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Excess mortality among patients with severe mental disorders has not previously been investigated in detail in large complete national populations. To investigate the excess mortality in different diagnostic categories due to suicide and other external causes of death, and due to specific causes in connection with diseases and medical conditions. In longitudinal national psychiatric case registers from Denmark, Finland, and Sweden, a cohort of 270,770 recent-onset patients, who at least once during the period 2000 to 2006 were admitted due to a psychiatric disorder, were followed until death or the end of 2006. They were followed for 912,279 person years, and 28,088 deaths were analyzed. Life expectancy and standardized cause-specific mortality rates were estimated in each diagnostic group in all three countries. The life expectancy was generally approximately 15 years shorter for women and 20 years shorter for men, compared to the general population. Mortality due to diseases and medical conditions was increased two- to three-fold, while excess mortality from external causes ranged from three- to 77-fold. Mortality due to diseases and medical conditions was generally lowest in patients with affective disorders and highest in patients with substance abuse and personality disorders, while mortality due to suicide was highest in patients with affective disorders and personality disorders, and mortality due to other external causes was highest in patients with substance abuse. These alarming figures call for action in order to prevent the high mortality.

Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler's method. The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter. Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years.

IntroductionOpioid analgesic medications play a critical role in pain management but are associated with significant risks, including addiction. General practitioners in primary care account for a substantial proportion of opioid prescriptions, and prescribing practices may not always fully align with clinical guidelines. Given the limited evidence supporting long-term opioid use for chronic non-cancer pain, there is a pressing need for interventions that promote safer, guideline-concordant prescribing. The Smarta Val (Smart Choices) trial will evaluate whether a new multicomponent intervention, comprising an educational seminar, written materials and feedback on prescribing over 12 months, can improve opioid prescribing practices in primary care.Methods and analysisThis cluster randomised pragmatic trial will assess changes in opioid prescribing across primary healthcare centres (PHCCs) in Stockholm, Sweden. Consenting PHCCs will be randomised 1:1 to either the intervention group, receiving the multicomponent intervention, or the active control group, receiving a leaflet on prescribing recommendations. A sample size of 24 PHCCs per group is required to detect differences in opioid prescribing between groups. A third group of non-randomised observational reference PHCCs will be included to provide contextual information on prescribing practices during the study period. Data sources include regional healthcare databases, baseline and 12-month follow-up questionnaires, and an intervention delivery form. The primary outcome is the change in prescription of opioids at 12 months. Secondary outcomes are the change in prescription of opioids at 24 months and the change in the specific opioid substances prescribed at 12 months.Ethics and disseminationThe study has been approved by the Swedish Ethical Review Authority (Dnr 2021-06739-01). Participation in the study requires informed consent from PHCC managers in the intervention and active control groups. Results will be disseminated through international peer-reviewed journals and conference presentations.Trial registration numberNCT05577026.

Concerns exist that psychostimulants may increase the risk of psychosis, particularly in individuals with a history of psychosis. This study assessed whether psychosis risk increases after initiating psychostimulant or atomoxetine treatment in individuals with prior psychotic events. In this cohort study, we used Swedish population-based register data that contain data on all Swedish residents. We identified adults aged 18–64, who had a history of psychosis and initiated psychostimulant or atomoxetine treatment between 2008 and 2021. A within-individual design compared the rate of psychotic events in two 6-month periods before and after treatment initiation. Rate ratios (RR) with 95% confidence intervals (CI) were estimated. Sensitivity analyses were stratified by sex, age groups, and medication classes and also investigated substance-related psychosis as alternative outcome. We identified 3,770 individuals with a history of psychosis that received psychostimulant or atomoxetine prescriptions during the study period. Compared to the period before treatment initiation, the RR for psychotic events in the six months following treatment initiation was 0.95 (95% CI 0.84–1.08). Sensitivity analyses, considering only substance-induced psychotic events, or eight-week intervals and subgroup analyses by sex, age groups and separately for individuals receiving either (dex-)methyphenidate or (lis-)dexamphetamine or atomoxetine or (ar-)modafinil showed consistent results. Contrary to concerns, psychostimulant or atomoxetine treatment was not associated with an increased risk of psychotic events in adults with a history of psychosis. These findings may inform clinicians considering psychostimulant prescriptions in this population.

