Suicide and death by other causes among patients with a severe mental illness: cohort study comparing risks among patients discharged from inpatient carev. those treated in the community

Abstract

Aims People diagnosed with a severe mental illness (SMI) are at elevated risk of dying prematurely compared to the general population. We aimed to understand the additional risk among people with SMI after discharge from inpatient psychiatric care, when many patients experience an acute phase of their illness. Methods In the Clinical Practice Research Datalink (CPRD) GOLD and Aurum datasets, adults aged 18 years and older who were discharged from psychiatric inpatient care in England between 2001 and 2018 with primary diagnoses of SMI (schizophrenia, bipolar disorder, other psychoses) were matched by age and gender with up to five individuals with SMI and without recent hospital stays. Using survival analysis approaches, cumulative incidence and adjusted hazard ratios were estimated for all-cause mortality, external and natural causes of death, and suicide. All analyses were stratified by younger, middle and older ages and also by gender. Results In the year after their discharge, the risk of dying by all causes examined was higher than among individuals with SMI who had not received inpatient psychiatric care recently. Suicide risk was 11.6 times (95% CI 6.4–20.9) higher in the first 3 months and remained greater at 2–5 years after discharge (HR 2.3, 1.7–3.2). This risk elevation remained after adjustment for self-harm in the 6 months prior to the discharge date. The relative risk of dying by natural causes was raised in the first 3 months (HR 1.6, 1.3–1.9), with no evidence of elevation during the second year following discharge. Conclusions There is an additional risk of death by suicide and natural causes for people with SMI who have been recently discharged from inpatient care over and above the general risk among people with the same diagnosis who have not recently been treated as an inpatient. This mortality gap shows the importance of continued focus, following discharge, on individuals who require inpatient care.

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

“…The current study showed similar findings with the results of previous studies 3,7,8,15,16,34–37 . In keeping with past research, 12,24,38 suicide risk peaked during the first 3 months after discharge and increased suicide risk could persist for many years post‐discharge. We also found greater relative risk elevation for suicide in females than males, similar to previous findings that relative risk for suicide increased more markedly in female than male patients with a history of psychiatric admission 38,39 .…”

“…The proportional hazards assumption was assessed by plotting Schoenfeld residuals versus time and examining their correlation; there was evidence for violation of the assumption. Therefore, in line with our aim to examine the mortality trajectories, we estimated HRs for each of the six follow‐up periods to allow a direct comparison of the relative mortality risks across different post‐discharge periods, similar to the approach used in some recent studies on post‐discharge mortality in psychiatric patients 11,12 . Overall and sex‐specific HRs and their 95% confidence intervals (CIs) were estimated in each of the six separate models for different follow‐up periods; each model had different starting and end points of follow‐up.…”

“…This mortality gap seems to have grown in recent decades 4–6 and is more pronounced among the most severely ill who have been psychiatrically hospitalized 6–8 . Past research has found excess mortality among hospitalized psychiatric patients compared with non‐hospitalized patients or the general population 6,7,9–13 . Among psychiatrically hospitalized populations, mortality is most increased in the first year post‐discharge with a less marked mortality risk over longer periods of follow‐up 11,12,14 .…”

“…[6][7][8] Past research has found excess mortality among hospitalized psychiatric patients compared with non-hospitalized patients or the general population. 6,7,[9][10][11][12][13] Among psychiatrically hospitalized populations, mortality is most increased in the first year post-discharge with a less marked mortality risk over longer periods of follow-up. 11,12,14 There is a pressing need to better understand the mortality pattern during this high-risk period to inform clinical care and intervention strategies.…”

“…6,7,[9][10][11][12][13] Among psychiatrically hospitalized populations, mortality is most increased in the first year post-discharge with a less marked mortality risk over longer periods of follow-up. 11,12,14 There is a pressing need to better understand the mortality pattern during this high-risk period to inform clinical care and intervention strategies. Some of the increased mortality risk during the postdischarge period could be explained by markedly elevated suicide rates soon after discharge.…”