Is usage of hypnotics associated with mortality?

ObjectiveTo investigate the influence of hypnotic usage on all-cause and cause-specific mortality in a middle-aged population.MethodsA cohort of 1750 men and 1773 women aged 30–65 years who responded to a postal questionnaire in 1983. The questionnaire included questions about hypnotic usage, sleep duration, sleep complaints, medical conditions, depression, demographic and life style variables. Mortality data for the period 1983–2003 were collected.ResultsRegular hypnotic usage was reported by 1.7% of men and 2.2% of women, and was associated with short sleep, sleeping difficulties, several health problems and depression. During the 20-year follow-up period 379 men (21.5%) and 278 women (15.5%) died. After adjustment for potential risk factors in multivariate analyses regular hypnotic usage was associated with significantly increased risk of all-cause mortality in men (Hazard ratios [HR], 4.54; 95% confidence interval [CI], 2.47–8.37) and in women 2.03 (95% CI, 1.07–3.86). With regard to cause-specific mortality, regular hypnotic usage in men was a risk factor for coronary artery disease death, cancer death, suicide and death from “all remaining causes.” In women it was a risk factor for suicide.ConclusionsOur results show an increased risk of all-cause mortality and cause-specific mortality in regular users of hypnotics.     

Mortality risk in adults with newly diagnosed and chronic epilepsy: a population‐based study

Background: We analyzed mortality in adult patients with newly diagnosed and chronic epilepsy over a 13‐year period. Methods: Eighty‐one patients aged ≥20 years with newly diagnosed epilepsy and 309 adult patients with chronic epilepsy were originally identified from population‐based incidence and prevalence studies conducted in Tartu between 1994 and 1996. Patients with epilepsy were followed until the date of death or until the end of 2007. The standardized mortality ratio (SMR) was analyzed for both cohorts. The influences of age at diagnosis, sex, epilepsy syndrome, seizure type, risk factors and treatment compliance on the SMR were also investigated. Results: The SMR was significantly increased in both cohorts, but was higher in patients with chronic epilepsy (SMR 3.1; 95% confidence interval [CI] 2.5–3.8) relative to patients with newly diagnosed epilepsy (SMR 2.6; 95% CI 1.8–3.5). In the newly diagnosed epilepsy cohort, the increased mortality risk was more pronounced in patients with complex partial seizures (SMR 5.6; 95% CI 2.4–11.0). In the chronic epilepsy cohort, the mortality risk was higher in patients with secondary generalized tonic‐clonic seizures (SMR 3.4; 95% CI 2.5–4.5). Non‐compliant patients had twice the mortality risk (SMR 4.2; CI 95% 2.7–6.2) compared to those who were on anticonvulsant treatment. Conclusions: Mortality rates are higher in people with newly diagnosed and chronic epilepsy. Mortality risks should be discussed with patients with epilepsy, especially if anticonvulsant treatment is refused despite recurrent seizures.     

Cause-specific mortality in adults with unprovoked seizures. A population-based incidence cohort study.

PURPOSE: To determine the cause-specific mortality relative to that expected in a population-based incidence cohort of people with unprovoked seizures. METHODS: The cohort comprises 224 inhabitants of Iceland first diagnosed as suffering from unprovoked seizures during a 5-year period from 1960 to 1964. The expected number of deaths was calculated by multiplying person-years of observation within 5-year age categories for each year from diagnosis through 1995 by cause-specific and sex-specific national death rates for those aged 20 years and above. The standardized mortality ratio (SMR) and 95% confidence intervals (95% CI) were calculated. RESULTS: All-cause mortality was increased among men (SMR 2.25, 95% CI 1.56-3.14) but not women (SMR 0.79, 95% CI 0.38-1.46). Among men, there were 8 deaths from accidents, poisoning and violence observed versus 2.82 expected (SMR 2.84, 95% CI 1.22-5.59) and 4 deaths from suicide versus 0.69 expected (SMR 5.80, 95% CI 1.56-14.84). All-cause mortality for men was still elevated after restriction of analysis to those with seizures of unknown etiology (SMR 1.73, 95% CI 1.05-2.67) with the excess deaths attributable to suicide (SMR 5.26, 95% CI 1.06-15.38). Both males and females with remote symptomatic unprovoked seizures had an increase in all-cause mortality due to excess mortality from all cancers, cerebrovascular disease and accidents. CONCLUSION: When compared with the age-, time-period- and gender-specific mortality in the general population, there is excess mortality in men but not women. The increased mortality for men is partly attributable to excess mortality from accidents and suicides.     

