Hospital-treated physical illnesses and mortality: An 11-year follow-up study of long-stay psychiatric patients

Causes of mortality in a large population-based cohort of psychiatric patients in Southern Europe

The World Health Organization considers excess morbidity and mortality among people with mental disorders as a high public health priority. This study aims to estimate the mortality risk and causes of death among a large population-based cohort of psychiatric patients. All residents in Veneto (Northeastern Italy) aged between 18 and 84 years with a contact with Community Mental Health Centers in 2008 and a psychiatric diagnosis (n = 54,350) were followed-up for 10 years. Standardized Mortality Ratios (SMR) and excess mortality were computed, with the general regional population as a reference. Mortality was more than doubled (males SMR = 2.4; females SMR = 2.2) and the relative increase in mortality was much larger in young and middle-aged adults (18-44 and 45-64 years) across all diagnostic groups. The most frequent causes were circulatory diseases (27%) and neoplasms (26%). Although the risk was increased by about tenfold, deaths from suicide were limited to 6% and 4% of all decedents in males and females, respectively. Patients with schizophrenia showed a very high risk for mortality for diabetes and cardiovascular disorders. A large excess was found also for respiratory diseases and a two-fold increase for lung cancer in males and breast cancer in females. Although chronic physical disorders are known to be the main causes of mortality in such patients, they receive far less attention than suicide or accidents. Our results suggest that there is still a need to plan actions to prevent excess mortality and to improve the quality of life of patients with mental disorders.

[Comorbid somatic illnesses in psychiatric inpatients - an analysis of administrative data]

PURPOSE

This study intended to analyze the prevalence of physical diagnoses at psychiatric inpatient hospital wards.

METHODS

For this purpose we used partially aggregated administrative data from routine diagnostic documentation of Austrian hospitals. All psychiatric and physical main and secondary diagnoses according to ICD-10 of all psychiatric inpatient units in Austria of the years 2007 were used.

RESULTS

Of 79,027 psychiatric hospital admissions 75,224 received a psychiatric and 3803 a somatic main diagnosis at discharge. Diseases of the vascular system (20 %) were the most frequent somatic diagnoses, followed by endocrine and metabolic diseases (16.4 %) and neurological diseases (14.4 %). Among patients suffering from schizophrenia, the most frequent physical diagnoses were endocrine and metabolic diseases. Among those with affective disorders, vascular diseases as well as endocrine and metabolic diseases were found most often.

CONCLUSIONS

Physical diagnoses are very common among psychiatric inpatients. Mass screening and specialized prevention programs should be evaluated regarding their effectiveness for this population.

Patterns in mortality among people with severe mental disorders across birth cohorts: a register-based study of Denmark and Finland in 1982-2006

Background

Mortality among patients with mental disorders is higher than in general population. By using national longitudinal registers, we studied mortality changes and excess mortality across birth cohorts among people with severe mental disorders in Denmark and Finland.

Methods

A cohort of all patients admitted with a psychiatric disorder in 1982–2006 was followed until death or 31 December 2006. Total mortality rates were calculated for five-year birth cohorts from 1918–1922 until 1983–1987 for people with mental disorder and compared to the mortality rates among the general population.

Results

Mortality among patients with severe mental disorders declined, but patients with mental disorders had a higher mortality than general population in all birth cohorts in both countries. We observed two exceptions to the declining mortality differences. First, the excess mortality stagnated among Finnish men born in 1963–1987, and remained five to six times higher than at ages 15–24 years in general. Second, the excess mortality stagnated for Danish and Finnish women born in 1933–1957, and remained six-fold in Denmark and Finland at ages 45–49 years and seven-fold in Denmark at ages 40–44 years compared to general population.

Conclusions

The mortality gap between people with severe mental disorders and the general population decreased, but there was no improvement for young Finnish men with mental disorders. The Finnish recession in the early 1990s may have adversely affected mortality of adolescent and young adult men with mental disorders. Among women born 1933–1957, the lack of improvement may reflect adverse effects of the era of extensive hospitalisation of people with mental disorders in both countries.

