Criminal Behaviour and Mental Health 26: 6–17 (2016) Published online 23 February 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cbm.1944
Mental disorder, imprisonment and reduced life expectancy – A nationwide psychiatric inpatient cohort study
STEINN STEINGRIMSSON1,2,4, MARTIN I. SIGURDSSON2, HAFDIS GUDMUNDSDOTTIR3, THOR ASPELUND2 AND ANDRES MAGNUSSON1, 1Mental Health Services, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland; 2Faculty of Medicine, University of Iceland, Reykjavik, Iceland; 3Prison and Probation Administration of Iceland, Reykjavik, Iceland; 4Centre for Ethics, Law and Mental Health (CELAM), Institute of Neuroscience and Physiology, The Sahlgrenska Academy, The University of Gothenburg, Gothenburg, Sweden ABSTRACT Background There is a strong correlation between severe mental illness and criminality, but little is known about how these two problem areas together may affect health outcomes. Aim The objective of this paper is to compare survival rates of male psychiatric inpatients over a 25-year period who have and have not been subject to imprisonment, allowing for nature of psychiatric morbidity. Methods A nationwide cohort of men who had ever been psychiatric inpatients was identified from Icelandic data-registers, and their diagnoses after first discharge, cumulative incidence of imprisonment, and mortality established from records. Using a nested case-control design, survival differences were determined between those ever imprisoned and those never imprisoned. Results Between January 1983 and March 2008, 7665 men were admitted to psychiatric wards in Iceland, of whom 812 (10.6%) had served a prison sentence during that time. Cumulative incidence of imprisonment was highest in the youngest age group (21%). Substance use and personality disorders were more common amongst those imprisoned. All-cause mortality, adjusted for diagnosis, age, and year of admission, was twice as high amongst those imprisoned as those not imprisoned (Hazard ratio = 2.0, 95% CI 1.5–2.6, p < 0.001).
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
Male psychiatric inpatients and imprisonment
Clinical implications Our findings indicate that psychiatric inpatients with criminal records should receive special attention with respect to all aspects of their health, not only within psychiatric services but also through more collaboration between the healthcare and judicial systems. Copyright © 2015 John Wiley & Sons, Ltd.
Introduction The high rate of psychiatric problems in prison populations is well recognised (Fazel and Danesh, 2002; Fazel and Seewald, 2012), as is a link between mental disorder and offending more generally (e.g. Hodgins et al., 2007). There has, however, been less attention to criminality amongst general psychiatric inpatients since the early 1980s, or to the effect of criminality on the course of a psychiatric illness. Engqvist and Rydelius (2006) showed increased mortality rates amongst former child and adolescent psychiatry patients and found that criminality was a predictor of mortality in this group. In general, psychiatric patients have significantly lower life expectancy compared with the general population (Wahlbeck et al., 2011). It is important to know whether criminality is associated with further deterioration of their mortality rate. Kariminia et al. (2007) showed that in a large cohort of Australian male prisoners, admission to a psychiatric hospital during imprisonment were at 41% higher risk of dying. A more recent study of another cohort from Australia showed that treatment for mental illness prior to imprisonment doubled the risk of death within 2 years of release from prison (Sodhi-Berry et al., 2014). We are not aware, however, of any nationwide studies in unselected psychiatric inpatient populations using imprisonment as an exposure variable for mortality. Our aim in this study was to establish, in a nationwide cohort the prevalence of imprisonment amongst males admitted to psychiatric hospitals, their discharge diagnoses and compare survival rates amongst psychiatric inpatients with and without a history of imprisonment. Our hypothesis was that inpatients with mental disorder and a history of imprisonment would have a higher mortality rate than those who had suffered hospitalisation alone.
