Mortality and metabolic disorder in schizophrenia and bipolar disorder in Sweden, Denmark and Finland Urban Ösby Karolinska Institutet, Stockholm, Sweden Department of Psychiatry, Tiohundra AB, Norrtälje
Standard Mortality Ratios (SMR, Obs/Exp) and excess deaths (Obs-Exp) for Schizophrenia in Stockholm and Bipolar disorder in Sweden 1973-95 Schizophrenia Bipolar disorder Cause of death Obs Exp O/E O-E Obs Exp O/E O-E Cardiovascular 563 257 2.2 306 1073 482 2.2 591 Natural causes 1274 659 1.9 615 2465 1236 2.0 1229 Suicide 380 23 16.5 357 642 38 17.7 634 Unnatural causes 575 62 9.3 513 998 98 10.2 900 All causes 1849 720 2.6 1129 3463 1334 2.6 2129 Osby et al 2000, Osby et al 2001
Excess deaths by natural and unnatural causes for schizophrenia patients in Stockholm County 1973 1995 Men Women Unnatural n=218 38% Natural n=264 47% Unnatural n=296 53% Natural n=352 62% Osby et al 2000
Prevalence of diabetes in schizophrenia compared to general population Prevalence of diabetes (%) 30 General population Patients 25 25.0 20 15 12.7 10 6.1 5.8 5 3.2 2.0 2.4 0.9 1.1 0.4 0 15 25 25 35 35 45 45 55 55 65 Age group (years) 8.6% diabetes; n=415 De Hert et al 2006
CATIE: rates of pharmacological interventions for abnormal blood pressure, lipids and glucose Patients (%) 100 n=1488 n=685 n=690 89.4 80 60 62.4 68.3 45.3 40 33.2 20 10.9 0 n=481 n=300 n=75 n=34 n=471 n=421 Hypertension Diabetes Dyslipidaemia Prevalence Lack of medical intervention Nasrallah et al 2006
Diabetes diagnosis, treatment and achievement of treatment goals in (n=881) patients with long-term psychotic disorders. Diagnosis n % Diabetes diagnosis + medical treatment Fasting glucose 7.0 mmol/l* Diabetes diagnosis + no medical treatment Fasting glucose 7.0 mmol/l* 41 100 30 73 43 100 15 35 No diabetes diagnosis Fasting glucose 7.0 mmol/l* Fasting glucose 6.1-6.9 mmol/l Fasting glucose 5.6-6.0 mmol/l$ 797 100 43 5 84 11 153 19
Hypertension diagnosis, antihypertensive treatment and achievement of treatment goals in (n=927) patients with long-term psychotic disorders. Diagnosis n % Hypertension diagnosis + medical treatment 64 100 Systolic blood pressure 140 mm Hg or diastolic blood pressure 90* 47 73 Hypertension diagnosis + no medical treatment Systolic blood pressure 140 mm Hg or diastolic blood pressure 90* No hypertension diagnosis + medical treatment Systolic blood pressure 140 mm Hg or diastolic blood pressure 90* 94 100 73 78 29 100 10 35 No hypertension diagnosis + no medical treatment Systolic blood pressure 140 mm Hg or diastolic blood pressure 90* 740 100 243 33
Hyperlipidemia diagnosis with LDL>3.0 mmol/l, lipid lowering treatment and achievement of treatment goals in (n=939) patients with long-term psychotic disorders. Diagnosis N % Hyperlipidemia diagnosis + medical treatment 33 100 LDL>3.0 mmol/l* 7 21 Hyperlipidemia diagnosis + no medical treatment LDL>3.0 mmol/l* No hyperlipidemia diagnosis + no treatment LDL>3.0 mmol/l* 90 100 70 78 809 100 539 67
Hyperlipidemia diagnosis with total cholesterol >5 mmol/l, lipid lowering treatment and achievement of treatment goals in (n=992) patients with longterm psychotic disorders. Diagnosis N % Hyperlipidemia diagnosis + medical treatment 39 100 tot. chol >5.0 mmol/l* 13 21 Hyperlipidemia diagnosis + no medical treatment tot. chol >5.0 mmol/l* No hyperlipidemia diagnosis + no medical treatment tot. chol >5.0 mmol/l* 103 100 79 78 843 100 527 67
Patients fulfilling the criteria for the metabolic syndrome Risk factors n % Hyperglycemia1 278 36 Elevated triglyceride levels2 292 37 Reduced levels of high density lipoprotein, males3 178 41 Reduced levels of high density lipoprotein, females3 164 45 Elevated waist circumference, males4 248 57 Elevated waist circumference, females4 254 72 Elevated blood pressure5 470 59 1 Elevated fasting plasma glucose ³5.6 mmol/l, or drug treatment for elevated glucose 2 Elevated triglyceride levels: ³1.7 mmol/l, or drug treatment for dyslipidemia 3 Reduced high-density lipoprotein levels: <1.0 mmol/l in males and 1.3 mmol/l in females, or drug treatment for dyslipidemia 4 Waist circumference 102 cm in males and 88 cm in females. 5 Elevated blood pressure: systolic BP ³130 mm Hg or diastolic BP ³85 mm Hg, or antihypertensive drug treatment
