Excess mortality in persons with severe mental disorder in Sweden: a cohort study of 12 103 individuals with and without contact with psychiatric services

Anticholinergic load: A commonly neglected and preventable risk to cognition during schizophrenia treatment?

Background

Cognitive impairment is a widespread feature of schizophrenia, affecting nearly 80 % of patients. Prior research has linked the anticholinergic burden of psychiatric medications to these cognitive deficits. However, the impact of the anticholinergic burden from medications for physical morbidity remains underexplored. This study aimed to evaluate the anticholinergic burden of psychiatric and physical medications in patients with schizophrenia and assess its impact on cognitive function.

Methods

A total of 178 patients with schizophrenia were recruited. The assessments included an ad hoc questionnaire for collecting demographic and clinical data. Anticholinergic burden was evaluated using the cumulative Drug Burden Index (cDBI) for each participant, and cognitive function was assessed using MATRICS. Psychopathology was measured using the PANSS, CDSS, CAINS, and the CGI-S. Statistical analysis included Student's t-tests, ANOVA, Pearson correlations, and multiple linear regressions.

Results

The average cDBI was 1.3 (SD = 0.9). The model developed explained 40.80 % of the variance. The variable with the greatest weight was the cDBI (B = -11.148, p = 0.010). Negative-expression (B = -2.740, p = 0.011) and negative-experiential (B = -1.175, p = 0.030) symptoms were also associated with lower global cognitive score. However, more years of education (B = 5.140, p < 0.001) and cigarettes per day (B = 1.331, p < 0.001) predicted a better global cognitive score.

Conclusion

This study identified specific predictors of global cognition in schizophrenia, with anticholinergic burden emerging as the strongest factor. Our findings underscore the importance of considering the anticholinergic burden of treatments, in addition to negative symptoms, when designing interventions to optimize or maintain cognitive function in patients with schizophrenia.

Factors that influence participation in physical activity for people with bipolar disorder: a synthesis of qualitative evidence

BACKGROUND

Mental health problems contribute significantly to the overall disease burden worldwide and are major causes of disability, suicide, and ischaemic heart disease. People with bipolar disorder report lower levels of physical activity than the general population, and are at greater risk of chronic health conditions including cardiovascular disease and obesity. These contribute to poor health outcomes. Physical activity has the potential to improve quality of life and physical and mental well-being.

OBJECTIVES

To identify the factors that influence participation in physical activity for people diagnosed with bipolar disorder from the perspectives of service users, carers, service providers, and practitioners to help inform the design and implementation of interventions that promote physical activity.

SEARCH METHODS

We searched MEDLINE, PsycINFO, and eight other databases to March 2021. We also contacted experts in the field, searched the grey literature, and carried out reference checking and citation searching to identify additional studies. There were no language restrictions.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that focused on the experiences and attitudes of service users, carers, service providers, and healthcare professionals towards physical activity for bipolar disorder.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined questions. We used the "best fit" framework synthesis based on a revised version of the Health Belief Model to analyse and present the evidence. We assessed methodological limitations using the CASP Qualitative Checklist. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) guidance to assess our confidence in each finding. We examined each finding to identify factors to inform the practice of health and care professionals and the design and development of physical activity interventions for people with bipolar disorder.

