Mortality in mental health patients of the Emilia-Romagna region of Italy: A registry-based study

Mortality in people with mental disorders in Poland during the COVID-19 pandemic: a nationwide, register-based cohort study

PURPOSE OF REVIEW

People with mental disorders in Poland have increased standardized mortality ratios (SMRs). This is the first study to assess all-cause mortality in people with mental disorders in Poland during the COVID-19 pandemic.

RECENT FINDINGS

A nationwide, register-based cohort study utilizing data from the registry of healthcare services (2011-2020) and the all-cause death registry (2021) in Poland was conducted. Individuals who were consulted or hospitalized in public mental healthcare facilities and received at least one diagnosis of mental disorders (ICD-10) from 2011 to 2020 were identified. SMRs were compared between people with a history of mental disorder and the general population. SMRs for the pandemic period were also compared with prepandemic SMRs calculated for 2019.No significant differences in SMRs were observed overall between 2021 and 2019. A minor increase in SMR was observed in 2021 for people treated only in outpatient mental health clinics. In 2021, a significant decrease in SMRs was shown for individuals with diagnoses from groups F10-F19 and F20-F29, and a significant increase in SMRs was observed for those with diagnoses from group F40-F48.

SUMMARY

SMRs for people with any mental disorder in Poland in 2021 remained at comparable levels to those in 2019.

Effects of antipsychotic treatment on cardio-cerebrovascular related mortality in schizophrenia: A subanalysis of a systematic review and meta-analysis with meta-regression of moderators

To further explore the role of different antipsychotic treatments for cardio-cerebrovascular mortality, we performed several subgroup, sensitivity and meta-regression analyses based on a large previous meta-analysis focusing on cohort studies assessing mortality relative risk (RR) for cardio-cerebrovascular disorders in people with schizophrenia, comparing antipsychotic treatment versus no antipsychotic. Quality assessment through the Newcastle-Ottawa Scale (NOS) and publication bias was measured. We meta-analyzed 53 different studies (schizophrenia patients: n = 2,513,359; controls: n = 360,504,484) to highlight the differential effects of antipsychotic treatment regimens on cardio-cerebrovascular-related mortality in incident and prevalent samples of patients with schizophrenia. We found first generation antipsychotics (FGA) to be associated with higher mortality in incident samples of schizophrenia (oral FGA [RR=2.20, 95 %CI=1.29-3.77, k = 1] and any FGA [RR=1.70, 95 %CI=1.20-2.41, k = 1]). Conversely, second generation antipsychotics (SGAs) and clozapine were associated with reduced cardio-cerebrovascular-related mortality, in prevalent samples of schizophrenia. Subgroup analyses with NOS score ≥7 (higher quality) demonstrated a significantly increased cardio-cerebrovascular disorder-related mortality, among those exposed to FGAs vs SGAs. Meta-regression analyses demonstrated a larger association between antipsychotics and decreased risk of mortality with longer follow-up, recent study year, and higher number of adjustment variables. Overall, this subanalysis of a systematic review contributes to the evolving understanding of the complex role of antipsychotic treatment for cardio-cerebrovascular mortality in schizophrenia, paving the way for more targeted interventions and improved patient outcomes.

Mortality Risk Among Women With Premenstrual Disorders in Sweden

Importance

Premenstrual disorders (PMDs) adversely affect the quality of life of millions of women worldwide, yet research on the long-term consequences of PMDs is limited, and the risk of mortality has not been explored.

Objective

To estimate the associations of PMDs with overall and cause-specific mortality.

Design, Setting, and Participants

This nationwide, population-based, matched cohort study used data from population and health registers in Sweden. Participants included women of reproductive age with a first diagnosis of PMDs between January 1, 2001, and December 31, 2018. Data analysis was performed from September 2022 to April 2023.

Exposures

PMDs were identified through inpatient and outpatient diagnoses and drug dispensing.