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

Purpose

To investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).

Methods

All residents admitted to Norwegian in- and outpatient specialist health care services during 2009–2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.

Results

Mortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6–4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0–12.0), but increased also for natural causes of death (2.2, 95% CI 2.0–2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.

Conclusion

The SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

     

Excessive mortality and causes of death among patients with personality disorder with comorbid psychiatric disorders

Purpose

Excessive mortality has been seen in patients with personality disorder (PD), but it has not been well-studied when patients also have other psychiatric comorbidities. This study investigated the mortality rates and causes of death in an Asian cohort with PD.

Method

We enrolled patients ≥ 18 years of age with PD as defined by DSM-IV criteria (N = 1172), who had been admitted to a psychiatric service center in northern Taiwan between 1985 and 2008. By linking with the national mortality database (1985–2008), cases of mortality (n = 156, 13.3%) were obtained. We calculated the standardized mortality ratios (SMRs) to estimate the mortality gap between patients with PD and the general population. Stratified analyses of mortality rates by Axis I psychiatric comorbidity and sex were performed.

Results

Borderline PD (n = 391, 33.4%) was the dominant disorder among the subjects. The SMRs for all-cause mortality of PD alone, PD comorbid with non-substance use disorder(non-SUD), and PD comorbid with SUD were 4.46 (95% CI 1.94–6.98), 7.42 (5.99–8.85), and 15.96 (11.07–20.85), respectively. Among the causes of death, the SMR for suicide was the highest (46.92, 95% CI 34.29–59.56). The SMR for suicide in PD patients with comorbid SUD was unusually high (74.23, 95% CI 33.88-114.58). Women had a significant increase in suicide with an SMR of 59.00 (95% CI 37.89–80.11). Men had significant increase in SMRs for cardiovascular disease and gastrointestinal disease.

Conclusions

We found significant synergistic effects of PD and SUD on mortality risk. A personality assessment should be mandatory in all clinical settings to prevent premature death and detect SUD early.

     

Cause‐specific mortality among patients with epilepsy: Results from a 30‐year cohort study

Purpose: Death rates of patients with epilepsy are two to three times higher than expected. The aim of our study was to further delineate the causes and the patterns of premature death in patients with epilepsy. Methods: We included all patients who were prospectively enrolled between 1970 and 1999 in our epilepsy outpatient clinical database. Patients were followed until death or December 31, 2003. Standardized mortality ratios (SMRs) were calculated using reference rates from the same region. Key Findings: After 48,595 person years of follow‐up, 648 of 3,334 patients had died, resulting in an overall SMR of 2.2 (95% confidence interval [CI] 2.0–2.4). The highest SMRs were for patients aged 26–45 years (6.8, 95% CI 3.8–11.2) and with symptomatic epilepsies (3.1, 95% CI 2.3–4.9); those for cryptogenic causes (2.2, 95% CI 1.6–3.1) were also elevated, whereas those for idiopathic causes were not increased (2.7, 95% CI 0.7–7.0) after 2 years of follow‐up. SMRs for patients with persistent seizures (3.3, 95% CI 2.6–4.4) were higher than those for seizure‐free patients (1.4, 95% CI 0.8–2.3). The highest cause‐specific SMRs were for epilepsy (91.6, 95% CI 66.3–123.4), brain tumors (22.7, 95% CI 15.7–31.8), and external causes (2.4, 95% CI 1.8–3.3) at end of study period. Significance: Epilepsy patients have a higher‐than‐expected risk of death throughout life and especially during the first 2 years following diagnosis. Standardized mortality rates were especially high in younger patients and in patients with symptomatic epilepsies. Persistent seizures are strongly related to excess mortality.     

