Excess mortality of psychiatric inpatients in Taiwan

Excess Mortality and Life-Years Lost in People With Schizophrenia and Other Non-affective Psychoses: An 11-Year Population-Based Cohort Study

Psychotic disorders are associated with premature mortality, but research was primarily based on Western countries and rarely examined non-affective psychoses other than schizophrenia (ONAP). This population-based cohort study investigated excess mortality in 46 896 schizophrenia and 20 651 ONAP patients between January 2006 and December 2016 in Hong Kong (HK), by estimating all-cause and cause-specific standardized mortality ratios (SMRs), and life-years lost (LYLs), a recently developed, more precise reduced life expectancy measure taking into account the illness onset (age at first-recorded diagnosis). Changes in mortality metrics over the study period were assessed. Study data were retrieved from a territory-wide medical-record database of public healthcare services to 7.5 million HK residents. Results showed that schizophrenia and ONAP patients had higher all-cause (schizophrenia: SMR: 2.49 [95% CI: 2.43-2.55]; ONAP: 2.00 [1.92-2.09]), natural-cause (1.80 [1.74-1.85]; 1.47 [1.40-1.54]), and unnatural-cause (6.97 [6.47-7.49]; 8.53 [7.61-9.52]) mortality rates than general population. Respiratory diseases, cardiovascular diseases, and cancers accounted for the majority of deaths in patient cohorts. Men and women with schizophrenia had 9.53 years and 8.07 years of excess LYLs, respectively. For ONAP, excess LYLs was 8.18 years for men and 5.44 years for women. The overall mortality gap remained similar for both patient groups over time despite their improved longevity and declined unnatural-cause mortality rates. Taken together, schizophrenia and ONAP are associated with increased premature mortality and substantially reduced lifespan in a predominantly Chinese population, with excess deaths mainly attributed to a natural cause. Persistent mortality gap highlights an urgent need for targeted interventions to improve the physical health of patients with psychotic disorders.

Increased mortality among people with schizophrenia and other non-affective psychotic disorders in the community: A systematic review and meta-analysis

INTRODUCTION

There is increasing evidence of excess mortality in schizophrenia but less information on other non-affective psychoses. We therefore generated standardised mortality ratios (SMRs) for community-dwelling people with schizophrenia and other non-affective psychoses, relative to the general population, and examined changes to the SMR over time.

METHODS

We conducted a systematic review in which Pubmed, CINAHL, EMBASE, Google Scholar and PsycINFO were searched for publications that reported SMRs for all-cause mortality among community-dwelling people with schizophrenia and psychotic disorders. Meta-analyses of SMRs were conducted, pooled across genders and then separately by gender. Sub-group analyses were conducted for diagnostic group, global region, decade and risk of study bias.

RESULTS

We were able to include 34 studies covering 1,724,906 participants. The gender pooled SMR for schizophrenia and psychotic disorders was 3.08 (95%CI 2.88-3.31). Schizophrenia and broader psychotic disorders had similar SMRs. Stratification by decade of observation suggests that the difference in SMR is not declining and may possibly be widening. Analyses showed high levels of heterogeneity.

CONCLUSIONS

The appearance of a static or widening mortality gap over time between people with schizophrenia and psychotic disorders and the general population is of concern. However, whether it is an increase over time is unclear, as there are insufficient studies to confirm this.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis

Importance

High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.

Objectives

To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.

Data Sources

English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.

Study Selection

Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.

Data Extraction and Synthesis

The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.

Main Outcomes and Measures

The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.

Results

A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.

Conclusions and Relevance

The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

Mortality among patients with schizophrenia and vocational rehabilitation program services under Taiwan's psychiatric care reform

Background

Vocational rehabilitation programs are implemented to enhance the occupational functioning of long-stay patients with schizophrenia. Unemployment is associated with a higher risk of death. Schizophrenia patients who participate in vocational rehabilitation programs may have better health outcomes with participation in employment.

Aim

To evaluate the relationship between mortality among schizophrenia patients and vocational rehabilitation program services under Taiwan’s psychiatric care reform.

Methods

A total of 2457 long-stay schizophrenia patients were followed-up retrospectively from 1998 to 2008 at Taipei Veterans General Hospital Yuli Branch in Taiwan. We collected data on annual measurements of effectiveness and the human resources utilized in the vocational rehabilitation program. Pearson’s correlations between the above-collected data and the crude death rates for all patients were examined. We also assessed the association between participation in supported or sheltered employment and death.

Results

Most of the patients were male (81.3 %). The mean ± SD age of the patients was 57.8 ± 17.0 years. The annual crude death rate averaged 5.3 %. Both the number of community workplaces and the total wages earned from sheltered and supported employment had significantly negative linear correlations with the crude death rate among all patients (both γ ≤ −0.64, p < 0.05). After controlling the confounding factors, participation in supported or sheltered employment was significantly associated with a lower risk of death (n = 2174, HR = 0.22, 95 % CI 0.16–0.29).

