Suicide and Mortality Patterns in Anxiety Neurosisand Depressive NeurosisChrister Allgulander, MD

Background: The diverging views on suicide risk in pa-tients with morbid anxiety called for a sufficiently largestudy to estimate the suicide risk in patients with anxi-ety neurosis and depressive neurosis.Methods: The identities of all 9912 patients with anxi-ety neurosis and all 38 529 patients with depressive neu-rosis in the national Psychiatric Case Register in Swe-den between 1973 and 1983, without any other psychiatricdiagnoses, were matched with the national Cause-of-Death Register. The observed causes of death among the9910 patients who died in 1990 or earlier were com-pared with those expected in the general population.Results: There were 1481 determined and 265 unde-termined suicides among the patients; ie, 18% ofall deaths.The standardized mortality ratio of suicide before the ageof 45 years among men and women with anxiety neuro-sis was 6.7 and 4.9, respectively; for depressive neuro-

sis, 12.6 and 15.7, respectively. The suicide risk was muchhigher within 3 months of leaving the hospital. Stan-dardized mortality ratios of death caused by ischemic- heartdisease and traumatic injury were marginally elevatedamong men in both diagnostic groups. Women in bothcategories were at increased risk for death caused by al-cohol abuse and cirrhosis of the liver. Obstructive pul-monary disease was another notable cause of death, re-flecting the aggravation of anxiety-depressive symptomsby airway obstruction or the effects of tobacco smoking.Conclusions: The risk of completed suicide amongformer inpatients with primary anxiety neurosis washigher than in previous, smaller studies and higher yetin patients with depressive neurosis. This hazard mayhopefully be reduced by optimizing immediate and long-term treatment for the severely affected.

(Arch Gen Psychiatry. 1994;51:708-712)

From the Karolinska Institute,Stockholm, Sweden;the Department of ClinicalNeuroscience and FamilyMedicine, Section ofPsychiatry, Huddinge (Sweden)University Hospital; and theDepartment of Psychiatry,Washington University Schoolof Medicine, St Louis, Mo.

The EXCESS mortality in psychiatric patients is thoughtto have biological and psychosocial determinants butalso to be confounded byselection bias in inpatient studies.1 Suicide, accounting for the largest number oflost years among death causes, ought tobe preventable by treatment of the preexisting mental disorder in many instances.2 Suicide often occurs soon afterhospital discharge in patients characterized by hopelessness or interpersonal disruptions, regardless of the type of diagnosis.3"5 This calls for continued preventiveefforts directed at high-risk patients.

A genetic contribution to mortality patterns has been reported for adoptees in thegeneral population and for twins with psychiatric disorders.6"9 This pertains both tosuicide and to disease-related causes of

death. There is some support for the hypothesis that heritability for suicide may exist,independent of a concurrent symptom diagnosis.1011 Furthermore, it has been proposed that individuals with the same geneticsubstrate and personality traits may presentwith predominantly anxious or depressivesymptoms, depending on circumstances.1213Three prospective studies of communitysamples support this possibility by showingdiagnostic instability in anxiety disorders.14

In the new nosology, panic disorder hasbeen associated with suicidal ideation andattempts.13 Whether these are conducive to

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METHODS

All discharge diagnoses from all psychiatric inpatient facilities in Sweden (mean population, 8.2 million) were cumulatively filed on computer between 1973 and 1983. Ofa total of 1 328 766 admissions, 1 243 152 (94%) were attributable to 366 003 identifiable patients. Their identitieswere matched with the national Cause-of-Death Register,which is a cumulative database of all death certificates. Thisyielded 122 245 patients who had died by 1990. A copy ofthe file without patient names was created for this study.It included diagnoses and death causes according to theWorld Health Organization's 1966 International Classification of Diseases, Eighth Revision (ICD-8), as well as demographic data. The Data Inspection Board, the NationalBoard of Health and Welfare, and Statistics Sweden all consented to the study.

In the study file, all probands were located who hadbeen discharged from the hospital with at least one diagnosis ofanxiety neurosis (ICD-8 300.00), phobic neurosis(ICD-8 300.20), neurasthenic neurosis (ICD-8 300.50), orcombinations of these but with no other psychiatric diagnoses. Patients could have obtained one or more of thesediagnoses during repeated inpatient stays since 1973. Allpatients with additional psychiatric diagnoses were ex-

eluded. This selection was considered to best approximatethe DSM-III-R diagnoses of panic disorder, phobic disorder, and generalized anxiety disorder, hence called anxietyneurosis." Similarly, all probands with depressive neurosis weretargeted (ICD-8 300.40, 300.41), with no other psychiatricdiagnoses on record. This category is similar to dysthymicdisorder in DSM-I-R. The causes ofdeath were divided intorelevant categories, including determined (ICD-8 E950-E959) and undetermined (ICD-8 E980-E989) suicides. Thelatter code is used "when it is stated that an investigation bya medical or legal authority has not determined whether theinjuries are accidental, suicidal or homicidal."

