Patterns in mortality among people with severe mental disorders across birth cohorts: a register-based study of Denmark and Finland in 1982–2006
BMC Public Health
Patterns in mortality among people with severe mental disorders across birth cohorts: a register-based study of Denmark and Finland in 1982-2006
Mika Gissler 0 1
Thomas Munk Laursen 1
Kristian Wahlbeck 0 1
0 THL National Institute for Health and Welfare , Helsinki , Finland
1 Nordic Research Academy in Mental Health, Nordic School of Public Health , Gothenburg , Sweden
Background: Mortality among patients with mental disorders is higher than in general population. By using national longitudinal registers, we studied mortality changes and excess mortality across birth cohorts among people with severe mental disorders in Denmark and Finland. Methods: A cohort of all patients admitted with a psychiatric disorder in 1982-2006 was followed until death or 31 December 2006. Total mortality rates were calculated for five-year birth cohorts from 1918-1922 until 1983-1987 for people with mental disorder and compared to the mortality rates among the general population. Results: Mortality among patients with severe mental disorders declined, but patients with mental disorders had a higher mortality than general population in all birth cohorts in both countries. We observed two exceptions to the declining mortality differences. First, the excess mortality stagnated among Finnish men born in 1963-1987, and remained five to six times higher than at ages 15-24 years in general. Second, the excess mortality stagnated for Danish and Finnish women born in 1933-1957, and remained six-fold in Denmark and Finland at ages 45-49 years and seven-fold in Denmark at ages 40-44 years compared to general population. Conclusions: The mortality gap between people with severe mental disorders and the general population decreased, but there was no improvement for young Finnish men with mental disorders. The Finnish recession in the early 1990s may have adversely affected mortality of adolescent and young adult men with mental disorders. Among women born 1933-1957, the lack of improvement may reflect adverse effects of the era of extensive hospitalisation of people with mental disorders in both countries.
Birth cohort; Mental disorder; Mortality; Psychiatric care; Register study
Life span has increased during the last decades in
Europe. Since 1982, the life expectancy at birth increased
by four years in Denmark and by six years in Finland
. Our previous studies have shown that the life
expectancy among people with severe mental disorders
also has increased from the 1980s in Denmark and
Finland [2,3]. It is not clear whether this progress has
been gradual across generations, or whether there are
some birth cohorts who divert from the general picture.
Even though the general trend has been positive, men
with severe mental disorders still live 20 years less and
women 15 years less than general population in the
The excess mortality among people with severe mental
disorders is not only caused by an increased risk for
suicides and unintentional injuries, but also from an
increased risk for mortality from diseases and medical
conditions, such as diseases of the circulatory system,
cancer and diabetes [4-6]. The literature suggests that
this can partly be explained by low socioeconomic status
[7,8], unhealthy lifestyle habits [9,10] and lack of access
to health care with good quality [5,11]. Neither can the
metabolic side effects of psychiatric medication in form
of hyperglycemia and diabetes, weight gain, and lipid
disturbances be excluded.
Both Denmark and Finland have undergone the major
shift from an emphasis on psychiatric hospitalisations to
integrated community-based mental health services.
Between 1982 and 2006, the number of hospital beds in
psychiatric hospitals per 100 000 population decreased
from 171 to 63 in Denmark (63%) and from 390 to 92
in Finland (76%) . The reduction reflects shorter
treatment periods, improved primary health care based
services and housing services (in Finland) and
community mental health services (in Denmark), and the
transfer of long-term inpatients in other institutions.
There are good possibilities for population-based
studies on mortality among psychiatric patients in the
Nordic countries, since the entire population is covered in
the comprehensive nation-wide registers on general
population, inpatient care and causes of death .
Mortality patterns are linked to macroeconomics, and
increase in unemployment has been linked to higher
suicide and alcohol-related mortality . Economic
recessions and depressions have been linked to increased
risk of depression and anxiety as well as increased
violent behaviour and excess use of alcohol and drugs,
which have been hypothesised to have their origin in
work-related stress and difficulties in family economy
. Excluding suicides, however, no data exists on the
links between macroeconomics and mortality in the
vulnerable group of people with severe mental disorders.
