Validation of diagnoses on death certificates for male alcoholics in Stockholm

Alcohol-associated liver disease-Global epidemiology

Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.

Cause-specific mortality in patients with alcohol-related liver disease in Denmark: a population-based study

BACKGROUND

Increased knowledge of the causes of death will be essential to prevent premature death in alcohol-related liver disease. We examined cause-specific mortality, including death due to specific cancers, in the 15 years after diagnosis of alcohol-related liver disease.

METHODS

We used nationwide health registries to identify patients (aged ≥18 years) with a first diagnosis of alcohol-related liver disease between Jan 1, 2002, and Dec 31, 2017, in Denmark and followed up patients for their underlying cause of death up to Dec 31, 2019. We estimated the cause-specific mortality and investigated whether the cause-specific mortality differed by sex, age (<50, 50-59, and ≥60 years), alcohol-related liver disease severity at diagnosis (decompensated cirrhosis, compensated cirrhosis, alcoholic hepatitis, and steatosis or unspecified liver disease), and presence of diabetes.

FINDINGS

The study included 23 385 patients with incident alcohol-related liver disease. Patients had a median age of 58 years (IQR 51-65), 15 819 (68%) were men and 7566 (32%) were women, and 15 358 (66%) had cirrhosis. During 111 532 person-years of follow-up, 15 692 (67%) patients died. Liver disease was the leading cause of death. In the first 5 years after alcohol-related liver disease diagnosis, liver disease caused almost half of all deaths, and the 5-year risk of death due to liver disease was 25·8% (95% CI 25·3-26·4). Beyond 5 years, causes other than liver disease combined became more common; of these extrahepatic causes, cancer, cardiovascular disease, and alcohol use disorder were the most common. Hepatocellular carcinoma was the dominant cause of cancer death (10-year risk of 2·5%, 95% CI 2·3-2·7), followed by lung cancer (1·9%, 1·7-2·1). The 10-year risk of death due to liver disease (around 30%) was similar for patients in all age groups and independent of sex and diabetes but was three times higher for those with decompensated cirrhosis (46·7%, 44·8-48·4) than steatosis or unspecified liver disease (16·2%, 15·3-17·2).

INTERPRETATION

Patients diagnosed with alcohol-related liver disease were at high risk of dying from liver disease many years after diagnosis, irrespective of age and sex. Death due to specific cancers, including hepatocellular carcinoma, each contributed minimally to the total mortality in patients with alcohol-related liver disease.

FUNDING

TrygFonden and the Novo Nordisk Foundation.

Hospital admissions and mortality in the 15 years after a first-time hospital contact with an alcohol problem: a prospective cohort study using the entire Danish population

BACKGROUND

Potential benefits of preventing continued alcohol intake in individuals presenting at the hospital with an alcohol problem can be highlighted by studying their excess risk of subsequent morbidity and mortality.

METHODS

All Danish residents with a first-time hospital contact with alcohol problems (intoxication, harmful use or dependence) in 1998-2002 were followed through 2012 using healthcare registries. We compared their cause-specific rates of hospital admission and mortality to the expected rates derived from the general population by calculating standardized incidence rate ratios.

RESULTS

The 26 716 men and 12 169 women who were hospitalized with alcohol problems (median age 44 years) had more than 10 times the rate of subsequent admission to psychiatric departments and three times the rate of subsequent admission to somatic departments compared with the general population. In particular, the hospital admission rates for gastroenterological disease and injuries were high. The cumulative all-cause 10-year mortality risk was 29% [95% confidence interval (CI), 28-30] in men and 26% (95% CI, 24-27) in women with alcohol problems. The ratios of observed to expected death rate for all-cause mortality were 4.0 (95% CI, 3.8-4.1) in men and 4.3 (95% CI, 4.0-4.7) in women and, for causes of death fully attributable to alcohol, 16 (95% CI, 15-17) in men and 33 (95% CI, 29-38) in women.

CONCLUSIONS

Individuals hospitalized with alcohol problems have much higher rates of subsequent alcohol-related hospital admission and mortality than the general population. Increased focus on preventing continued alcohol consumption in these individuals may reduce their subsequent morbidity and mortality.

Opportunities to Prevent Alcoholic Liver Cirrhosis in High-Risk Populations: A Systematic Review With Meta-Analysis

BACKGROUND

Alcoholic liver cirrhosis is preventable and caused by heavy drinking. Few in the general population may be at risk and interventions targeting individuals at high risk may be a more feasible opportunity for prevention than interventions targeting the whole population.