Long-term outcome after aneurysmal subarachnoid hemorrhage—risks of vascular events,death from cancer and all-cause death

Smoking and hypertension are risk factors for aneurysmal subarachnoid hemorrhage (aSAH), but also for other cardiovascular diseases and cancer. Few prospective data are available on the very long term risks of vascular diseases and vascular, cancer-related and overall death after aSAH. We determined vascular events and survival status in 1,765 patients with aSAH admitted to our center from 1985 to 2010. Cumulative risks were estimated with survival analysis. We compared risks of vascular, cancer-related and all-cause death with the general population with standardized mortality ratios (SMRs). Incidences of vascular events and death were compared with those after TIA/minor stroke. Conditional on surviving 3 months after aSAH, the risk of death was 8.7 % (95 % CI 7.3–10.1) within 5 years, 17.9 % (16.1–19.9) within 10 years, 29.5 % (27.3–31.8) within 15 years, and 43.6 % (41.2–46.1) within 20 years after SAH. The SMR for all-cause death was 1.8 (1.6–2.1), for vascular death 2.0 (95 % CI 1.6–2.5) and for cancer-related death 1.2 (0.9–1.5; sensitivity analysis 1.4; 95 % CI 1.1–1.8). The increased SMR for all-cause death persevered up to 20 years after aSAH. Compared with TIA/minor stroke patients, the age- and sex-adjusted cumulative incidence on vascular events was lower for aSAH patients [hazard ratio (HR) 0.48; 95 % CI 0.40–0.57); the HR for all-cause death was 0.96 (95 % CI 0.84–1.10). After aSAH, risks of vascular events and death, and probably also that of cancer-related death, are higher than in the general population. Although the long-term risk of vascular events was lower in aSAH patients than in TIA/minor stroke patients, the risk of death was similar.     

Mortality after temporal lobe epilepsy surgery

Purpose: To report mortality, after a longer interval, in a cohort of patients with drug‐resistant epilepsy treated by temporal lobe surgery between 1975 and 1995. A previous audit of these patients ending December 1, 1997 observed a standardized mortality ratio (SMR) of 4.5. Methods: We analyzed mortality in a cohort of 306 patients with temporal lobe epilepsy (TLE) who underwent temporal lobe resections between December 1, 1975 and December 1, 1995. Deaths occurring after December 1,1997 and until December 1, 2009 were evaluated. Medical records, death certificates, postmortem examination reports, coroner officer’s reports, and coroner’s inquest reports were sought, and causes of death were ascertained. Sudden unexpected death in epilepsy (SUDEP) cases were identified. Key Findings: In 3,569 person‐years of follow‐up 19 deaths occurred, [SMR 2.00, 95% confidence interval (CI) 1.27–3.13], 14 men (SMR 2.01, 95% CI 1.19–3.39) and 5 women (SMR 1.68, 95% CI 0.70–4.03). On analysis of subgroups, SMRs were significantly elevated in patients with mesial temporal sclerosis (MTS) (SMR 2.50, 95% CI 1.38–4.51), men with MTS (SMR 3.12, 95% CI 1.56–6.25), men with nonspecific lesions (SMR 2.68, 95% CI 1.00–7.09), and right‐sided resections in MTS (SMR 3.33, 95% CI 1.39–8.00). During follow‐up, six SUDEP cases were observed with a rate of 1/595 person‐years. Significance: In this cohort, the risk for premature death in patients undergoing TLE surgery decreased over time but remained above the standard population. Men had a slightly higher risk than women, as did right‐sided resections in MTS, confirming this observation in the original cohort. Although lower, the risk of SUDEP remained. Without up‐to‐date information on seizure outcome, we were unable to directly relate this to mortality.     

Associations of shift work and night work with risk of all-cause,cardiovascular and cancer mortality: a meta-analysis of cohort studies