Descriptive tabulations were made with the use of software (SAS Institute, Gary, NC). Excess mortality amongthe probands was analyzed using standardized mortalityratios (SMRs), the number of deaths occurring among theprobands divided by the number of deaths expected if theage-specific death rate were the same as in the general population. These ratios were calculated using mortality statistics for 1973 to 1989 from the general population by sexand 5-year age groups. The time of entry into the group atrisk was the time of first hospital discharge. The time ofdeparture was the time of death or the end of the follow-upperiod. The life-table technique was used to describe the hazard of suicide by time from hospital discharge in three agegroups: 15 to 44, 45 to 64, and 65 to 94 years.

completed suicide has been questioned.1617 About 20% ofthe deaths among previously hospitalizedpatients with anxiety disorders are suicides, a proportion similar to that in depressive disorders.1819 One prospective community studyshowed the highest rate ofsuicide attempts, 30%, in thosewith both panic and depressive symptoms.20 Suicides havealso been overlooked in the past, as was the case in a follow-up study of 126 neurotic patients treated in the 1930s; fourof nine deaths were suicides.21

Whether cardiovascular disease is more common inanxiety or depressive disorders and whether there is a preventive effect of treatment are being discussed.22"26 Thisstudy aimed at exploring a large and representative groupofpatients to estimate the risk for suicide and disease-relateddeaths in patients with anxiety or depressive neurosis, un-contaminated by other psychiatric diagnoses. It built ontwo smaller studies that showed an excess ofsuicide amongpatients with anxiety or depressive neuroses.27,28

RESULTS

A total of 9911 probands were categorized as having pureanxiety neurosis, of whom 58% had an ICD-8 diagnosisof anxiety neurosis, 29% had neurasthenic neurosis, 7%had phobic neurosis, and 7% had at least two of the above.A total of 38 529 probands had a diagnosis of pure depressive neurosis. There were 1481 determined and 265undetermined suicides among them.

DESCRIPTIVE DATA

Among the probands with a diagnosis of anxiety neurosis, the median age at the time of first admission to a psychiatric unit was 39 years (range, 15 to 89 years), whilethose with depressive neurosis were older, with a median age of 48 years (range, 15 to 93 years). The mediantotal number of inpatient days during the 11-year period was 16 days (mean, 38 days) among those with anxiety neurosis, with 90% having a total of 83 days or less.For those with depressive neurosis, the median numberwas 14 days (mean, 36 days), with 90% having a total of78 days or less. With the caution that recorded maritalstatus was missing for 34% of the probands in both categories, 35% of those anxious or depressed were married at the time of first index admission, and 12% and17% of those anxious and depressed, respectively, weredivorced or widowed. Only 2.9% of those with anxietyneurosis and 3.4% of those with depressive neurosis hada somatic diagnosis recorded at the time of first admission (Table 1).

MORTALITY PATTERN

Among the men, 24% died; among the women, 19% died.Eighteen percent of all 9910 deaths were determined orundetermined suicides (Table 2). There were 74 deaths(0.75%) caused by alcohol or drug abuse or alcohol he-

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patic cirrhosis, and there were 14 homicides. Among themen in both categories, there were 1159 deaths (30%)caused by ischemie heart disease, while the proportionwas lower among the women, with 1468 deaths (25%).

RISK ESTIMATES

Focusing on suicide, women with depressive neurosiswere at highest risk, declining slightly with increasingage (Table 3). The suicide SMR in both men and womenwith anxiety neurosis was also substantially increased,with no decline with increasing age.

The risk of nontraumatic death (excluding suicide,homicide, and traumatic injury) was somewhat reduced among women in both categories (SMR, 0.7; 95%confidence interval [CI], 0.6 to 0.7) and slightly elevated among men with anxiety neurosis (SMR, 1.3; 95%CI, 1.2 to 1.4; P

*P

of the undetermined suicide category is customary, sinceabout one third of these deaths are rated as intentionalsuicide on closer scrutiny. We therefore erred on the conservative side.

Despite the proliferation of psychiatric services inSweden, most suicides occur among persons who havenot sought treatment, and while the risk increases manytimes with hospitalization, the type of inpatient diagnosis has less to do with the magnitude of the risk than generally believed.5 The findings of this study imply that suicide prevention must be pursued vigorously in patientswith morbid anxiety and impaired functioning. The muchhigher risk soon after leaving the hospital suggests thatpreventive monitoring should be instituted immediately.

From a public health perspective, efforts should bemade to identify cases in the community and to educatecare providers in diagnosing and treating patients withanxiety and depressive disorders.32 Prospective, repli-cable, controlled treatment studies of representative community cases will be required to assess the cost-effectiveness of treatment intervention, both immediateand long-term. Based on current wisdom, such studiesshould compare behavioral therapy with cognitive therapyand pharmacotherapy and with various combinations ofthese, pending further etiological research. The public(and health economists) may assess our performance todetermine whether the expense is justified.Accepted for publication June 24, 1994.

This study was supported by grants from the Swedish Council on Technology Assessment in Health Care andfrom the SALUS Fund, Stockholm, Sweden, and from theUpjohn Co, Kalamazoo, Mich.

Lena Brandt, BSc, Karolinska Institute, Stockholm,performed the statistical analyses. Curt-Lennart Spetz, theNational Board of Health and Welfare, Stockholm, created the data set. George E. Murphy, MD, and Philip W.Lavori, PhD, gave advice.

Reprint requests to Section of Psychiatry, HuddingeHospital, R63, Huddinge, S-141 86, Sweden (Dr Allgu-lander).

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