Psychiatric Admission and Mortality Risk
Overview
The study investigated the impact of clinical characteristics on mortality risk among patients admitted to a psychiatric acute ward at Haukeland University Hospital in Bergen, Norway, between 2005 and 2014. A total of 6,125 patients were included in the prospective total-cohort study, with clinical interviews conducted upon first admission and subsequent follow-up for up to 15 years through the Norwegian Cause of Death Registry.
Results revealed that higher age, male sex, unemployment, cognitive deficits, and physical illness were associated with an increased risk of natural death. Conversely, male sex, lack of a partner, physical illness, suicide attempts, and excessive use of alcohol and illicit substances were linked to a heightened risk of unnatural death.
Interestingly, psychiatric symptoms, barring suicide attempts, did not demonstrate a significant association with increased mortality risk. The findings underscored the importance of addressing modifiable risk factors related to physical health, as well as curtailing the excessive use of alcohol and illicit substances, in efforts to mitigate the heightened mortality risk observed among individuals with mental disorders.
In conclusion, the study highlights the need for targeted interventions aimed at addressing the modifiable risk factors identified, rather than solely focusing on psychiatric symptoms, to effectively reduce mortality risk among individuals with mental health conditions. This nuanced approach could lead to more tailored and impactful strategies for improving the overall health outcomes of this vulnerable population.
Introduction
The impact of mental disorders on mortality rates is profound, with studies indicating a potential reduction in life expectancy by 10–20 years among individuals with severe mental illnesses. Despite advancements in understanding these disorders, the risk of premature death remains alarmingly high and has even escalated in recent years. Physical illnesses are the primary contributors to mortality in individuals with mental disorders, accounting for approximately 70%–80% of deaths. This heightened mortality risk, two to three times higher than the general population, stems from a combination of factors.
Severe mental illnesses like schizophrenia and bipolar disorder are linked to an elevated risk of cardiovascular disease and diabetes, partly due to genetic predispositions and unhealthy lifestyle factors such as sedentary behavior, poor diet, substance abuse, and smoking. Additionally, individuals with mental disorders often exhibit lower levels of physical health literacy, which may further exacerbate their susceptibility to physical health complications. The suboptimal follow-up care for physical illnesses among this population also contributes to increased mortality rates.
Furthermore, the use of psychotropic medications, particularly antipsychotics, can pose additional risks, including myocardial infarction, cerebrovascular events, and sudden cardiac death. However, non-adherence to antipsychotic medications may also elevate mortality risk, highlighting the complex interplay between medication management, lifestyle factors, and disease severity.
Unnatural deaths, such as suicides, accidents, and drug overdoses, are disproportionately prevalent among individuals with mental disorders. Substance abuse, often co-occurring with mental illness, significantly contributes to these fatalities. Additionally, psychiatric symptoms like depression, hallucinations, and delusions, along with factors like impulsivity and poor problem-solving skills, increase the risk of self-harm and suicide. Moreover, individuals with mental disorders are more susceptible to accidents and violent crimes, partly due to impaired judgment and socio-economic factors.
Identifying modifiable risk factors associated with premature death in this population is crucial. While psychiatric diagnoses offer some insights, focusing on specific symptoms, functional impairments, and lifestyle factors may enhance the precision of risk assessment and intervention strategies. In a study examining the impact of various factors on mortality risk among patients admitted to psychiatric wards, psychiatric symptoms were not consistently associated with increased mortality risk. However, modifiable factors such as physical illness, substance abuse, and medication non-adherence emerged as significant predictors of mortality.
In conclusion, addressing modifiable risk factors and improving access to comprehensive healthcare for individuals with mental disorders are essential steps toward reducing mortality rates in this vulnerable population. Further research focusing on refining risk assessment tools and interventions tailored to individual needs is warranted.
Method
This study, drawn from the Suicidality in Psychiatric Emergency Admissions (SIPEA-II) investigation, encompassed 7,000 patients admitted to the psychiatric emergency ward at Haukeland University Hospital in Bergen, Norway, between May 1st, 2005, and June 15th, 2014. Covering around 95% of acute psychiatric hospitalizations in a catchment area of approximately 400,000 people, the study aimed to comprehensively explore the relationship between various clinical factors and suicidal behavior.
Patients underwent clinical interviews, primarily at their index admission, conducted by healthcare professionals trained in relevant rating scales. Sociodemographic data such as age, sex, marital status, and educational level were recorded, along with assessments of psychiatric symptoms, physical health, addiction, medication adherence, cognitive function, and social functioning.
The Health of the Nation Outcome Scales (HoNOS) served as a key instrument for evaluating symptoms and functional status across various domains. Additionally, questions regarding suicidal ideation, suicide attempts, and non-suicidal self-harm were included, with binary responses (yes/no) distinguishing between intent to die in self-harm acts.
Assessment of alcohol and drug use utilized the Alcohol Use Scale (AUS) and Drug Use Scale (DUS), respectively, while retrospective queries addressed psychotropic medication adherence. Data on patient mortality and causes of death were retrospectively collected from the Norwegian Cause of Death Registry.