MAIN RESULTS

We included 12 studies involving a total of 592 participants (422 participants who contributed qualitative data to an online survey, 170 participants in qualitative research studies). Most studies explored the views and experiences of physical activity of people with experience of bipolar disorder. A number of studies also reported on personal experiences of physical activity components of lifestyle interventions. One study included views from family carers and clinicians. The majority of studies were from high-income countries, with only one study conducted in a middle-income country. Most participants were described as stable and had been living with a diagnosis of bipolar disorder for a number of years. We downgraded our confidence in several of the findings from high confidence to moderate or low confidence, as some findings were based on only small amounts of data, and the findings were based on studies from only a few countries, questioning the relevance of these findings to other settings. We also had very few perspectives of family members, other carers, or health professionals supporting people with bipolar disorder. The studies did not include any findings from service providers about their perspectives on supporting this aspect of care. There were a number of factors that limited people's ability to undertake physical activity. Shame and stigma about one's physical appearance and mental health diagnosis were discussed. Some people felt their sporting skills/competencies had been lost when they left school. Those who had been able to maintain exercise through the transition into adulthood appeared to be more likely to include physical activity in their regular routine. Physical health limits and comorbid health conditions limited activity. This included bipolar medication, being overweight, smoking, alcohol use, poor diet and sleep, and these barriers were linked to negative coping skills. Practical problems included affordability, accessibility, transport links, and the weather. Workplace or health schemes that offered discounts were viewed positively. The lack of opportunity for exercise within inpatient mental health settings was a problem. Facilitating factors included being psychologically stable and ready to adopt new lifestyle behaviours. There were positive benefits of being active outdoors and connecting with nature. Achieving balance, rhythm, and routine helped to support mood management. Fitting physical activity into a regular routine despite fluctuating mood or motivation appeared to be beneficial if practised at the right intensity and pace. Over- or under-exercising could be counterproductive and accelerate depressive or manic moods. Physical activity also helped to provide a structure to people's daily routines and could lead to other positive lifestyle benefits. Monitoring physical or other activities could be an effective way to identify potential triggers or early warning signs. Technology was helpful for some. People who had researched bipolar disorder and had developed a better understanding of the condition showed greater confidence in managing their care or providing care to others. Social support from friends/family or health professionals was an enabling factor, as was finding the right type of exercise, which for many people was walking. Other benefits included making social connections, weight loss, improved quality of life, and better mood regulation. Few people had been told of the benefits of physical activity. Better education and training of health professionals could support a more holistic approach to physical and mental well-being. Involving mental health professionals in the multidisciplinary delivery of physical activity interventions could be beneficial and improve care. Clear guidelines could help people to initiate and incorporate lifestyle changes.

AUTHORS' CONCLUSIONS

There is very little research focusing on factors that influence participation in physical activity in bipolar disorder. The studies we identified suggest that men and women with bipolar disorder face a range of obstacles and challenges to being active. The evidence also suggests that there are effective ways to promote managed physical activity. The research highlighted the important role that health and care settings, and professionals, can play in assessing individuals' physical health needs and how healthy lifestyles may be promoted. Based on these findings, we have provided a summary of key elements to consider for developing physical activity interventions for bipolar disorder.

Impact of institutional quality improvement initiatives on metabolic monitoring in mental disorder in patients treated with antipsychotics: A meta-analysis of intervention studies

Background

Compliance with guidelines regarding monitoring of metabolic adverse effects induced by antipsychotics has been consistently low. We characterised and evaluated the quality of institutional quality improvement (QI) interventions designed to address disparities between guidelines and real-world practices. Furthermore, we assessed the impact of these interventions on the screening and management of metabolic risks for inpatients receiving treatment with antipsychotic medications.

Methods

We conducted a meta-analysis of institutional QI intervention studies aimed at improving antipsychotic-associated metabolic risk monitoring in hospitalised mental disease patients. Relevant studies were identified through searches conducted in the Embase and PubMed databases, as well as by reviewing previous reviews and meta-analyses. Quantitative analyses were performed, calculating odds ratios (ORs) and 95% confidence intervals (CIs) to assess the impact of QI programmes on guideline adherence in clinical practice.

Results

We identified 12 intervention studies (n = 10 128 and n = 2667 patients in the pre-and post-intervention groups, respectively) and included them in our meta-analysis. QI interventions demonstrated effectiveness in bridging the guideline-practice gap in monitoring antipsychotic-induced metabolic adverse effects, as supported by the ORs and 95% CIs for post-intervention monitoring of plasma glucose, lipids, and blood pressure (BP) vs the pre-intervention period being OR = 6.90 (95% CI = 1.51-31.48), OR = 5.39 (95% CI = 4.01-7.24), and OR = 4.81 (95% CI = 1.23-18.79), respectively. Only 33.3% (4/12) of studies reported screening rates for all four metabolic parameters (plasma glucose, lipids, weight/body mass index (BMI), and BP). The median rates for metabolic screening of plasma glucose, lipids, and BP increased from 51.0-80.0%, 28.7-66.7%, and 91.7-95.8%, respectively. Up to 66.7% (8/12) of intervention studies lacked follow-up measures to treat or manage identified risks in hospitalised psychiatric patients, such as patient referrals, prescription of medications, and switching of antipsychotics. The odds of monitoring weight/BMI and glucose were greatest when QI programmes involved the participation of multidisciplinary health care professionals and patients, yielding OR = 3.35 (95% CI = 2.45-4.59) and OR = 57.51 (95% CI = 24.11-137.21), respectively.

