Mortality in people with mental disorders in the Czech Republic: a nationwide, register-based cohort study

Temporal trends in mortality and associated factors among persons with mental disorders: A register-based cohort study

This study aims to examine 20-year temporal trends in all-cause mortality among psychiatric patients and investigating impacts of risk factors on the time trends based on 218,703 Finnish adults with mental disorders who were discharged from 87 psychiatric hospitals between 1 Jan 1995 and 31 Dec 2014. The age-period-cohort analysis of Poisson model with random hospital effects estimated temporal trends in death rate and associated factors at individual, healthcare system, and society levels, following the WHO multilevel intervention framework model for six major psychiatric diagnosis. The adjusted annual mortality declined by 2.2 % annually (RR: 0.978 [95 % CI 0.976-0.980]) for all individuals, and by 2.8 % after adjusting for all risk factors, with varied decreasing rate between 2.0 % and 3.6 % by diagnosis. Individual level factors accounted for the declining rate by 54.5 % for all patients, with the highest impact on patients with personality disorders, followed by patients with affective disorders and patients with schizophrenia. Identified declining trends and associated factors which are preventable and modifiable for individuals with specific psychiatric diagnosis may lead to develop targeted service and intervention strategies in bringing down mortality further for the population.

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.

Uneven Between-Hospital Distribution of Patient-Related Risk Factors for Adverse Outcomes of Colorectal Cancer Treatment: A Population-Based Register Study

Purpose

The purpose of this study was to elucidate between-hospital variation in the prevalence at the time of diagnosis of patient-related risk factors for adverse outcomes of colorectal cancer (CRC) treatment.

Patients and Methods

A register-based national cohort of 44,471 patients diagnosed with CRC and registered in the Danish Colorectal Cancer Group database in 2009-2018 was included in the study. Patient-related risk factors present at diagnosis were collected from national Danish registers within the areas of demography, lifestyle factors, comorbidity, participation in screening, disease-related factors and socioeconomic factors. Prediction models of short-term postoperative outcomes and mortality were modelled to examine the potential aggregated impact of patient-related risk factors on outcomes, and variations between hospitals were examined.

Results

The most conspicuous variations found were for old age (75+ years), ranging from 31% (95% confidence interval (95% CI): 29-33%) to 46% (95% CI: 43-48%), Union for International Cancer Control Stage I ranging from 12% (95% CI: 10-14%) to 21% (95% CI: 19-22%), Stage IV ranging from 23% (95% CI: 21-25%) to 35% (95% CI: 34-37%) and American Society of Anesthesiologists score ≥III ranging from 18% (95% CI: 16-19%) to 40% (95% CI: 37-43%). Clinically significant variations were found in predicted probability of 30-day surgical complications which varied from 17% (95% CI: 16-17%) to 23% (95% CI: 22-23%) and 90-day postoperative mortality which varied between 3.2% (95% CI: 3-3.4%) and 5.5% (95% CI: 4.9-6%).

Conclusion

Marked variation in the prevalence of patient-related risk factors for adverse outcomes of colorectal cancer treatment exists between hospitals in Denmark. It seems reasonable to take these differences into account when comparing outcomes between hospitals.

Increased risk of incident atrial fibrillation in young adults with mental disorders: A nationwide population-based study

BACKGROUND

Mental disorders and cardiovascular diseases are closely related. However, a paucity of information on the risk of incident atrial fibrillation (AF) in patients with mental disorders exists.

OBJECTIVE

We aimed to assess the association between mental disorders and the risk of AF, particularly in young adults.

METHODS

Using the Korean National Health Insurance Database between 2009 and 2012, we identified adults aged 20-39 years without a history of AF and who have been diagnosed with mental disorders. Mental disorders were defined as having one of the following diagnoses: depression, insomnia, anxiety disorder, bipolar disorder, or schizophrenia. The primary outcome was new-onset AF during follow-up.

RESULTS

A total of 6,576,582 subjects (mean age 30.9 ± 5.0 years; 3,919,339 [59.6%] men) were included. Among the total population, 10% had mental disorders. During the follow-up period, 8932 incident AF events occurred. Patients with mental disorders showed a higher AF incidence than did those without (25.4 per 100,000 person-years vs 17.7 per 100,000 person-years). After multivariable adjustment, mental disorders were associated with a significantly higher risk of AF (adjusted hazard ratio 1.526; 95% confidence interval 1.436-1.621). Patients with bipolar disorder or schizophrenia had a 2-fold higher risk of AF and those with depression, insomnia, and anxiety disorder had a 1.5- to 1.7-fold higher risk of AF than did those without mental disorders.

