Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland

OBJECTIVE: This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization. METHODS: Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk. RESULTS: In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%). CONCLUSIONS: The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.     

Mortality in Western Australian psychiatric patients

  Background: The aim was to examine mortality in psychiatric patients in Western Australia (WA), over a time period of considerable change in the delivery of mental health services. Methods: A population-based record linkage analysis was undertaken to quantify mortality among people with mental illness in WA. Mortality rates were calculated in users of mental health services and compared with rates in the whole population of WA. Trends in mortality were also examined using relative survival analysis, and proportional hazards regression. Results: The overall mortality rate ratio was 2.57 in males (95% CI: 2.51–2.64), and 2.18 in females (2.12–2.24). The highest cause-specific mortality rate ratio was for deaths due to suicide [RR: 7.37 in males (95% CI: 6.74–8.05) and 8.38 in females (95% CI: 7.11–9.89)], with mortality rate ratios being significantly greater than 1 for all other major causes of death. A relative survival analysis found that the excess mortality risk was concentrated in the first few years after first contact with mental health services. Proportional hazards regression analysis found a slight elevation of mortality rates over time. Conclusions: Mortality among psychiatric patients remains high and appears to be increasing. Highest excess mortality rate is associated with suicide, but mortality rates are significantly elevated for all major causes of death. Accepted: 10 April 2000     

Mortality in persons with mental disorders is substantially overestimated using inpatient psychiatric diagnoses

Mental disorders are associated with premature mortality, and the magnitudes of risk have commonly been estimated using hospital data. However, psychiatric patients who are hospitalized have more severe illness and do not adequately represent mental disorders in the general population. We conducted a national cohort study using outpatient and inpatient diagnoses for the entire Swedish adult population (N = 7,253,516) to examine the extent to which mortality risks are overestimated using inpatient diagnoses only. Outcomes were all-cause and suicide mortality during 8 years of follow-up (2001–2008). There were 377,339 (5.2%) persons with any inpatient psychiatric diagnosis, vs. 680,596 (9.4%) with any inpatient or outpatient diagnosis, hence 44.6% of diagnoses were missed using inpatient data only. When including and accounting for prevalent psychiatric cases, all-cause mortality risk among persons with any mental disorder was overestimated by 15.3% using only inpatient diagnoses (adjusted hazard ratio [aHR], 5.89; 95% CI, 5.85–5.92) vs. both inpatient and outpatient diagnoses (aHR, 5.11; 95% CI, 5.08–5.14). Suicide risk was overestimated by 18.5% (aHRs, 23.91 vs. 20.18), but this varied widely by specific disorders, from 4.4% for substance use to 49.1% for anxiety disorders. The sole use of inpatient diagnoses resulted in even greater overestimation of all-cause or suicide mortality risks when prevalent cases were unidentified (∼20–30%) or excluded (∼25–40%). However, different methods for handling prevalent cases resulted in only modest variation in risk estimates when using both inpatient and outpatient diagnoses. These findings have important implications for the interpretation of hospital-based studies and the design of future studies.     

Mortality among discharged psychiatric patients in Florence, Italy

OBJECTIVE: Psychiatric disorders involve an increased risk of mortality. In Italy psychiatric services are community based, and hospitalization is mostly reserved for patients with acute illness. This study examined mortality risk in a cohort of psychiatric inpatients for 16 years after hospital discharge to assess the association of excess mortality from natural or unnatural causes with clinical and sociodemographic variables and time from first admission. METHODS: At the end of 2002 mortality and cause of death were determined for all patients (N=845) who were admitted during 1987 to the eight psychiatric units active in Florence. The mortality risk of psychiatric patients was compared with that of the general population of the region of Tuscany by calculating standardized mortality ratios (SMRs). Poisson multivariate analyses of the observed-to-expected ratio for natural and unnatural deaths were conducted. RESULTS: The SMR for the sample of psychiatric patients was threefold higher than that for the general population (SMR=3.0; 95 percent confidence interval [CI]=2.7-3.4). Individuals younger than 45 years were at higher risk (SMR=11.0; 95 percent CI 8.0-14.9). The SMR for deaths from natural causes was 2.6 (95 percent CI=2.3-2.9), and for deaths from unnatural causes it was 13.0 (95 percent CI=10.1-13.6). For deaths from unnatural causes, the mortality excess was primarily limited to the first years after the first admission. For deaths from natural causes, excess mortality was more stable during the follow-up period. CONCLUSIONS: Prevention of deaths from unnatural causes among psychiatric patients may require promotion of earlier follow-up after discharge. Improving prevention and treatment of somatic diseases of psychiatric patients is important to reduce excess mortality from natural causes.     