Conclusions

Under psychiatric care reform, the vocational rehabilitation program was more effective and there was less patient mortality. Patients who had experienced sheltered or supported employment had a lower risk of death than those who had not.

Estimation of life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for schizophrenia in Taiwan

By employing a novel semi-parametric extrapolation method, the life expectancies after the first hospitalization for schizophrenia and the associated lifetime healthcare expenditures were both estimated. Based on the linkage between the National Health Insurance Research Database and the National Mortality Registry of Taiwan, we have established a schizophrenic cohort for 2000-2010 and followed up to 2011. Survival function was estimated through Kaplan-Meier's method and extrapolated throughout life. We applied a simple linear regression to the logit-transformed survival ratio between the schizophrenic cohort and the sex-, age-matched referents via Monte Carlo simulation from the national life table. The monthly survival probability was multiplied by the average healthcare expenditures and summed throughout life to estimate the lifelong cost reimbursed by the National Health Insurance. The results showed that patients diagnosed at age 20-29 had the highest expected years of life lost (EYLL), 15 and 9years, in men and women, respectively, with corresponding lifetime healthcare expenditures of USD 48,000 and 53,000. Males generally had higher health cost per life-year than their female counterparts across their lifespan. We applied the same method to the first 6years of the cohort and extrapolated to 12years, which showed that the relative biases for different age strata were less than 5%. We thus concluded that the semi-parametric extrapolation method might provide a timely estimation of lifetime outcomes for health care planning of schizophrenia.

Mortality among inpatients of a psychiatric hospital: Indian perspective

OBJECTIVE

The objective of this study is to assess mortality and its correlates among psychiatric inpatients of a tertiary care neuropsychiatric hospital. Given the background that such a study has never been undertaken in India, the findings would have a large bearing on policy making from a mental health-care perspective.

MATERIALS AND METHODS

The medical records of those psychiatric inpatients (n = 333) who died during their stay at the National Institute of Mental Health and Neurosciences in past 26 years (January 1983 to December 2008) constituted the study population.

RESULTS

During the 26 years, there were a total of 103,252 psychiatric in-patient admissions, out of which 333 people died during their inpatient stay. Majority (n = 135, 44.6%) of the mortality was seen in the age group of 21-40 years. Most of the subjects were males (n = 202, 67%), married (n = 172, 56.8%) and from urban areas (n = 191, 63%). About, 54% of the subjects had short inpatient stay (<5 days, median for the sample). In 118 (39%) of the subjects, there was a history of physical illness. Leading cause of death were cardiovascular system disorders (n = 132, 43.6%), followed by respiratory system disorders (n = 45, 14.9%), nervous system disorders (n = 30, 9.9%) and infections (n = 31, 10.1%). In 21 (7%), cause of death was suicide.

CONCLUSIONS

Identifying the factors associated with the death of inpatients is of utmost importance in assessing the care in a neuropsychiatric hospital and in formulating better treatment plan and policy in mental health. The discussion focuses on the analysis of different factors associated with inpatient mortality.

Mortality among long-stay patients with schizophrenia during the setting-up of community facilities under the Yuli model

Objective: Over the past 15 years, Yuli Veterans Hospital (YVH) in Taiwan has developed the Yuli model to reform long-stay care for psychiatric patients. The development of the Yuli model could be divided into pre-early (1998–1999), early (2000–2006) and late (2007–2008) periods according to the setting-up of the community facilities. In the pre-early period, a vocational rehabilitation program was established for psychiatric patients in YVH. In the later periods, the independent living skills training and the program for social reintegration were instituted in the community facilities. This study aimed to evaluate mortality among the long-stay patients with schizophrenia during the three periods. Methods: In all, 2457 patients with schizophrenia who had been hospitalized for at least one year initially were retrospectively followed from 1 January 1998 to 31 December 2008. Compared with the general population in Taiwan, we calculated the age- and sex-specific standardized mortality ratios (SMRs) of those patients by cause of death during the three periods. Results: Most of the patients were male (81.3%). The mean ± SD age of the patients was 57.83 ± 16.95 years. The all-, natural- and unnatural-cause mortalities of the patients were nearly two times greater than those of the general population during the whole study period. Compared with those in the pre-early and early periods, all patients in the late period had the lowest mortality gaps. In the pre-early, early and late periods, the all-cause SMR were 5.40 (95% confidence interval (CI) = 4.27–6.81), 2.90 (95% CI = 2.20–3.79) and 1.17 (95% CI = 0.54–2.22), respectively, for the 50–69-year-old male patients. Nearly half of all the patients who participated the whole comprehensive rehabilitation program belonged to this sex and age group (N = 156, 46.6%). Conclusions: With the setting-up of community facilities for the comprehensive rehabilitation program, the mortality gaps among the 50–69-year-old male patients apparently decreased using the Yuli model.