Conclusions

Institutional QI interventions were effective in enhancing monitoring practices in alignment with established guidelines for metabolic risk screening among hospitalised patients with mental disorders maintained on antipsychotic medications. Future institutional QI programmes should incorporate multidisciplinary strategies involving patient engagement and extend their focus beyond screening to incorporate follow-up risk management strategies once risks have been identified.

Registration

PROSPERO CRD42023452138.

Associations between adiposity measures and depression and well-being scores: A cross-sectional analysis of middle- to older-aged adults

BACKGROUND

Obesity and mental health are significant global health concerns. Evidence has linked increased adiposity with depression and well-being; however, there is limited documented evidence in Ireland. Research also suggests lifestyle factors and disease conditions to be related to mental health. These may modulate relationships between adiposity and depression and well-being.

METHODS

This was a cross-sectional study of 1,821 men and women aged 46-73 years, randomly selected from a large primary care centre. Depression and well-being were assessed using the 20-item Centre for Epidemiologic Studies Depression Scale (CES-D) and the World Health Organization-Five (WHO-5) Well-Being Index. Linear regression analyses were performed to examine relationships between mental health scores (dependent variable) and adiposity (independent variable) defined using body mass index (BMI) and waist-height ratio while adjusting for demographic characteristics, lifestyle factors and disease conditions.

RESULTS

BMI and waist-height ratio had a significant positive association with depression scores and a significant inverse association with well-being scores in males and females. These associations were maintained following adjustment for demographic variables and lifestyle factors. In final models where disease conditions were adjusted for, BMI (β = 0.743, p < .001) and waist-height ratio (β = 0.719, p < .001) associations with the CES-D score remained significant. In stratified analyses, relationships between measures of adiposity and depression were found to be stronger in females (BMI: β = 0.806, p = .007; waist-height ratio: β = 0.768, p = .01) than males (BMI: β = 0.573, p = .049; waist-height ratio: β = 0.593, p = .044) but no effect modification was identified.

CONCLUSIONS

These findings suggest that increased adiposity is significantly associated with poorer mental health, independent of lifestyle factors and disease conditions. Targeted interventions for reducing depression should include better population-level weight management measures.

Characteristics of Patients Who Complete Suicide and Suicide Attempts While Undergoing Treatment in Norway: Findings from Compensation Claims Records

The aim of this study was to identify characteristics that differentiate patients who complete suicide (SC) from patients with suicide attempts (SA) while undergoing treatment in Norway. We examined data from the Norwegian System of Patient Injury Compensation (Norsk Pasientskade Erstatning-NPE). Data were extracted from NPE case records from a 10-year period (2009-2019) for 356 individuals who attempted (n = 78) or died by (n = 278) suicide. The two groups differed significantly in the types of medical errors identified by experts. Inadequate suicide risk assessment tended to be proportionally and significantly more prevalent among SC compared to SA. There was a weak but significant trend that SA had received medication only, whereas SC had received both medication and psychotherapy. There were no significant differences with respect to age group, gender, diagnostic category, number of previous suicide attempts, inpatient/outpatient status, or category of responsible clinic. We conclude that suicide attempters and suicide completers differed in terms of identified medical errors. Focusing on the prevention of these and other types of errors could help to reduce the number of suicides of patients in treatment.

People with serious mental illness are at higher risk for acute care hospitalization in Israel, 2000-2019

BACKGROUND

People with severe mental disorders have higher mortality rates and more chronic physical conditions than the general population. Recent reforms in the Israeli mental health system included reducing the number of psychiatric hospital beds ("Structural Reform"), establishing community- based rehabilitation services ("Rehabilitation Reform"), and the transfer of governmental responsibility to the Health Maintenance Organizations (HMOs) ("Insurance Reform"). We examined how these changes have impacted the physical health of people with severe mental illness as reflected in acute care hospitalizations.

METHODS

Data from the National Psychiatric Case Register were linked with data from the National Hospital Discharges Database for 2000-2019. Acute care discharges from public hospitals were identified for people who had a psychiatric hospitalization with a diagnosis of severe mental illness (SMI, ICD-10 codes F10-F69 or F90-F99) within the preceding 5 years. The discharge rate of SMI patients was compared to that of the total population by age, diagnosis group, and period of hospitalization. Total and age-standardized discharge ratios (SDR) were calculated, using indirect standardization.