METHODS

We conducted a systematic review to identify opportunities to prevent alcoholic liver cirrhosis in high-risk populations. Following MOOSE guidelines, we included observational studies published between 1980 and 2017. Prospective studies of alcohol-problem cohorts were included to investigate whether alcohol-problem cohorts qualify as high-risk populations for alcoholic liver cirrhosis. Studies on the alcohol amount consumed by alcoholic liver cirrhosis patients were included to compare with the amount consumed by the general population. Moreover, studies on alcohol-related healthcare contacts prior to alcoholic liver cirrhosis diagnosis were included to identify opportunities to offer prevention interventions. Of 7198 screened references, 38 studies (N = 120,928) were included.

RESULTS

Alcohol-problem cohorts qualified as high-risk populations with an incidence of alcoholic liver cirrhosis ranging from 7 to 16% after 8-12 years. The alcohol amount consumed by alcoholic liver cirrhosis patients was high compared to the general population. For example, 45% (95%CI 34, 56) of alcoholic liver cirrhosis patients were drinking >110 g alcohol/day. Finally, there were opportunities to reach alcoholic liver cirrhosis patients prior to diagnosis; 40-61% of alcoholic liver cirrhosis patients had a previous alcohol-related healthcare contact.

CONCLUSIONS

We conclude that alcohol-problem cohorts are high-risk populations for alcoholic liver cirrhosis and there seems to be opportunities to reach later alcoholic liver cirrhosis cases with preventive interventions in healthcare settings.

Liver cirrhosis mortality in 15 European countries: Differences and trends during the post-war period

Mats Ramstedt: Liver cirrhosis mortality in 15 European countries – differences and trends during the post-war period

The aim of this paper was to describe and analyse differences and trends in liver cirrhosis mortality rates during the post-war era in 15 European countries. The study countries include all EU member states (except Luxembourg) and Norway. Liver cirrhosis mortality data and population figures were gathered from the WHO Mortality Database.

The rank order of these countries, with respect to cirrhosis rates, were in general stable during the post-war period and most countries had increasing cirrhosis rates until the 1970s and then declining rates. This general picture was true also when sex-specific rates were studied. A deviant case was Sweden, with an exceptionally sharp increase from 1950 until the 1970s. Other deviant cases were Denmark, Finland and the UK, where cirrhosis mortality has not declined since the 1970s. Age specific analyses revealed that in one group of countries, mortality trends seem to be collective with respect to age, while in another cluster, different age groups exhibited divergent trends. Furthermore, the age-profile of cirrhosis mortality varies considerably between the study countries.

Cross-country analyses were performed to elucidate the influence of some plausible determinants of cirrhosis mortality. According to the outcome, there was a fairly close relationship between cirrhosis mortality, on the one hand, and per capita alcohol consumption, alcohol prices, and the restrictiveness of alcohol policy, on the other. More detailed analyses based on time series data are needed to test how these variables are interrelated.

Alcohol-attributed disease burden in four Nordic countries: a comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

AIMS

(1) To compare alcohol-attributed disease burden in four Nordic countries 1990-2013, by overall disability-adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non-fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol-attributed disease burden; and (3) to compare the distribution of disease burden separated by causes.

DESIGN

A comparative risk assessment approach.

SETTING

Sweden, Norway, Denmark and Finland.

PARTICIPANTS

Male and female populations of each country.

MEASUREMENTS

Age-standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs).

FINDINGS

In Finland, with the highest burden over the study period, overall alcohol-attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62-76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self-harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively.

CONCLUSIONS

Finland and Denmark has a higher alcohol-attributed disease burden than Sweden and Norway in the period 1990-2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability-adjusted life years were due to premature mortality. Alcohol use disorder by non-fatal conditions accounted for a higher proportion of disability-adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Levels of aggressiveness are higher among alcohol-related suicides: results from a psychological autopsy study