Denmark and Finland are Nordic countries with a
similar culture, societal structure and welfare system. In
spite of the social and cultural similarities, they differ in
macroeconomic trends due to differing trade and
industry. Denmark had a slower economic growth than other
Nordic countries in the 1970s (Figure 1), and the
country faced a recession 1980s with unemployment rates
between 8% and 10%. The unemployment rose also in the
beginning of the 1990s up to 12%, but cannot be
compared to the Finnish rates in the early 1990s. Finland
experienced then a sudden and severe economic recession
with a five-fold increase in unemployment and a
decrease of more than 10% in the GDP, which led to cuts
in public services. The GDP remained below the level of
1990 for five years until 1995 (Figure 1).
Our aim was to compare different birth cohorts to
investigate if the development in relative mortality among
people with mental disorders in birth cohorts at risk were
similar in the two study countries Denmark and Finland,
and especially whether major macro-economic cycles had
an impact on these trends. A specific question was
whether stagnating or declining economy affected the
Figure 1 Gross Domestic Product (GDP) in Denmark, Finland
and Sweden in a) 19701985 and b) 19862006. The GDP in
Sweden in 1970 (22 772 Swedish Crowns, 4402 US Dollars) is the
reference point (1970 = 100).
mortality among people with severe mental disorders
leading to hospitalisation. Any significant differences may be
caused by differences how the contemporary societal
changes have affected cultural generations, i.e. cohorts of
people who were born in the same year range and share
similar socio-cultural experience.
Cases of severe mental disorders included were identified
from discharge diagnoses recorded in the nationwide
hospital discharge registers. Both countries use the
International Classification of Diseases (ICD), established by
the World Health Organization (WHO), for definition and
classification of psychiatric and physical diseases in their
hospital discharge registers. We used the primary
diagnoses given in ICD-8, ICD-9 or ICD-10, recorded for each
hospitalisation to define our study population with
diagnosed mental disorder. The diagnoses given in ICD-8 and
ICD-9 were transformed to ICD-10 diagnoses.
All patients admitted at least once during the period 1
January 1982 and 31 December 2006 with a primary
diagnosis of mental disorder (ICD-10: F10-F69) were
Table 1 The number of follow-up years and deaths by study period, birth cohort and sex in Denmark and Finland
retrieved from the Danish and Finnish national hospital
registers. Patients with a diagnosis of intellectual
disability (F70-79) at any point in time were excluded.
Hospitalisations due to organic mental disorders, e.g.
dementia, (F00-09) resulted in exclusion of the subject
starting from the first hospitalisation due to dementia
and any episode afterwards. Patients with a diagnosis
related to intellectual disability and dementia were
excluded because of the high risk for premature mortality
inherent to the organic nature of these disorders.
Information on deaths
Information on deaths was taken from national cause-of-death
registers, which cover all citizens and permanent
residents, and linked to the hospital data with the unique
personal identity code, which is given to all citizens at
birth and permanent residents at migration.
The Danish Psychiatric Central Register  covers all
psychiatric inpatient facilities in Denmark and has been
computerised since 1969. In Denmark, the ICD-8
classification was used as the diagnostic system used
until 1993 and the ICD-10 was introduced in 1994.
The Danish Cause of Death Register contains
information about all deaths of Danish citizens and residents,
date of death, and circumstances and causes of death.
The register has a high level of completeness and its
validity has been evaluated with very good results .
The Finnish Hospital Discharge Register (FHDR)
includes data on all inpatient episodes on an individual
level since 1969. For diagnosis, ICD-8 was used during
the period 19691986, ICD-9 during the period 1987
1995 and ICD-10 from 1996 onwards. The FHDR has
been found to be a valid and reliable tool for
epidemiological research .
The Finnish Cause of Death Register records data on
the deaths of all citizens and permanent residents in
Finland. The register has a high level of completeness.
All diagnoses of the causes of death have to pass a
routine validation carried out by regional medical officers
and physicians at Statistics Finland. Generally, the
quality has been found to be very good .
The population at risk consisted of all patients admitted
at least once during the period 1 January 1982 and 31
December 2006. Mortality follow-up was based on death
during the same period. The mortality rates were studied
separately for men and women for five-year birth
cohorts born in 19181922 until 19831987 and for death
year groups, grouped in five year periods as follows:
19821986, 19871991, 19921996, 19972001 and
20022006. Basic information on the number of cases
and deaths are presented in Table 1.
Comparisons were made for total mortality rate for
the whole population for the same birth cohorts and for
both sexes. Observed/expected ratios (O/E ratios) with
95% confidence intervals were calculated for each
mortality rate comparison. Expected mortality rates were
based on mortality rates among total population
provided by sex and five-year age groups by the national
statistical offices. The mortality differences between
birth cohorts were calculated by using the test for
relative proportions. The statistical analysis was made by
using SAS version 9.3.