Five-year mortality in a cohort of people with schizophrenia in Ethiopia

BACKGROUND

Schizophrenia is associated with a two to three fold excess mortality. Both natural and unnatural causes were reported. However, there is dearth of evidence from low and middle income (LAMIC) countries, particularly in Africa. To our knowledge this is the first community based report from Africa.

METHODS

We followed a cohort of 307 (82.1% males) patients with schizophrenia for five years in Butajira, rural Ethiopia. Mortality was recorded using broad rating schedule as well as verbal autopsy. Standardized Mortality Ratio (SMR) was calculated using the mortality in the demographic and surveillance site as a reference.

RESULT

Thirty eight (12.4%) patients, 34 men (11.1%) and 4 women (1.3%), died during the five-year follow up period. The mean age (SD) of the deceased for both sexes was 35 (7.35). The difference was not statistically significant (p = 0.69). It was 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87). Rural residents had lower mortality with adjusted hazard ratio (HR) of 0.30 (95% CI = 0.12-0.69) but insidious onset and antipsychotic treatment for less than 50% of the follow up period were associated with higher mortality, adjusted HR 2.37 (95% CI = 1.04-5. 41) and 2.66(1.054-6.72) respectively.

CONCLUSION

The alarmingly high mortality observed in this patient population is of major concern. Most patients died from potentially treatable conditions. Improving medical and psychiatric care as well as provision of basic needs is recommended.

Mortality among psychiatric patients in Taiwan--results from a universal National Health Insurance programme

This study investigated 6-year follow-up mortality rates and cause of death for persons younger than 45 years old with a history of hospitalisation for major psychiatric disorders after the introduction of the National Health Insurance (NHI). Linkage data combining death certificates with Taiwan NHI research claims data were used. The study cohort was comprised all patients under the age of 45 years, who had been hospitalised for major psychiatric disorders in 1998. Patients aged <45 years undergoing an appendectomy were selected as a control group. Cox proportional hazard regressions were performed to compute the adjusted 6-year hazard ratios. For patients with schizophrenia, major depression, or bipolar disorder, the adjusted risks of dying during the follow-up period were significantly 4.614, 3.707 and 3.866, respectively, times higher than that for appendectomy patients. The adjusted hazard ratios of non-natural dying during the follow-up period were significantly 16.316, 14.626 and 8.481 times for female patients with schizophrenia, major depression, and bipolar disorder, respectively, as high as for female appendectomy patients. The continuing excess mortality among psychiatric patients, from both natural and unnatural causes, still remains even after implementation of a NHI.

Quality of life of mental health consumers in Hong Kong: Analysis of service perceptions

OBJECTIVES

Successful psychiatric rehabilitation entails fostering overall quality of life of individuals recovering from severe mental illnesses. Understanding how service-related perceptions may be related to quality of life can be useful in improving the effectiveness of community-based care. This study investigated the quality of life of mental health consumers using a service-oriented paradigm.

METHODS

162 mental health consumers from community-based psychiatric rehabilitation centers were interviewed. Analyses were conducted to investigate the relationships between service perceptions (perceived treatment coercion, rehabilitation needs, and continuity of care) and quality of life.

RESULTS

Physical health quality was negatively related to rehabilitation needs. Mental health quality was negatively related to both rehabilitation needs and poorer continuity of service. Life satisfaction was negatively related to poorer continuity of service and higher perceived treatment coercion.

CONCLUSIONS

This study highlighted the significance of service perceptions in the well-being of individuals with severe mental illness.

Mortalidade em pacientes psiquiátricos: revisão bibliográfica

OBJETIVO: Avaliar as informações referentes às taxas de mortalidade em pacientes psiquiátricos publicadas na literatura científica. MÉTODOS: Nesta revisão bibliográfica (bases de dados, sites e periódicos especializados) foram selecionados estudos descritivos e interpretativos que avaliaram as seguintes dimensões: caracterização sociodemográfica, co-morbidades clínicas, tempo de tratamento e diagnósticos relacionados à mortalidade psiquiátrica. As bases de dados avaliadas foram Medline, SciELO e LILACS. RESULTADOS: Os estudos selecionados sobre o tema sugerem que indivíduos com transtornos mentais maiores têm menor tempo de sobrevida em relação à população geral, e há diferenças significativas de mortalidade entre pacientes institucionalizados e aqueles que freqüentam serviços extra-hospitalares. A política de desinstitucionalização do paciente psiquiátrico, que se iniciou no último século, tem causado redução dos leitos psiquiátricos em todos os países; seus efeitos para a saúde geral dos doentes mentais ainda não estão muito claros e necessitam de mais investigações. CONCLUSÃO: É necessária a implantação de intervenções preventivas e terapêuticas que visem à saúde geral dos pacientes psiquiátricos em todos os níveis de assistência de saúde mental.