Suicide among Danes with multiple sclerosis

OBJECTIVE

To compare the suicide risk among Danish citizens with multiple sclerosis with that of the general population, and to evaluate changes over 45 years.

METHODS

The study was based on linkage of the Danish Multiple Sclerosis Registry to the Cause of Death Registry. It comprised all 10,174 persons in whom multiple sclerosis was diagnosed in the period 1953 to 1996. The end of follow up was 1 January 1999. Standardised mortality ratios (SMRs) were calculated for various times after diagnosis and for age and calendar period of diagnosis.

RESULTS

In all, 115 persons (63 men, 52 women) had taken their own lives, whereas the expected number of suicides was 54.2 (29.1 men, 25.1 women). Thus the suicide risk among persons with multiple sclerosis was more than twice that of the general population (SMR = 2.12). The increased risk was particularly high during the first year after diagnosis (SMR = 3.15).

CONCLUSIONS

The risk of suicide in multiple sclerosis was almost twice as high as expected more than 20 years after diagnosis. The excess suicide risk has not declined since 1953.

The risk of multiple sclerosis in bereaved parents: A nationwide cohort study in Denmark

BACKGROUND

Previous studies have suggested that psychological stress may play a role in the risk of multiple sclerosis (MS), but the evidence is very limited.

OBJECTIVE

To examine the association between MS and a well-defined major stressful life event: the death of a child.

METHODS

In this follow-up study based on nationwide and population-based registers, all 21,062 parents who lost a child younger than 18 years from 1980 to 1996 in Denmark were included in the exposed cohort and 293,745 matched parents who did not lose a child in the unexposed cohort. The two cohorts were followed for incident MS from 1980 to 1997. Hazard ratios (HR) with 95% CI were calculated as the measure of association between the exposure and MS, using the Cox proportional hazards regression model.

RESULTS

Two hundred fifty-eight MS patients were identified (28 in the exposed cohort and 230 in the unexposed cohort). The exposed parents had an increased risk of MS (HR 1.56, 95% CI 1.05 to 2.31), which is significant only when follow-up was at least 8 years. The HR for definite/probable MS was 1.42 (95% CI 0.90 to 2.24). Parents who lost a child unexpectedly had an HR of 2.13 (95% CI 1.13 to 4.03) for all MS, which is higher than that for other bereaved parents (HR 1.33; 95% CI 0.81 to 2.16).

CONCLUSION

Psychological stress may play a role in the development of MS.

The Danish Multiple Sclerosis Registry. History, data collection and validity

The Danish Multiple Sclerosis Registry was formally established in 1956 but started operating in 1949 with a nationwide prevalence survey. Since then, the Registry has continued collecting data on new and old cases of multiple sclerosis (MS) or suspected MS from multiple sources. The Registry reclassifies cases according to standardized diagnostic criteria (currently those of Poser et al). A total of 14,441 cases fulfilling the diagnostic criteria had been registered at the most recently completed follow-up by 1 January 1997; 10,851 had onset from 1948 to 1996 and 3560 before 1948. The completeness has formerly been estimated at about 90%, higher for cohorts with older onset and lower for cohorts with onset close to follow-up. The estimated validity of the diagnosis for autopsy cases classified as definite MS in the Registry is 94%. A long-term nationwide Registry has proved to be a valuable instrument for monitoring incidence and prevalence, analysing survival, performing genetic analysis, providing unselected patient samples for clinical analyses, performing case-control studies and prospective studies and estimating the need for treatment and care.

[Clinical, radiological, histopathological and genetic findings in a Danish "CADASIL" family]

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare adult-onset inherited arterial disease with a distinctive neuropathological phenotype. Owing to its recent identification and variable mode of presentation, the disease is often misdiagnosed. The CADASIL gene is Notch 3 and has been mapped on chromosome 19q12 in several unrelated families. Knowledge of the phenotypic range of CADASIL, however, remains incomplete. Clinical, pathological radiological, and genetic findings in the first known Danish CADASIL pedigree are presented. Genetic testing confirmed a Notch 3 mutation. The mutation consisted of the substitution of a nucleotide at position 475 leading to the replacement of amino acid arginine for cysteine at position 133 in the third EGF motif.