Overall mortality, measured as total number of deaths
per 100,000 years of follow-up, among patients with
severe mental disorders declined for each cohort in both
countries (Table 2, Figure 2). For Danish men aged 15
34 years old and women aged 1539 years old as well as
for Finnish men and women aged 2034 years old, the
mortality rates more than halved during the study
period. The smallest decline was observed for Finnish
men aged 1519 years old (27%) and 5054 years old
(23%) as well as for Danish men aged 4559 years old
(24%, -15% and 29% in each five-year age group,
respectively). For women, the smallest decline was
observed in Finland in age group 1519 years old (6%),
and in Denmark in age groups 4554 years old (26%
and 27% in the two five-year age groups, respectively).
In both countries and in all cohorts, patient with
severe mental disorders had a higher mortality than
general population (Table 3 for men and Table 4 for
women). Generally, the excess mortality was higher in
Denmark than in Finland. Among Danish men aged 15
64 years old, the mean excess mortality was 9-fold in
198286, but declined to 7-fold in 20022006 compared
to general population (p < 0.001). For Finnish men, the
excess mortality remained between 4- and 5-fold
during the whole study period. For women in the same age
groups, the mean excess mortality declined in both
countries. The relative improvement was larger for
Danish women (from 12-fold in 198286 to 6-fold
b) men in Finland
c) women in Denmark
d) women in Finland
mortality in 200206, p < 0.001) than for Finnish
women (from 9-fold to 6-fold, p < 0.001). By age
groups, the excess mortality declined most for Danish
men and women aged 1549 years old as well as for
Finnish men aged 2539 years old and Finnish women
aged 2059 years old.
Two exceptions were observed when investigating
mortality by birth cohorts. First, the excess mortality risk
stagnated among Finnish men born in 19631987, and
remained more than five-fold compared to general
population at ages 1524 years. In both countries, the
mortality among male patients with severe mental
disorders decreased, when comparing men born 196372 and
197887 (<0.001), but the decline was more substantial
in Denmark (43%) compared to Finland (23%). The
excess mortality declined in Denmark from being
11.9fold (95% confidence interval 10.0-14.0) for men born
196372 to 8.7-fold (7.1-10.5) for men born 197887,
while no progress was observed in Finland: the excess
risks for mortality among patients with severe mental
disorders were 5.2-fold (4.7-5.8) for Finnish men born
197882 and 5.3-fold (4.9-5.7) for Finnish men born
Second, the excess mortality risk stagnated for Danish
and Finnish women born in 19331957 at their 40s.
Their mortality remained six-fold in Denmark and
Finland at ages 4549 years and seven-fold in Denmark
at ages 4044 years. Between cohorts 193337 and
195357, the mortality at 4044 years and 4549 years
declined both in Denmark (33%, p = 0.002 and 27%,
p < 0.001) and in Finland (26%, p < 0.001 and 19%,
p < 0.001), but the excess mortality remained at the same
level. In Denmark, it was for women aged 4044 years
old 6.3-fold (95% confidence interval 6.1-6.5) for women
born 193337 and 5.9-fold (5.5-6.3) for women born
195357. For women aged 4549 years old the excess
risks were 5.1-fold (4.9-5.4) and 5.2-fold (4.9-5.5),
respectively. For Finland, the excess mortality decreased
for women aged 4044 years old from 5.8-fold (5.6-6.0)
for women born 193337 to 4.7-fold (4.5-4.9) for
women born 195357, but the difference remains
statistically insignificant for women aged 4549 years with a
change from being 4.2-fold (4.0-4.4) to being 3.8-fold
Our data confirmed the declining mortality trends among
hospitalised patients with severe mental disorders in
Denmark and Finland. In general, the mortality gap
diminished for each consecutive birth cohort, but patients with
mental disorders still had a significantly higher mortality
rate than the total population in general.
We observed that the relative mortality among young
Finnish men born in 19631987 with severe mental
disorders leading to hospitalisation did not improve at all.
One explanation may be the Finnish recession in the
early 1990s, which seems to have affected these birth
cohorts most. At the time of the recession in Finland, these
boys and young men were affected by adversities in their
families of origin  and faced considerable problems
in accessing the labour market .
