Familial risk of early suicide: variations by age and sex of children and parents.

To determine familial risk of early suicide, data on cause of death of all Dutch residents aged 20-55 years who died between 1995 and 2001 were linked to data of their parents. Men whose father died by suicide had a higher odds of suicide themselves, relative to men whose father died of other causes (Odds Ratio (OR): 2.5; 95% confidence interval: 1.8-3.6). This effect was slightly stronger in the case of mother's suicide (OR: 3.4; 2.3-5.0). The same effect was observed for women, for suicide by father (OR: 2.2; 1.3-3.7) and mother (OR: 4.6; 2.6-8.0). The odds of suicide increased with decreasing age at death of parent. Parental suicide is predictive for offspring suicide. Our data suggest that the predictive value is higher in case the mother died by suicide, particularly if the mother died by suicide at a young age.

The diversity in associations between community social capital and health per health outcome, population group and location studied.

BACKGROUND: Literature on the effect of community social capital on health is inconsistent and could be related to differences in social capital measures, health outcomes, population groups and locations studied. Therefore this study examines the diversity in associations between community social capital and health by investigating different diseases, populations groups and locations. METHODS: Mortality records and individual data on sex, age, marital status, ethnic origin and place of residence were available for 6 years (1995-2000). Neighbourhood data, i.e. community social capital, socio-economic level and urbanicity, were linked through postcode information. Community social capital was indicated by measures of community interaction, belongingness, satisfaction and involvement. Variations in all-cause and cause-specific mortality across low and high social capital neighbourhoods were estimated through Poisson regression. In addition, analyses were stratified according to population group and to urbanization level. RESULTS: In the total population, community social capital was not related to all-cause mortality (RR = 1.00; CI: 0.99-1.01). However, residents of high social capital neighbourhoods had lower mortality risks for cancer [especially lung cancer (RR = 0.92; CI: 0.89-0.96)] and for suicide (RR = 0.90; CI: 0.83-0.98). Slightly lower mortality risks were also found for men (RR = 0.98; CI: 0.97-0.99), married individuals (RR = 0.96; CI: 0.94-0.97) and for residents living in socially strong neighbourhoods located in large cities (RR = 0.95; CI: 0.91-0.99). CONCLUSIONS: The association between community social capital and health differs per health outcome, study population and location studied. This underlines the need to take such diversity into account when aiming to conceptualize the relation between community social capital and health.

Estimating the total mortality among problem drug users.

This paper's objective is to develop a method to estimate the total mortality among problem drug users. The total mortality is given by a base rate of mortality not related to drugs and the deaths that are directly and indirectly related to drugs. A fatal poisoning by drugs (overdose) is directly related to drugs, whereas a casualty due to a drug-related disease or a drug-related accident is indirectly related to drugs. As an example of a method to estimate the total mortality, the results from a cohort study among methadone patients in Amsterdam were projected on the whole population of problem drug users in The Netherlands. Due to differences between the problem drug users in Amsterdam and the rest of the country, adjustments were required. It was found that an initial estimation did not require adjustment for injection behavior and gender but did require adjustment for age and the percentage of HIV infection. In a first unadjusted estimation, the total number of deaths among problem drug users in The Netherlands in 2001 was estimated at 606 deaths. After adjustment for age, the estimated mortality decreased to 573 deaths, and after adjustment for HIV infection, this estimation again decreased to 479 deaths. From the ultimately estimated mortality, 11% was considered to be not related to drugs, 23% was attributed directly to drugs, and 66% was attributed indirectly to drugs. The number of direct deaths, as estimated by this method, falls in the same order of magnitude as the number extracted from the Causes of Death Statistics, when selecting cases according to the Drug-Related Deaths Standard as established by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Further cross-validation with other measures will be needed to assess the accuracy of the method, the limitations of which are discussed with respect to stipulating directions for future research.

End-of-life practices in the Netherlands under the Euthanasia Act.