Gaps in health care for the somatic health of outpatients with severe mental illness

The physical health of outpatients with severe mental illness (SMI) can be improved by changes in the health-care system. Analysis of current practice is necessary to develop these strategies. We compared the number of somatic health problems of outpatients with SMI with the frequency of consulting a general practitioner (GP). This was a cross-sectional study based on interviews, and records from the GP and the pharmacy. We checked whether Dutch community pharmacies had complete and correct information about the patients' medication. We observed that all patients (n = 118) had somatic problems in need of clinical attention. Patients who visited their GP less than once a year (35%, n = 42), had a mean of 2.8 somatic health problems. This was less than patients who consulted their GP more than once a year (P ≤ 0.01). In 37% of cases, the pharmacy did not have adequate information on the drug use. Many patients with SMI seemed to have insufficient contact with their GP for their somatic health problems. Insufficient information about the patients' medication suggested that the pharmacist and GP should increase exchange of information. Mental health nurses can take a lead in coordinating the care to improve somatic health for their patients.

Genetic vulnerability and premature death in schizophrenia spectrum disorders: a 28-year follow-up of adoptees in the Finnish Adoptive Family Study of Schizophrenia

BACKGROUND

Excess mortality is widely reported among schizophrenia patients, but rarely examined in adoption study settings.

AIM

We investigated whether genetic background plays a role in the premature death of adoptees with schizophrenia.

METHODS

Mortality among 382 adoptees in the Finnish Adoptive Family Study of Schizophrenia was monitored from 1977 to 2005 through the national causes-of-death register. The sample covered 190 adoptees with a high genetic risk of schizophrenia (HR) and 192 with a low risk (LR).

RESULTS

Overall mortality among the adoptees did not differ between the HR and LR groups, as 10% and 9% respectively had died during the follow-up, at mean ages of 45 and 46 years. Schizophrenia spectrum disorder was the most significant predictor of premature death in both groups, with dysfunction in the rearing family environment associated with mortality, unnatural deaths and suicides in the HR but not in the LR group. All the suicides involved HR cases.

CONCLUSIONS

Mortality among the adoptees was not related to genetic factors but to environmental ones. The association of unnatural deaths and suicides with dysfunction in the rearing environment among the HR adoptees may indicate that they had a greater genetically determined vulnerability to environmental effects than their LR counterparts. The genetic and rearing environments can be disentangled in this setting because the biological parents give the offspring their genes and the adoptive parents give them their rearing environment. Our findings add to knowledge of the factors associated with the premature death of adoptees in mid-life.

Heart disease treatment and mortality in schizophrenia and bipolar disorder - changes in the Danish population between 1994 and 2006

Persons with schizophrenia and bipolar disorder have much higher heart disease mortality rates than the general population. The objective was to compare the general population with persons with schizophrenia, bipolar disorder or other psychiatric disorders in terms of rates of somatic hospitalization and invasive heart disease procedures, and in terms of heart disease mortality during the period 1994 to 2006. Survival analysis was used to analyze heart disease mortality and somatic care trends in a cohort of all persons residing in Denmark. During the study period, heart disease mortality rose significantly among persons with schizophrenia: compared with the general population, the rise in the mortality rate ratio equalled 1.12 (95% confidence interval (CI) 1.08-1.15) every second year. This was not the case for persons with bipolar disorder [1.02 (0.98-1.05), not significant] or other psychiatric disorders [1.00 (0.99-1.01), not significant]. The entire period saw a lower hospitalization rate and fewer invasive cardiac procedures among persons with schizophrenia than among the general population. The higher mortality (with increasing trends) from heart disease in persons with schizophrenia compared to the rest of the cohort members can be explained partly by low rates of invasive cardiac procedures. However, other reasons, such as antipsychotic-induced weight gain, primary prevention, and difficulty following smoking cessation advice could also be part of the explanation. The results call for a greater focus on improvement in somatic care and lifestyle factors for this group of patients.