Background There is limited knowledge on long-term outcomes of tapering treatment for individuals with problematic use of prescription narcotics, including opioids and benzodiazepines. The overall aim of the study is to investigate clinical trajectories and treatment outcomes of patients seeking treatment in addiction care. Methods This paper presents the study protocol and baseline characteristics of a cohort of patients seeking treatment for problematic use of prescription narcotic drugs at specialized outpatient addiction services. Treatment for addiction at the clinic includes drug tapering and treatment for underlying psychiatric disorders. Data in this prospective cohort study is collected from biomarkers, self-report questionnaires, patient medical records, and national registers at baseline and follow-up visits at 6, 12, and 24 months. Results A clinical cohort of 405 participants were enrolled in the study between 2018 and 2023. The study population (57.5% women; 42.5% men) at baseline had a mean age of 49.2 years (SD = 14.0). Participants in the cohort had used prescription narcotics for 11 years on average before seeking treatment, with opioid analgesics (66.2%) being the most common at baseline, followed by benzodiazepines (50.9%). Most participants (75.9%) had received prescription narcotics from their health care provider, although illegal sources were common. Besides substance use disorders, many also had anxiety disorders (46.3%) and depression (40.4%) at baseline. Previous treatment for problematic alcohol or drug use were reported by 14.0% and 21.6%, respectively. Discussion This prospective, naturalistic cohort will provide novel information on long-term outcomes of tapering treatment and identify prognostic factors for treatment success, including abstinence. Future papers will investigate individual and treatment-related characteristics of the patient population. Baseline data suggest that many patients with problematic use of prescription narcotics receive prescriptions over many years from their regular health care providers, which contradicts most clinical guidelines. Trial registration NCT03713983 22/10/2018.

Objective To estimate the cardiovascular mortality among persons with bipolar disorder in Sweden compared to the general population. Design Population register-based cohort study with a 20-year follow-up. Setting Sweden. Participants The entire population of Sweden (n=10.6 million) of whom 17 101 persons were diagnosed with bipolar disorder between 1987 and 2006. Main outcome measures Mortality rate ratios (MRR), excess mortality (excess deaths), cardiovascular disorder (CVD) and specifically cerebrovascular disease, coronary heart disease, acute myocardial infarction, sudden cardiac deaths and hospital admission rate ratio (ARR). Results Persons with bipolar disorder died of CVD approximately 10 years earlier than the general population. One third (38%) of all deaths in persons with bipolar disorder were caused by CVD and almost half (44%) by other somatic diseases, whereas suicide and other external causes accounted for less than a fifth of all deaths (18%). Excess mortality of both CVD (n=824) and other somatic diseases (n=988) was higher than that of suicide and other external causes (n=675 deaths). MRRs for cerebrovascular disease, coronary heart disease and acute myocardial infarction were twice as high in persons with bipolar disorder compared to the general population. Despite the increased mortality of CVD, hospital admissions (ARR) for CVD treatment were only slightly increased in persons with bipolar disorder when compared to the general population. Conclusions The increased cardiovascular mortality in persons with bipolar disorder calls for renewed efforts to prevent and treat somatic diseases in this group. Specifically, our findings further imply that it would be critical to ensure that persons with bipolar disorder receive the same quality care for CVD as persons without bipolar disorder.

Aim: We investigated mortality from external causes in Swedish people who had been hospitalised with a severe mental disorder. Methods: Hospitalisations in people aged 15 years or older admitted to hospital with a main diagnosis of schizophrenia, bipolar mood disorder or unipolar mood disorder between 1987 and 2010 were linked to their causes of death. Results: The mortality rate from all external causes was 20-fold higher in those with unipolar mood disorder, 15-fold higher in those with bipolar disorder and 12-fold higher in those with schizophrenia than in the general population. Over the study periods, the mortality rate declined more for people with unipolar mood disorder (−35%) and schizophrenia (−29%) than the total population (−25%) and those with bipolar mood disorder (−15%). The suicide rate declined most for those with unipolar mood disorder and schizophrenia (−42% for both) and less for the general population (−37%) and those with bipolar mood disorder (−21%). For external causes other than suicide, the mortality rate declined in the general population (−17%) but increased in people with schizophrenia (14%), bipolar mood disorder (30%) and unipolar mood disorder (52%). Conclusions: People with mental disorders have high but declining excess mortality from suicide. Mortality from other external causes has increased, as has the gap in mortality rates between psychiatric patients and the general population.

ObjectivesTo investigate the correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Secondary aims were to investigate length of sick leave by diagnoses on sick leave certificates, diagnoses made in structured interviews and symptom severity.DesignObservational study consisting of a secondary analysis of data from a randomised controlled trial and an observational study.SettingThe regions of Stockholm and Västra Götaland, Sweden.Participants480 people on sick leave for common mental disorders.InterventionsParticipants were examined with structured psychiatric interviews and self-rated symptom severity scales.Outcome measures(1) Sick leave certificate diagnoses, (2) diagnoses from the Mini International Neuropsychiatric Interview and the Self-rated Stress-Induced Exhaustion Disorder (SED) Instrument (s-ED), (3) symptom severity (Montgomery-Asberg Depression Rating Scale-self-rating version and the Karolinska Exhaustion Disorder Scale) and (4) number of sick leave days.ResultsThere was little correspondence between diagnoses on sick leave certificates and diagnoses made in structured psychiatric interviews. Many participants on sick leave for SED, anxiety disorder or depression fulfilled criteria for other mental disorders. Most on sick leave for SED (76%) and anxiety disorder (67%) had depression (p=0.041). Length of sick leave did not differ by certificate diagnoses. Participants with SED (s-ED) had longer sick leave than participants without SED (144 vs 84 days; 1.72 (1.37–2.16); p<0.001). More severe symptoms were associated with longer sick leave.ConclusionDiagnoses on sick leave certificates did not reflect the complex and overlapping nature of the diagnoses found in the structured psychiatric interviews. This finding is relevant to the interpretation of information from health data registers, including studies and guidelines based on these data. A result of clinical interest was that more severe symptoms predicted long-term sick leave better than actual diagnoses.