Methods Iceland is a Nordic country with a population of 315,459 in 2007, a high level of education and standard of living relative to many countries even in Europe. The health care system is largely publically funded and admission to psychiatric hospitals is free of charge. There are two psychiatric centres in Iceland; the University Hospital in Reykjavík and the regional hospital in Akureyri. These two centres provide specialist care to psychiatric patients for all of Iceland. In addition, there is a private hospital associated with Alcoholics Anonymous, where
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
7
8
Steingrimsson et al.
most people with uncomplicated substance use disorders are admitted for management of withdrawal symptoms, also free of charge. Reykjavik and conjoined communities, where most of the population lives, comprises the only urbanised area in Iceland. Data compilation We compiled a nationwide registry of all men admitted to psychiatric hospitals in Iceland between January 1983 and March 2008. Using unique personal identifying numbers assigned to each individual in Iceland, the database was constructed from three sources: the discharge diagnoses register from all psychiatric centres in Iceland, the Prison Administration of Iceland database and the National Register of causes of death at the Statistical Office of Iceland. Psychiatric diagnoses All discharge diagnoses were made by consultants in psychiatry. ICD-9 was in use until 1997 when it was replaced by ICD-10. Diagnoses prior to 1997 were converted to ICD-10 diagnoses according to the following protocol based on the World Health Organization recommendations: • • • • • • • • • • •
Organic mental disorder: 290, 293, 294, 310 (ICD-9) to F00–09 (ICD-10) Any substance use disorder: 291 and 292 to F10–19 Alcohol use disorder: 291, 303 and 305.0 to F10 Other substance (non-alcohol) use disorder: 292, 304, 305.1–7 and 305.9 to F11–19 Any schizophrenia related diagnosis: 295, 297 and 298.1–298.9 to F20–F29 Schizophrenia: 295.1–195.3, 295.6 and 295.9 to F20 Any mood disorder: 296, 298.0, 300.4, 301.1 and 311 to F30–39 Manic episode or bipolar disorder: 296.0, 296.2–296.6 and 296.8 to F30–31 Depressive episode or unipolar affective disorder: 296.1, 298.0 and 311 to F32–33 Any anxiety disorder: 300.0–300.3, 300.5–300.9, 306.0–206.5, 306.7–306.9, 308 and 309 to F40–48 Specific personality disorders: 301.0, 301.2–301.9 to F60
The discharge diagnosis after the first admission during the study period was defined as the index diagnosis. Diagnoses were not considered mutually exclusive, so in the case of an individual receiving more than one diagnosis at admission, all diagnoses were considered valid. For a number of ICD categories, however, some diagnoses explicitly exclude others, and this guidance was respected, but where the presenting problem was better explained by more than one diagnostic category (e.g. a patient diagnosed with an affective disorder, substance use disorder and
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
Male psychiatric inpatients and imprisonment
personality disorder), all diagnoses were recorded. Insofar as discharge diagnoses after later admissions were different from the originals, the earliest diagnoses were taken as valid for this study. Imprisonment The Prison Administration of Iceland keeps a continuous register of all individuals who have served a prison sentence since 1985. Imprisonment status was defined as one or more prison sentences during the study period, regardless of whether the patient had been admitted before or after the imprisonment. Cause of death The Statistical Office of Iceland has kept a record of causes of death for all registered individuals in Iceland since 1950. Individuals dying in accidents, by suicide or homicide were considered to have died of unnatural causes. All other causes were classified as ‘natural’. Ethical considerations The Bioethical Committee of Iceland (registration number: 08-051) and The Data Protection Authority of Iceland (2008/189) approved the study, as did Landspitali University Hospital, Akureyri Hospital, the Statistical Office of Iceland and the Prison Administration of Iceland. Because the personal identifying number was deleted immediately after construction of the database and birth dates converted to age intervals, informed consent was not required. Statistical analyses Descriptive statistics were used to compare men between 18 and 65 years of age at index admission who had been imprisoned or not. The 20-year cumulative imprisonment incidence was estimated and plotted using the Kaplan-Meyer method. To compare differences in incidence of diagnoses at index admission, a χ 2 test was used. In accordance with ethical approval requirements, subgroups of less than 30 individuals were presented in tables as ‘
