[Norwegian]

Mortality and Standardized Mortality Ratios (SMR) for Mental Illness including Schizophrenia

The standardized mortality ratio or SMR, is a quantity, expressed as either a ratio quantifying the increase or decrease in mortality of a study cohort with respect to the general population.

Dramatic increase of suicides in hospitals from the 50's to the 80's

In the mid-50s antipsychotics / neuroleptics where introduced. In the 3 decades from 1950s to 1980s inpatient suicides in psychiatric hospitals ten doubled in Norway (Retterstøl 1988), raised from 50 to 400 per 100 000 in V.A. Hospitals ( Farberow 1975). Similar tendencies are reported from more that 8 countries (Chart 1: Bowers et al. 2008).

Highly reduced life expectancy for psychiatric patients in the 2000s

“SMRs for the 1970s, 1980s, and 1990s were 1.8, 3.0, and 3.2, respectively” (John McGrath et al. 2008) i.e. mortality rates continue to increase in several countries. “The most striking figure in this study is that eliminating suicide in schizophrenia would restore life expectancy to normal.” (David Healy et al 2012). Tiihonens 2009 FIN11 cohort study suggested that antipsychotic use decreased all-cause mortality. De Hert et al. 2010 showed incomplete reporting of data e. g. “exclusion of deaths occurring during hospitalization leading to exclusion of 64% of deaths on current antipsychotics from the analysis”.

Reduced lifetime expectancy for male psychiatric patients in the 21st century was 22 years in Denmark, 19 years in Finland and 20 years in Sweden. This corresponded to the SMR for life expectancy of 2.5 for Denmark, 1.8 for Finland and 2.2 for Sweden, respectively. SMR for suicide was 25, 9 and 21, i.e. suicide is the dominant cause. Women's numbers are lower (Wahlbeck et al 2011).

(Norwegian) nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20–79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals: SMR=11.6 for schizophrenia (Ina H. Heiberg et al. 2018).

“Thirty‐one participants (11%) were dead at follow‐up (SMR 11.56; 95% CI: 7.86‐16.42). Sixteen (6%) died by suicide (SMR 46.50, 95% CI: 26.58‐75.51); seven (2.5%) by accidental overdoses or other accidents, and eight (2.8%) from physical illnesses, including three (1%) from cardiovascular illness.” (Ingrid Melle et al. 2017)

“Cognitive behavioural therapy compared to treatment as usual reduced the risk of a new suicide attempt; risk ratio 0.47; 95% confidence interval 0.30–0.73; p = 0.0009; I2 = 57%.” (Peter C Gøtzsche et al. 2017)

In “Suicide in the Age of Prozac” Robert Whitaker focuses on the influence of antidepressants since the 90s.

However other studies mention neuroleptics. "Antipsychotics should be used more selectively, for shorter durations and with lowest possible effective dose." (Weinmann et al. 2010).

“People with serious mental illness die up to 20 years younger ...” … “Healthcare services should consider a shift away from physical health monitoring strategies and instead focus their resources on primary prevention strategies ... These include assertive smoking cessation (with pharmacological support), diet and exercise interventions and where possible, to avoid long-term prescription of antipsychotics associated with adverse metabolic outcomes.” (Athif Ilyas et al. 2017)

Literature/References:

  1. Len Bowers, Henk Nijman, Tumi Banda 2008. Suicide inside: a literature review on inpatient suicide https://www.kcl.ac.uk/ioppn/depts/hspr/archive/mhn/projects/litreview/LitRevSuicide.pdf
    “Reported rates of inpatient suicide varied by all three commonly used denominators – admissions, population and total number of suicides – indicating that such figures are influenced by social and service organisation factors. Rates in some countries have risen during the latter half of the 20th Century. The reasons for this are unknown”

  2. Suicides in V.A: hospitals 1950 - 1974: http://wkeim.bplaced.net/files/antipsychotics-Figure-2-1024x768.gif (Farberow NL, Mac Kinnon D (1975) Status of suicide in the veterans administration. Report III ?)