RESULTS

The SDR for total acute care hospitalizations showed that discharge rates in 2016-2019 were 2.7 times higher for the SMI population than expected from the total population. The highest SDR was for external causes (5.7), followed by respiratory diseases (4.4), infectious diseases (3.9), skin diseases (3.7) and diabetes (3.3). The lowest SDR was for cancer (1.6). The total discharge rate ratio was lowest at ages 65-74 (2.2) and highest at ages 45-54 (3.2). The SDR was lowest for females at ages 25-34 (2.1) and for males at ages 18-24 (2.3). SDRs increased over the study period for all diagnoses. This increasing trend slowed at the end of the period, and between 2012-2015 and 2016-2019 there was a small decrease for skin and liver diseases, the SDR was stable for cancer and the increase was smaller for respiratory, infectious and circulatory diseases and diabetes.

CONCLUSION

This study showed higher hospitalization rates in people with SMI compared to the total population. These differences increased between 2000 and 2019 following the opening of alternative services in the community, possibly due to a higher likelihood of psychiatric hospitalization only for those with more severe mental disease. We recommend that general practitioners and mental health professionals in the community be made aware of the essential importance of good physical healthcare, and collaborate on health promotion and disease prevention in the SMI population.

Patients Who Die by Suicide: A Study of Treatment Patterns and Patient Safety Incidents in Norway

Underlying patterns and factors behind suicides of patients in treatment are still unclear and there is a pressing need for more studies to address this knowledge gap. We analysed 278 cases of suicide reported to The Norwegian System of Patient Injury Compensation, drawing on anonymised data, i.e., age group, gender, diagnostic category, type of treatment provided, inpatient vs. outpatient status, type of treatment facility, and expert assessments of medical errors. The data originated from compensation claim forms, expert assessments, and medical records. Chi-square tests for independence, multinominal logistic regression, and Bayes factors for independence were used to analyse whether the age group, gender, diagnostic category, inpatient/outpatient status, type of institution, and type of treatment received by patients that had died by suicide were associated with different types of medical errors. Patients who received medication tended to be proportionally more exposed to an insufficient level of observation. Those who received medication and psychotherapy tended to be proportionally more exposed to inadequate treatment, including inadequate medication. Inpatients were more likely to be exposed to inappropriate diagnostics and inadequate treatment and follow up while outpatients to insufficient level of observation and inadequate suicide risk assessment. We conclude that the patients who had received medication as their main treatment tended to have been insufficiently observed, while patients who had received psychotherapy and medication tended to have been provided insufficient treatment, including inadequate medication. These observations may be used as learning points for the suicide prevention of patients in treatment in Norwegian psychiatric services.

Addressing Dual Disorders in a Medium-Term Admission Unit

Due to the significant functional repercussions suffered by patients with dual disorder, we must evaluate which ones can benefit from intensive rehabilitative therapies in medium-stay psychiatric units. This was a retrospective study of patient medical records which intended to analyze sociodemographic and clinical variables and parameters related to the hospitalization and discharge of patients admitted to the Medium-Stay Unit (MSU) at the Castellón Provincial Hospital Consortium over 2 years (2017 and 2018), according to the presence or absence of dual disorders in these patients. Patients with a dual disorder represented 55.2% of the hospitalized patients. A higher proportion of them were male, were relatively younger, and had an earlier onset of mental illness, fewer associated medical pathologies, and shorter hospital admission times to the Short-Term Hospitalization Unit than those who did not present a dual disorder. A diagnosis on the schizophrenia spectrum with cannabis use or polyconsumption was the most common diagnosis; 98.2% of all the patients responded adequately to admission to the MSU. This work highlighted the need for higher doses of depot paliperidone in patients with dual disorders.

Cross-sectional mixed-methods study protocol exploring the enablers and barriers for people with severe and enduring mental illness in Jamaica when accessing healthcare for chronic physical illness

INTRODUCTION

Extant international research suggests that people with severe and enduring mental illness (PWSEMI) experience increased rates of chronic physical illness (CPI), reduced life expectancy and higher mortality than those in the general population. The high prevalence of CPI among PWSEMI is associated with a number of barriers that this population experiences when accessing physical healthcare. Although substantial research has been conducted in North America, Europe and Australia, there appears to be a paucity of research exploring CPI among PWSEMI in the Caribbean region, although this region has reported very high rates of non-communicable diseases within its populations. The current study will be situated in Jamaica and will explore the enablers and barriers to PWSEMI accessing healthcare for CPI.