[Suicide among patients with apoplexy. An epidemiological study]

The purpose of this study was, on the basis of a cohort of patients with a discharge diagnosis of stroke (ICD8 code: 430-438) diagnosed in the period 1.4.1973-31.12.1989 in a representatively selected area of Denmark (County of Funen), to estimate whether or not the risk of suicide in stroke patients was increased compared to the background population, i.e. the total population of the County of Funen. The patients were followed for causes of death until end of 1989. Standard Mortality Ratios for suicide standardized for age and sex in male and female stroke patients were calculated. A total of 37,869 stroke patients were included in the study, 140 committed suicide in the study period (80 females and 60 males). Standard Mortality Ratio for suicide was significantly increased for all stroke patients. For women below 49 years and from 50-59 years Standard Mortality Ratios were 1376 and 1378 respectively. For men below 49 years and from 50-59 years Standard Mortality Ratios were 656 and 580 respectively. The suicides did not occur at any specific time-point after the stroke. The results of this study emphasize the need, concurrently with improvements in prevention and treatment of stroke, to improve the care of patients suffering from the impairment of a stroke. This is a continuous process, and studies are needed in order to decide how this is best done.

Underlying cause of death in Danish patients with multiple sclerosis: results from the Danish Multiple Sclerosis Registry

OBJECTIVES

To determine the underlying causes of death in a large population based register series of patients with multiple sclerosis.

METHODS

The Danish Multiple Sclerosis Registry, which contains virtually all diagnosed cases of multiple sclerosis in Denmark who were alive in 1949 plus cases with onset of multiple sclerosis in the period 1949-93, who have been diagnosed and notified by 1 January 1994, was linked with the Danish Registry of Causes of Death, in which ICD codes for causes of death from the death certificate are stored for all Danish citizens.

RESULTS

6068 register cases of multiple sclerosis, who had died in the period 1951-93, were included. Multiple sclerosis was noted on the death certificate as the underlying cause of death in 55.4%; cardiac or vascular diseases in 17.6%; cancers in 8.6%; respiratory or infectious diseases in 5.1%; other natural causes in 9.5%; accident or suicide in 3.8%. The distribution varied with age at death. Standardised mortality ratios (SMRs) were computed on the basis of the 8142 incident cases, who had onset of multiple sclerosis within the period 1951-93; the SMRs for causes of death other than multiple sclerosis were highest for infectious or pulmonary diseases: 2.46 (95% confidence interval (95% CI) 2.04-2.94); suicide: 1.62 (95% CI 1.29-2.01); cardiac or vascular diseases: 1.34 (95% CI 1.22-1.48); accidents 1.34 (95% CI 1.02-1.71); and significantly lower than unity for cancers: 0.79 (95% CI 0.70-0.90), lower for men than for women.

CONCLUSIONS

More than half of the patients with multiple sclerosis die from multiple sclerosis or complications of the disease. Among other causes, patients with multiple sclerosis have an increased risk of dying from heart or vascular diseases but a reduced risk of dying from cancer. An increased risk of death from suicide and accidents can be indirectly attributed to multiple sclerosis. The diminished risk of dying from cancer may be a result of incomplete ascertainment of cancers in disabled patients with multiple sclerosis.

[Risk factors for suicide in patients with disseminated sclerosis]

The purpose of the present study was to describe risk factors for suicide in patients with multiple sclerosis (MS). The study is based on available information about MS-patients identified in the Danish MS Registry with onset of disease in the period 1950-1985. In order to characterize MS suicides with respect to risk factors comparisons were made for male and female suicides, and for various groups of MS suicides according to disability status. The male suicides were characterized by a tendency to commit suicide in the age interval 40-49 years, the use of a violent method, previous suicidal behaviour, previous mental disorder, recent deterioration of MS, and moderate disability. For women the characteristics were less distinct. Patients with a severe course of MS had been subjected to more risk factors before the suicide. Careful counselling and good information to MS-patients are advocated.