Smoking
Odds ratios for variables related to increased fasting glucose OR 95% CI Fasting insulin ( 114 pmol/l) 3.24 2.77-3.78 Group (control/patient) 2.40 1.83 3.16 Waist circumference ( 94 for men, 80 for women) 2.03 1.72 2.38 Hypertension 1.70 1.41 2.05 Age (>55 yrs) 1.50 1.28 1.77 First-degree relative with diabetes 1.47 1.26 1.71 Current smoker 1.32 1.10 1.59 Gender (female) 0.43 0.37 0.50
Odds ratios for variables related to increased waist circumference OR 95% CI Group (control/patient) 4.12 3.18-5.32 Gender (female) 2.98 2.60-3.41 Hypertension 2.29 1.99-2.65 Fasting glucose ( 5.6 mmol/l) First-degree relative with diabetes 1.98 1.68-2.33 1.21 1.07-1.37 Age (>55 yrs) 0.82 0.73-0.94
Mortality in bipolar disorder in Sweden all causes of death (MRR*, 1987 2006) RR 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Mortality in bipolar disorder in Sweden unnatural causes of death (MRR*, 1987 2006) RR 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Mortality in bipolar disorder in Sweden Mortality in bipolar disorder in Sweden cardiovascular causes of death (MRR,* 1987-2006) death (MRR*, 1987 2006) RR 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 25-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Mortality in bipolar disorder in Sweden cmortality in bipolar disorder in Sweden cerebrovascular causes of death (MRR,* 1987-2006) s of death (MRR*, 1987 2006) RR 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Mortality in bipolar disorder in Sweden Mortality in bipolar disorder in Sweden coronary heart disease (MRR,* 1987-2006) ase (MRR*, 1987 2006) RR 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Mortality in bipolar disorder in Sweden acute myocardial infarction (MRR,* 1987-2006) olar disorder in Sweden Acute myocardial infarction (MRR*, 1987 2006) RR 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age *Mortality rate ratio
Five-year survival of cardiovascular disease in bipolar disorder after discharge from first cardiovascular admission stratified by age at hospital contact. in bipolar disorder in Sweden 1.0 Survival after first CVD diagnosis 0.9 Survivor function estimate 0.8 0.7 0.6 0.5 0.4 0.3 0 1 2 3 4 5 Time since hospital admission Bipolar 20-59 Bipolar 60-79 Bipolar 80+ Population 20-59 Population 60-79 Population 80+
Mortality rate ratio from cardiovascular disease. 1994 to 2006 in Denmark Thomas Munk Laursen, National Centre for Register-based Research
Time change in mortality due to cardiovascular diseases, men, Denmark Schizophrenia General population General population Laursen og Nordentoft, Psych Research, 2010
Life expectancy and loss of years compared to general population among patients with bipolar disorder and schizophrenia in Denmark, Finland, and Sweden. Life expectanc y Denmark Finland Sweden Loss of years Life expectanc y Men Loss of years Life expectanc y Loss of years General 75.7-78.2-75.7 - population Bipolar disorder 62.1 13.6 55.9 19.8 65.5 12.7 Schizophrenia 55.7 20.0 58.6 17.1 59.3 18.9 Life expectanc y Loss of years Life expectanc y Women Loss of years Life expectanc y Loss of years General 80.3-82.6-82.5 - population Bipolar disorder 69.3 11.0 66.3 16.2 70.0 12.6 Schizophrenia 63.8 16.5 66.9 15.6 65.7 16.9 Life expectancy and cardiovascular deaths of patients with bipolar disorder or schizophrenia in the Nordic countries. Thomas Munk Laursen, Kristian Wahlbeck, Jonas Hällgren, Jeanette Westman, Urban Ösby, Hassan Alinaghizadeh, Mika Gissler, Merete Nordentoft. In press, Plos One.