worry about a newborn child dying of whooping cough, measles, scarlet fever or meningitis. However, many other infectious diseases have not disappeared, either in individuals or globally. The reasons are manifold: for some diseases the science is not straightforward, but, more frustratingly, the means by which the advances taking place through molecular biology could be implemented are not in place for other diseases. > The excessive number of deaths and disease is part of the pathology of poverty The diseases that still cause the greatest concern have many different profiles. There are everyday ailments, such as the common cold and other respiratory or gastrointestinal infections, which are especially common in children and continue to cause discomfort, worry, need of medical services and use of antibiotics in the developed world. The same infections are equally or even more abundant in developing countries, with the essential difference of being highly likely to cause death. Mild or even asymptomatic infections might predispose the sufferer to diseases that are not generally considered to be infectious in origin, such as gastric ulcers, many types of carcinoma, and perhaps even atherosclerosis and juvenile diabetes. In the developing world, high‐profile diseases, such as HIV/AIDS, tuberculosis and malaria, are devastating in terms of the numbers of people infected and lethality, and parasitic infections, …

Annual mortality rates and excess deaths of children under five in Iraq, 1991-98

Data from two parallel household surveys conducted in Iraq by UNICEF in 1999 show that under-5 mortality declined steadily from 1974 to 1990, reaching about 63 per 1,000 live births in the period 1986-90. It then rose dramatically to 118 per 1,000 in 1991, the year of the Gulf War. The number of 'excess' under-5 deaths (i.e., the number in excess of the number predicted from past trends) in Iraq between 1991 and 1998 was calculated assuming that, instead of the rates measured by the 1999 survey for this period, either (a) average mortality rates for the period 1986-90 had been maintained, or (b) mortality had continued to decline at the rate observed between 1974 and 1990. According to these calculations, the estimated number of excess deaths resulting from the Gulf War and its aftermath up to 1998 was between 400,000 (assumption a) and 500,000 (assumption b).

The new Swedish national public health policy

By international comparison, Swedish public health public sector and a restructuring of Swedish welfare policy. The labour market underwent transformations work has been successful. The age-standardized mortality ® gures are low in most age groups. Although and there was a signi® cant decrease in the total employment rate. Furthermore there was an increase in job inequity in health is considerable in relative terms, the number of excess deaths in lower social classes is strain, especially in the care sector. These changes took place without any governmental agency taking responssmaller than in most other countries. In spite of this rather positive picture, Sweden has ibility for an analysis of the health consequences. In 1994 the new social democratic government no comprehensive public health policy. It has been recognized that politics is a health determinant in declared that public health was a central political issue. In 1997 a public health committee with a broad parliadiVerent sectors of society but there has not been any eVort to coordinate diVerent governmental oYces in mentary base was formed. The major objective was to propose a national strategy and speci® c goals for public order to promote public health. The problem of how to implement a public health health that would guide governmental oYces, regional and local public authorities, and NGOs. The committee policy has been discussed for more than a decade. In 1987 the Swedish government appointed a task group at comprised members from all major political parties and a number of experts, representing governmental high administrative level with the participation of oYcials and scientists in the ® eld of public health. The aim authorities, scienti® c institutions, labour-market organizations, and representatives for immigrants and was to outline a national public health strategy. An allembracing objective was to promote increased equity in retired persons. The committee worked openly and in dialogue health. Another important issue was how to integrate public health with the general welfare policy system. with public health activists. Two preliminary reports were published and distributed to several hundred The task group proposed a new governmental authority, the National Institute of Public Health. The authorities and voluntary organizations. In the end of 2000 a green paper was published with purpose of the institute was to direct health promotion and disease prevention activities at a national level and proposals for 18 national public health goals. All goals were formulated in terms of health determinants and to cooperate with other national authorities and NGOs in health matters. fundamental infrastructure for preventive work. The goals related to structural and environmental determinThe National Institute of Public Health was established in 1992. At that time there had been a change ants of health as well as lifestyles. All goals are broken down into a number of sub-goals and quantitative of government, which may have contributed to the fact that the institute did not take on its intended strategic indicators have been constructed. It is presumed that the targets will be achieved in 2010. It is also proposed role in the Swedish public health work. Instead its activities focused on programmes directed towards that each respective public sector will be accountable for contributing to the achievement of the goals. speci® c health problems such as alcohol, illicit drugs, HIV/AIDS, injuries, allergic disorders and tobacco use. At present the government is revising the goals and a governmental bill will be put forward to the Swedish There was a quite strong emphasis on information directly to the public. parliament in the end of 2001. There are a number of advantages in expressing the In the 1990s there were considerable cutbacks in the