Main Outcomes and Measures

Dates of death and underlying causes were ascertained from the National Cause of Death Register. Conditional Cox regression was used to estimate the hazard ratios (HRs) of overall and cause-specific death (eg, death due to natural or nonnatural cause, suicide, or cardiovascular events), adjusting for age, socioeconomic status, and somatic and psychiatric comorbidities; in a separate sibling comparison, models were also adjusted for all factors that sisters share.

Results

A total of 67 748 women with clinically diagnosed PMDs and 338 740 matched unaffected women were included, for a total of 406 488 women. Women with PMDs received a diagnosis at a mean (SD) age of 35.8 (8.2) years. During a mean (SD) follow-up of 6.2 (4.6) years (range, 1-18 years), 367 deaths were observed among women with PMDs (rate, 8.4 deaths per 10 000 person-years; 95% CI, 7.6-9.3 deaths per 10 000 person-years), and 1958 deaths were observed among women without PMDs (rate, 9.1 deaths per 10 000 person-years; 95% CI, 8.7-9.6 deaths per 10 000 person-years). Compared with unaffected women, women with PMDs had increased risk of death due to nonnatural causes (HR, 1.59; 95% CI, 1.25-2.04), particularly suicide (HR, 1.92; 95% CI, 1.43-2.60), but they did not have increased risk of overall mortality (adjusted HR, 0.91; 95% CI, 0.82-1.02). Notably, women who received a diagnosis before the age of 25 years experienced higher all-cause mortality (HR, 2.51; 95% CI, 1.42-4.42) and death from both suicide (HR, 3.84; 95% CI, 1.18-12.45) and natural causes (HR, 2.59; 95% CI, 1.21-5.54).

Conclusions and Relevance

The findings of this matched cohort study suggest that women with PMDs are not at increased risk of early death overall. However, the risk was elevated among young women and for death by suicide. This supports the importance of careful follow-up for young patients and highlights the need to develop suicide prevention strategies for all women with PMDs.

Severe depression and all-cause and cause-specific mortality in Scotland: 20 year national cohort study

BACKGROUND

Understanding cause of death in people with depression could inform approaches to reducing premature mortality.

AIM

To describe all-cause and cause-specific mortality for people with severe depression in Scotland, by sex, relative to the general population.

METHOD

We performed a retrospective cohort study, using psychiatric hospital admission data linked to death data, to identify adults (≥18 years old) with severe depression and ascertain cause-specific deaths, during 2000-2019. We estimated relative all-cause and cause-specific mortality for people with severe depression using standardised mortality ratios (SMRs), stratified by sex using the whole Scottish population as the standard.

RESULTS

Of 28 808 people with severe depression, 7903 (27.4%) died during a median follow-up of 8.7 years. All-cause relative mortality was over three times higher than expected (SMR, both sexes combined: 3.26, 95% CI 3.19-3.34). Circulatory disease was the leading cause of death, and, among natural causes of death, excess relative mortality was highest for circulatory diseases (SMR 2.51, 2.40-2.66), respiratory diseases (SMR 3.79, 3.56-4.01) and 'other' causes (SMR 4.10, 3.89-4.30). Among circulatory disease subtypes, excess death was highest for cerebrovascular disease. Both males and females with severe depression had higher all-cause and cause-specific mortality than the general population. Suicide had the highest SMR among both males (SMR 12.44, 95% CI 11.33-13.54) and females (22.86, 95% CI 20.35-25.36).

CONCLUSION

People with severe depression have markedly higher all-cause mortality than the general population in Scotland, with relative mortality varying by cause of death. Effective interventions are needed to reduce premature mortality for people with severe depression.

Life years lost for users of specialized mental healthcare

BACKGROUND

Mental disorders are burdensome and are associated with increased mortality. Mortality has been researched for various mental disorders, especially in countries with national registries, including the Nordic countries. Yet, knowledge gaps exist around national differences, while also relatively less studies compare mortality of those seeking help for mental disorders in specialized mental healthcare (SMH) by diagnosis. Additional insight into such mortality distributions for SMH users would be beneficial for both policy and research purposes. We aim to describe and compare the mortality in a population of SMH users with the mortality of the general population. Additionally, we aim to investigate mortality differences between sexes and major diagnosis categories: anxiety, depression, schizophrenia spectrum and other psychotic disorders, and bipolar disorder.