BackgroundEpidemiological studies on the relationship of shift work or night work with risk of total and cause-specific mortality have given conflicting results. We aimed at conducting a meta-analysis to summarize the evidence from cohort studies.MethodsEmbase, PubMed, Web of Science and Scopus databases were searched for eligible studies up to Mar 2021. Cohort studies evaluating the associations of shift work or night work with risk of all-cause, cardiovascular or cancer mortality were reviewed. Study-specific risk estimates were pooled by fixed-effect models when the heterogeneity was not detected; otherwise, random-effect models were employed.ResultsWe identified seventeen eligible articles (sixteen cohorts). A total of 958,674 cohort participants were included, with 38,413 total deaths, 24,713 cardiovascular deaths and 10,219 cancer deaths during follow-up. According to the Newcastle–Ottawa Scale, fifteen studies were considered as relatively high quality with low risk of bias. Compared with regular daytime workers, the pooled relative risks for all-cause, cardiovascular and cancer mortality were 1.02 (95% CI: 0.99, 1.06), 1.18 (95% CI: 0.94, 1.47) and 1.05 (95% CI: 0.83, 1.34) for those ever exposing to shift work, respectively. Compared with daytime workers or those never exposing to night work, the pooled relative risks for all-cause, cardiovascular and cancer mortality were 1.06 (95% CI: 1.03, 1.08), 1.15 (95% CI: 1.03, 1.29) and 1.04 (95% CI: 1.00, 1.08) for those ever exposing to night work, respectively. Moderate to high level of heterogeneity across the studies was detected. Publication bias was not detected.ConclusionNight work may be associated with higher risk of all-cause, cardiovascular and cancer mortality, suggesting that night workers compared with daytime workers may be at higher risk of death, especially due to cardiovascular disease.     

Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort

The United Kingdom National General Practice Study of Epilepsy is a prospective, population-based study of newly diagnosed epilepsy. A cohort of 792 patients has now been followed for up to 14 years (median follow-up [25th, 75th percentiles] 11.8 years, range 10.6-11.7 years), a total of 11,400 person-years. These data are sufficient for a detailed analysis of mortality in this early phase of epilepsy. Over 70% of patients in this cohort have developed lasting remission from seizures, although the mortality rate in the long term was still twice that of the general population. The standardized mortality ratio (SMR), the number of observed deaths per number of expected deaths, was 2.1 (95% confidence interval [CI] = 1.8, 2.4). Patients with acute symptomatic epilepsy (SMR 3.0; 95% CI = 2.0, 4.3), remote symptomatic epilepsy (SMR 3.7; 95% CI = 2.9, 4.6), and epilepsy due to congenital neurological deficits (SMR 25; 95% CI = 5.1, 73.1) had significantly increased long-term mortality rates, whereas patients with idiopathic epilepsy did not (SMR 1.3; 95% CI = 0.9, 1.9). This increase in mortality rate was noted particularly in the first few years after diagnosis. Multivariate Cox regression and time-dependent co-variate analyses were utilized for the first time in a prospective study of mortality in epilepsy. The former showed that patients with generalized tonic-clonic seizures had an increased risk of mortality. The hazard ratio (HR), or risk of mortality in a particular group with a particular risk factor compared to another group without that particular risk factor, was 6.2 (95% CI = 1.4, 27.7; p = 0.049). Cerebrovascular disease (HR 2.4; 95% CI = 1.7, 3.4; p < 0.0001), central nervous system tumor (HR 12.0; 95% CI = 7.9, 18.2; p < 0.0001), alcohol (HR 2.9; 95% CI = 1.5, 5.7; p = 0.004), and congenital neurological deficits (HR 10.9; 95% CI = 3.2, 36.1; p = 0.003) as causes for epilepsy and older age at index seizure (HR 1.9; 95% CI = 1.7,2.0; p < 0.0001) were also associated with significantly increased mortality rates. These hazard ratios suggest that epilepsy due to congenital neurological deficits may carry almost the same risk of mortality as epilepsy due to central nervous system tumors and that epileptic seizures subsequent to alcohol abuse may carry almost the same risk of mortality as epilepsy due to cerebrovascular disease. The occurrence of one or more seizures before the index seizure (the seizure that led to the diagnosis of epilepsy and enrolment in the study) was associated with a significantly reduced mortality rate (HR 0.57; 95% CI = 0.42, 0.76; p = 0.00001). Time-dependent co-variate analysis was used to examine the influence of ongoing factors, such as seizure recurrence, remission, and antiepileptic drug use, on mortality rates in the cohort. Seizure recurrence (HR 1.30; 95% CI = 0.84, 2.01) and antiepileptic drug treatment (HR 0.97; 95% CI = 0.67, 1.38) did not influence mortality rate. There were only 5 epilepsy-related deaths (1 each of sudden unexpected death in epilepsy, status epilepticus, burns, drowning, and cervical fracture), suggesting that death directly due to epileptic seizures is uncommon in a population-based cohort with epilepsy.     