Mental disorder, imprisonment and reduced life expectancy – A nationwide psychiatric inpatient cohort study
STEINN STEINGRIMSSON1,2,4, MARTIN I. SIGURDSSON2, HAFDIS GUDMUNDSDOTTIR3, THOR ASPELUND2 AND ANDRES MAGNUSSON1, 1Mental Health Services, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland; 2Faculty of Medicine, University of Iceland, Reykjavik, Iceland; 3Prison and Probation Administration of Iceland, Reykjavik, Iceland; 4Centre for Ethics, Law and Mental Health (CELAM), Institute of Neuroscience and Physiology, The Sahlgrenska Academy, The University of Gothenburg, Gothenburg, Sweden ABSTRACT Background There is a strong correlation between severe mental illness and criminality, but little is known about how these two problem areas together may affect health outcomes. Aim The objective of this paper is to compare survival rates of male psychiatric inpatients over a 25-year period who have and have not been subject to imprisonment, allowing for nature of psychiatric morbidity. Methods A nationwide cohort of men who had ever been psychiatric inpatients was identified from Icelandic data-registers, and their diagnoses after first discharge, cumulative incidence of imprisonment, and mortality established from records. Using a nested case-control design, survival differences were determined between those ever imprisoned and those never imprisoned. Results Between January 1983 and March 2008, 7665 men were admitted to psychiatric wards in Iceland, of whom 812 (10.6%) had served a prison sentence during that time. Cumulative incidence of imprisonment was highest in the youngest age group (21%). Substance use and personality disorders were more common amongst those imprisoned. All-cause mortality, adjusted for diagnosis, age, and year of admission, was twice as high amongst those imprisoned as those not imprisoned (Hazard ratio = 2.0, 95% CI 1.5–2.6, p < 0.001).
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
Male psychiatric inpatients and imprisonment
Clinical implications Our findings indicate that psychiatric inpatients with criminal records should receive special attention with respect to all aspects of their health, not only within psychiatric services but also through more collaboration between the healthcare and judicial systems. Copyright © 2015 John Wiley & Sons, Ltd.
Introduction The high rate of psychiatric problems in prison populations is well recognised (Fazel and Danesh, 2002; Fazel and Seewald, 2012), as is a link between mental disorder and offending more generally (e.g. Hodgins et al., 2007). There has, however, been less attention to criminality amongst general psychiatric inpatients since the early 1980s, or to the effect of criminality on the course of a psychiatric illness. Engqvist and Rydelius (2006) showed increased mortality rates amongst former child and adolescent psychiatry patients and found that criminality was a predictor of mortality in this group. In general, psychiatric patients have significantly lower life expectancy compared with the general population (Wahlbeck et al., 2011). It is important to know whether criminality is associated with further deterioration of their mortality rate. Kariminia et al. (2007) showed that in a large cohort of Australian male prisoners, admission to a psychiatric hospital during imprisonment were at 41% higher risk of dying. A more recent study of another cohort from Australia showed that treatment for mental illness prior to imprisonment doubled the risk of death within 2 years of release from prison (Sodhi-Berry et al., 2014). We are not aware, however, of any nationwide studies in unselected psychiatric inpatient populations using imprisonment as an exposure variable for mortality. Our aim in this study was to establish, in a nationwide cohort the prevalence of imprisonment amongst males admitted to psychiatric hospitals, their discharge diagnoses and compare survival rates amongst psychiatric inpatients with and without a history of imprisonment. Our hypothesis was that inpatients with mental disorder and a history of imprisonment would have a higher mortality rate than those who had suffered hospitalisation alone.