Background Opioids are essential medicines for pain management; however, long-term use is associated with negative outcomes, including addiction. The aim of the study was to analyze the risk of long-term use after an initial opioid prescription and examine associated sociodemographic and health care-related risk factors. Methods We identified a strictly defined, five-year opioid-naïve population of adults aged 18–64 years who received an initial opioid prescription between 2016 and 2020 in Swedish national registers. We modeled the association between individual characteristics and odds of long-term ( > 3 months) versus short-term ( ≤ 3 months) use, and odds of different durations of use ( > 3–6, >6–12, and >12 months) using logistic regression analyses. Results Of 754,982 opioid-naïve individuals with an initial opioid prescription, 8.1% use opioids long-term. Individuals treated for a recent external injury have lower odds of long-term opioid use (e.g., >12 vs ≤3 months: OR 0.55, 95% CI 0.52–0.59), whereas those who initiated treatment in primary care have higher odds (e.g., >12 vs ≤3 months: OR 3.02, 95% CI 2.90–3.14). Individuals with a history of substance use disorders and greater use of psycholeptic drugs have higher odds of long-term use. Sociodemographic factors, including older age, lower education level, and not cohabiting are also associated with longer durations of use. Conclusions Of opioid-naïve individuals, 8.1% develop long-term prescription opioid use, with higher odds among individuals with psychiatric history and whose opioid treatment initiated in primary care. Careful evaluation of patient health and regular follow-up are essential to reduce the risk of long-term opioid use. Plain language summary Opioids are strong pain-relieving medicines, but long-term use can lead to serious health problems, including addiction. This study looked at how often Swedish adults continued using opioids after their first prescription, and what factors increased that risk. We found that 8 out of 100 people continued using prescription opioids for more than three months, and some for much longer periods of time. Those with mental health conditions, substance use disorders, or who received their first prescription in primary care were more likely to continue, while people treated for injuries such as broken bones had lower risk. These findings highlight the need to consider the risk of prolonged use before prescribing opioids, and to provide careful follow-up for patients who use them. Krüger et al. analyze the risk of long-term opioid use in a cohort of over 750,000 Swedish adults after a first prescription. They find that 8.1% continue to use opioids for longer than 3 months, with higher odds among individuals with psychiatric history and those initiating treatment in primary care.

Objective To determine factors influencing long term risks for acquiring or dying from invasive cervical or vaginal cancer in women previously treated for cervical intraepithelial neoplasia grade 3 (CIN3).Design Population based cohort study conducted in 1958-2008, followed up until 2009 in the Swedish Cancer Registry and Swedish Cause of Death Register, linked to the Swedish Population Register. Standardised incidence and mortality ratios were calculated for the risk of acquiring or dying from vaginal or cervical cancer, with the general female population in Sweden as reference. Relative risks in multivariable regression models were also calculated, adjusting for follow-up duration, treatment period, and age at CIN3 treatment or attained age.Setting Entire female population of Sweden.Participants 150 883 women in Sweden diagnosed and treated with CIN3 and followed up for invasive cervical or vaginal cancer, and related mortality. The cohort comprised 3 148 222 woman years.Main outcome measures Standardised incidence and mortality ratios, stratified by period for treatment. Relative standardised incidence ratios and standardised mortality ratios for age at acquiring or dying from cervical or vaginal cancer (attained age), adjusted for preset variables.Results Women previously diagnosed with CIN3 had an increased risk of dying from invasive cervical or vaginal cancer, compared with the general female population (standardised mortality ratio 2.35, 95% confidence interval 2.11 to 2.61). After age 60 years, these women had an accelerated increased risk of acquiring invasive cancer; a similar steep increase in mortality risk was seen after age 70. Regression analyses indicated that the increase in risk over time is highly attributable to ageing.Conclusions Women previously treated for CIN3 are at increased risk of developing and dying from cervical or vaginal cancer, compared with the general female population. The risk accelerates above age 60 years, suggesting a need for lifelong surveillance of these women.