CONCLUSION

Young adults diagnosed with mental disorders have a higher risk of incident AF. Awareness for AF in high-risk populations should thus be considered.

Mortality and life-years lost following subsequent physical comorbidity in people with pre-existing substance use disorders: a national registry-based retrospective cohort study of hospitalised individuals in Czechia

BACKGROUND

Substance use disorders constitute a major global public health problem, attributable largely to their subsequent comorbidity with other health conditions. This study aimed to investigate the risk of all-cause death and life-years lost following hospitalisation for 28 subsequent physical comorbid conditions in people with a previous hospitalisation for substance use disorder, compared with matched counterparts without substance use disorder.

METHODS

We did a retrospective cohort study on data from Czech nationwide registers of all-cause hospitalisations and deaths during the period from Jan 1, 1994, to Dec 31, 2017. The cohorts consisted of individuals who had initially been hospitalised between 15 and 70 years of age (index hospitalisation) and who were subsequently hospitalised with one or more of 28 comorbid physical health conditions. We included individuals with an index hospitalisation for substance use disorders and up to three counterparts without substance use disorders with a subsequent hospitalisation for the same physical health condition, with matching on sex, age (±3 years), work status, and discharge year at first hospitalisation for the subsequent condition. Data on ethnicity were not available. Risk of death due to any cause following the first hospitalisation for each physical health condition until Dec 31, 2017, and life-years lost after disease onset at ages 30, 45, and 60 years, and before 81 years of age, were examined.

FINDINGS

From a total 56 229 563 records of hospitalisations identified, we included 121 153 people with hospitalisation for substance use disorders and 6 742 134 people without hospitalisation for substance use disorders in the study. The 28 condition-specific cohorts comprised a median of 6444 individuals (IQR 2033-12 358), ranging from 444 for multiple sclerosis to 36 356 for diseases of the circulatory system. Across the cohorts, the proportion of males ranged from 31·4% for thyroid disorder to 100·0% for prostate disorders. The mean baseline age ranged from 30·0 years (SD 9·1) for chronic viral hepatitis in people with pre-existing substance use disorders to 62·2 years (9·7) for Parkinson's disease in people without pre-existing substance use disorders. After adjusting for potential confounders using stratified Cox proportional hazards models, individuals with a pre-existing substance use disorder had an increased risk of death due to any cause after the onset of 26 out of 28 physical health conditions, relative to their counterparts without substance use disorders, with adjusted hazard ratios ranging from 1·15 (1·09-1·21) for chronic liver disease to 3·86 (2·62-5·67) for thyroid disorder. For seven subsequent health conditions, the risk of death was more than doubled in the group with pre-existing substance use disorders. When compared with the general population via mortality tables, people with pre-existing substance use disorders had substantial losses in life-years after the onset of most of the subsequent physical health conditions regardless of age of onset, and, for the majority of comorbidities, lost considerably more life-years than their counterparts without substance use disorders.

INTERPRETATION

A history of hospitalisation for substance use disorders appears to have a significant negative effect on prognosis following the development of various subsequent physical health conditions. These findings strongly suggest that clinical vigilance and high-quality integrated treatment for people with substance use disorders could be life-saving and should be given higher priority on the public health agenda.

FUNDING

National Institute for Health and Care Research Applied Research Collaboration East of England at Cambridge and Peterborough National Health Service Foundation Trust.

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.

Premature death and causes of death among patients with panic disorder and comorbid psychiatric disorders: A nationwide cohort study

OBJECTIVES

Panic disorder (PD) is associated with high psychiatric and physical comorbidity, but the cause of mortality has not been well studied. This study investigated mortality rates and causes of death in an Asian cohort with PD.

METHODS

We enrolled a nationwide retrospective cohort of 298,466 persons diagnosed with PD from January 1, 2001, to December 31, 2016. Each cohort member was matched with a comparison one randomly selected from the general population with the same sex, age at entry, and birth year. The data of both the PD cohort and the comparison group were linked with the national mortality database to obtain each individual's mortality status. We used mortality rate ratios (MRRs) to compare mortality risks between the patients with PD and the general population. Stratified analysis of mortality risks was performed based on sex and psychiatric comorbidities.

