Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke. This study aimed to determine the absolute and relative survival and the independent baseline prognostic factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth, Western Australia. METHODS: Between February 1989 and August 1990, all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS: Three hundred seventy patients with first-ever stroke were registered, and 362 (98%) were followed up at 5 years, by which time 210 (58%) had died. In the first year after stroke the risk of death was 36.5% (95% CI, 31.5% to 41.4%), which was 10-fold (95% CI, 8.3% to 11.7%) higher than that expected among the general population of the same age and sex. The most common cause of death was the index stroke (64%). Between 1 and 5 years after stroke, the annual risk of death was approximately 10% per year, which was approximately 2-fold greater than expected, and the most common cause of death was cardiovascular disease (41%). The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent claudication (hazard ratio [HR], 1.9; 95% CI, 1.2 to 2.9), urinary incontinence (HR, 2.0; 95% CI, 1. 3 to 3.0), previous transient ischemic attack (HR, 2.4; 95% CI, 1.4 to 4.1), and prestroke Barthel Index <20/20 (HR, 2.0; 95% CI, 1.2 to 3.2). CONCLUSIONS: One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10% per year, which is twice the rate expected among the general population of the same age and sex. The most common cause of death is cardiovascular disease. Long-term survival after stroke may be improved by early, active, and sustained implementation of effective strategies for preventing subsequent cardiovascular events.

Epidemiology of liver cirrhosis morbidity and mortality in Western Australia, 1971-82: some preliminary findings.

Liver cirrhosis mortality and morbidity (primary and secondary diagnosis) data for Western Australian men and women over the age of 30 years for the period 1971-82 are presented. Correlations between the morbidity and mortality data and adult consumption of beer, wine, spirits and absolute alcohol are also reported. Possible reasons for the various significant correlations are discussed, and in particular, with respect to the increasing wine consumption of adults (greater than or equal to 15 years).

Rural psychiatric services in western Australia.

The literature pertinent to the delivery of psychiatric services to rural areas is briefly surveyed. Existing rural psychiatric services in Western Australia, the largest State in Australia and a vast sparsely populated area, are described. These services are currently only of a rudimentary nature. Lack of appropriate professional staff is the major factor inhibiting further development of the services. Possible alternative models for the future are described. Flexibility and diversity of services to meet local conditions and staff availability are advocated.

The relationship between distance from inpatient facilities and the rate of psychiatric admissions in Western Australia.

Western Australia is the largest and most sparsely populated state in Australia with all its specialised psychiatric inpatient facilities in Perth, the capital city. This study tested a number of hypotheses concerning the effect of distance from Perth, firstly, on total hospitalisation rates for psychiatric illness of the rural population and secondly, on the proportion who were hospitalized in Perth. High rates of alcoholism in males and of neuroses in females, together with local conditions in various rural centres, rather than distance from Perth, were major determining factors affecting both total hospitalisation and th proportion sent to Perth. The major exception was that the proportion of male alcoholics admitted to Perth hospitals decreased the further the patient lived from Perth. These findings were contrary to those reported in the literature. However the distances from Perth were much greater than those usually reported elsewhere. It was concluded that beyond a certain distance from psychiatric facilities, distance per se was not a major factor governing admissions to these facilities.

Comparison of suicide rates and methods in English, Scots and Irish migrants in Australia.

A comparison was made of the suicide rates and methods for the period 1962-1971 of migrants in Australia from England and Wales, Scotland and Ireland with those in their country of origin. Suicide rates for all three migrant groups were very similar to each other, although greater than in their country of origin especially those for Eire. The data suggest that the official lower rates in Scotland compared with England and Wales are due to ascertainment differences. Similar conclusions were drawn regarding the official rates in Eire. Several hypotheses were raised regarding the influence of religion on suicide rates in Eire, Northern Ireland and Australia.

Relationship between alcohol consumption and attempted suicide morbidity rates in Perth, Western Australia, 1968-1984.

