1. Excess mortality in people with mental disorders: a nationwide record-linkage study in the Czech Republic
D. Krupchanka* 1, 3, 4 , K. Mlada1, P. Winkler1,2, Y.Khazal3,4, E. Albanese 3,4
1 Department of Social Psychiatry, National Institute of Mental Health, Prague, Czech Republic
2 Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
3 Department of Psychiatry and Institute of Global Health, University of Geneva, Switzerland
4 Swiss School of Public Health Plus, Zurich, Switzerland
* Corresponding author
KEY MESSAGES
Central and Eastern Europe is the region with estimated highest level of Years of Life Lost (YLL) due to mental, behavioral and substance use disorders globally.
Evidence on mortality associated with mental disorders in the region is patchy, and insufficient to inform policy actions and health system reform.
The annual mortality among people with mental and behavioral disorders was found to be more then 2-times (SMR=2.2; 95%CI: 2.2, 2.3) of the general population
Highest Standardized Mortality Ratio (SMR) was found among those with disorders due to psychoactive substance use (SMR=3.5; 95%CI: 3.4, 3.7), followed by schizophrenia, schizotypal and delusional disorders (SMR=2.3; 95%CI: 2.1, 2.5); personality (SMR=2.3; 95%CI: 2.0, 2.6), neurotic, stress-related and somatoform (SMR=1.8; 95%CI: 1.6, 1.9) and mood disorders (SMR=1.6; 95%CI: 1.5, 1.7).
Distribution of causes of deaths varied across diagnostic groups, with cardiovascular disorders being the most often.
External causes of deaths (MR=4.8; 95%CI: 4.3, 5.4) and especially intentional self-harm (MR=6.5; 95%CI: 5.3, 7.8) found to be more then 3 times higher compare to the general population
It is feasible to conduct register-based studies on databases existing in the Czech Republic.
Introduction
„The scandal of pre mature mortality“ among people with mental Illnesses [1]:
Higher risks of death compare to general population [2]
Shorter life expectancies: 20 years for men and 15 for women [3]
Mortality gap is likely increasing over time [4]
“Blind Spot on a global mental health map” [5]
Central and Eastern Europe is the region with the highest burden of mental disorders [6]
world’s highest level of DALYs due to mental, behavioral and substance use disorders
world’s highest level of YLLs (especially high among males) due to mental, behavioral and substance use disorders
High prevalence of AUD & SUD, high Suicide Rate [7]
Research are rare, evidence is extremely patchy
Mortality has never been a focus of research
No register-based studies despite long history of data collection.
Aim: to explore the excess mortality associated with mental and behavioral disorders in the Czech Republic. In particular, we aimed to compare annual mortality, age and causes of death of people with a history of psychiatric in-patient treatment and the Czech general population.
Methods
This is a register-based nation-wide study relying on the linkage and analysis of two main sources of Czech nation-wide observational, routinely collected health data: (1) all-cause inpatient hospitalizations database; (2) all-cause deaths database. Both databases are maintained by the Institute of Health Information and Statistics of the Czech Republic, which has granted full access to the National Institute of Mental Health, for all calendar years between 1994 and Figure 1 presents a flow chart of study population derivation.
Results
The final study population consisted of 283,618 cases having history of discharge from mental health facilities in and alive in the beginning of The socio-demographic characteristic of the study population is presented within the Table 1. In this group, 3,819 people died in 2014 what was compared to the mortality of Czech general population in The Standardized (by age and sex) Mortality Ratio (SMR) are presented in the Table 2. Distribution of age at deaths is presented within the Figure 1. Distribution of causes of deaths is presented in the Table 3.