METHODS

Mortality and basic demographics were available for a population of N = 10,914 SMH users in the north of The Netherlands from 2010 until 2017. To estimate mortality over the adult lifespan, parametric Gompertz distributions were fitted on observed mortality using interval regression. Life years lost were computed by calculating the difference between integrals of the survival functions for the general population and the study sample, thus correcting for age. Survival for the general population was obtained from Statistics Netherlands (CBS).

RESULTS

SMH users were estimated to lose 9.5 life years (95% CI: 9.4-9.6). Every major diagnosis category was associated with a significant loss of life years, ranging from 7.2 (95% CI: 6.4-7.9) years for anxiety patients to 11.7 (95% CI: 11.0-12.5) years for bipolar disorder patients. Significant differences in mortality were observed between male SMH users and female SMH users, with men losing relatively more life years: 11.0 (95% CI: 10.9-11.2) versus 8.3 (95% CI: 8.2-8.4) respectively. This difference was also observed between sexes within every diagnosis, although the difference was insignificant for bipolar disorder.

CONCLUSION

There were significant differences in mortality between SMH users and the general population. Substantial differences were observed between sexes and between diagnoses. Additional attention is required, and possibly specific interventions are needed to reduce the amount of life years lost by SMH users.

Cancer mortality in Common Mental Disorders: A 10-year retrospective cohort study

PURPOSE

Individuals with Common Mental Disorders (CMDs) may have a higher cancer mortality. The purpose of this study was to examine cancer-related mortality among patients with CMDs and verify which cancer types are predominantly involved.

METHODS

We used the Regional Mental Health Registry of the Emilia-Romagna region, in Northern Italy to identify patients aged ≥ 18 years who received an ICD 9-CM diagnosis of CMDs (i.e., depressive and neurotic disorders) over a 10 year period (2008-2017). Information on cause of death was retrieved from the Regional Cause of Death Registry. Comparisons were made with data from the regional population without CMDs.

RESULTS

Among 101,487 patients suffering from CMDs (55.7% depression; 44.3% neurotic disorders), 3,087 (37.8%) died from neoplasms. The total standardized mortality ratio (SMR) was 1.82 (95% CI 1.78-1.86) while the SMR for all neoplasms was 2.08 (95% CI 2.01-2.16). Individuals of both genders, with both depressive and neurotic disorders had a higher risk of death from almost all cancers compared with the regional population.

CONCLUSION

Patients with CMDs have considerably higher cancer mortality risk than the general population. Higher mortality was observed for a broad range of cancers associated with different aetiologies. It is imperative to promote cancer awareness, prevention and treatment for people with CMDs.

Mortality in people with mental disorders in Poland: A nationwide, register-based cohort study

BACKGROUND

Mortality among people with mental disorders is higher in comparison with the general population. There is a scarcity of studies on mortality in the abovementioned group of people in Central and Eastern European countries.

METHODS

The study aimed to assess all-cause mortality in people with mental disorders in Poland. We conducted a nationwide, register-based cohort study utilizing data from two nationwide registries in Poland: the registry of healthcare services reported to the National Health Fund (2009-2018) and the all-cause death registry from Statistics Poland (2019). We identified individuals who were consulted or hospitalized in public mental healthcare facilities and received at least one diagnosis of mental disorders (International Statistical Classification of Diseases and Health Problems [ICD-10]) from 2009 to 2018. Standardized mortality ratios (SMRs) were compared between people with a history of mental disorder and the general population.