Mortality in Kraepelinian schizophrenic patients: a prospective study with a median follow-up of 8.4 years

Kraepelinian schizophrenia is a subtype of schizophrenia defined by its very poor outcome. Several studies have demonstrated the validity of this distinction, but the expected excess mortality has not been investigated. The aim of the present study was to test the hypothesis that Kraepelinian schizophrenic subjects have a higher mortality rate, notably due to natural causes, than non-Kraepelinian schizophrenic subjects. The results of a prospective study with a median follow-up of 8.4 years are reported. Three hundred ten schizophrenic subjects meeting the International Classification of Diseases, 10th Revision, criteria for schizophrenia were classified on admission as Kraepelinian schizophrenia (n = 31) and non-Kraepelinian schizophrenia (n = 279); 31 deaths (16 from unnatural causes, 13 from natural causes, and 2 from undetermined causes) were observed during follow-up. Univariate and multivariate Cox regression analyses were performed using schizophrenia subtype (Kraepelinian vs non-Kraepelinian), age, and duration of illness as predictors. Schizophrenia subtype was a significant predictor of mortality in univariate analysis only for death from natural causes, and a trend was observed after adjusting for age and duration of illness. A log-rank test was used to compare mortality rates between Kraepelinian and non-Kraepelinian schizophrenic subjects and showed a significantly higher mortality rate from natural causes in Kraepelinian schizophrenia (16.7%) than in non-Kraepelinian schizophrenia (4.1%).

European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS): background, aims and methods

Background

People with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy as compared with the general population. However, there is a lack of knowledge across Europe concerning interventions that aim at reducing somatic morbidity and excess mortality by promoting behaviour-based and/or environment-based interventions.

Methods and design

HELPS is an interdisciplinary European network that aims at (i) gathering relevant knowledge on physical illness in people with mental illness, (ii) identifying health promotion initiatives in European countries that meet country-specific needs, and (iii) at identifying best practice across Europe. Criteria for best practice will include evidence on the efficacy of physical health interventions and of their effectiveness in routine care, cost implications and feasibility for adaptation and implementation of interventions across different settings in Europe. HELPS will develop and implement a "physical health promotion toolkit". The toolkit will provide information to empower residents and staff to identify the most relevant risk factors in their specific context and to select the most appropriate action out of a range of defined health promoting interventions. The key methods are (a) stakeholder analysis, (b) international literature reviews, (c) Delphi rounds with experts from participating centres, and (d) focus groups with staff and residents of mental health care facilities.

Meanwhile a multi-disciplinary network consisting of 15 European countries has been established and took up the work. As one main result of the project they expect that a widespread use of the HELPS toolkit could have a significant positive effect on the physical health status of residents of mental health and social care facilities, as well as to hold resonance for community dwelling people with mental health problems.

Discussion

A general strategy on health promotion for people with mental disorders must take into account behavioural, environmental and iatrogenic health risks. A European health promotion toolkit needs to consider heterogeneity of mental disorders, the multitude of physical health problems, health-relevant behaviour, health-related attitudes, health-relevant living conditions, and resource levels in mental health and social care facilities.

Comorbid mental and somatic disorders: an epidemiological perspective

PURPOSE OF REVIEW

The comorbidity of mental and somatic disorders is a complicated issue, especially concerning its epidemiological perspective. Complications are usually associated with the research approach, the etiological coherence of co-occurrence, and the obscurity or absence of diagnostic criteria for mental disorders due to a general medical condition or drugs, age, etc. This review aims to investigate contemporary epidemiological data on mental and somatic comorbidity.

RECENT FINDINGS

The frequent co-occurrence of certain physical diseases and certain mental disorders is corroborated by contemporary epidemiological data. Cardiovascular disease, hypertension, respiratory disorders, diabetes mellitus and other metabolic disorders seem to be associated with mental disorders; the rates of occurrence, however, depend on the special characteristics of the sample. Utilization of healthcare systems and costs for patients with mental-somatic comorbidities are suggested to be higher than those for patients without comorbidities.

SUMMARY

Although it is generally accepted that many physical conditions have been associated with serious mental disorders, the exact nature of the relationship between them is still unclear. Various factors such as unhealthy lifestyle habits, psychotropic medication, and inadequate medical treatment or provision are implicated. Further research is required.