Suicide is one of the major causes of deaths worldwide. Several studies have showed that alcohol use disorders (AUD) are associated with suicide ideation, suicide attempts, and suicide completion. The majority of the theoretical conceptualization and the bulk of evidence on suicidal behavior and AUD are based on investigations of nonfatal cases because data on nonfatal suicidal behaviors are more readily available. This study aims to explore demographic, clinical, and behavioral dimensions in a large sample of alcohol-related suicides compared to an age-gender matched sample of non-AUD suicides to identify specific factors associated with AUD suicides. We conducted a psychological autopsy study with 158 pairs of AUD and non-AUD suicides. Findings showed that AUD suicides have lower educational level, more biological children and were more likely to be heavy smokers (OR=3.32). Cases were more likely to have family history of alcohol (OR=1.73) and drug abuse (OR=3.61). Subjects had similar prevalences of depressive disorders, anxiety disorders or psychotic disorders. AUD suicides were more likely to meet criteria for current cocaine abuse/dependence (OR=6.64). With respect to personality disorders, AUD suicides presented higher prevalence of Antisocial Personality Disorder (OR=4.68), and were less likely to meet criteria for Avoidant (OR=0.26) and Obsessive-Compulsive Personality Disorders (OR=0.35). Impulsivity scores were higher in AUD suicides (p=0.18), as well as aggression scores (p<0.001). Results form the conditional logistic regression models showed that cocaine abuse/dependence (OR=4.20) and Antisocial Personality Disorder (OR=6.24) were associated with AUD suicide. After controlling for impulsive-aggressive behaviors, levels of aggression were the only psychopathological feature statistically different between AUD and non-AUD suicides (OR=1.28). In conclusion, higher levels of aggressive behaviors are a specific characteristic of AUD suicides. Apart from substance-related diagnoses, AUD and non-AUD suicides have comparable Axis I psychiatric diagnoses and familial transmission of suicidal behavior.

Mortality and causes of death among homeless women and men in Stockholm

AIM

To study the mortality and causes of death among homeless men and women in relation to the risk indicators, previous treatment for alcohol and drug abuse, previous treatment for mental disorders and non-Swedish citizenship.

METHODS

The mortality was studied in a cohort comprising 1,757 men and 526 women compared with the general population and persons with inpatient treatment for alcohol- and drug-related disorders. The follow-up period was from 1995 to 1997 until the end of 2005. The causes of death were analyzed.

RESULTS

421 deaths occurred during the follow-up period. The relative risk of death was 3.1, with no difference in mortality between homeless men and homeless women. Previous treatment for alcohol and drug abuse disorders was related to excess mortality and previous treatment for mental disease to lower mortality. Homeless people with inpatient treatment for alcohol or drug use disorders had no higher mortality than the general population in Stockholm with a similar history. There was a dominance of alcohol- and drug-related causes of death.

DISCUSSION

Compared with previous studies of homeless people in Stockholm the excess mortality among men found in this study is of the same magnitude. Mortality among women is lower. The mortality rate in homeless people with previous treatment for an alcohol and illicit drug use disorder did not differ from those treated for these disorders in the general population.

CONCLUSIONS

The most important finding is that excess mortality among homeless men and women in Stockholm is entirely related to alcohol and drug abuse.

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

Gender differences in role of alcohol in fatal injury events

BACKGROUND

The aim was to investigate the differences in alcohol involvement in fatal injury events between females and males.

METHODS

Information was obtained from the Forensic Medicine Database and the Forensic Toxicology Database of the National Board of Forensic Medicine, and from the inpatient register of the National Board of Health and Welfare. Alcohol was regarded to be involved in the injury event: if there was any indication that the deceased was a 'known alcoholic'; if the underlying or contributing causes of death were alcohol-related; if the deceased had alcohol-related inpatient diagnosis during a 3-year period prior to death; or if the deceased tested positive for blood alcohol at autopsy. All injured cases who underwent medico-legal autopsies (1992-1996) in Sweden were analysed (4471 females and 11 156 males).

RESULTS

Compared to males, females died more often (P < 0.05) in intentional injury events (48.0% females, 44.2% males), were less often (P < 0.001) blood alcohol-positive (29% females, 43% males), had lower (P < 0.05) blood alcohol concentrations (0.17% in females, 0.18% in males), and were less likely (P < 0.001) to have an alcohol-related history (18.4% females, 24.4% males). For females, intentional deaths (31.4%) were significantly (P < 0.001) more often alcohol-related than unintentional deaths (22.9%). A significantly (P < 0.001) higher proportion of deaths in males (48.4%) were alcohol-related compared to females (32.9%).

CONCLUSIONS

Almost every third injury event in females and in almost every other event in males is alcohol-related, showing that alcohol plays an important part in fatal injuries in females even though it is mostly a male problem.