RESULTS

The study comprised 4,038,517 people. The SMR for individuals with any mental disorder compared with the general population was 1.54. SMRs varied across diagnostic groups, with the highest values for substance use disorders (3.04; 95% CI 3.00-3.09), schizophrenia, schizotypal and delusional disorders (2.12; 95% CI 2.06-2.18), and pervasive and specific developmental disorders (1.68; 95% CI 1.08-2.29). When only inpatients were considered, all-cause mortality risk was almost threefold higher than in the general population (SMR 2.90; 95% CI 2.86-2.94).

CONCLUSIONS

In Poland, mortality in people with mental disorders is significantly higher than in the general population. The results provide a reference point for future longitudinal studies on mortality in Poland.

Nurses’ Perspectives on Smoking Policies, Safety and Cessation Support in Psychiatric Wards: A Cross-Sectional Survey

A high prevalence of smoking and low rates of smoking cessation interventions can be observed in psychiatric wards. A questionnaire-based, cross-sectional study was performed in five hospitals among 107 psychiatric ward nurses. The aim was to investigate nurses’ views on patients’ smoking practices and their influence on the safety of both the patients and medical personnel. In addition, we asked about the availability of smoking cessation support. Most of the respondents noticed the negative impacts of smoking on patients and medical personnel. Nearly a third of our respondents (29.0%) recalled smoking-related accidents in their facilities. In 45.2% of these accidents, a patient set someone else on fire. Around one fifth of nurses had rather permissive attitudes towards tobacco use in hospital wards. Significant associations were identified between respondents’ smoking status and their opinions on amending smoking policies and on unsupervised smoking. Regarding professional help available to smoking patients, 88.8% of participants reported that interventions to address smoking were available in their wards. Psychiatric hospitalisation can be an opportunity to offer tobacco treatment to patients with mental health conditions. To make use of this opportunity, smoke-free policies need to be put in place and hospital personnel, particularly nurses, should be trained and equipped with the knowledge and skills needed to assist in the smoking care of psychiatric ward patients.

Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors

People with schizophrenia die 15-20 years prematurely. Understanding mortality risk and aggravating/attenuating factors is essential to reduce this gap. We conducted a systematic review and random-effects meta-analysis of prospective and retrospective, nationwide and targeted cohort studies assessing mortality risk in people with schizophrenia versus the general population or groups matched for physical comorbidities or groups with different psychiatric disorders, also assessing moderators. Primary outcome was all-cause mortality risk ratio (RR); key secondary outcomes were mortality due to suicide and natural causes. Other secondary outcomes included any other specific-cause mortality. Publication bias, subgroup and meta-regression analyses, and quality assessment (Newcastle-Ottawa Scale) were conducted. Across 135 studies spanning from 1957 to 2021 (schizophrenia: N=4,536,447; general population controls: N=1,115,600,059; other psychiatric illness controls: N=3,827,955), all-cause mortality was increased in people with schizophrenia versus any non-schizophrenia control group (RR=2.52, 95% CI: 2.38-2.68, n=79), with the largest risk in first-episode (RR=7.43, 95% CI: 4.02-13.75, n=2) and incident (i.e., earlier-phase) schizophrenia (RR=3.52, 95% CI: 3.09-4.00, n=7) versus the general population. Specific-cause mortality was highest for suicide or injury-poisoning or undetermined non-natural cause (RR=9.76-8.42), followed by pneumonia among natural causes (RR=7.00, 95% CI: 6.79-7.23), decreasing through infectious or endocrine or respiratory or urogenital or diabetes causes (RR=3 to 4), to alcohol or gastrointestinal or renal or nervous system or cardio-cerebrovascular or all natural causes (RR=2 to 3), and liver or cerebrovascular, or breast or colon or pancreas or any cancer causes (RR=1.33 to 1.96). All-cause mortality increased slightly but significantly with median study year (beta=0.0009, 95% CI: 0.001-0.02, p=0.02). Individuals with schizophrenia <40 years of age had increased all-cause and suicide-related mortality compared to those ≥40 years old, and a higher percentage of females increased suicide-related mortality risk in incident schizophrenia samples. All-cause mortality was higher in incident than prevalent schizophrenia (RR=3.52 vs. 2.86, p=0.009). Comorbid substance use disorder increased all-cause mortality (RR=1.62, 95% CI: 1.47-1.80, n=3). Antipsychotics were protective against all-cause mortality versus no antipsychotic use (RR=0.71, 95% CI: 0.59-0.84, n=11), with largest effects for second-generation long-acting injectable anti-psychotics (SGA-LAIs) (RR=0.39, 95% CI: 0.27-0.56, n=3), clozapine (RR=0.43, 95% CI: 0.34-0.55, n=3), any LAI (RR=0.47, 95% CI: 0.39-0.58, n=2), and any SGA (RR=0.53, 95% CI: 0.44-0.63, n=4). Antipsychotics were also protective against natural cause-related mortality, yet first-generation antipsychotics (FGAs) were associated with increased mortality due to suicide and natural cause in incident schizophrenia. Higher study quality and number of variables used to adjust the analyses moderated larger natural-cause mortality risk, and more recent study year moderated larger protective effects of antipsychotics. These results indicate that the excess mortality in schizophrenia is associated with several modifiable factors. Targeting comorbid substance abuse, long-term maintenance antipsychotic treatment and appropriate/earlier use of SGA-LAIs and clozapine could reduce this mortality gap.