Cause-specific mortality after discharge from inpatient psychiatric care in Taiwan: A national matched cohort study

Aims

We aimed to investigate the trajectories of absolute and relative risks of cause-specific mortality among patients discharged from inpatient psychiatric services.

Methods

We conducted a national matched cohort study (2002–2013) using data from the Taiwan National Health Insurance database linked to national cause-of-death data files. Patients discharged from inpatient psychiatric care without prior psychiatric hospitalizations were individually matched to 20 comparison individuals based on sex and age. The rates, rate differences, and relative risks (hazard ratios, HRs) of cause-specific mortality were calculated at six follow-up periods post-discharge. Cumulative mortality incidence was assessed at 5 years of follow-up.

Results

The mortality risks of all causes were increased among patients (n = 158 065) relative to comparison individuals (n = 3 161 300). Mortality rate differences were greater for natural causes, while relative risks (HRs) were higher for unnatural causes. Suicide was the leading cause of death within the first year of discharge, while circulatory and respiratory diseases were the leading causes of death from the second year. The mortality rates and HRs for all causes of death (except homicide) were highest during the first 3 months. The elevated risk of unnatural-cause mortality declined rapidly after discharge but remained high in the long term; in contrast, risk elevation for natural-cause mortality was more stable over time. Approximately one-eighth of patients (12.9%, 95% confidence interval 12.7–13.7%) died within 5 years of follow-up.

Conclusions

Integrated physical and mental health care is needed to reduce excess mortality, particularly during the first 3 months post-discharge, among psychiatric patients.     

Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong

OBJECTIVE: To identify the risk period and the risk factors for suicide in Chinese psychiatric patients after discharge from inpatient psychiatric treatment. The nature of psychiatric aftercare provided to these patients was also explored. METHOD: A case control study with 73 patients who were discharged from a large psychiatric unit in Hong Kong between January 1996 and December 1999 and had received coroners' verdict of suicide or undetermined death within the same period. Controls were 73 surviving patients discharged from the same unit. They were individually matched for sex, age, psychiatric diagnosis, and date of discharge. RESULTS: Post-discharge clustering of suicides was observed among the cases. Nearly 80% of them died within 1 year of discharge. The most common principal diagnosis among the cases was schizophrenia and related psychotic disorders. Multivariate analysis showed that suicide was associated with: unemployment (OR = 12.2, 95% CI = 2.1 - 70.4), past suicidal attempts (OR = 3.4, 95% CI = 1.2 - 9.6), maternal mental illness (OR = 13.4, 95% CI = 1.0 - 170.0), and suicidal ideation or attempt before the last admission (OR = 5.0, 95% CI = 1.4 - 18.0). The psychiatric aftercare received by cases and controls were generally similar. However, cases were more likely to have had contact with health care services in the last week before death (OR = 4.0, 95% CI = 1.3 - 11.9). CONCLUSIONS: Suicidal risk is high in Chinese psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but several differences are evident: the predominance of schizophrenia in the suicides; the lower prevalence of substance abuse and comorbidity; the low proportion of patients living alone; and the increased clinical contact before death but the less suicidal intent expressed in Chinese patients. It is necessary to consider these socio-cultural factors in assessment of suicidal risk and implementation of suicide prevention strategies in Chinese psychiatric patients.     

Excess cancer mortality in Western Australian psychiatric patients due to higher case fatality rates

OBJECTIVE: To investigate the association between mental illness and cancer incidence, mortality and case fatality. METHOD: A population-based record linkage study was undertaken based on 172,932 patients of mental health services in Western Australia. Records of mental health service contacts were linked with cancer registrations and death records. RESULTS: While there was little difference in overall cancer incidence rates between psychiatric patients and the general community (RR in males 1.05, 95%, CI 1.02-1.09, RR in females 1.02, 0.98-1.05), cancer mortality was 39%, higher in males (95%) CI: 32-46%) and 24% higher in females (17-32%). CONCLUSION: People with mental illness in Western Australia do not show an increased incidence rate of cancer, but do have higher cancer mortality. This was attributed to a higher cancer case fatality rate among people with mental illness.     