RESULTS

PD was associated with a slightly increased mortality risk (MRR, 1.14 [99% CI, 1.11-1.17]). The risk of unnatural death (MRR, 2.83 [99% CI, 2.59-3.10]) was significantly higher among the individuals with PD than among the general population, whereas the risk of overall natural death across all categories was not (MRR, 1.01 [99% CI, 0.98-1.04]). The mortality risk was the highest for suicide (MRR, 4.94 [99% CI, 4.32-5.72]) and was higher in women (MRR, 6.37 [99% CI, 5.25-7.96]) than in men (MRR, 3.77 [99% CI, 3.14-4.64]). Comorbid substance use disorders increased the risk of mortality from natural (MRR, 3.23 [99% CI, 2.59-4.14]) and unnatural (MRR, 9.45 [99% CI, 6.29-17.85]) causes.

CONCLUSION

PD was associated with increased all-cause mortality, especially suicide. Substance use further increased mortality risk in persons with PD. Targeted treatment for substance use and suicide prevention are essential among persons with PD.

Impact of history of mental disorders on short-term mortality among hospitalized patients with sepsis: A population-based cohort study

Background

Mental disorders are associated with markedly reduced life expectancy, in part due to an increased risk of death due to infection, likely reflecting sepsis-associated mortality. Patients with mental disorders are at an increased risk of sepsis, but data on the prognostic impact of mental disorders in sepsis are sparse, showing conflicting findings.

Methods

We used statewide data to identify hospitalizations aged ≥18 years with sepsis in Texas during 2014–2017. Mental disorders, including mood, anxiety, psychosis, and personality disorders were identified using Clinical Classification Software codes. Multilevel, multivariable logistic regression with propensity adjustment (primary model), with propensity score matching, and multivariable logistic regression as alternative models, were used to estimate the association between mental disorders and short-term mortality (defined as in-hospital mortality or discharge to hospice). Additional models were fitted for sensitivity analyses and to estimate the prognostic associations of individual categories of mental disorders.

Results

Among 283,025 hospitalizations with sepsis, 56,904 (20.1%) had mental disorders. Hospitalizations with vs without mental disorders were younger (age 18–44 years 12.2% vs 10.6%), more commonly white (61.0% vs 49.8%), with lower burden of comorbidities (mean [SD] Deyo comorbidity index 2.53 [2.27] vs 2.73 [2.47]), and with lower need for organ support (mechanical ventilation 32.8% vs 36.0%); p<0.0001 for all comparisons. Crude short-term mortality among sepsis hospitalizations with and without mental disorders was 25.0% vs 32.8%, respectively. On adjusted analyses, mental disorders remained associated with lower odds of short-term mortality (adjusted odds ratio 0.792 [95% CI 0.772–0.812]). This finding was consistent on the alternative modeling approaches, sensitivity analyses, and examination of individual categories of mental disorders.

Conclusions

Mental disorders were associated, unexpectedly, with markedly lower risk of short-term mortality in sepsis. Further studies to examine the mechanisms underlying these findings may inform future efforts to improve sepsis outcomes.

Serious physical assault and subsequent risk for rehospitalization in individuals with severe mental illness: a nationwide, register-based retrospective cohort study

BACKGROUND

Victimization is associated with worse social and clinical outcomes of individuals with severe mental illness (SMI). A relapse of SMI may be one of the clinical consequences of assaultive trauma. As far as we know, there is no published study that analyzes nationwide health registers to assess the risk of SMI rehospitalization following assault.

AIM

We aimed to assess whether exposure to assault is associated with an increased risk of psychiatric hospitalization in those with SMI.

METHODS

We utilized data from the Czech nationwide registers of all-cause hospitalizations and all-cause deaths. We defined exposed individuals as those discharged from a hospitalization for SMI between 2002 and 2007, and hospitalized for serious injuries sustained in an assault in the subsequent 7 years. For each assaulted individual, we randomly selected five counterparts, matched on SMI diagnosis, age and sex, who were not assaulted in the examined time period. We used mixed effect logistic regression to assess the effect of assault on the risk of SMI rehospitalization within the following 6 months. We fitted unadjusted models and models adjusted for the number of previous SMI hospitalizations and drug use disorders.

RESULTS

The sample consisted of 248 exposed and 1 240 unexposed individuals. In the unadjusted model, assaulted individuals were almost four times more likely to be rehospitalized than their non-assaulted counterparts (odds ratio (OR) = 3.96; 95% CI 2.75; 5.71). After adjusting for all covariates, the OR remained threefold higher (OR = 3.07; 95% CI 2.10; 4.49).

CONCLUSION

People with a history of SMI hospitalization were approximately three times more likely to be rehospitalized for SMI within 6 months after an assault than their non-assaulted SMI counterparts. Soon after a person with SMI is physically assaulted, there should be a psychiatric evaluation and a close follow-up.