Health care system and patient costs associated with receipt of minimally adequate treatment for depression and anxiety disorders in older adults

BACKGROUND

Depression and anxiety disorders in older adults are associated with a great burden. Research has shown that less than 50% of adults receive adequate treatment in primary care settings for these disorders. Rare are the studies however assessing adequate treatment in older adults and associated costs from the societal perspective. Given the episodic nature of common mental disorders, this study aims to assess the three-year costs from a restricted societal perspective (including health system and patient perspectives) associated with receipt of minimally adequate treatment for depression and anxiety disorders in older adults consulting in primary care.

METHODS

This primary care cohort study included 358 older adults aged 65 years and older with either a self-reported or physician diagnosis of depression or an anxiety disorder covered under Quebec's public drug plan. Receipt of minimally adequate treatment was assessed according to Canadian guidelines and relevant reports. Outpatient and inpatient service use, medication costs and physician billing fees were obtained from provincial administrative databases. Unit costs were calculated using provincial financial and activity reports and relevant literature. A propensity score was created to estimate the probability of receiving minimally adequate treatment and the inverse probability was used as a weight in analyses. Generalized linear models, with gamma distribution and log link, were conducted to assess the association between receipt of minimally adequate treatment and costs.

RESULTS

Overall, receipt of minimally adequate treatment was associated with increased three-year costs averaging $5752, $536, $6266 for the health system, patient and societal perspectives, respectively, compared to those not receiving minimally adequate treatment. From the health system perspective, participants receiving minimally adequate treatment had higher costs related to emergency department (ED) (difference: $457, p = 0.001) and outpatient visits (difference: $620, p < 0.001), inpatient stays (difference: $2564, p = 0.025), drug prescriptions (difference: $1243, p = 0.002) and physician fees (difference: $1224, p < 0.001). From the patient perspective, receipt of minimally adequate treatment was associated with higher costs related to loss of productivity related to ED (difference: $213, p < 0.001) and outpatient visits (difference: $89, p < 0.001).

CONCLUSIONS

Older adults receiving minimally adequate treatment for depression and anxiety disorders incurred higher societal costs reaching $2089 annually compared to older adults not receiving minimally adequate treatment. The main cost drivers were attributable to hospitalizations and prescription drug costs.

The quality of mental health care delivered to patients with schizophrenia and related disorders in the Italian mental health system. The QUADIM project: a multi-regional Italian investigation based on healthcare utilisation databases

AIMS

To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).

METHODS

Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions.

RESULTS

A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains.

CONCLUSIONS

The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy

Objective

To examine cancer‐related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008–2017 and compare it with the regional population.

Methods

We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD‐9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10‐year period (2008–2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period.

Results

Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%–29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site‐specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender.

Conclusions

Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho‐oncology.