  3. Retterstøl N. (1988) Increasing Suicide Rate in Scandinavian Psychiatric Hospitals. In: Möller HJ., Schmidtke A., Welz R. (eds) Current Issues of Suicidology. Springer, Berlin, Heidelberg. Suicides per 100000 patients per year in the psychiatric hospitals in Norway increased from 35 in the period 1950-1954 to 373 in 1980-1984.
    https://link.springer.com/chapter/10.1007/978-3-642-73358-1_12

  4. Ina H. Heiberg et al. 2018. Total and cause-specific standardized mortality ratios in patients with schizophrenia and/or substance use disorder. “We performed a (Norwegian) nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20–79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. The SMRs were 4.9 (95% CI 4.7–5.1) for all schizophrenia patients, 4.4 (95% CI 4.2–4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5–6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0–8.2) in patients with both schizophrenia and substance use disorder. ” https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0202028&type=printable

  5. Wahlbeck, K., Westman, J., Nordentoft, M., Gissler, M., & Laursen, T. (2011). Outcomes of Nordic mental health systems: Life expectancy of patients with mental disorders. British Journal of Psychiatry, 199(6), 453-458. doi:10.1192/bjp.bp.110.085100
    https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/outcomes-of-nordic-mental-health-systems-life-expectancy-of-patients-with-mental-disorders/D9769E301E9C238CA3B43E21E1913DF7
    “Our results show that deinstitutionalisation can be implemented while maintaining or even improving the life expectancy of people with mental disorders across countries. In spite of the transition of mental health services, however, the life expectancy gap has remained largely unchanged over 20 years, and major health inequalities persist between people with mental disorders and the rest of the population.”

  6. Psychiatry Ignores an Elephant in the Room By Peter Gøtzsche, MD September 21, 2017. https://www.madinamerica.com/2017/09/psychiatry-ignores-elephant-room/ “Large cohort studies of people with a first-episode psychosis provide a unique opportunity for finding out why so many young people with schizophrenia spectrum disorders die at a young age. However, it seems that those psychiatrists who have access to the mortality data generally do not want the facts to come out. In published cohort studies, there is virtually always too little information or no information at all about the causes of death.”

  7. Ingrid Melle et al. 2017. Causes and predictors of premature death in first‐episode schizophrenia spectrum disorders. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20431 “Thirty‐one participants (11%) were dead at follow‐up (SMR 11.56; 95% CI: 7.86‐16.42). Sixteen (6%) died by suicide (SMR 46.50, 95% CI: 26.58‐75.51); seven (2.5%) by accidental overdoses or other accidents, and eight (2.8%) from physical illnesses, including three (1%) from cardiovascular illness.”

  8. John McGrath et al. 2008: Schizophrenia: A Concise Overview of Incidence, Prevalence, and Mortality https://academic.oup.com/epirev/article/30/1/67/621138
    The SMRs for all-cause mortality significantly increased over recent decades (p = 0.03): the median SMRs for the 1970s, 1980s, and 1990s were 1.8, 3.0, and 3.2, respectively.

  9. Edward Chesney et al. 2014: Risks of all-cause and suicide mortality in mental disorders: a meta-review
    https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20128
    The reduction in life expectancy associated with moderate to heavy smoking ranged from 8 to 10 years. This range is similar to that reported for a single depressive episode or recurrent depressive disorder (7-11 years), but lower than that associated with substance use (9-24 years), personality disorders (13-22 years), schizophrenia (10-0 years), and bipolar disorder (9-20 years) (Table 3).

  10. Stefan Weinmann, Volkmar Aderhold: Antipsychotic medication, mortality and neurodegeneration: The need for more selective use and lower doses
    February 2010(Psychosis) Psychological, Social and Integrative Approaches 2(1):50-69
    DOI: 10.1080/17522430903501999 https://www.researchgate.net/publication/233138682_Antipsychotic_medication_mortality_and_neurodegeneration_The_need_for_more_selective_use_and_lower_doses
    "Antipsychotics should be used more selectively, for shorter durations and with lowest possible effective dose."