[Sexual function in patients with disseminated sclerosis. A 5-year follow-up study]

Sexual dysfunction is known to occur in multiple sclerosis (MS). The purpose of the study is to describe the change in sexual function and symptoms in a five year follow-up study. Forty-nine patients (27 females, 22 males) with definite MS were interviewed and examined. The number of patients with sexual dysfunction increased significantly (p = 0.004) and involved females and males equally. Males usually had one or two symptoms, while females frequently had two or more symptoms. It is concluded that the risk of sexual dysfunction increases over time. Further studies concerning treatment possibilities are needed.

Progressive multifocal leucoencephalopathy

Progressive multifocal leucoencephalopathy (PML) is a rarely occurring demyelinating disease of the central nervous system caused by a neurotropic papovavirus named JC virus (JCV). The most frequently affected affected regions are the cerebral hemispheres, especially the parietooccipital region, followed by the cerebellum and brain stem. The disease occurs predominantly in individuals with an immunocompromised state and impaired cellular mediated immunity (CMI) due to other underlying illness. More extensive use of irradiation and immunosuppressive therapy in relation to increased transplantational activities as well as treatment of autoimmune diseases and malignancies, in addition to the appearance of the acquired immunodeficiency syndrome (AIDS) as a consequence of infection with the human immunodeficiency virus (HIV), has caused a considerable increase in the occurrence of PML. The course of the disease is still most often rapidly progressive and fatal, but several cases with prolonged survival and even remission have been reported, and various antiviral treatments have been tried. The only drug that until now has shown favourable results is cytosine arabinoside. In HIV-infected PML-patients immunomodulation with AZT/zidovudine may alleviate the course and improve the prognosis in some patients. Suspicion of PML should lead to an extensive immunological investigation before considering of brain biopsy, which is still the only specific test. On the basis of the increased frequency of PML in relation to HIV-infection, it is likely that our knowledge of the pathogenetic aspects will increase, which, hopefully, may lead to an effective therapeutic strategy.

A note on the treatment of drummer Bock: an early Danish account of multiple sclerosis?

Multiple sclerosis (MS) was first presented in a clinical setting in 1838. In this paper the presentation and treatment of a transient hemiparesis in a drummer in 1789 is discussed. This may have been an early case of MS and presents evidence against the theory that MS is an infectious disease beginning in the 19th century.

Clinically unexpected multiple sclerosis in patients with mental disorders. A series of 7301 psychiatric autopsies

Some studies have indicated that silent and perhaps pure mental forms of multiple sclerosis (MS) exist. With the aim of examining that, the records of 9478 autopsies from patients with mental disorders were reviewed. A total of 7252 had both clinical and histological diagnosis, and 7301 had only pathoanatomical diagnosis. Twenty-three patients were suspected of having MS, which were confirmed histologically in 14. None had unsuspected, silent or a pure mental form of MS. It is concluded that the risk of mistaking MS for a psychiatric disorder is small in MS high-risk area.

Risk factors for suicide in multiple sclerosis

BACKGROUND

The purpose of the present study was to identify risk factors for suicide in patients with multiple sclerosis (MS).

METHODS

The study is based on available information about MS patients identified in the Danish MS Registry (DMSR) with onset in the period 1950-1985. We compared the MS suicides with the 1950-1985 onset cohort patients in the DSMR as to distribution of age at onset, presenting symptoms, and time from onset to diagnosis. We reviewed sociodemographic data, age of onset, the course of the disease, recent deterioration, type of deterioration, Kurtzke Disability Status Scale (DSS) score, previous mental disorder, type of mental disorder, previous suicide attempts, expression of suicidal intentions, circumstances at suicide, and suicide method for all MS patients who had committed suicide. In order to characterize MS suicides with respect to risk factors, comparisons were made for male and female suicides and for various groups of MS suicides according to disability status.

RESULTS

The male suicide patients were characterized by a tendency to commit suicide in the age interval 40-49 years, by the use of a violent suicide method, by previous suicidal behaviour, by a previous mental disorder, by recent deterioration of MS, and by a moderate disability. For women the characteristics were less distinct. Patients with a severe course of MS had been subjected to more risk factors before the suicide than patients with a moderate course of the disease.