Mortality risk in an adult cohort with a newly diagnosed unprovoked epileptic seizure: a population-based study

PURPOSE: We sought to investigate mortality risk in an adult cohort with newly diagnosed unprovoked epileptic seizures. METHODS: One hundred seven patients who were at least 17 years old and had newly diagnosed unprovoked epileptic seizures were prospectively identified during a period of 20 months between 1985 and 1987. Patients were followed until the date of death or the end of 1996. The standard mortality ratio (SMR) was analyzed in the whole cohort and in the portion of the cohort with recurrent seizures at inclusion. The influences on the SMR of time since diagnosis, sex, age at diagnosis, seizure cause, seizure type, and cause of death were also investigated. RESULTS: The SMR was significantly increased (SMR, 2.5; 95% confidence interval [CI], 1. 2-3.2). This significantly increased risk was found during the first 2 years after diagnosis (year 1: SMR, 7.3; 95% CI, 4.4-12.1; year 2: SMR, 3.6; 95% CI, 1.6-8.1) and at years 9-11 (SMR, 5.4; 95% CI, 2. 7-11.2). The increased mortality risk was most pronounced when the seizures occurred before the age of 60 years. Mortality risk was elevated among patients with remote symptomatic epilepsy (SMR, 3.3; 95% CI, 2.4-4.5) but not idiopathic epilepsy. CONCLUSIONS: There is increased mortality risk in an adult cohort with newly diagnosed unprovoked epileptic seizures. This increase is found in symptomatic patients, young patients, and during the first 2 years after the diagnosis.     

Cause-Specific Mortality in Epilepsy: A Cohort Study of More Than 9,000 Patients Once Hospitalized for Epilepsy

Summary: Purpose: We studied overall and cause-specific mortality rates in a large cohort of patients with epilepsy compared with mortality rates of the general population in the same geographic area.
Methods: The cohort consisted of all patients (N = 9,061) aged >15 years admitted with a diagnosis of epilepsy for inpatient care in Stockholm during the years 1980–1989. All patients were followed in the National Cause-of-Death Register, from which the causes of death were obtained, until December 31, 1992. Thus, 53,520 person-years were observed. Mortality rates were compared with those of the general population of Stockholm.
Results: We observed 4,001 deaths in the cohort, compared with an expected number of 1,109 deaths in the general population. This yielded a standardized mortality ratio (SMR) of 3.6 [95% confidence interval (CI) 3.5–3.71] Although highest in the younger patients, the SMR was significantly increased in all age groups. The excess mortality rate in the cohort was due to a wide range of causes of death, including malignant neoplasms [SMR 2.6 (2.4–2.8)], diseases of the circulatory system, [SMR 3.1 (3.0–3.3)], diseases of the respiratory system [SMR 4.0 (3.64.5)], diseases of the digestive system [SMR 5.1 (4.4–5.8)], and injuries and poisoning [SMR 5.6 (5.0–6.3)].
Conclusions: Our results demonstrate that this large subgroup of patients with a diagnosis of epilepsy, once hospitalized and discharged, is a population at risk, with an excess mortality rate due to several different causes.     

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan

BackgroundJapanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan.MethodsParticipants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants’ prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model.ResultsThe participants included 3.3 times as many men (n = 739) compared to women (n = 227), and their combined mean age was 47.3 (SD = 12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD = 369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio = 3.599, 95% CI [1.041, 12.445]).ConclusionThe all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.     

Long-Term Survival of People with Unprovoked Seizures: A Population-Based Study

Summary: Purpose : Few population-based studies of longterm survival in people with seizures or epilepsy have been made.
Methods: Between January 1, 1960 and December 31, 1964, we identified 224 incidence cases of unprovoked seizures in Iceland and determined survivorship status and date of death for the cases as of January 1, 1996. We compared survivorship with that expected based on data from age-/sex-specific life tables from the country for 1961–1990 and calculated the standardized mortality ratio (SMR).
Results: By 30 years after diagnosis, there were 45 deaths among patients with unprovoked seizures as compared with an expected 28 deaths [standardized mortality ratio (SMR) 1.6; 95% confidence interval (CI) 1.2–2.21. Patients with unprovoked seizures of unknown etiology did not have a significant increase in mortality overall (SMR 1.3, 95% CI 0.8–1.9) or in any time interval. For patients with remote symptomatic un provoked seizures, mortality was increased (SMR 2.3, 95% CI 1.4–3.5). This increase was attributable to excess mortality for the first 15 years after diagnosis (SMR 4.1, 95% CI 2.4–6.6), and SMR was not different after that time.
Conclusions: Survivorship was decreased for the population of patients with unprovoked seizures. The increased mortality was primarily due to excess mortality in patients with remote symptomatic seizures, occurring in the first 15 years after diagnosis. Overall mortality for idiopathic unprovoked seizures was not significantly increased.     