Per adult (greater than or equal to 15 years) consumption of beer, wine, spirits, and absolute alcohol for a 17-year period (1968-1984) was related to the attempted suicide morbidity rates in the Perth urban area of Western Australia. For both males and females aged 15-39 years, Mann-Whitney U tests showed that during the years of highest spirits consumption, the highest rates for attempted suicide occurred. A similar finding also applied to 15-39-year-old males for wine. The effect of a rapidly rising blood alcohol level, together with a preselection factor as to the personal characteristics of persons who consumed the higher alcohol content drinks, may explain the results, which need to be confirmed by clinical studies of the type of alcoholic beverage consumed by persons prior to attempting suicide.

Changing patterns of suicide in Australia, 1910-1977.

Presented for the period 1910-1977 were the sex specific annual age standaradised suicide rates for Australia, together with age-sec specific rates and methods of suicide. During this time there was marked changes in male rates, the changes mainly occuring during four periods - 1910-19, 1925-40, 1940-49 and 1955-77. The changes in female rates were less marked and confined chiefly to 1955-77. There has been a drop in suicide rates since the mid 1960's in all age groups, except in males aged 15-29 years whose rate has steadily rise. Methods of suicide have changed considerably during the period 1910-77. There was no evidence found to sustain the hypothesis that elimination of a common suicide method resulted in a sustained lower overall suicide rate. Current theories of suicide causation were often found to be inadequate to explain many of the findings. It is suggested that we need to develop radically different approaches to the aetiology of suicide.

An appraisal of the NIMH Epidemiologic Catchment Area Program.

The Epidemiologic Catchment Area Program was a massive United States community survey of psychiatric illness, dwarfing all prior similar surveys. It has been described as a 'landmark in the development of American contributions to the psychiatric knowledge base'. The results pose a number of challenges to psychiatry. This paper briefly describes the program and appraises it, raising considerable doubts regarding the validity and usefulness of the Diagnostic Interview Schedule as a measuring instrument for the diagnosis of psychiatric illness, especially in the elderly; the use of lay interviewers to measure psychiatric illness; whether it is possible to measure lifetime prevalence of psychiatric illness; some of the reported prevalence rates, especially of phobia; the failure to include generalised anxiety among the 15 psychiatric diagnoses measured; and the failure to compare the results with those reported elsewhere in the literature.

Migrant suicide rates in Australia and in country of birth.

BACKGROUND: Various studies from Australia, Canada and the United States have shown significant rank correlations between the suicide rates of immigrants and those of their country of birth (COB). This study compares the rank ordering of age standardized suicide rates of immigrants in Australia for two periods, 1961-70 and 1979-90: (a) between each period; and (b) with their COB for each period. METHODS: Data were obtained from the World Health Organization Annual Statistics and from the Australian Bureau of Statistics. Comparisons were made for 11 countries from England and Wales, Ireland and Europe, for which there was a sufficiently large number of immigrant suicides to warrant statistical analysis. RESULTS: The data showed considerable heterogeneity in rates of immigrants from various countries, with increased rates in Australia compared with their COB. There were consistently significant Spearman rank correlations between the rates after immigration and those in their COB for each period, and between rates in the two periods for both immigrants and for their COB, despite increases in suicide rates, and considerable socio-economic demographic changes between the various countries over that time span. CONCLUSIONS: The findings are used to argue two conclusions: (i) the important influence of premigrant social and cultural experiences in subsequent suicide rates in immigrants in their host country; and (ii) to support the case for the reliability of using international suicide data for comparative epidemiological research.

Suicide in the multiethnic elderly population of Australia, 1979-1990.

Australia is a multiethnic society with 25% of its elderly population born outside the country. Rates and methods, gender, and country of birth are given for all suicides aged 65 and over in Australia during the 12-year period of 1979-1990. There was a marked heterogeneity in rates and methods of suicide among the various migrant groups. The data also showed that the suicide rates of migrants were mostly higher than in their country of origin. Migrants born in countries with high suicide rates generally had high rates in Australia, and vice versa. Possible reasons for this finding are discussed. Factors influencing rates and methods of suicide in elderly migrants appeared to have much in common with factors operating in migrants of all age groups.

Attempted suicide in the Perth Statistical Division 1971-1972.