The suicide risk of discharged psychiatric patients

BACKGROUND: The suicide risk of psychiatric patients fluctuated along the course of their illness and was found to be high in the immediate post-discharge period in some settings. The epidemiology and psychiatric services for the suicide population in Hong Kong have differed from those of the West (i.e., low youth suicide rate, high elderly suicide rate, high female/male ratio, and heavily government-subsidized psychiatric service). This study examined the suicide rates within a year of discharge from psychiatric inpatient care in Hong Kong. METHOD: Discharges from all psychiatric hospitals or psychiatric wards in general hospitals in Hong Kong from 1997 through 1999 were followed up for suicides (ICD-9, E950-E959) and "undetermined" causes of deaths (E980-E989) by record linkage with the Coroner's Court until their deaths or Dec. 31, 2000. The suicide rates (/1000 person-years at risk) and standardized mortality ratios (SMRs; assigning a value of 1 to the same age- and sex-specific suicide rates in the general population) were calculated. RESULTS: 21,921 patients (aged over 15 years) were discharged from psychiatric hospitals from 1997 through 1999. Two hundred eighty patients committed suicide within 1 year of discharge; 85 suicides (30%) occurred within 28 days after discharge. The SMRs for suicide in the first 28 days after discharge were 178 (95% CI = 132 to 235) for females and 113 (95% CI = 86 to 147) for males. These rates were 4.0 (95% CI = 2.7 to 5.6) times higher for females and 4.6 (95% CI = 3.2 to 6.3) times higher for males than the rate in the rest of the year. Young adults had higher SMRs than the elderly. No specific diagnoses had higher suicidal risk than others. Calculations including undetermined causes of deaths (N = 53) gave similar results. CONCLUSION: The immediate post-discharge period carries a high risk of suicide for psychiatric patients. The high-risk groups are young adults and females. No diagnosis appears to carry a particularly high risk.     

Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort

BACKGROUND: It is unknown if antidepressant treatment is associated with either increased or decreased risk of suicide. OBJECTIVE: To estimate the risk of suicide, attempted suicide, and overall mortality during antidepressant treatments in a real-life setting with high statistical power. DESIGN AND SETTING: A cohort study in which all subjects without psychosis, hospitalized because of a suicide attempt from January 1, 1997, to December 31, 2003, in Finland, were followed up through a nationwide computerized database. PARTICIPANTS: A total of 15 390 patients with a mean follow-up of 3.4 years. MAIN OUTCOME MEASURES: The propensity score-adjusted relative risks (RRs) during monotherapy with the most frequently used antidepressants compared with no antidepressant treatment. RESULTS: In the entire cohort, fluoxetine use was associated with the lowest risk (RR, 0.52; 95% confidence interval [CI], 0.30-0.93), and venlafaxine hydrochloride use with the highest risk (RR, 1.61; 95% CI, 1.01-2.57), of suicide. A substantially lower mortality was observed during selective serotonin reuptake inhibitor use (RR, 0.59; 95% CI, 0.49-0.71; P<.001), and this was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths (RR, 0.42; 95% CI, 0.24-0.71; P=.001). Among subjects who had ever used any antidepressant, the current use of medication was associated with a markedly increased risk of attempted suicide (39%, P<.001), but also with a markedly decreased risk of completed suicide (-32%, P=.002) and mortality (-49%, P<.001), when compared with no current use of medication. The results for subjects aged 10 to 19 years were basically the same as those in the total population, except for an increased risk of death with paroxetine hydrochloride use (RR, 5.44; 95% CI, 2.15-13.70; P<.001). CONCLUSIONS: Among suicidal subjects who had ever used antidepressants, the current use of any antidepressant was associated with a markedly increased risk of attempted suicide and, at the same time, with a markedly decreased risk of completed suicide and death. Lower mortality was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths during selective serotonin reuptake inhibitor use.     