The sex-specific effect may be explained by
socioeconomic disparities, which significantly differ between
men and women. The educational level of Finnish young
men is lower than among young women. In 2009, 23%
of men aged 2529 years old and 34% of men aged 30
34 years old had a tertiary education, while the
percentages were substantially higher (40% and 53%,
respectively) for women in the same age groups . Also the
unemployment figures have been higher for men aged
less than 25 years old. This suggests that the likelihood
to be excluded or underprivileged has remained high
among young Finnish men during the 1990s recession
and after it.
Also women with severe mental disorders born before,
during or after World War II, in the period 19331957,
failed to reduce their excess mortality. This may reflect
a generation of women with severe mental disorders
who initially were extensively hospitalised due to their
mental disorder, and were too old to benefit from the
deinstitutionalised psychiatry which began to evolve in
the 1970s. During the era of high level of psychiatric
hospitalisation, people with mental disorders that
nowadays are treated in community care were exposed to
extensive hospitalisation periods, which resulted in
iatrogenic adverse effects on level of functioning. It
is possible that our findings illustrate a lost
generation, i.e. a generation with excess mortality due to
excess hospitalisation. Previous reports have indicated
an excess mortality among in-patient psychiatric
Our study data covered all institutionalised people with
mental disorders in Denmark and Finland during 25 years.
The data collection systems are obligatory and their
quality for register-based research has been shown to be good
[14,16]. Also, the same exclusion and inclusion criteria
were applied for both countries. The register-based data
have, however, its limitations.
There may be differences in the provision of health
services, especially in the use of inpatient care services
between the two study countries. The proportion of
untreated or inappropriately treated people with severe
mental disorder may differ in the two study countries
and also during the study period. The distribution of
diagnoses is different, since Denmark has reported more
depression and drug-related treatments, while
schizophrenia and alcohol-related treatments were more
common in Finland . Epidemiological studies confirm
that schizophrenia spectrum disorders  and alcohol
use disorders  may be more common in Finland
than in other countries. Furthermore, our analyses do
not allow complete comparisons between cohorts. For
the older ones, the people with most serious mental
disorders have already died, and thus they are excluded
from our data.
The data was based on admission data, but the cohort
definition was based on primary diagnoses at discharge,
which is more accurate measure for patient with mental
disorders than the admission diagnoses. Our data did
not cover all psychiatric diagnoses. People with
intellectual disabilities were excluded. The patients were also
excluded from the date they received a diagnoses
related to organic mental disorder, such as dementia.
Both of these patient groups have high risk for
premature mortality. Furthermore, we could not compare the
distribution of mental disorders by year cohort due
to differences in the register data in Denmark and
Finland. Such differences by age group are well-known,
but we cannot say, if these varied between the two
Our study data did not include information on
international migration. Thus people who have permanently
migrated abroad are included in the population at risk
even though they may have died after leaving the
country where they were treated. Since the migration rates
are relatively low in the Nordic countries, we can
estimate that the effect of not having information on
migration is minor.
Due to the long follow-up period we were not able to
get detailed background information on the people with
severe mental disorders. The register-based information
systems based on personal identification numbers in
Denmark and Finland have been built from the 1970s
onwards, and the information available before that is
very limited. Therefore, we had to limit our analyses to
basic variables available in the data sources, and thus,
our conclusions remain partly speculative.
Although our data indicate that for each birth cohort the
mortality gap between people with mental disorders is
decreasing, our results also indicate that the favourable
overall trend in this vulnerable population can easily be
offset by selective disadvantages. Two major societal
changes, i.e. the deep Finnish recession in the 1990s and
the excessive long-term hospitalisation of people with
mental disorders in the 1950s to 1970s, may have
contributed to lack of progress in equity in terms of mortality in
groups who were particularly exposed to these major
Besides accessible and responsive primary health care,
active labour market policy, social welfare policies
supporting families and parenting and programmes to
support unmanageable dept should be used to diminish
mental and somatic health problems during economic
downturn and recession . If the economic crisis
continues for a longer time, it is important to fight against
poverty and its inheritance, since mental health
problems effect also families. .
The authors have no competing interest to report.
MG, TML, MN and KW planned the study. MG and TML made the analyses.
MG wrote the article with contributions from all other authors (TML, U, MN
and KW). All authors read and approved the final manuscript.
The permission to use health register data in scientific research was given by
the data administering authorities. The data protection authorities in
Denmark and Finland were informed on the study, as required by the
national legislations on data protection. Neither ethical committee statement
nor informed consents of the registered people were required.
This study was supported by a grant from the Nordic Council of Ministers.
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