Wednesday, 10 December 2014

Alcohol use disorders and mortality in Nordic countries

This post was originally written by Andrew Jones for the Mental Elf. You can see the original here.

Alcohol Use Disorder (AUD) is one of the most prevalent mental disorders, affecting an estimated 3.6 % of the world population. AUDs are a major contributor of morbidity and mortality, with excessive alcohol consumption associated with increased burden of disease, accidents and social problems (Samohkvalov et al, 2010).
A recent meta-analysis including studies across many countries demonstrated that men with AUD have three-fold higher mortality, whereas women have four-fold mortality, than the general population (Roerecke et al, 2013). Increased mortality is also seen in younger people and those in TREATMENT FOR addiction. However, little is known about the mortality data of patients with AUD in Nordic countries.
Because of alcohol-related problems, Sweden, Denmark and Finland created alcohol policies to restrict availability and reduce population consumption of alcohol. However in 1995, after joining the European Union, both Sweden and Finland shifted to more liberal polices such as tax reductions and lengthened opening hours.
In a recent population based REGISTER study published in Acta Pyschiatrica Scandinavica, the authors evaluated the mortality and life expectancy rates in people diagnosed with AUD in Denmark, Finland and Sweden over a twenty year period (Westman et al, 2014). Within these countries, Sweden has the most restrictive alcohol policies, whilst Denmark has the least restrictive policies.
The study
The study used National HEALTH Registers to follow the entire adult population of Denmark, Finland and Sweden.


The authors used National HEALTH Registers to follow the entire population of the three countries aged over 15 (approximately 20 million people in total). They identified all people who had been admitted to HOSPITAL through AUD over a twenty-year observation period, between 1987 and 2006. Data about alcohol consumption per capita was collected from an international database. Each person was followed from the date of their hospital administration until death or the end of a 5 year follow up period.
The study population was stratified into 5 age groups (15-29, 30-44, 45-59, 60-74, >75 years) and frequency of mortality was calculated for each group. For analysis of time trends the 20 year observation period was split into four periods (1987-1991, 1992-1996, 1997-2001 and 2002-2006).
The main outcome measures were the standardised mortality rate per 100,000 person-years and life-expectancy.
The authors
The authors were primarily interested in links between alcohol use disorder, mortality and life expectancy.


During the entire study alcohol consumption per capita was lowest in Sweden and highest in Denmark. Small fluctuations in consumption were evident across the time periods. For example, in Finland alcohol consumption peaked during 2002-2006, coinciding with alcohol tax reductions.


Mortality was higher overall in Denmark, than Finland or Sweden. Standardized mortality increased over the twenty years in both men and woman in Denmark. In Finland and Sweden standardized mortality decreased in both men and women over time.
In all three countries, mortality rates in people with AUD were higher in younger age groups. People with AUD had higher mortality from all causes of death, including all diseases, medication conditions and suicide.

Life expectancy

Life expectancy was highest in Sweden and lowest in Denmark. In all three countries, life expectancy was longer in woman than men. Difference in life expectancy was calculated as the life expectancy in the general population minus life expectancy of people with AUD. In Denmark this was approximately 27.6 years; Finland 26.9 years; Sweden 24.9 years.
Over the 20 year period life expectancy differences increased in Men (Denmark, 1.8 years; Finland, 2.6 years; Sweden, 1.0 years). In women, life expectancies differences increased in Denmark (0.3 years), but decreased in Finland (0.8 years) and Sweden (1.8 years).
Denmark had the
Denmark had the highest alcohol consumption and the worst outcomes in terms of mortality and life expectancy.


Across three Nordic countries, individuals who are HOSPITALIZED with AUD have an average life expectancy of 47-53 years if male, and 50-58 years if female. The main finding of the study was the shorter life expectancy (~26.5 years) of individuals with AUD compared with the general population.
A particular strength of this study was the comparison of mortality and life expectancy across the whole population in the three Nordic countries. The authors used nationwide HEALTH registers to provide highly reliable population data.


  • The main limitations of this study include the use of only inpatient data for establishing AUD. This may have led to selection bias towards AUD patients with the most severe HEALTH problems.
  • Secondly, as the study was register-based there was no clinical data about treatment or adherence. In support of these points, it is thought only one in three individuals with dependence will ever seek treatment.
  • Finally, alcohol consumption per capita was determined through aggregate data rather than individual alcohol exposure.
The results of this study have clear clinical implications for policy and treatment. The authors suggest that hazardous alcohol consumers should be a specific TARGET for preventative measures, to ensure they do not develop AUDs. Furthermore, the somatic care of people with AUD should be substantially improved.
To conclude, Alcohol Use Disorder is a significant public HEALTH concern, which severely impacts mortality and life-expectancy.
The authors suggest that
The authors suggest that public HEALTHprevention programmes should focus on hazardous drinkers, to ensure that they do not develop Alcohol Use Disorders.


Key paper
Westman J, Wahlbeck K, Laursen TM, et al (2014). Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden. Acta Psychiatrica Scandinavica, doi: 10.1111/acps.12330.
Further reading
Cunningham JA, Breslin FC (2004). Only one in three people with alcohol abuse or dependence ever seek treatment. Addictive Behaviours, 29: 221-3.
Roerecke M, Rehm J (2013). Alcohol use disorders and mortality: a systematic review and meta-analysis. Addiction, 9: 1562-78.
Samohkvalov AV, Popova S, Room R, Ramonas M, Rehm J (2010). Disability associated with alcohol use and dependence. Alcohol: Clinical and Experimental Research, 34: 1871-8.

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