Correlates of self-reported history of mental health help-seeking: a cross-sectional study among individuals with symptoms of a mental or substance use disorder initiating care for HIV in Cameroon

BACKGROUND

Mental health and substance use disorders (MSDs) increase the risk of poor human immunodeficiency virus (HIV) care outcomes among people living with HIV (PLWH). Receipt of mental health care may improve these adverse outcomes. We aimed to identify correlates of prior mental health help-seeking among PLWH with symptoms of an MSD in Cameroon.

METHODS

We characterize prior mental health help-seeking from formal (mental health specialist/general medical provider) and informal (traditional healer/religious leader) sources among 161 people with symptoms of depression (Patient Health Questionnaire-9 scores> 9), anxiety (General Anxiety Disorder-7 scores> 9), probable post-traumatic stress disorder (PTSD Checklist for DSM-5 scores> 30), or possible alcohol use disorder (Alcohol Use Disorders Identification Test scores≥16) who were newly entering HIV care at three healthcare facilities in Cameroon between June 2019 and March 2020. Help-seeking was defined as ever speaking to a formal or informal source about emotional problems, sadness, or the way they were feeling or behaving. We estimated the association between sociodemographic and psychosocial measures and lifetime mental health help-seeking from each type of source using log-binomial regression.

RESULTS

Overall, 55.3% of 161 PLWH with MSD symptoms reported prior mental health help-seeking, with 24.2% and 46.0% seeking help from formal and informal sources, respectively. Religious leaders were the most common source of help (40.4%), followed by general medical professionals (22.4%), traditional healers (16.8%), and mental health specialists (7.4%). Individuals with higher depressive, anxiety, and trauma symptom severity scores were more likely to have sought help than those with lower scores. Individuals with possible alcohol use disorder were the least likely to have sought help. Prior help-seeking was more common among those reporting a higher number of lifetime traumatic events (prevalence ratio [PR]: 1.06; 95% confidence interval [CI]: 1.01, 1.11) and those with a history of emotional intimate partner violence (PR: 1.34; 95% CI: 1.01, 1.80).

CONCLUSIONS

Prior mental health help-seeking was associated with psychosocial stressors. Help-seeking from informal networks was more common than formal help-seeking. Training in the provision of evidence-based mental health support for informal networks could improve access to mental health care for PLWH with MSDs in Cameroon.

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.

Investigation of risk of dementia diagnosis and death in patients in older people's secondary care mental health services

OBJECTIVES

Previous studies have shown increased rates of death and dementia in older people in specific serious mental illnesses (SMI) such as bipolar disorder or depression. We examined the rates of death and dementia in older people referred into a secondary care psychiatric service across a range of SMIs.

METHODS

We used an anonymised dataset across 6 consecutive years with 28,340 patients aged 65 years and older from a single secondary care psychiatric trust in the United Kingdom. We identified deaths and incident dementia in patients with bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders. We compared mortality and dementia rates between these diagnostic groups and in different treatment settings. We also examined mortality rates and dementia rates compared with general population rates.

RESULTS

Patients with schizophrenia showed the highest hazard rate for death compared to other groups with SMIs (hazard ratio, 1.58; 95% confidence interval (CI), 1.18-2.1, with anxiety group the reference). Survival was reduced in patients referred to liaison psychiatry services. There were no significant differences between the SMI groups in terms of rates of dementia. However, risks of death and dementia were significantly increased compared to the general population (standardized mortality rates with 95% CI, 2.6(2.0-3.3), 3.5(2.6-4.5), 2.5(2.0-3.0) and 1.8 (1.4-2.2) and standardized dementia incidence rates with 95% CI, 2.7(1.5-4.1), 2.9(1.5-4.7), 3.8(2.6-5.2) and 4.3 (3.0-5.7) for bipolar disorder/mania, schizophrenia, recurrent depression and anxiety disorders respectively.

CONCLUSIONS

Older adults referred into an old age psychiatry service show higher rates of dementia and death than those reported for the general population.