METHODS AND ANALYSIS

A convergent mixed-method design will explore the enablers and barriers to accessing healthcare for CPI among PWSEMI. This cross-sectional study will collect data from PWSEMI, caregivers and family members, community health aides, primary care physicians, psychiatrists and health policymakers.

ETHICS AND DISSEMINATION

The study findings will provide baseline data describing the prevalence of CPI among PWSEMI in Jamaica and will identify enablers for, and barriers to, PWSEMI accessing CPI care. Findings will be disseminated widely in Jamaica and internationally to key stakeholders through publications and conferences. Institutional ethical approval was granted from Jamaica's Ministry of Health and Wellness Medico-legal Ethics Review Panel (# 2019/49), the Curtin University Human Research and Ethics Committee (HRE 2020-0022) and the University of the West Indies FMS Ethics Committee (ECP 101, 19/20).

Factors that influence participation in physical activity for anxiety or depression: a synthesis of qualitative evidence

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Main objective: To identify the factors that create barriers or facilitate physical activity for people with a diagnosis of anxiety or depression from the perspectives of service users, carers, service providers and practitioners to help inform the design and implementation of interventions that promote physical activity.

The overall aim of this review is to identify, appraise, and synthesise qualitative research evidence on the barriers and facilitators to engaging in physical activity in general lifestyle settings or as part of an intervention designed to increase physical activity for people with anxiety and depression. This will allow us to identify factors that create barriers and facilitators of physical activity in this population to inform the development, design, and implementation of future interventions. We will also integrate the findings from the QES with the two associated effectiveness reviews (Cooney 2014 ; Larun 2006 ). We will communicate our findings to public health commissioners and other stakeholders.

Impact of mental illness on care for somatic comorbidities in France: a nation-wide hospital-based observational study

AIMS.

People with a mental illness have a shorter lifespan and higher rates of somatic illnesses than the general population. They also face multiple barriers which interfere with access to healthcare. Our objective was to assess the effect of mental illness on the timeliness and optimality of access to healthcare for somatic reasons by comparing indicators reflecting the quality of prior somatic care in hospitalised patients.

METHODS.

An observational nation-wide study was carried out using exhaustive national hospital discharge databases for the years 2009-2013. All adult inpatient stays for somatic reasons in acute care hospitals were included with the exception of obstetrics and day admissions. Admissions with coding errors were excluded. Patients with a mental illness were identified by their admissions for a psychiatric reason and/or contacts with psychiatric hospitals. The quality of prior somatic care was assessed using the number of admissions, admissions through the emergency room (ER), avoidable hospitalisations, high-severity hospitalisations, mean length of stay (LOS) and in-hospital death. Generalised linear models studied the factors associated with poor quality of primary care.

RESULTS.

A total of 17 620 770 patients were included, and 6.58% had been admitted at least once for a mental illness, corresponding to 8.96% of hospital admissions. Mentally ill patients were more often hospitalised (+41% compared with non-mentally patients) and for a longer LOS (+16%). They also had more high-severity hospitalisations (+77%), were more often admitted to the ER (+113%) and had more avoidable hospitalisations (+50%). After adjusting for other covariates, regression models found that suffering from a mental illness was significantly associated with a worse state for each indicator of the quality of care except in-hospital death.

CONCLUSION.

Inadequate primary care of mentally ill patients leads to more serious conditions upon admission to hospital and avoidable hospitalisations. It is, therefore, necessary to improve primary care and prevention for those patients.

Teaching psychiatry to large groups in society

BACKGROUND

There is a need to educate a range of professionals in caring for individuals with long-term mental disability who reside within our communities. Empathy alone is insufficient. The Kognus 4-Step Education Program was developed to achieve this goal.

METHOD

The program consisted of independent courses, including an 18-session basic course on psychiatric disability (on-site or online), advanced courses, and highly specialized training programs (Nidotherapy/Peer Consultation). Experts lectured together with clients with psychiatric disabilities. We first report Swedish reforms in which institutionalized patients were relocated to semi-independent individual households. We then describe the design and implementation of the education program. Approximately 50% of participants who were younger than 36 years old lacked any healthcare education. The participants' backgrounds, perceptions, participation in the education program, and costs are presented.