  11. Sukanta Saha et al. Meta-analysis October 2007
    A Systematic Review of Mortality in Schizophrenia Is the Differential Mortality Gap Worsening Over Time?
    https://jamanetwork.com/journals/jamapsychiatry/fullarticle/210034
    "With respect to mortality, a substantial gap exists between the health of people with schizophrenia and the general community. This differential mortality gap has worsened in recent decades. In light of the potential for second-generation antipsychotic medications to further adversely influence mortality rates in the decades to come, optimizing the general health of people with schizophrenia warrants urgent attention."
    "People with schizophrenia have a substantially increased risk of death compared with the general population. Overall, people with schizophrenia have 2.5 times the risk of dying. This review was able to extract data from 37 studies that were conducted in 25 countries. As predicted, the distribution of all-cause SMRs showed prominent variability.
    Confirming the hypothesis that the relative mortality risk associated with schizophrenia is increasing, we found that SMRs have increased in a linear fashion during the 3 decades examined in this study. It is now widely acknowledged that schizophrenia contributes substantially to the global burden of disease. It is also well known that schizophrenia is associated with elevated suicide rates."

  12. Joukamaa M et al. 2006: Schizophrenia, neuroleptic medication and mortality.
    https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/schizophrenia-neuroleptic-medication-and-mortality/713F6B46E0A34BA1203761015F18684B
    "The number of neuroleptics used at the time of the baseline survey showed a graded relation to mortality. Adjusted for age, gender, somatic diseases and other potential risk factors for premature death, the relative risk was 2.50 (95% CI1.46–4.30) per increment of one neuroleptic."

  13. David Healy et al 2012: Mortality in schizophrenia and related psychoses: data from two cohorts, 1875–1924 and 1994–2010
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488735/
    "We found a 10-year survival probability of 75% in the historical cohort and a 90% survival probability in the contemporary cohort with a fourfold increase in standardised death rates in schizophrenia and related psychoses in both historical and contemporary periods. Suicide is the commonest cause of death in schizophrenia in the contemporary period (SMR 35), while tuberculosis was the commonest cause historically (SMR 9). In the contemporary data, deaths from cardiovascular causes arise in the elderly and deaths from suicide in the young.
    The most striking figure in this study is that eliminating suicide in schizophrenia would restore life expectancy to normal."

  14. Anne Høye et al. 2011: Increasing mortality in schizophrenia: Are women at particular risk? A follow-up of 1111 patients admitted during 1980–2006 in Northern Norway
    https://helse-nord.no/Documents/SKDE/SKDE%20Artikler/Increasing%20mortality%20in%20schizophrenia,%20are%20women%20at%20particular%20risk%20(2011).pdf
    "In Norway, mortality of patients with mental illness has been reported
    regularly since 1916 (Ødegård, 1936, 1951, 1952; Ødegård, 1967;
    Saugstad and Ødegård, 1979,1985; Hansen et al., 1997). A previous
    study based on the case register of the University Hospital of North
    Norway with follow-up 1980–1992 (Hansen et al., 2001) documented
    increase in SMRs compared to earlier periods, especially high for men...
    Our study confirms the persisting mortality gap between patients
    with schizophrenia and the general population over a period of 27 years,
    with a tendency of increasing SMRs."

  15. Ilyas, A., Chesney, E., & Patel, R. (2017). Improving life expectancy in people with serious mental illness: Should we place more emphasis on primary prevention? The British Journal of Psychiatry, 211(4), 194-197. doi:10.1192/bjp.bp.117.203240 https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/improving-life-expectancy-in-people-with-serious-mental-illness-should-we-place-more-emphasis-on-primary-prevention/5BA82EA9FBBA0E932478CDC4AF6B4601/core-reader
    “People with serious mental illness die up to 20 years younger because of preventable physical disorders” … “Healthcare services should consider a shift away from physical health monitoring strategies and instead focus their resources on primary prevention strategies that are provided to all people with serious mental illness from the moment they first present to mental healthcare services. These include assertive smoking cessation (with pharmacological support), diet and exercise interventions and where possible, to avoid long-term prescription of antipsychotics associated with adverse metabolic outcomes.”







Click on figure and table for enlargement:





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