Methods Iceland is a Nordic country with a population of 315,459 in 2007, a high level of education and standard of living relative to many countries even in Europe. The health care system is largely publically funded and admission to psychiatric hospitals is free of charge. There are two psychiatric centres in Iceland; the University Hospital in Reykjavík and the regional hospital in Akureyri. These two centres provide specialist care to psychiatric patients for all of Iceland. In addition, there is a private hospital associated with Alcoholics Anonymous, where
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
7
8
Steingrimsson et al.
most people with uncomplicated substance use disorders are admitted for management of withdrawal symptoms, also free of charge. Reykjavik and conjoined communities, where most of the population lives, comprises the only urbanised area in Iceland. Data compilation We compiled a nationwide registry of all men admitted to psychiatric hospitals in Iceland between January 1983 and March 2008. Using unique personal identifying numbers assigned to each individual in Iceland, the database was constructed from three sources: the discharge diagnoses register from all psychiatric centres in Iceland, the Prison Administration of Iceland database and the National Register of causes of death at the Statistical Office of Iceland. Psychiatric diagnoses All discharge diagnoses were made by consultants in psychiatry. ICD-9 was in use until 1997 when it was replaced by ICD-10. Diagnoses prior to 1997 were converted to ICD-10 diagnoses according to the following protocol based on the World Health Organization recommendations: • • • • • • • • • • •
Organic mental disorder: 290, 293, 294, 310 (ICD-9) to F00–09 (ICD-10) Any substance use disorder: 291 and 292 to F10–19 Alcohol use disorder: 291, 303 and 305.0 to F10 Other substance (non-alcohol) use disorder: 292, 304, 305.1–7 and 305.9 to F11–19 Any schizophrenia related diagnosis: 295, 297 and 298.1–298.9 to F20–F29 Schizophrenia: 295.1–195.3, 295.6 and 295.9 to F20 Any mood disorder: 296, 298.0, 300.4, 301.1 and 311 to F30–39 Manic episode or bipolar disorder: 296.0, 296.2–296.6 and 296.8 to F30–31 Depressive episode or unipolar affective disorder: 296.1, 298.0 and 311 to F32–33 Any anxiety disorder: 300.0–300.3, 300.5–300.9, 306.0–206.5, 306.7–306.9, 308 and 309 to F40–48 Specific personality disorders: 301.0, 301.2–301.9 to F60
The discharge diagnosis after the first admission during the study period was defined as the index diagnosis. Diagnoses were not considered mutually exclusive, so in the case of an individual receiving more than one diagnosis at admission, all diagnoses were considered valid. For a number of ICD categories, however, some diagnoses explicitly exclude others, and this guidance was respected, but where the presenting problem was better explained by more than one diagnostic category (e.g. a patient diagnosed with an affective disorder, substance use disorder and
Copyright © 2015 John Wiley & Sons, Ltd.
26: 6–17 (2016) DOI: 10.1002/cbm
Male psychiatric inpatients and imprisonment
personality disorder), all diagnoses were recorded. Insofar as discharge diagnoses after later admissions were different from the originals, the earliest diagnoses were taken as valid for this study. Imprisonment The Prison Administration of Iceland keeps a continuous register of all individuals who have served a prison sentence since 1985. Imprisonment status was defined as one or more prison sentences during the study period, regardless of whether the patient had been admitted before or after the imprisonment. Cause of death The Statistical Office of Iceland has kept a record of causes of death for all registered individuals in Iceland since 1950. Individuals dying in accidents, by suicide or homicide were considered to have died of unnatural causes. All other causes were classified as ‘natural’. Ethical considerations The Bioethical Committee of Iceland (registration number: 08-051) and The Data Protection Authority of Iceland (2008/189) approved the study, as did Landspitali University Hospital, Akureyri Hospital, the Statistical Office of Iceland and the Prison Administration of Iceland. Because the personal identifying number was deleted immediately after construction of the database and birth dates converted to age intervals, informed consent was not required. Statistical analyses Descriptive statistics were used to compare men between 18 and 65 years of age at index admission who had been imprisoned or not. The 20-year cumulative imprisonment incidence was estimated and plotted using the Kaplan-Meyer method. To compare differences in incidence of diagnoses at index admission, a χ 2 test was used. In accordance with ethical approval requirements, subgroups of less than 30 individuals were presented in tables as ‘