BACKGROUND: In 2002, an act regulating the ending of life by a physician at the request of a patient with unbearable suffering came into effect in the Netherlands. In 2005, we performed a follow-up study of euthanasia, physician-assisted suicide, and other end-of-life practices. METHODS: We mailed questionnaires to physicians attending 6860 deaths that were identified from death certificates. The response rate was 77.8%. RESULTS: In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia and 0.1% were the result of physician-assisted suicide. These percentages were significantly lower than those in 2001, when 2.6% of all deaths resulted from euthanasia and 0.2% from assisted suicide. Of all deaths, 0.4% were the result of the ending of life without an explicit request by the patient. Continuous deep sedation was used in conjunction with possible hastening of death in 7.1% of all deaths in 2005, significantly increased from 5.6% in 2001. In 73.9% of all cases of euthanasia or assisted suicide in 2005, life was ended with the use of neuromuscular relaxants or barbiturates; opioids were used in 16.2% of cases. In 2005, 80.2% of all cases of euthanasia or assisted suicide were reported. Physicians were most likely to report their end-of-life practices if they considered them to be an act of euthanasia or assisted suicide, which was rarely true when opioids were used. CONCLUSIONS: The Dutch Euthanasia Act was followed by a modest decrease in the rates of euthanasia and physician-assisted suicide. The decrease may have resulted from the increased application of other end-of-life care interventions, such as palliative sedation.

The effect of age at immigration and generational status of the mother on infant mortality in ethnic minority populations in The Netherlands.

BACKGROUND: Migrant populations consist of migrants with differences in generational status and length of residence. Several studies suggest that health outcomes differ by generational status and duration of residence. We examined the association of generational status and age at immigration of the mother with infant mortality in migrant populations in The Netherlands. METHODS: Data from Statistics Netherlands were obtained from 1995 through 2000 for infants of mothers with Dutch, Turkish and Surinamese ethnicity. Mothers were categorized by generational status (Dutch-born and foreign-born) and by age at immigration (0-16 and >16 years). The associations of generational status and age at immigration of the mother with total and cause-specific infant mortality were examined. RESULTS: The infant mortality rate in Turkish mothers rose with lower age at immigration (from 5.5 to 6.4 per 1000) and was highest for Dutch-born Turkish mothers (6.8 per 1000). Infant death from perinatal and congenital causes increased with lower age at immigration and was highest in the Dutch-born Turkish women. In contrast, in Surinamese mothers infant mortality declined with lower age at immigration (from 8.0 to 6.3 per 1000) and was lowest for Dutch-born Surinamese mothers (5.5 per 1000). Generational status and lower age at immigration of Surinamese women were associated with declining mortality of congenital causes. CONCLUSIONS: Total and cause-specific infant mortality seem to differ according to generational status and age at immigration of the mother. The direction of these trends however differs between ethnic populations. This may be related to acculturation and selective migration.

Ethnic differences in total and cause-specific infant mortality in The Netherlands.

We examined ethnic differences in infant mortality and the contribution of several explanatory variables. Data of Statistics Netherlands from 1995 to 2000 were studied (1,178,949 live borns). Proportional hazard analysis was used to show ethnic differences in total and cause-specific infant mortality. Obstetric, demographic and -geographical variables, and socio-economic status were considered as possible determinants. The four major ethnic minority groups showed an elevated risk of infant mortality, ranging from 1.28 in Turkish infants to 1.50 in Antillean/Aruban infants. In the early neonatal period, risks were elevated for Surinamese (hazard ratio [HR] 1.48, 95% confidence intervals [CI] 1.23, 1.78) and Antilleans/Arubans (HR 1.43, 95% CI 1.06, 1.92). In the post-neonatal period, risks were only elevated for Turkish (HR 2.20, 95% CI 1.80, 2.69) and Moroccan infants (HR 2.06, 95% CI 1.67, 2.55). Surinamese and Antillean/Aruban infants had an elevated risk of dying from perinatal causes (HR 1.62, 95% CI 1.33, 1.98 and 1.69, 95% CI 1.24, 2.29 respectively), Turkish and Moroccan infants had an elevated risk of dying from congenital anomalies (HR 1.42, 95% CI 1.16, 1.73 and 1.46, 95% CI 1.20, 1.79 respectively). Inequalities as a result of socio-economic position and demographic factors, such as marital status and maternal age, partially explain the ethnic differences in infant mortality. We conclude that ethnic minority groups in The Netherlands have a higher infant mortality than the native population, which in part seems preventable by reducing inequalities in socio-economic status. Marital status and age of the mother are important other risk factors of infant mortality.