Effect of conditional release from hospitalization on mortality risk

OBJECTIVES: This study considered the protective value provided by conditional release. It assessed the contribution of conditional release to mortality risk among patients with mental disorders severe enough to require psychiatric hospitalization during a mental health treatment span of 13.5 years in Victoria, Australia. METHODS: Death records were obtained from the Australian National Death Index for a sample of 24,973 Victorian Psychiatric Case Register patients with a history of psychiatric hospitalizations: 8,879 had experienced at least one conditional release during community care intervals and 16,094 had not. Risk of death was assessed with standardized mortality ratios of the general population of Victoria. Relative risk of death among patients with and without past experience of conditional release was computed with risk and odds ratios. The contribution of conditional release to mortality, taking into account use of community care services, age, gender, inpatient experience, and diagnosis, as well as other controls, was assessed with logistic regression. RESULTS: Patients who had been hospitalized showed higher mortality risk than the general population. Sixteen percent (4,034) died. Patients exposed to conditional release, however, had a 14 percent reduction in probability of non-injury-related death and a 24 percent reduction per day on orders in the probability of death from injury compared with those not offered such oversight throughout their mental health treatment, all other factors taken into account. CONCLUSIONS: Conditional release can offer protective oversight for those considered dangerous to self or others and appears to reduce mortality risk among those with disorders severe enough to require psychiatric hospitalization.     

Risk factors for suicide and other deaths following hospital treated self-poisoning in Australia

OBJECTIVE: To analyze the risk factors for suicide, premature death and all-cause death in a representative population of hospital-treated deliberate self-poisoning patients. METHOD: A prospective cohort study using data-linkage between the Hunter Area Toxicology Service Database and the National Death Index of the Australian Institute of Health and Welfare, from January 1991 to December 2000. RESULTS: There were 4105 subjects, of whom 228 (5.6%) died, 122 (2.9%) by premature death and 58 (1.4%) by suicide. The probability of suicide after 10 years follow-up was 2%. The adjusted hazard ratios (95% CI) for suicide were: 'disorders usually diagnosed in infancy, childhood and adolescence', 5.28 (95% CI = 2.04-13.65): male gender, 4.25 (95% CI = 2.21-8.14); discharge to involuntary psychiatric hospital admission, 3.20 (95% CI = 1.78-5.76); and increasing age, 1.02 (95% CI = 1.01-1.04). Men and women showed different patterns of multivariate risks, although increased risk with increasing age and discharge to an involuntary psychiatric admission was true for both. The standardized all-cause mortality ratio (95% CI) was: for men, 6.42 (95% CI = 5.44-7.57), and for women 4.39 (95% CI = 3.56-5.41). The standardized suicide mortality ratio (95% CI) was: for men, 20.55 (95% CI = 15.24-27.73), and for women 22.95 (95% CI = 13.82-38.11). CONCLUSIONS: Men and women have different risk factors for subsequent suicide after self-poisoning. Hospital-treated self-poisoning patients have increased risk of subsequent suicide, premature and all-cause death. Psychiatric assessment, leading to discharge decisions, is worthwhile in identifying patients at long-term risk of suicide, premature and all-cause death.     

Risk factors for suicide in epilepsy: a case control study

PURPOSE: Suicide is considered to be one of the most important causes of death contributing to the increased mortality of persons with epilepsy. We investigated the association between the risk of suicide in persons with epilepsy and clinical factors that might increase or have been suggested to increase the risk of suicide. METHODS: A case-control study was nested within a cohort of 6,880 patients registered in the Stockholm County In-Patient Register with a diagnosis of epilepsy. The study population was followed up through the National Cause of Death Register. Twenty-six cases of suicide, 23 cases of suspected but not proven suicide, and 171 controls, living epilepsy patients, were selected from the cohort. Clinical data were collected through medical record review. RESULTS: There was a ninefold increase in risk of suicide with mental illness and a 10-fold increase in relative risk (RR) with the use of antipsychotic drugs. The estimated RR of suicide was 16.0 [95% confidence interval (CI), 4.4-58.3] for onset of epilepsy at younger than 18 years, compared with onset after 29 years. The risk of suicide seemed to increase with high seizure frequency and antiepileptic drug (AED) polytherapy, although the estimates were imprecise and the associations not statistically significant. Insufficient data on seizure frequency and changes in AED dosage due to incomplete case records were associated with high RRs. We found no association between risk of suicide and any particular AED, with type of epilepsy, or localization or lateralization of epileptogenic focus on EEG [RR = 0.3 (95% CI, 0.1-1.7)]. CONCLUSIONS: The profile of the epilepsy patient who commits suicide that emerges from our study is a patient with early onset (particularly onset during adolescence) but not necessarily severe epilepsy, psychiatric illness, and perhaps inadequate neurologic follow-up. Previous reports of an association with temporal lobe epilepsy could not be confirmed.     