CONCLUSION

Careful counselling and good information on all aspects of the disease, especially in the first stages and at time of progression, could be an instrument of prevention of suicides in MS patients. Furthermore, recognition and treatment of depression and pain is important.

Sexual function in multiple sclerosis. A 5-year follow-up study

Sexual dysfunction is known to occur in multiple sclerosis (MS). The purpose of the study is to describe the change in sexual function and symptoms in a longitudinal study. Forty-nine patients (27 females, 22 males) with definite MS were interviewed and examined with 5 years interval. The number of patients with sexual dysfunction increased significantly (p = 0.009) and involved females and males equally. Males usually had 1 or two symptoms of sexual dysfunction, while females frequently had 2 or more symptoms. It is concluded that the risk of sexual dysfunction increases over time. Further studies in treatment possibilities are needed.

Acute and chronic pain syndromes in multiple sclerosis. A 5-year follow-up study

Forty-nine (22 males, 27 females) patients with definite multiple sclerosis were examined twice with 5 years interval regarding acute (less than 1 month duration) and chronic (more than 1 month duration) pain syndromes. From the first to the second examination a significant increase was found in the number of acute and chronic pain syndromes, including tension and pain in the extremities, spasms, low back pain, Lhermitte's sign and neuralgia. The increase included both men and women. The increase was especially found in patients with deterioration of disability.

Mortality in patients with Parkinson's disease

INTRODUCTION

After the introduction of L-dopa the mortality rate in Parkinson's disease (PD) patients has changed, but is still higher than in the background population.

MATERIAL & METHODS

Mortality, age at death and cause of death in a group of PD patients compared with the background population were studied. The diagnosis on the death certificate were registered. The material consisted of 458 patients who in a period 1.4.1973-31.10.1991 were registered as having PD.

RESULTS

Death in the period amounted to 253 patients. Median age of death was 77.29 years for men and 79.11 years for women. In the background population the median age at death was 80.69 years for men and 84.37 years for women. The SMR for men was 1.92 and for women 2.47. Infections, in particular lung infections, and heart diseases were the most common causes of death. Seventy percent of the death certificates had PD as a diagnosis.

CONCLUSION

It is likely that several factors can influence the changed mortality of PD: more effective treatment, changing diagnostic practice, and inter-disease competition.

Sexual problems in young patients with Parkinson's disease

The purpose of this study was to describe sexual function in a representative group of young patients with Parkinson's disease (PD). Twenty-five patients (15 men, 10 women; age range 36-56 yrs) participated in a structured interview on sexual function. Forty percent of the men and 70% of the women reported changed libido while 33.4% of the men and 80% of the women experienced changed sexual activity after onset of PD. A tendency to changes in libido and sexual function was seen with increasing time of treatment and advanced Hoehn-Yahr stages. It is concluded that changes in libido and sexual function occur more frequently than previously reported, especially in women, and more attention should be paid to these problems.

[Psychosocial aspects of disseminated sclerosis]

Using multiple sclerosis as a model, it is demonstrated how a chronic neurological disorder has psychosocial consequences during the period between onset and diagnosis, at the time of diagnosis, and in the post-diagnostic period. The impact of the disorder on self-esteem, civil status, habitation, economy, social and leisure activities and need for help is described. It is concluded that it will increasingly be expected that the physician has knowledge of these relations.

[Progressive multifocal leukoencephalopathy]

Progressive multifocal leucoencephalopathy (PML) is a rarely occurring demyelinating disease of the central nervous system caused by a neurotropic papovavirus named JC virus (JCV). The most frequently affected areas are the cerebral hemispheres, especially the parieto-occipital region, followed by the cerebellum and brain stem. The disease occurs predominantly in individuals with an immunocompromised state and impaired cellular mediated immunity (CMI) due to other underlying illness. More extensive use of irradiation and immunosuppressive therapy in relation to increased transplantational activities as well as treatment of autoimmune diseases and malignancies, in addition to the appearance of the acquired immunodeficiency syndrome (AIDS) as a consequence of infection with the human immunodeficiency virus (HIV), has caused a considerable increase in the occurrence of PML. The course of the disease is still most often rapidly progressive and fatal, but several cases with prolonged survival and even remission have been reported, and various antiviral treatments have been tried. The only drug that until now has shown favourable results is cytosine arabinoside. In HIV-infected PML-patients immunomodulation with AZT/zidovudine may alleviate the course and improve the prognosis in some patients. Suspicion of PML should lead to an extensive immunological investigation before considering of brain biopsy, which is still the only specific test. On the basis of the increased frequency of PML in relation to HIV-infection, it is likely that our knowledge of the pathogenetic aspects will increase, which, hopefully, may lead to an effective therapeutic strategy. A review of this disease, based upon studies of the literature, is presented.