Mortality in adult patients with epilepsy in Taiwan.

To investigate mortality in adult patients with epilepsy in Taiwan, a total of 263 patients with epilepsy aged > or = 17 years, referred to the outpatient epilepsy clinic between 1 Jan and 31 December 1991, were prospectively enrolled and followed up until 31 December 2000. A total of 32 deaths were reported. Overall case-fatality rate was 12.2%. The age-adjusted standard mortality ratio (SMR) was calculated to compare the risk of death in patients with epilepsy to the general population. Patients with epilepsy had a 3.5-fold higher risk of death as compared with the general population (SMR: 3.47, 95% CI: 2.46-4.91). The Cox proportional hazards regression model was used to assess relevant clinical contributions to death. Patients with an age-at-onset > or = 40 years had a 4-fold higher risk of death as compared with those with an earlier onset. The multivariate analysis revealed that age-at-onset between 40 and 59 years, tumor etiology, and being male increased the risk of death in epilepsy. One-third of the deaths in patients with age-at-onset between 40-59 years died of liver cirrhosis and hepatoma. Hepatitis B virus infection is endemic in Taiwan, and this is closely associated with liver cirrhosis and hepatoma. Whether anticonvulsants contributed to the hepatotoxicity that led to fatal liver disease in this group needs further investigation.     

Cause-specific mortality in Finnish forensic psychiatric patients

Purpose: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980–2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths.

Materials and methods: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population.

Results: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7.

Conclusions: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.     

Association of napping and all-cause mortality and incident cardiovascular diseases: a dose–response meta analysis of cohort studies

BackgroundNapping is a habit prevalent worldwide and occurs from an early age. However, the association between napping and the risk of incident cardiovascular disease (CVD) and all-cause mortality remains unclear.MethodsWe conducted a systematic search of Medline, Embase, and Cochrane databases from inception to December 2019 for cohort studies investigating the association between napping and the risk of incident CVD and/or all-cause mortality. Overall estimates were calculated using random-effect models with inverse variance weighting. Dose–response meta-analysis was performed using restricted cubic spline models.ResultsA total of 313,651 participants (57.8% female, 38.9% took naps) from 20 cohort studies were included in the analysis. All-cause mortality was associated with napping overall (HR 1.19, 95% CI 1.12–1.26). Pooled analysis detected no association between daytime nap and incident CVD. However, in subgroup analysis including only participants who were female (HR 1.31, 95% CI 1.09–1.58), older (HR 1.36, 95% CI 1.07–1.72), or took a long nap (HR 1.34, 95% CI 1.05–1.63), napping was significantly associated with a higher risk of CVD. Dose–response analysis showed a J-curve relation between nap time and incident CVD. The HR decreased from 0 to 25 min/day, followed by a sharp increase in the risk at longer times. A positive linear relationship between nap time and all-cause mortality was also observed.ConclusionsLong napping was associated with increased risks of incident CVD and all-cause mortality. Further, large-scale studies and genetic studies need to confirm our conclusion and investigate the underlying mechanisms driving these associations.     

