Abstract
Background
Higher mortality risks among carriers of mental disorders are well recognized and these may get even worse over time. Schizophrenia is often referred to as one of the most severe mental disorders, primarily because of its very high morbidity and mortality rates. Substance use is commonly comorbid to other mental illness and they mutually amplify the risk to premature death, often by suicide. Despite the importance of this portrait, mortality rates in low- and middle-income countries are unknown. The aims of this study were: to quantify the mortality risk in Brazilian psychiatric patients after hospital admission with a follow-up of at least nine-year and to investigate temporal trends in mortality risk and predictive factors associated with mortality.
Methods
This is a cohort of patients firstly admitted to the public mental health inpatient services of the Ribeirão Preto catchment area (São Paulo, Brazil). This catchment area consists of 25 cities (estimated population of 1,327,989 inhabitants) and 108 psychiatric beds: 6 in an emergency hospital, 22 in psychiatric wards in a general hospital and 80 in a psychiatric hospital. All patients admitted to an inpatient psychiatric unit between January 1st 2002 and December 31st 2007 was included and vital status and death causes were determined up to December 31st 2016. The date and causes of the death were collected from the SEADE Foundation (Brazilian cause of death official registry). The observed number of deaths was compared with the expected number of deaths in the general population. Crude mortality rates (CMR) and standardized mortality ratios (SMR) adjusted for age and sex were computed. A survival analysis from hospital discharge to death or end of observation was also computed.
Results
In the period 2002–2007, 4,604 patients were admitted (mean age 37.4 years, standard deviation 14.5 years, 54.5% male) and until December 31st 2016, 1,044 died (mean age 52.9 years, standard deviation 16.1 years, 69.2% male). Mortality risk was higher in males (CRM = 28.75 and SMR = 41.58; 95% CI 34.58–49.70) than in females (CRM = 15.38 and SMR = 30.45; 95% CI 23.15–39.65). There was a significant sex difference in the survival; male survival was much lower than female survival (log-rank test; p<0.01). Individuals aged less than 50 years were at higher risk in both sexes. The decline in the survival curve was faster at the early years after the hospital discharge. Regarding the most prevalent diagnoses, 1,427 (31.0%) received the diagnoses of affective disorders (ICD-10 F30-F39), 1,045 (22.7%) had diagnosis of schizophrenia and other psychotic disorders (ICD-10 F20-F29), while 1,137 (24.7%) had substance use related disorders (ICD-10 F10-F19). One hundred and seventy eight (20.5%) inpatients died from unnatural causes, such as suicides, murders and accidents (ICD-10 V01-Y98). We highlight that 43 of them (4.1%) committed suicide (ICD-10 X60-X84) during the follow-up period. Taken together, the patient’s group with schizophrenia and those with substance use have a 1.66-fold increased risk of death compared to other mental disorders.
Discussion
The present study shows the impact of mental disorders on mortality in a Brazilian cohort followed for at least nine-year. We found higher mortality rates in Brazilian psychiatric patients when compared to rates in other countries: Finland: 23.9; France: 14; Netherlands: 22.2; New Zealand: 12.3; Norway: 17.1; United Kingdom: 16.2 and Italy: 6.5. Causes of natural death were more prevalent in our cohort. Notwithstanding, preventing unnatural causes of death is an important objective. Young men with mental disorders should be a priority group to be approached with health-directed preventive measures.
The case of inorganic hypersomnia treated with light therapy in the course of schizoaffective disorder