Attitudes towards People with Mental Illness and Low Interest in Psychiatry among Medical Students in Central and Eastern Europe

This study aimed to examine attitudes towards people with mental illness and psychiatry and interest in career choice in psychiatry among medical students from three medical schools in Czechia and Slovakia. A total of 495 medical students participated in a cross-sectional study. Participants completed (1) the Medical students' version of mental illness: clinicians' attitudes (MICA-2) scale, (2) the Reported and intended behaviour scale (RIBS), (3) the Attractiveness of working on a psychiatry-related position scale (P-ATTRACT), and (4) the Status of psychiatry scale (P-STATUS). Descriptive statistics, group comparisons and regression models were calculated. From 23 to 30% of students considered a specialization in psychiatry. However, only about 1% of them had a strong interest in psychiatry as a future career, moreover, students of higher years of study found psychiatry less attractive compared to those who are in the beginning of the study. The consideration of specialization in psychiatry was found to be statistically significantly associated with less stigmatizing attitudes and lower social distance towards people with mental illness. There were statistically significant differences in stigmatizing attitudes among medical schools, with a medical school emphasizing the education in psychiatry the most showing more positive attitudes. It is necessary to increase the interest in psychiatry and minimize stigma among medical students. Psychiatry curriculum in Central and Eastern European region should include more psychiatry-related courses, training in community and out-patient facilities, peer-lectors, and offer counselling after exposure to emotionally challenging clinical situations.

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

Evidence from previous research demonstrated a gap in mortality between patients with mental disorders and the general population. However, a more exhaustive assessment is required to address this public health issue. The aim of this study was to provide comprehensive analysis of mortality examining all causes of death and all psychiatric diagnoses. We conducted a 10-year retrospective cohort study, including all in and out patients registered in the Mental Health Registry of Emilia-Romagna, Italy. Standardized mortality ratios (SMRs) were calculated. The cohort consisted of 137,351 patients 11,236 of whom died during the study period and the overall SMR was 1.99. 85.9 % of excess mortality was attributable to a broad range of natural causes. Diseases of circulatory and respiratory systems as well as neoplasms were the principal contributors to the mortality gap. All psychiatric conditions led to a higher risk of death. The greatest excess was due to neoplasms in depressed and neurotic patients and to cardiovascular diseases in patients with schizophrenia and personality disorders. Our results highlight the need for close collaboration between mental and primary health care services with the aim of reducing excess mortality as a result of medical diseases among all patients suffering from psychiatric condition.

Disparities in the Use of General Somatic Care among Individuals Treated for Severe Mental Disorders and the General Population in France

Individuals with severe mental illnesses (SMI) face a striking excess and premature mortality which has been demonstrated in several national contexts. This phenomenon, which constitutes a red-flag indicator of public health inequities, can be hypothesized to result from healthcare access issues which have been insufficiently documented so far. In this context, our objective was to explore patterns of general somatic healthcare use of individuals treated for SMI in comparison to those of the general population in France using national health administrative data and a matched case-control study. Differences in the use of general and specific somatic preventive care services, primary care, routine specialized somatic care and admissions to non-psychiatric hospital departments for somatic causes were described between cases and controls after adjustment on differing clinical needs, socio-economic status, and living environment. Our results show a lower use of general preventive care services and of routine specialized somatic care in the SMI population, despite more frequent comorbidities, and a higher occurrence of avoidable hospitalizations, despite higher contacts with primary care physicians. These findings suggest that the health system fails to address the specific needs of this vulnerable population and support the development of measures aimed at reducing this gap.

Causes of premature mortality in schizophrenia: a review of literature published in 2018

PURPOSE OF REVIEW

The current review examines the recent literature on the causes of premature mortality in schizophrenia.

RECENT FINDINGS

People with schizophrenia have higher premature mortality rates compared with the general population. Suicides and accidents account for a nontrivial part of the excess mortality, but the largest part is attributable to natural causes of death. Five major causes have been identified: first, adverse effects of medication; second, suboptimal lifestyle; third, somatic comorbidity; fourth, suboptimal treatment of somatic disorders; and fifth, accelerated ageing/genetic explanations. The positive aspect is that people with schizophrenia have increasing life expectancy, at least in high-income countries, and this development seems to largely follow the increase in the general population. Especially mortality rates from unnatural causes appear to have a positive impact. Nevertheless, despite more than 100 years of research and progress, the excess mortality in persons with schizophrenia remains unacceptably high, with no prospects of reaching the level in the general population.

SUMMARY

The excess mortality in schizophrenia has received much focus. Future studies should explore the reasons for the high rates of natural causes of death, while aiming to disentangle the complex interplay between medication, lifestyle, comorbidity, treatment of somatic disorders, and genetic effects.

The treatment gap for mental disorders and associated factors in the Czech Republic

OBJECTIVES

To assess the extent of the treatment gap for mental disorders in the Czech Republic, determine factors associated with the utilization of mental health services and explore what influences willingness to seek mental health care.