Injury risk in young psychiatric outpatients

BACKGROUND: Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients. SUBJECTS AND METHODS: Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation. RESULTS: Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation. CONCLUSION: Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.     

Experience of sibling death in childhood and risk of psychiatric care in adulthood: a national cohort study from Sweden

Studies have found that sibling loss is associated with an increased risk of death from external causes (i.e. suicides, accidents and homicides). Increased psychiatric health problems following bereavement could underlie such an association. We studied the influence of sibling loss during childhood on psychiatric care in young adulthood, adjusting for psychosocial covariates shared by siblings in childhood. A national cohort born in Sweden in 1973–1982 (N = 701,270) was followed prospectively until 2013. Cox proportional hazards models were used to analyse the association between sibling loss during childhood and psychiatric inpatient and outpatient care identified by the Hospital Discharge Register. After adjustment for confounders, the HRs of psychiatric care in men who experienced sibling loss were 1.17 (95% CI 1.07–1.27) while the associations turned non-significant in women after adjustment for family-related psychosocial covariates, HR 1.07 (95% CI 0.99–1.16). An increased risk was found in men bereaved in early childhood (1.22 95% CI 1.07–1.38) and adolescence (1.27 95% CI 1.08–1.48). Among women, loss of a sibling during adolescence was significantly associated with psychiatric care (1.19 95% CI 1.03–1.36). Increased psychiatric health problems following bereavement could underlie the previously found association between sibling loss and mortality from external causes. Family-related psychosocial conditions shared by siblings in childhood may account for the association between sibling death and psychiatric care in adulthood.

     

Depression and other mental health diagnoses increase mortality risk after ischemic stroke

OBJECTIVE: Poststroke depression has been linked to higher mortality after stroke. However, the effect of other mental health conditions on poststroke mortality has not been examined. The objective of this study was to evaluate the effect of poststroke depression and other mental health diagnoses on mortality after ischemic stroke. METHOD: The authors examined a national cohort of veterans hospitalized after an ischemic stroke at any U.S. Department of Veterans Affairs (VA) medical center from 1990 to 1998. Demographic, admission, and all-cause mortality data were abstracted from VA administrative databases. Chronic conditions present at discharge and new poststroke depression and other mental health diagnoses within 3 years after the stroke were identified with ICD-9 codes. Mortality hazard ratios were modeled by using Cox regression models. RESULTS: A total of 51,119 patients hospitalized after an ischemic stroke who survived beyond 30 days afterward were identified; 2,405 (5%) received a diagnosis of depression, and 2,257 (4%) received another mental health diagnosis within 3 years of their stroke. Patients with poststroke depression were younger, more often white, and less likely to be alive at the end of the 3-year follow-up period. Both poststroke depression (hazard ratio=1.13, 95% CI=1.06-1.21) and other mental health diagnoses (hazard ratio=1.13, 95% CI=1.07-1.22) independently increased the hazard for death even after other chronic conditions were controlled. CONCLUSIONS: Despite being younger and having fewer chronic conditions, a higher 3-year mortality risk was seen in patients with poststroke depression and other mental health diagnoses after hospitalization for an ischemic stroke. The biological and psychosocial mechanisms driving this greater risk should be further explored, and the effect of depression treatment on mortality after stroke should be tested.     

Suicide and hospitalization for mental disorders in Sweden: A population-based case-control study

The aim of this study was to estimate suicide risk during hospitalization and in the year following discharge for patients with mental disorders.All suicide cases in Sweden 18 years and older, between 1991 and 2003 (N = 20,675; 70% male), were individually matched to 10 controls from the general Swedish population. Discharge diagnoses in the year before suicide of any mental disorder, mood disorder, schizophrenia spectrum disorder, and alcohol use disorder were identified from the Swedish Patient Register.Highest suicide risk during hospitalization and in the year following discharge was found for mood disorder [odds ratio (OR) 55 (95% CI, 47-65) for men and 86 (95% CI, 70-107) for women], with the risk peaking in the first week following discharge [OR 177 (95% CI, 78-401) for men and OR 268 (95% CI, 85-846) for women]. Compared to that for mood disorder, the suicide risk for schizophrenia spectrum disorder and alcohol use disorder was about half and more constant over time. The majority of suicide victims with a psychiatric diagnosis had been discharged from psychiatric treatment more than a month before the suicide. Over time, a constant proportion of 25% of the suicide victims had been hospitalized with a mental disorder in the year before suicide (23% of males and 31% of females), despite a significant decrease in psychiatric hospitalizations in the population.In conclusion, suicide risk was found to vary by type of mental disorder, time since discharge, and sex. This should be taken into account when planning suicide preventive efforts.     