Diagnostic Groups
SMR
95% CI
General population
1 (reference)
Disorders due to psychoactive substance abuse (F1x)
3·5
(3·4, 3·7)
Schizophrenia  schizotypal and delusional disorders (F2x)
2·3
(2·1, 2·5)
Mood (affective) disorders (F3x)
1·6
(1·5, 1·7)
Neurotic  stress-related and somatoform disorders (F4x)
1·8
(1·6, 1·9)
Disorders of adult personality and behavior (F6x)
(2·0, 2·6)
With a history of multiple diagnoses
2·9
(2·7, 3·2)
Any diagnoses
2·2
(2·2, 2·3)
Table 2. Standardized (by age and gender) annual mortality ratios (SMR)
Variable N
col %
n (died)
Total
283,618
100
3,819
Sex
Male
151,667
53.5
2,379
62.3
Female
131,951
46.5
1,440
37.7
Age
15-19
7,942
2.8 3
0.1
20-24
16,397
5.8 18
0.5
25-29
23,595
8.3 76
2.0
30-34
32,511
11.5
105
35-39
35,068
12.4
141
3.7
40-44
27,756
9.8
237
6.2
45-49
26,538
9.3
265
6.9
50-54
25,972
9.2
348
9.1
55-59
27,754
538
14.1
60-64
25,083
8.8
577
15.1
65-69
17,685
586
15.3
70-74
9,670
3.4
419
11.0
75-79
4,598
1.6
256
6.7
80-84
3,049
1.1
250
6.5
Diagnostic groups
F1x
92,271
27.3
1,899
41.4
F2x
49,822
14.8
724
15.8
F3x
38,061
11.3
616
13.4
F4x
92,995
27.5
958
20.9
F5x
6,001
1.8 26
0.6
F6x
32,993
309
F8x
1,393
0.4 1
0.0
F9x
24,152
7.2 54
1.2
All people discharged from Czech mental health institutions in with diagnoses of mental disorders (ICD-10, F00-F99) n=
Linking with the mortality registry and cleaning data n=
Excluded:
observations with incorrect of missing data (n=134)
Figure 2. Age at deaths among people with history of MI and general population
Causes of Death (ICD-10 codes)
Study population (all deaths (%))
General population (all deaths (%))
MR (95%CI)
Certain infectious and parasitic diseases (A00-B99)
58 (1·5)
1 245 (1·6)
1·4 (0·9, 2·2)
Neoplasms (C00-D48)
718 (18·8)
24 182 (32·0)
0·9 (0·8, 1·1)
Endocrine, nutritional and metabolic diseases (E00-E90)
102 (2·7)
2 789 (3·7)
1·1 (0·5, 5·6)
Mental and behavioural disorders (F00-F99)
66 (1·7)
629 (0·8)
3·2 (2·1, 4·9)
Diseases of the nervous system (G00-G99)
96 (2·5)
1 906 (2·5)
1·6 (1·1, 2·1)
Diseases of the circulatory system (I00-I99)
1 225 (32·1)
29 637 (39·2)
1·3 (1·2, 1·4)
Diseases of the respiratory system (J00-J99)
235 (6·1)
4 430 (5·9)
1·6 (1·3, 2·0)
Diseases of the digestive system (K00-K93)
458 (12·0)
3 813 (5·0)
3·7 (3·1, 4·3)
Symptoms, signs and abnormal clinical and laboratory findings (R00-R99)
75 (2·0)
887 (1·2)
2·6 (1·7, 2·8)
Other causes of deaths
49 (1·3)
1270 (1·7)
1·2 (0·7, 1·9)
External causes of morbidity and mortality (V01-Y98)
737 (19·3)
4 745 (6·3)
4·8 (4·3, 5·4)
Intentional self-harm (X60-X84)
312 (8·2)
1 488 (1·8)
6·5 (5·3, 7·8)
Other external causes of morbidity and mortality
425 (11·1)
3 257 (4·5)
4·0 (3·4, 4·7)
Total
3 819 (100)
75 533 (100)
2·2 (2·1, 2·9)
People alive at n=
Excluded:
died in
(n= )
Applying criteria of diagnoses n=
Excluded:
having history of F0x or F7x
(n=35 916)
Applying criteria of age (15-84 y.o.) n=
<15 y.o. (n=3 966)
Excluded:
>84 y.o. (n=2 995)
FINAL STUDY POPULATION n=
Figure 1. Flow diagram of study population selection
Table 1. The socio-demographic characteristic of the study population
Table 3. Distribution of causes of death in 2014
References:
Thornicroft, G., Physical health disparities and mental illness: the scandal of premature mortality. The British journal of psychiatry : the journal of mental science, 199(6), pp.441–2
De Hert, M. et al., Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World psychiatry : official journal of the World Psychiatric Association (WPA), 10(1), pp.52–77.
Wahlbeck, K. et al., Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. The British journal of psychiatry : the journal of mental science, 199(6), pp.453–8.
Lawrence, D., Hancock, K.J. & Kisely, S., The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ (Clinical research ed.), 346, p.f2539.
Winkler* P., Krupchanka* D. et al. (2017) Revealing a blind spot on the global mental health map: scoping review of 25 years development of mental health care for people with severe mental illnesses in Central and Eastern Europe. Lancet Psychiatry. Accepted for publication
Whiteford, H.A. et al., Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study Lancet, 382(9904), pp.1575–86
Leon, D.A., Shkolnikov, V.M. & McKee, M., Alcohol and Russian mortality: a continuing crisis. Addiction (Abingdon, England), 104(10), pp.1630–6.
Discussion
This is the first attempt to undermine a case-register study of mortality among people with mental illnesses in Central and Eastern Europe. While keeping in mind limitations of register-based studies, the outcome of the project may stimulate and inform interventions and a structured national reform of mental health services and strategies, and provide the epidemiological evidence base for further hypothesis generation and testing as well as for cross-region collaborations.
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