METHODS

Data from the CZEch Mental health Study, a nationally representative study of community-dwelling adults in the Czech Republic were used. The Mini International Neuropsychiatric Interview assessed the presence of mental disorders. 659 participants with current affective, anxiety, alcohol use and substance use disorders were studied.

RESULTS

The treatment gap for mental disorders ranged from 61% for affective to 93% for alcohol use disorders. Mental health service use was associated with greater disability (OR 1.04; 95% CI 1.02-1.05; p < 0.001), female gender (OR 3.31; 95% CI 1.97-5.57; p < 0.001), urban residence (OR 1.84; 95% CI 1.12-3.04; p < 0.05) and a higher number of somatic diseases (OR 1.32; 95% CI 1.03-1.67; p < 0.05). Self-identification as having a mental illness was associated with greater willingness to seek a psychiatrist and a psychologist.

CONCLUSIONS

The treatment gap for mental disorders is alarmingly high in the Czech Republic. Interventions to decrease it should target in particular rural areas, men and people with low self-identification as having a mental illness.

Cost-effectiveness of care for people with psychosis in the community and psychiatric hospitals in the Czech Republic: an economic analysis

BACKGROUND

The absence of economic evidence hinders current reforms of hospital-based mental health systems in central and eastern Europe. We aimed to assess the cost-effectiveness of discharge to community care for people with chronic psychoses compared with care in psychiatric hospitals in the Czech Republic.

METHODS

We did a prospective study of people aged 18-64 years with chronic psychotic disorders in the Czech Republic who had been discharged into community services or were receiving inpatient psychiatric care for at least 3 months at baseline. We measured health-related quality of life with the EuroQol five-dimension five-level questionnaire. Adjusting for baseline differences between the two groups, we assessed differences in societal costs in 2016 and quality-adjusted life-years (QALYs) during a 12-month follow-up, which we then used to estimate the incremental cost-effectiveness ratio (ICER). We did multiple sensitivity analyses to assess the robustness of our results.

FINDINGS

In our baseline case scenario, we included 115 patients who were either community service users (n=35) or inpatients (n=80) at baseline. The two groups were similar in terms of baseline characteristics. The annual QALY was 0·77 in patients receiving community care at baseline compared with 0·80 in patients in hospital at baseline (difference 0·03, 95% CI -0·04 to 0·10), but the costs of discharge to the community were €8503 compared with €16 425 for no discharge (difference €7922, 95% CI 4497-11 346), such that the ICER reached more than €250 000 per QALY. This ICER is substantially higher than levels that are conventionally considered to be cost-effective and the estimated probability that discharge to the community was cost-effective was very high (≥97%). None of the sensitivity analyses changed these results qualitatively.

INTERPRETATION

This study provides economic evidence for deinstitutionalisation by showing that discharge to community care is cost-effective compared with care in psychiatric hospitals in the Czech Republic. These findings add to the human rights and clinical-based arguments for mental health-care reforms in central and eastern Europe.

FUNDING

Ministry of Education, Youth and Sports of the Czech Republic; EEA and Norway Grants.

Value of schizophrenia treatment II: Decision modelling for developing early detection and early intervention services in the Czech Republic

Background:

Positive findings on early detection and early intervention services have been consistently reported from many different countries. The aim of this study, conducted within the European Brain Council project “The Value of Treatment”, was to estimate costs and the potential cost- savings associated with adopting these services within the context of the Czech mental health care reform.

Methods:

Czech epidemiological data, probabilities derived from meta-analyses, and data on costs of mental health services in the Czech Republic were used to populate a decision analytical model. From the health care and societal perspectives, costs associated with health care services and productivity lost were taken into account. One-way sensitivity analyses were conducted to explore the uncertainty around the key parameters.

Results:

It was estimated that annual costs associated with care as usual for people with the first episode of psychosis were as high as 46 million Euro in the Czech Republic 2016. These annual costs could be reduced by 25% if ED services were adopted, 33% if EI services were adopted, and 40% if both, ED and EI services, were adopted in the country. Cost-savings would be generated due to decreased hospitalisations and better employment outcomes in people with psychoses.

Conclusions:

Adopting early detection and early intervention services in mental health systems based on psychiatric hospitals and with limited access to acute and community care could generate considerable cost- savings. Although the results of this modelling study needs to be taken with caution, early detection and early intervention services are recommended for multi-centre pilot testing accompanied by full economic evaluation in the region of Central and Eastern Europe.