Alcohol-Related Mortality in Europe: A Tentative Analysis from the EU Project "Alcohol Consumption and Alcohol Problems among Women in European Countries"

Mortality data were collected for eight of the nine study countries in the BIOMED-II concerted action "Alcohol Consumption and Alcohol Problems among Women in European Countries": Finland, France, Germany, Italy, The Netherlands, the United Kingdom (Scotland), Sweden, and Switzerland. An analysis of mortality that is limited to causes of death that are fully attributable to alcohol (DAA) results in a large underestimation of alcohol-related mortality (ARM) rates in all study countries and especially among females. These estimates can be improved by including an analysis of selected causes of death that are indirectly attributable to alcohol. This produces geographic and time-trend variability of ARM rates that are more congruent with alcohol drinking levels and trends. From this study, it is evident that when German data are analyzed separately for the former German Democratic Republic (GDR) and the former Federal Republic of Germany (FRG), two distinct ARM patterns result. The authors underline methodologic limits of this study and recommend procedures for a more reliable calculation of European ARM estimates

Middle-aged men--a risk category regarding fatal poisoning due to dextropropoxyphene and alcohol in combination

BACKGROUND

Dextropropoxyphene (DXP) toxicity is highly potentiated by alcohol and the aim of this study was to determine the characteristics of non-suicidal deceased with simultaneous occurrence of alcohol and DXP in the blood.

METHODS

The investigated population was based on the total medico-legal autopsy material in Sweden during the years 1992-1996. Toxicological analyses and death certificates were examined.

RESULTS

Simultaneous occurrence of DXP and alcohol was detected in 425 cases. The mean blood alcohol concentration was 0.14%. One-third had a blood alcohol concentration >;0.20% and 42%, <0.1%. The majority of the cases were found between the ages 30 and 59 years;, 71% were male and 29% were female. Notes on alcoholism were found in 16% of the cases.

CONCLUSION

Middle-aged, habitual or social-drinking men, on medication for pain, are most prone to combine DXP and alcohol and are most vulnerable to be victims of accidental poisoning due to the combination of DXP and alcohol. We propose strict regulations in prescription, or even a ban on prescription of DXP, and that physicians in the meantime pay extra attention to this risk category of patients and make sure that the patient is well informed of the life-threatening risks of simultaneous use of DXP and alcohol.

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These differences in mortality rates seem to have arisen for complex reasons.

Towards a direct definition of an alcohol-related death: an analysis in Aboriginal adults

This paper addresses the conceptual and methodological difficulties in obtaining reliable information on alcohol-related mortality in Aboriginal communities. A working definition is proposed; this requires an alcohol-positive history together with a consistent mode of death, and is applied retrospectively to a series of 29 adult deaths in a large Aboriginal community. An informant history of alcohol abuse was found to be the most sensitive indicator of an alcohol-positive history and correlated well with autopsy findings and medical records. Alcohol-positive histories were found for 17 of 29 deaths by informant history, for 9 of 29 by autopsy findings, and for 12 of 29 by medical record review. These indicators were combined with a mode of death categorisation to arrive at an estimate of 5 of 29 definite, 5 of 29 probable, and 1 of 29 possible alcohol-related deaths. We conclude by examining the process by which such a definition might be further developed and the context in which resulting information might then be used.

The prevalence of alcohol-related mortality in both sexes: variation between indicators, Stockholm, 1987

OBJECTIVES

The purpose of this study was to analyze the prevalence rates of alcohol-related mortality--according to various indicators--in both sexes in Stockholm, Sweden.

METHODS

A study of alcohol involvement at death was undertaken for all 668 deceased persons aged 15 through 54 years in 1987 in Stockholm. Death certificates, autopsy information, police records, and information about earlier conviction were analyzed.

RESULTS

When different measures of estimation were compared, there were great differences in the prevalence rates of alcohol involvement. According to the death certificates, 9.2% of the males and 11.2% of the females had alcoholism, alcohol intoxication, pancreatitis or liver cirrhosis as underlying cause of death. When all accessible information was used, potential alcohol involvement was found in 57.5% of the male and in 32.2% of the female deaths. There was a marked association between earlier drunken driving and alcohol involvement. After reevaluation of the diagnoses with autopsy findings, the number of cases with cardiac enlargement and suspected cardiomyopathy increased from 10 to 62.

CONCLUSION

The results point to the serious underdiagnosis of alcohol involvement in death certificates and the misclassification of important causes of death (i.e., liver cirrhosis and cardiac disease); they also call for increased efforts regarding prevention.