Medical end-of-life decisions made for neonates and infants in the Netherlands, 1995-2001.

End-of-life decision-making for severely affected infants might be influenced by technical advances and societal debates. In 2001, we assessed the proportion of deaths of infants younger than 1 year that were preceded by end-of-life decisions, by replicating a questionnaire study from 1995. This proportion increased from 62% to 68% (weighted percentages), but the difference was not significant. Most of these decisions were to forgo life-sustaining treatment. Decisions to actively end the lives of infants not dependent on life-sustaining treatment remained stable at 1%. The practice of end-of-life decision-making in neonatology of 2001 has changed little since 1995.

Effects of socio-economic status on mortality: separating the nearby from the farther away.

Socio-economic status effects on total and cause-specific mortality are studied using data on all 15.8 million inhabitants of the Netherlands in 1999. Two problems are addressed that often hamper this kind of research: the lack of reliable social status information at the individual level and the intermingling of individual and neighbourhood status effects. The first problem is dealt with by using socio-economic status information of the very close environment of the detailed postcode areas (average 41 inhabitants) in which one is living and the second one by combining this information with such area information at the much larger level of neighbourhoods (1500 inhabitants) or boroughs (6600 inhabitants). Clear and independent effects of socio-economic status at all three levels of aggregation are found on total mortality and for a majority of causes of death. In almost all cases, the effects are to the disadvantage of people living in the lowest status areas. The effects are generally strongest at the detailed postcode level and weakest at the borough level, suggesting greater importance of factors at the nearby or individual level than at the farther away level(s).

Ethnic inequalities in age- and cause-specific mortality in The Netherlands.

BACKGROUND: By describing ethnic differences in age- and cause-specific mortality in The Netherlands we aim to identify factors that determine whether ethnic minority groups have higher or lower mortality than the native population of the host country. METHODS: We used data for 1995-2000 from the municipal population registers and cause of death registry. All inhabitants of The Netherlands were included in the study. The mortality of people who themselves or whose parent(s) were born in Turkey, Morocco, Surinam, or the Dutch Antilles/Aruba was compared with that of the native Dutch population. Mortality differences were estimated by Poisson regression analyses and by directly standardized mortality rates. RESULTS: Compared with native Dutch men, mortality was higher among Turkish (relative risk [RR] = 1.21, 95% CI: 1.16, 1.26), Surinamese (RR = 1.24, 95% CI: 1.19, 1.29), and Antillean/Aruban (RR = 1.25, 95% CI: 1.15, 1.36) males, and lower among Moroccan males (RR = 0.85, 95% CI: 0.81, 0.90). Among females, inequalities in mortality were small. In general, mortality differences were influenced by socio-economic and marital status. Most minority groups had a high mortality at young ages and low mortality at older ages, a high mortality from ill-defined conditions (which is related to mortality abroad) and external causes, and a low mortality from neoplasms. Cardiovascular disease mortality was low among Moroccan males (RR = 0.51, 95% CI: 0.44, 0.59) and high among Surinamese males (RR = 1.13, 95% CI: 1.05, 1.21) and females (RR = 1.14, 95% CI: 1.06, 1.23). Homicide mortality was elevated in all groups. CONCLUSION: Socio-economic factors and marital status were important determinants of ethnic inequalities in mortality in The Netherlands. Mortality from cardiovascular diseases, homicide, and mortality abroad were of particular importance for shifting the balance from high towards low all-cause mortality.

Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001.

Empirical data on the rate of euthanasia, physician-assisted suicide, and other end-of-life decisions have greatly contributed to the debate about the role of such practices in modern health care. In the Netherlands, the continuing debate about whether and when physician-assisted dying is acceptable seems to be resulting in a gradual stabilisation of end-of-life practices. We replicated interview and death-certificate studies done in 1990 and 1995 to investigate whether end-of-life practices had altered between 1995 and 2001. Since 1995, the demand for physician-assisted death has not risen among patients and physicians, who seem to have become somewhat more reluctant in their attitude towards this practice.