Effect of pregnancy on the prognosis for multiple sclerosis. A 5-year follow up investigation

INTRODUCTION

The purpose of the study was to evaluate the effect of pregnancy and childbirth on the longterm prognosis for women with multiple sclerosis (MS).

METHOD AND MATERIAL

A cohort of 39 women with definite MS were identified on 1.1.1986 using a reproducible selection method. The investigation was initiated in 1986 when handicap was evaluated by Kurtzke Disability Status Score (DSS). At a 5-year follow up 4 had died and 6 could not participate. There were 29 women in the investigation of whom 7 were childless, 10 had onset of MS at least 6 months after last childbirth, and 12 had onset of MS before or in connection with childbirth. Age and disease duration of the group was uniform.

RESULT

At follow up the DSS significantly deteriorated (p = 0.008). The deterioration was seen particularly for childless women (p = 0.03) and women with onset of MS before or in connection with childbirth (p = 0.005).

CONCLUSION

On the basis of this prospective investigation and the literature, it may be concluded that it is unlikely that pregnancy and childbirth have an influence on the longterm prognosis for MS. However, the conclusion must be interpreted with caution as the number of patients is small.

Suicide in patients with Parkinson's disease. An epidemiological study

The purpose of this study was to estimate the risk of suicide for patients with Parkinson's disease (PD) in Denmark compared with that in the background population. The study involved 458 patients with a PD diagnosis, 226 men and 232 women. The follow-up period to either death or end of follow-up on December 31, 1990 was 0 to 17 years, mean 5.7 years. Deaths in the follow-up period amounted to 254, 135 men and 119 women. Two women committed suicide. The number of expected suicides was 1.06 for men and 0.55 for women, a total of 1.62. Neither for men nor for women was the difference between expected and observed suicides statistically significant.

Multiple sclerosis: the impact on family and social life

In a cross-sectional study of 117 randomly selected patients (52 men, 65 women) with definite multiple sclerosis, it was found that 76 percent were married or cohabitant, 8 percent divorced. Social contacts remained unchanged for 70 percent, but outgoing social contacts were reduced for 45 percent. Ninety-five percent lived in own house or flat and 70 percent received disablement pension. More than half of the patients (56.4 percent) were dependent on help from close relatives, most frequently spouse. The need for help, the risk of divorce, loss of contact with relatives, difficulty in going out, need for structural changes in home and need for pension became greater with increasing physical handicap. No significant differences between gender were found. It is concluded that patients and relatives are under increased social strain, when multiple sclerosis progresses to a moderate handicap (Kurtzke Disability Rating Scale, 3-5).

Multiple sclerosis: correlation of anxiety, physical impairment and cognitive dysfunction

The aim of the study was to examine the correlation between anxiety and physical impairment and to discover whether anxiety correlated with specific forms of cognitive dysfunction. Ninety-four patients (42 females, 52 males) with definite MS entered the study. Anxiety was measured using the State-Trait Anxiety Inventory, physical impairment by means of the Kurtzke Disability Status scale, and cognitive impairment by using the Trail Making, Symbol Digit Modalities, Auditory Verbal Learning, Story Recall and the Recurring Figures tests. Moderately handicapped patients (DSS 4-5) showed signs of anxiety, and physical impairment correlated with anxiety (p < 0.05; d.f. 1.92). Trail Making also correlated with anxiety (p < 0.01; d.f. 1.86). On the basis of the results of this and previous studies, it is concluded that anxiety can be a sign of cognitive dysfunction, physical impairment or social strain.