Mortality in alcohol-related diseases in Sweden during 1971-80 in relation to occupation, marital status and citizenship in 1970

A new Swedish population register, created by linking Census data to the Cause of Death Registry and covering over 99% of the population, has been used to study the relationship between occupational category, marital status and citizenship in 1970 and mortality in closely alcohol-related diseases during 1971-1980 for the ages 25-64 years. Age-standardized rate ratios (SRR) have been computed for mortality in alcoholism, alcohol intoxication and alcohol psychosis ("AAA") and in liver cirrhosis. SRR-values for both diagnose categories and both sexes were higher than average among not gainfully employed (SRR = 3.71 among males and SRR = 1.96 among females in 1976-80 for "AAA"), among employees in the service sector, engine-drivers and unskilled workers and increased in liver cirrhosis among artists and authors. Among females there were smaller variations in mortality for occupational groups than among males. The SRR-values showed a tendency to be higher in 1976-80 than in 1971-75, probably due to health-related selection to some extent. The alcohol-related mortality was also increased among divorced, widows (SRR = 1.37 for "AAA" and 2.81 for liver cirrhosis in 1976-80) and widowers and among never married males. SRR was much higher among Finnish citizens in Sweden (SRR for "AAA" = 3.85 among males and 2.35 among females in 1976-80) than among males and females living in Finland (SRR for "AAA" = 1.13 among males and 0.36 among females) and also higher than among immigrants from other countries, summed (SRR for "AAA" = 0.62 among males and 0.64 among females).(ABSTRACT TRUNCATED AT 250 WORDS)

Causes of death in a cohort of 50,465 young men--validity of recorded suicide as underlying cause of death

We studied causes of death in a cohort of all young males (n = 50,465) conscripted for military service in 1969-70. Six hundred eighty three deaths occurred in the cohort during the follow-up through 1983. Injury-related deaths accounted for 75% of all deaths. Of these, 38% were definite suicides, 10% undetermined suicides and 30% motor vehicle accidents. The validity of officially recorded causes of death was studied by scrutinizing all death certificates (n = 683) and forensic reports, including police reports, toxicological and histological data, from a sample (n = 322) of deaths with unclear circumstances. Of 161 officially recorded suicides (E950-959), only one case was reevaluated into poisoning, "undetermined" (E980). Of 47 cases officially recorded "undetermined" (E980-989), 9 were reevaluated into definite suicide (E950-959) although we believe that this is still an underestimation of "true" suicide cases. An alcohol concentration of more than 0.1 g% was found in 45% of all violent deaths (E800-999), 34% of all suicides and 60% of all "undetermined" deaths. We conclude that the causes of death in most cases of injury related death in young age are recorded with high accuracy. Reevaluation of recorded deaths from "undetermined" causes revealed a number of definite suicides, although the "true" number of suicides is difficult to assess even after close scrutiny of the information available.

Alcohol, social factors and mortality among young men

In a 20-year follow-up the association between alcohol consumption, social and personal background factors and mortality was studied in a cohort of 49,464 Swedish conscripts. The relative risk of death among high consumers (those consuming more than 250 g alcohol/week at conscription) was 2.8 (95% confidence interval 2.2-3.7) compared with moderate consumers (1-100 g/week). Deaths caused by direct toxic effects of alcohol were few, less than 5%. Instead suicides and accidents predominated. Abstainers had a slightly lower mortality than moderate consumers, with a relative risk of 0.8 (0.6-1.1), due to a significantly lower risk for traffic deaths. High consumers of alcohol had more than twice as many social and personal risk factors for premature death compared with the cohort as a whole. Yet presence of social risk factors added little to the already increased relative risk of death among high consumers.

Mortality among criminals with suspected mental disturbance

Mortality rates and cause of death are reported from a long-term follow-up study of 620 Swedish criminals who were subjects of a forensic psychiatric examination in 1965-1968. The results show that there is an increased mortality rate in criminals mainly due to violent deaths (suicides, accidents) and diseases related to alcohol abuse. The increased mortality was found in all age groups throughout the follow-up period of 13-16 years. The total mortality was 17%. An analysis of different mortality risk factors showed that drug abuse, type of crime (violent crimes or property crimes) and criminal recidivism did not further increase the mortality risk. There were relatively few deaths due to overdose of drugs. Alcohol abuse increased the mortality rate significantly.