RESULTS

Between 2009 and 2014, 8959 participants attended the Kognus psychiatry courses online or on-site in Stockholm (basic on-site course, n = 2111; online course, n = 4480; advanced courses, n = 2322; highly specialized programs, n = 46). A total of 73% of the participants satisfactorily attended the basic sessions on-site compared with 11% of the online participants. The developers conducted the education program for the first 3 years. Thereafter, another course provider continued the program with other types of participants. The program was perceived to be equally interesting and meaningful to participants with low and high levels of education, demonstrating the generalizability of the program. The quality of the basic and advanced courses was rated as 4.4 and 4.3, respectively, on a 5-point Likert scale.

CONCLUSIONS

Personnel without appropriate education who work with people with psychiatric/intellectual disabilities can be educated in large numbers. The Kognus program represents a novel and successful way of training people who have no formal education about some essentials of good mental healthcare. Moreover, the model can be easily implemented elsewhere.

Epidemiology of severe mental illness in Hunan province in central China during 2014-2015: A multistage cross-sectional study

Objective

Severe mental illness (SMI) represents major social and public health problem in China, especially in low- or middle-income regions. We aim to assess the prevalence and distribution of SMI in Hunan province in central China.

Methods

Multistage stratified random sampling methods were used to select qualified subjects in 123 districts and counties in Hunan province. 89465 individuals were randomly identified, and 72999 (81.6%) completed the supplemental 12-Item General Health Questionnaire (GHQ-12) and Cue questionnaire of psychiatric abnormal behaviors. 6082 suspected individuals having high or moderate risk, or psychiatric cues, were administered the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) by psychiatrists.

Results

720 respondents were definitely diagnosed as SMI. The 1-month and lifetime prevalence was 9.35‰ and 10.10‰, respectively. The most frequent SMI was schizophrenia, followed by bipolar disorder, intellectual disability, epileptic mental disorder, paranoid psychosis and schizoaffective disorders, with 1-month prevalence ranging from 0.11‰ to 6.50‰ and lifetime prevalence ranging from 0.24‰ to 6.86‰. Multivariate logistic regression analysis revealed that lower education, farmer occupation, retirees or jobless/unemployed, unmarried or divorced and age of 30–64 years old were major factors that associated with the increased risk of SMI. In addition, only 33.3% of 528 patients who completed questionnaire sought help in psychiatric institutions, and up to 51.7% of 720 patients were not referred to the SMI management system in Hunan province.

Conclusions

These findings provided a large-scale prevalence data of SMI in a provincial sample of China. The psychiatric disorders brought economical and psychological burden for family and society, which may shed light on the significance of scaling up province-wide mental health service and strengthening the SMI management.

Medical Co-morbidities Among Patients with Severe Mental Illnesses in a Community Health Facility in Nigeria

To examine prevalence of medical comorbidity (MCM) in schizophrenia (n = 1310) and in bipolar disorder (n = 1307) and the association of high burden of MCM (≥3 MCM) with duration of untreated illness, number of episodes, functioning, poly-medication and lifetime hospitalization for the mental disorder. Participants were recruited from a private psychiatric facility in Ibadan, Nigeria between 2004 and 2013 and enquiry made about the lifetime occurrence of 20 common chronic diseases including common tropical diseases. Psychiatric diagnosis was made using the Structured Clinical Interview for DSM IV Axis I disorder (SCID). Except for nutritional anemia, dermatitis and intestinal Helminthiasis, patients with schizophrenia were not at higher odds of reporting MCM than those with bipolar disorder. DUI ≥2 years, episodes of illness ≥3, being on multiple neuroleptics and history of previous hospitalization were significantly associated with high burden of MCM in schizophrenia and episodes of illness ≥3, reduced functioning and history of previous hospitalization with bipolar disorder. Schizophrenia and bipolar disorder are associated with high rates of medical comorbidity. Treatment of this medical comorbidity is essential in order to improve the outcomes for patients with bipolar disorder and schizophrenia.