Excess Mortality in Bipolar and Unipolar Disorder in Sweden

Selected groups of patients with bipolar and unipolar disorder have an increased mortality rate from suicide and natural causes of death. However, there has been no population-based study of mortality of patients followed up from the onset of the illness. All patients with a hospital diagnosis of bipolar (n = 15 386) or unipolar (n = 39 182) disorder in Sweden from 1973 to 1995 were identified from the inpatient register and linked with the national cause-of-death register to determine the date and cause of death. Overall and cause-specific standardized mortality ratios (SMRs) and numbers of excess deaths were calculated by 5-year age classes and 5-year calendar periods. The SMRs for suicide were 15.0 for males and 22.4 for females with bipolar disorder, and 20.9 and 27.0, respectively, for unipolar disorder. For all natural causes of death, SMRs were 1.9 for males and 2.1 for females with bipolar disorder, and 1.5 and 1.6, respectively, for unipolar disorder. For bipolar disorder, most excess deaths were from natural causes, whereas for unipolar disorder, most excess deaths were from unnatural causes. The SMR for suicide was especially high for younger patients during the first years after the first diagnosis. Increasing SMR for suicide during the period of study was found for female patients with unipolar disorder. This population-based study of patients treated in the hospital documented increased SMRs for suicide in patients with bipolar and unipolar disorder. The SMR for all natural causes of death was also increased, causing about half the excess deaths.

Geographical patterns of excess mortality in Spain explained by two indices of deprivation.

STUDY OBJECTIVE: To analyse the geographical patterns and the magnitude of the association between deprivation and mortality in Spain. To estimate the excess of mortality in more deprived areas of...

Infant mortality in Norway and Sweden 1975–88: a cause‐specific analysis of an increasing difference

In a previous article, a high infant mortality was reported in the 1980s in Norway compared with Sweden. The aim of the present study was to assess secular trends in this difference, and to clarify whether the difference was confined to particular causes of death. Mortality rates, ratios of mortality rates and numbers of excess deaths were calculated on the basis of birth records comprising all livebirths in Norway and Sweden during the two periods 1975-79 and 1985-88. From the first to the second period, the infant mortality ratio for Norway to Sweden increased from 1.22 to 1.45 for single births, and from 1.23 to 1.54 for twin births. Increasing mortality ratios were observed for all ages at death. These were lowest in the early neonatal period (1.09 and 1.20 respectively) and highest in the postneonatal period (1.53 and 1.78 respectively). Within each cause of death category, the mortality rate in Norway was equal to or higher than the rate in Sweden. The highest mortality rate ratios were observed for sudden infant death syndrome (SIDS), 2.44 and 2.46 respectively, for the two time periods. SIDS was also the single cause of death that gave the largest contribution to the Norwegian excess mortality (45% and 53% overall, 65% and 78% for postneonatal deaths, and 65% and 79% for birthweights above 2500 g). In the second period, the excess SIDS mortality in Norway pertained mainly to infants of young mothers, infants of birth order two or more and twin births. An adverse trend for infants of young mothers in Norway was also observed in non-SIDS deaths. This suggests that in Norway, preventive health care should be improved, particularly for young mothers and their infants.