A study of attempted suicides in the Perth Statistical Division for 1971-72 has been presented. The average annual rate was 8.5 per 10,000 for males and 20.3 for females. There had been a doubling in rate since 1961, the increase being greater for females than males. Age standardised rates were greater than the Australian born for immigrant males but not for females. There were marked differences in rates between different individual immigrant groups of each sex. Data presented showed a higher rate in aborigines compared with non-aborigines, but many reservations were made regarding the validity of the aboriginal rates.

Psychiatric units in general hospitals.

Psychiatric units in general hospitals will, increasingly, play a larger part in the delivery of psychiatric services to the community. Australian units are compared with those in England and Wales. It is very difficult to envisage the widespread adoption in Australia of large comprehensive district general hospital psychiatric units similar to those planned for Britain. A current challenge to existing psychiatric units in the large teaching hospitals in the capital cities of Australia is whether they will take on a catchment area responsibility, or remain independent of any plans for regionalization of psychiatric services.

The epidemiology of psychiatric illness in industrialised society.

There is no convincing evidence that the amount of formal psychiatric illness is any greater in industrialised than in non-industrialised societies, although the amount of social deviance probably is greater. It is seriously questioned whether modern industrialised society is any more stressful than any other type of society either current or in any earlier era. However, lack of comparable data between different societies and between different time periods presents major methodological problems in fully assessing these issues.

A survey of the distribution of psychiatrists in Australia and New Zealand in 1987.

A survey is described of the number and distribution of all psychiatrists and trainee psychiatrists in Australia and in New Zealand in 1987, with estimates of available psychiatrists over the next decade. Australia as a whole is not short of psychiatrists or of trainee psychiatrists, but has a marked maldistribution between States and between city and rural areas which needs to be seriously addressed. In 1987 the ratio of psychiatrists to population in Australia was 1:11 290 and in New Zealand 1:21 440. It is estimated that by 1997 the corresponding ratios will be 1:9 130 and 1:12 440. There were 549 trainee psychiatrists in Australia and 103 in New Zealand. Relativity of human resources needs are emphasised. Those Australian States with the highest ratio of psychiatrists to population also have the highest ratio of trainees to population, a fact which has obvious implications.

The changing pattern of suicide by gassing in Australia, 1910-1987: the role of natural gas and motor vehicles.

There have been large changes in the use of gas as a suicide method in Australia during this century, the most marked being the increased use of motor vehicle exhaust fumes, and the introduction of natural gas in the early 1960s. In males, use of motor vehicle exhaust fumes as a suicide method has substituted for use of domestic gas. It was concluded that in neither sex did the elimination of toxic carbon monoxide in domestic gas, with the introduction of natural gas, result in a lasting reduction of suicide rates. Attention is drawn to possible failed suicide attempts using motor vehicles with emission controls, resulting in serious cerebral damage.

The impact of criteria selection on prevalence rates.

In spite of major advances in the past 10 years in the development of standardized instruments for reliable psychiatric case detection, many selection factors can influence prevalence rates, impairing the compilation of comparable epidemiological data from different settings. This is especially so in the aged. Such factors include relatively small variations in the wording of questionnaires, the sophistication and training of interviewers, availability of an informant history, duration of symptoms and diagnostic hierarchies. Many different measuring instruments and diagnostic criteria are currently used to diagnose depressive illness in the elderly. It is not clear how these compare in estimating prevalence rates. There are no agreed reliable criteria for dementia, especially mild dementia: different criteria systems give widely differing prevalence rates. Gender, education and social class can influence the scores on some tests of cognition. More uniform generally accepted measures and criteria of major psychiatric syndromes in the elderly, must be developed if epidemiological approaches are to contribute to further major advances in our understanding of psychiatric syndromes in the aged.

Looking beyond the 1:10,000 ratio of psychiatrists to population.

The frequently quoted ratio of 1:10,000 psychiatrists to population originated in Canada in 1962 and was later adopted as the minimum by the American Psychiatric Association. Since then both Canada and the United States have found this ratio to be inadequate. Canada has since advocated an optimal target ratio of 1:6,500, but recommended a more attainable pragmatic ratio of 1:8,000 for the foreseeable future. The Royal Australian and New Zealand College of Psychiatrists' recently recommended range of 1:7,500 to 1:10,000 is applauded. Reasons are given why a reasonable upper limit to the ratio of psychiatrists to population is desirable.