Mortality and hidden mental disorder in the Lundby Study. Age-standardized death rates among mentally ill 'non-patients' in a total population observed during a 25-year period

In the Lundby Study, all mental illnesses, treated as well as untreated, that occurred during a 25-year period in a geographically defined Swedish general population sample were evaluated. All forms of psychiatric services used by the population during the same period were registered. The present study investigates the mortality pattern of mentally ill persons who did not receive psychiatric specialist treatment. Men with a 'hidden' mental disorder showed a significantly increased mortality from non-violet causes (p less than 0.001). The relative somatic death risk in this group was even slightly higher than that found among mentally ill men who had received psychiatric specialist care. The somatic overmortality found among women with a hidden mental disorder did not reach statistical significance, while mentally ill women who had been treated showed a significant excess mortality from natural causes (p less than 0.05). The total number of violet deaths was small and calculations on violet death risks were performed only for men. Among men with a hidden mental disorder the age-standardized violent death risk was twice that of the total male population, but the increase did not reach statistical significance. Men with a treated mental disorder showed a significant over-mortality from violent causes (p less than 0.001).     

The volume-quality relationship of mental health care: does practice make perfect?

OBJECTIVE: An extensive literature has demonstrated a relationship between hospital volume and outcomes for surgical care and other medical procedures. The authors examined whether an analogous association exists between the volume of mental health delivery and the quality of mental health care. METHOD: The study used data for the 384 health maintenance organizations participating in the Health Employer Data and Information Set (HEDIS), covering 73 million enrollees nationwide. Analyses examined the association between three measures of mental health volume (total annual ambulatory visits, inpatient discharges, and inpatient days) and the five HEDIS measures of mental health performance (two measures of follow-up after psychiatric hospitalization and three measures of outpatient antidepressant management), with adjustment for plan and enrollee characteristics. RESULTS: Plans in the lowest quartile of outpatient and inpatient mental health volume had an 8.45 (95% CI [confidence interval]=4.97-14.37) to 21.09 (95% CI=11.32-39.28) times increase in odds of poor 7- and 30-day follow-up after discharge from inpatient psychiatric hospitalization. Low-volume plans had a 3.49 (95% CI=2.15-5.67) to 5.42 (95% CI=3.21-9.15) times increase in odds of poor performance on the acute, continuation, and provider measures of antidepressant treatment. CONCLUSIONS: The large and consistent association between mental health volume and performance suggests parallels with the medical and surgical literature. As with that previous literature, further work is needed to better understand the mechanisms underlying this association and the potential implications for using volume as a criterion in plan choice.     

Death in aftercare

Modern studies on the mortality risk of persons with psychiatric illness have viewed the problem from a variety of different perspectives. Shinozaki¹ found the death rate among inpatients in a group of Japanese mental hospitals to be seven times the death rate of the general population. Other studies have identified persons at the time of hospital admission or discharge and presented mortality data on follow-up. Affleck et al.² after 12 years, found an average annual mortality more than three times greater than the general population for schizophrenic women. Zitrin et al.³ noted a death rate double the expected rate among 867 persons discharged from the psychiatric unit of New York's Bellevue Hospital and followed-up at 2 years. Tsuang and Woolson⁴ report increased mortality risk after four decades of follow-up in Iowa. The mortality risk varied with decade of follow-up, sex, and diagnosis but was highest for schizophrenics in the first decade of follow-up.Mortality rates among mixed groups of inpatients and outpatients are also reported. Babigian and Odoroff⁵ found the relative risk of death for persons seeking psychiatric care in Monroe County, New York to be 2.5 to 3 times greater than that of the general population. Innes and Miller⁶ found an overall death rate twice the expected rate for a group of inpatients and outpatients at 5-year follow-up in Scotland. Rorsman⁷ noted a death rate approximately 1.6 times the expected rate for a group of mainly nonpsychotic inpatients and outpatients in Sweden.Two studies, Sims⁸ and Keehn et al.⁹ report excess mortality among patients with exclusively nonpsychotic diagnoses. A single known study, Claghorn and Kinross-Wright¹⁰ found no increased mortality among a group of psychiatric patients followed-up for years.