Risk Estimates and Risk Factors Related to Psychiatric Inpatient Suicide-An Overview

People with mental illness have an increased risk of suicide. The aim of this paper is to provide an overview of suicide risk estimates among psychiatric inpatients based on the body of evidence found in scientific peer-reviewed literature; primarily focusing on the relative risks, rates, time trends, and socio-demographic and clinical risk factors of suicide in psychiatric inpatients. Psychiatric inpatients have a very high risk of suicide relative to the background population, but it remains challenging for clinicians to identify those patients that are most likely to die from suicide during admission. Most studies are based on low power, thus compromising quality and generalisability. The few studies with sufficient statistical power mainly identified non-modifiable risk predictors such as male gender, diagnosis, or recent deliberate self-harm. Also, the predictive value of these predictors is low. It would be of great benefit if future studies would be based on large samples while focusing on modifiable predictors over the course of an admission, such as hopelessness, depressive symptoms, and family/social situations. This would improve our chances of developing better risk assessment tools.

Excess Mortality in Patients with Severe Mental Disorders in 1996-2010 in Finland

Unselected population-based nationwide studies on the excess mortality of individuals with severe mental disorders are scarce with regard to several important causes of death. Using comprehensive register data, we set out to examine excess mortality and its trends among patients with severe mental disorders compared to the total population. Patients aged 25-74 and hospitalised with severe mental disorders in 1990-2010 in Finland were identified using the national hospital discharge register and linked individually to population register data on mortality and demographics. We studied mortality in the period 1996-2010 among patients with psychotic disorders, psychoactive substance use disorders, and mood disorders by several causes of death. In addition to all-cause mortality, we examined mortality amenable to health care interventions, ischaemic heart disease mortality, disease mortality, and alcohol-related mortality. Patients with severe mental disorders had a clearly higher mortality rate than the total population throughout the study period regardless of cause of death, with the exception of alcohol-related mortality among male patients with psychotic disorders without comorbidity with substance use disorders. The all-cause mortality rate ratio of patients with psychotic disorders compared to the total population was 3.48 (95% confidence interval 2.98-4.06) among men and 3.75 (95% CI 3.08-4.55) among women in the period 2008-10. The corresponding rate ratio of patients with psychoactive substance use disorders was 5.33 (95% CI 4.87-5.82) among men and 7.54 (95% CI 6.30-9.03) among women. Overall, the mortality of the total population and patients with severe mental disorders decreased between 1996 and 2010. However, the mortality rate ratio of patients with psychotic disorders and patients with psychoactive substance use disorders compared to the total population increased in general during the study period. Exceptions were alcohol-related mortality among patients with psychoactive substance use disorders and female patients with psychotic disorders, as well as amenable mortality among male patients with psychotic disorders. The mortality rate ratio of persons with mood disorders compared to the total population decreased. The markedly high mortality amenable to health care intervention among patients with severe mental disorders found in our study suggests indirectly that they may receive poorer quality somatic care. The results highlight the challenges in co-ordinating mental and somatic health services.

Barriers and facilitators to primary care for people with mental health and/or substance use issues: a qualitative study

Background

Mental health and/or substance use issues are associated with significant disparities in morbidity and mortality. The aim of this study was to identify the mechanisms underlying poor primary care access for this population.

Method

This was a community-based participatory action qualitative study, in which 85 adults who self-identified as having a serious mental health and/or substance use issue and 17 service providers from various disciplines who worked with this population participated in a semi-structured interview.

Results

Client, service provider and health system barriers to access were identified. Client factors, including socioeconomic and psychological barriers, make it difficult for clients to access primary care, keep appointments, and/or prioritize their own health care. Provider factors, including knowledge and personal values related to mental health and substance use, determine the extent to which clients report their specific needs are met in the primary care setting. Health system factors, such as models of primary care delivery, determine the context within which both client and service provider factors operate.

Conclusions

This study helps elucidate the mechanisms behind poor primary health care access among people with substance use and/or mental health issues. The results suggest that interdisciplinary, collaborative models of primary healthcare may improve accessibility and quality of care for this population, and that more education about mental health and substance use issues may be needed to support service providers in providing adequate care for their clients.

Predictors of natural and unnatural mortality among patients with personality disorder: evidence from a large UK case register

BACKGROUND

People with personality disorder have reduced life expectancy, yet, within this population, little is known about the clinical predictors of natural and unnatural deaths. We set out to investigate this, using a large cohort of secondary mental health patients with personality disorder.

METHODS

We identified patients with an ICD-10 diagnosis of personality disorder, aged ≥15 years in a large secondary mental healthcare case register. The case register was linked to national mortality tracing. Using Cox regression, we modelled the effect of a number of pre-specified clinical variables on all-cause, natural cause and unnatural cause mortality.