Deaths were categorized as natural or unnatural, with unnatural causes encompassing suicide, accidents, poisoning, and homicide, while natural deaths included those resulting from somatic diseases. This comprehensive approach allowed for a thorough examination of factors associated with suicidal behavior among psychiatric emergency admissions, providing valuable insights for clinical practice and suicide prevention efforts.
Statistical Analysis
The study employed Fine-Gray competing risks regression models to assess the relationship between clinical characteristics observed at the index admission and the risk of natural and unnatural death, treated as competing endpoints. Both multivariate and univariate analyses were conducted, incorporating a range of variables encompassing clinical characteristics such as physical illness, cognitive problems, mood disturbances, behavioral issues, and socio-demographic factors including age, sex, marital status, employment status, education level, and living arrangement. Sensitivity analyses, incorporating psychiatric diagnoses based on ICD-10 criteria, were also conducted to enhance the robustness of the findings.
To address missing data, multiple imputation techniques were employed under the assumption of missing at random (MAR). A total of 20 datasets were generated in the imputation model to mitigate the impact of missing values on the analysis. Furthermore, multicollinearity among the variables was carefully examined to ensure the validity of the regression models.
The statistical software R version 4.0.2 along with specialized packages such as survival and tidycmprsk were utilized for conducting the intricate statistical analyses. These tools enabled the researchers to effectively explore the associations between clinical characteristics and the risk of mortality, considering both natural and unnatural causes of death as competing risks.
Result
The study sample’s clinical and socio-demographic characteristics were comprehensively outlined, revealing a mean follow-up period of 9.5 years and a mortality rate of 22.5%. Among the deceased, 65.5% succumbed to natural causes, 30.4% to unnatural causes, while the causes remained unknown for 4.1%. Notably, the mortality rates for natural and unnatural deaths per 100,000 patient years were 1551 and 721, respectively.
Competing risks models elucidated significant associations between various factors and the risk of natural death. Age exhibited a notable positive correlation, with a 7% increase in mortality risk per year. Cognitive problems and physical illness, including disability, were linked to a 14% and 25% higher risk of natural death, respectively. Conversely, female sex and employment status were associated with 32% and 48% lower risks of natural death, respectively. Additionally, a history of depressed mood, non-suicidal self-harm, and suicide attempts prior to admission were associated with decreased risks of natural death.
Conversely, the analysis for unnatural death revealed distinct associations. Suicide attempts prior to admission were linked to a 62% increased risk of unnatural death, while excessive use of alcohol and illicit substances correlated with higher risks. Female sex and having a partner were associated with lower risks of unnatural death. Furthermore, problems with living conditions and certain behaviors were linked to decreased risks of unnatural death.
Despite the meticulous analysis, certain factors such as age, education level, employment status, and various psychiatric disorders did not exhibit statistically significant associations with the risk of unnatural death.
In conclusion, the study’s findings shed light on the multifaceted determinants of natural and unnatural deaths, providing valuable insights for healthcare professionals in risk assessment and preventive strategies. Further research may delve deeper into the interplay of these factors to enhance understanding and mitigate adverse outcomes.
Conclusion
This study, involving 6,125 patients consecutively admitted to an acute psychiatric ward, aimed to discern risk factors associated with both natural and unnatural death. Noteworthy findings included the correlation between higher age, male sex, unemployment, cognitive deficits, and physical illness with an elevated risk of natural death. Conversely, male sex, lack of a partner, physical illness, suicide attempts, and excessive alcohol/illicit substance use were linked to a heightened risk of unnatural death.
The study’s natural death rates (1551 per 100,000 patient years) and unnatural death rates (721 per 100,000 patient years) indicated higher morbidity and mortality rates compared to previous meta-analyses. Notably, the mean age at death among psychiatric patients (62.8 years) was significantly lower than that of the general population, underscoring a shortened life expectancy in severe mental disorders.
Risk factors for natural death aligned with those in the general population, including older age, physical illness, cognitive impairment, and male sex. Conversely, factors such as employment status and psychiatric symptoms showed nuanced associations. Notably, psychiatric symptoms, excluding suicide attempts, did not elevate the risk of mortality.
In the context of unnatural death, male sex, suicide attempts, physical illness, and substance abuse emerged as key risk factors. However, aggressive behavior and adverse living conditions paradoxically correlated with a reduced risk of unnatural death, suggesting potential protective factors within inpatient settings.
The study’s strengths included its large sample size, long follow-up period, and consideration of clinically relevant variables. However, limitations included a lack of data on certain risk factors, potential residual confounding, and exclusions of non-Norwegian patients.
Clinical implications underscored the importance of addressing modifiable risk factors, particularly physical illness and substance abuse, to mitigate mortality risk in psychiatric patients. The study’s comprehensive insights offer valuable guidance for healthcare professionals in designing targeted interventions to improve patient outcomes and reduce mortality rates in psychiatric settings.
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