Mortality in a population-based cohort of patients treated with antiparkinsonian drugs

Objectives - A number of studies have been focused on the mortality of parkinsonian patients, as compared with the rest of the population. In these studies, a mortality greater than expected on the basis of mortality of the general population has been shown. Nevertheless, just a few of these studies have investigated in detail the specific causes of death, probably as a consequence of both small cohort sizes and a short time period of observation. The aim of this study was to estimate cause-specific mortality in a cohort of patients treated with antiparkinsonian drugs. Methods - The study was performed on a wide population-based cohort of patients identified and followed-up through the computerized health databases of the Italian province of Rome (about 3,800,000 inhabitants). The follow-up lasted from January 1987 to December 1994. Standardized Mortality Ratios (SMR) were calculated for each specific cause of death, using the Rome province population as reference. Results - A cohort of 10,322 subjects, receiving antiparkinsonian drugs, were identified. There were 4328 deaths on an average follow-up of 5.7 years. This figure was 17% higher than was expected. A gradual decrease in SMR was observed in the oldest age groups. Statistically significant (95%) excesses of death were related to the nervous system (SMR=1037; 95% CI 964–1110), mental disorders (SMR=182; 95% CI 129–246), and endocrine and metabolic diseases (SMR=117; 95% CI 102–133). Lower than expected mortality was found to be caused by malignant neoplasms (SMR=56; 95% CI 51–61). Conclusions - Apart from deaths specifically related to Parkinson's disease, the main differences between our cohort of patients and the general population were related to mortality due to malignant neoplasms and mental disorders. The gradual decrease in SMR for the oldest age groups, seems to indicate a greater reduction of life expectancy for patients with early onset of symptoms. This age-related trend could explain the relatively small excess of mortality, as in our cohort the median age of patients at entry was 74 years.     

Mortality in Schizophrenia and Other Psychoses: A 10-Year Follow-up of the ?SOP First-Episode Cohort

The excess mortality in people with psychotic disorders is a major public health concern, but little is known about the clinical and social risk factors which may predict this health inequality and help inform preventative strategies. We aimed to investigate mortality in a large epidemiologically characterized cohort of individuals with first-episode psychosis compared with the general population and to determine clinical and social risk factors for premature death. All 557 individuals with first-episode psychosis initially identified in 2 areas (Southeast London and Nottinghamshire, United Kingdom) were traced over a 10-year period in the ӔSOP-10 study. Compared with the general population, all-cause (standardized mortality ratio [SMR] 3.6, 95% confidence interval [CI] 2.6–4.9), natural-cause (SMR 1.7, 95% CI 1.0–2.7) and unnatural-cause (SMR 13.3, 95% CI 8.7–20.4) mortality was very high. Illicit drug use was associated with an increased risk of all-cause mortality (adj. rate ratio [RR] 2.31, 95% CI 1.06–5.03). Risk of natural-cause mortality increased with a longer time to first remission (adj. RR 6.61, 95% CI 1.33–32.77). Family involvement at first contact strongly reduced risk of unnatural-cause mortality (adj. RR 0.09, 95% CI 0.01–0.69). Our findings suggest that the mortality gap in people with psychotic disorders remains huge and may be wider for unnatural-cause mortality than previously reported. Efforts should now focus on further understanding and targeting these tractable clinical and social risk factors of excess mortality. Early intervention and dual diagnosis services may play a key role in achieving more rapid remission and carer involvement and addressing substance use problems to reduce excess mortality in psychosis.Key words: schizophrenia/, mortality/, psychosis/, risk factors     

Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa

Background

Bulimia nervosa (BN) is associated with increased mortality. Frequent comorbidities of BN include substance use disorders, affective disorders and personality disorders (PD). These comorbidities may add an additional risk for mortality.

Methods

We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders over an observation period from January 2007 to March 2016 for 1501 people with BN using anonymised health records data from the South London and Maudsley NHS Foundation Trust (SLaM), retrieved through its Clinical Records Interactive Search (CRIS) data resource. Mortality was ascertained through monthly linkages to the nationwide tracing system administered by the Office for National Statistics (ONS). We used Cox proportional hazards regression to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Multivariable analyses were also performed to estimate effects when controlling for confounding of age, sex, ethnicity, borough, marital status and deprivation score.

Results

A total of 18 patients with BN died during the observation period. The standardised mortality ratio (SMR) for our study cohort (against the population of England and Wales in 2012 as a standard) was 2.52 (95% CI 1.49–3.97). Cox regressions revealed significant associations of mortality with older age and male gender. Comorbid PD (HR: 3.36; 95% CI 1.05–10.73) was significantly associated with all-cause mortality, even after controlling for demographic and socioeconomic covariates.

Conclusions

These results highlight increased mortality in patients with BN and the importance of recognising and treating PDs in patients with BN.