FINDINGS

2,440 patients were identified. Eighty-five deaths (3.5% of cohort) occurred over a 5-year observation period, of which over 50% were from natural causes. All-cause mortality was associated with alcohol or drug use (adjusted Hazard Ratio [aHR] 2.3; 95% CI 1.3-4.1), physical illness (aHR 1.9; 95% CI 1.0-3.6), and functional impairment (aHR 1.9; 95% CI 1.0-3.6). Natural cause mortality was associated with mild problems of alcohol or drug use (aHR 3.4; 95% CI 1.5-7.4), and physical illness (aHR 2.4; 95% CI 1.0-5.6). Unnatural cause mortality was associated only with severe alcohol or drug use (aHR 3.1; 95% CI 1.3-7.3).

INTERPRETATION

Alcohol and drug use, physical illness, and functional impairment are predictors of mortality in individuals with personality disorder. Clinicians should be aware of the existence of problems in these domains, even at mild levels, when assessing the needs of patients with personality disorder.

Excess mortality after disability retirement due to mental disorders: variations by socio-demographic factors and causes of death

PURPOSE

Mental disorders are the key causes of disability retirement and are associated with a high risk of mortality. Social variations in excess mortality after disability retirement are nevertheless poorly understood. We examined socio-demographic differences in all-cause and cause-specific mortality after disability retirement due to depression and other mental disorders.

METHODS

The data comprised a nationally representative sample of the Finnish population aged 25-64 in 1996 with no prior disability retirement due to mental disorders (N = 392,985). We used Cox regression analysis with disability retirement due to mental disorders as a time-varying covariate and mortality between 1997 and 2007 as the outcome variable.

RESULTS

We found excess mortality after disability retirement due to mental disorders as compared to those with no such retirement in all specific causes of death, in particular alcohol-related causes, suicide, and other unnatural causes. Excess suicide mortality was particularly large after depression-based disability retirement. Younger age groups, non-manual classes, and those living with a partner and children had largest excess mortality, especially from unnatural and alcohol-related causes. However, the absolute number of excess deaths was not always largest in these socio-demographic groups.

CONCLUSIONS

In young adulthood, disability retirement due to depression signifies severe health and other social disadvantages that lead to particularly large excess mortality, especially due to unnatural causes. The protective effects of a high socioeconomic position and family ties against unnatural and alcohol-related deaths are limited among those who have already developed depression or other mental disorders that have led to disability retirement.

Sex differences in mortality of admitted patients with personality disorders in North Norway--a prospective register study

BACKGROUND

It is well established that patients with serious mental disorders have higher mortality than the general population, yet there are few studies on mortality of both natural and unnatural causes in patients with personality disorders. The aim of this study was to investigate the mortality of in-patients with personality disorder diagnosis in a 27-year follow-up cohort in North Norway, with a special focus on gender differences.

METHOD

Based on a hospital case register covering 1980 to 2006, 284 female and 289 male patients were included. The cohort was linked to the Norwegian Cause of Death Registry for information concerning mortality. The mortality rates were adjusted for age by applying a Poisson regression model. The relative mortality in men compared to women was tested with Cox regression with attained age as the time variable. The number of deaths to be expected among the patients if the mortality rates of the general population in Norway had prevailed was estimated and excess mortality, expressed by the standardized mortality ratio (SMR), calculated.

RESULTS

When compared to the mortality in the general population, men and women with personality disorder diagnoses had 4.3 (95% CI: 3.2-5.9) and 2.9 (95% CI: 1.9-4.5) times, respectively, increased total mortality. Patients with personality disorder diagnoses have particularly high mortality for unnatural deaths; 9.7 (95% confidence interval (CI): 6.3-15.1) times higher for men and 17.8 (95% CI: 10.1-30.3) for women, respectively, and even higher for suicides--15 (95% CI: 9-27) for men and 38 (95% CI: 20-70) for women. The mortality due to natural causes was not statistically significantly increased in women, whereas men had 2.8 (95% CI: 1.8-4.4) times higher mortality of natural deaths than the general population.

CONCLUSION

Compared to the general population, patients with a personality disorder have high mortality, particularly mortality from unnatural causes. The number of deaths caused by suicides is especially high for women. Men also have higher mortality of natural causes than the general population.