519690 research-article2014
APY22210.1177/1039856213519690Australasian PsychiatryO’Connor et al.
AP
Psychiatric services
The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do?
Australasian Psychiatry 2014, Vol 22(2) 154–159 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856213519690 apy.sagepub.com
Nick O’Connor Clinical Director, North Shore Ryde Mental Health Service, St Leonards, NSW, and; Clinical Senior Lecturer, Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia
Glenn E Hunt Associate Professor, Discipline of Psychiatry, University of Sydney, Sydney, NSW, and; Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Maureen O’Hara-Aarons Research Assistant, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Allan Hall Director of Clinical Governance, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Jeff Snars Clinical Director, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia Victor Storm Area Director of Mental Health, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, and; Conjoint Associate Professor, University of Western Sydney, Sydney, NSW, Australia
Tim Lambert Professor of Psychiatry, Concord Clinical School, Concord, and; Brain and Mind Research Institute (BMRI), University of Sydney, Sydney, NSW, Australia
Abstract Objectives: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 – 2010. Methods: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. Results: The mean age of death for men was 45 years and for women, 47 years, compared to the general population’s male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m2) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). Conclusions: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation. Keywords: antipsychotics, heart disease, metabolic syndrome, mortality, obesity, premature death, quality of life, schizophrenia, suicide
P
eople with schizophrenia are dying at younger ages than their general population counterparts, even when suicide deaths are excluded.1–8 The main contributors are cardiac and respiratory9 disease: the contributors to this risk are multiple and complex. For example, one study shows that coercive treatment may be associated with increased mortality rates10 and hitherto unsuspected factors, such as poor dental hygiene and obstructive sleep apnoea, may play a role in cardiac events.11,12 Lambert13,14 summarised a number of
possible contributors that increase cardiovascular morbidity: the rates of obesity, metabolic syndrome, diabetes, dyslipidaemia and smoking are increased in people
Corresponding author: Nick O’Connor, North Shore Ryde Mental Health Service and; University of Sydney, Level 1 Community Health Centre, 2C Herbert Street, Saint Leonards, NSW 2065, Australia. Email: [email protected]
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O’Connor et al.
with schizophrenia; lack of exercise may play a significant role in reducing life expectancy. There is some contention about how much their neuroleptic treatment may contribute to increased nonsuicide mortality rates in people with schizophrenia.15 Joukamaa et al.16 found a graded relationship between the number of neuroleptic medications prescribed and mortality in those with schizophrenia. Stahl et al.17 describe a ‘metabolic highway’ by which neuroleptic medications may exert more rapid development of the stages that precede cardiovascular events and premature death, such as: rapid weight gain, elevated triglyceride levels and insulin resistance. The current study used a clinical audit tool to determine if it could be used to monitor early deaths and their causes, in a defined catchment area. This article reports the results for patients with schizophrenia and related psychoses, using clinical and incident managementrelated documentation; including, where available, the post-mortem reports of people who died whilst a client of a large metropolitan mental health service, in the period from 1 January 2005 to 31 December 2010.
Methods All mental health clients who died during the study period (1 January 2005 to 31 December 2010) were identifiable if known to the mental health service, because of a mandatory reporting procedure that has been in place in New South Wales (NSW) since the mid-1990s. On a centralised database, we identified a total of 175 mental health service users whom died in the period, within the Sydney Local Health District catchment area. Sydney Local Health District provides mental health services to approximately 390,316 people aged 18–64 years, in both central and inner western metropolitan Sydney; and for this study, we also included adult deaths from the Bankstown Mental Health Service, which serves a population of 110,990 in South Western Sydney. Of the 175 registered deaths, 109 (62% of the total) had a diagnosis of schizophrenia or a related disorder (schizoaffective disorder, first episode psychosis or drug-related psychosis). These patients with schizophrenia were selected because they comprised the largest diagnostic group and most, if not all, would have taken neuroleptic medications for extended periods. An audit tool, the Mental Health Client Mortality Audit Tool, containing 26 questions, was developed for the purpose of the audit. The questions examined demographic factors (sex, age and living arrangements), psychiatric history (first admission to hospital or community visit, diagnosis and number of hospitalisations), risk factors for somatic ill health (Body Mass Index (BMI), smoking status, diabetes, hypertension and past medical history), current medications, drug and alcohol use, recent primary health and mental health service contacts, and the cause of death. An experienced registered nurse with a back-
ground in general and mental health nursing undertook the audit, which included examining electronic medical records stored on a secure server, hospital and community files, and when available, Coroner’s reports. Ethics approval was obtained from the Human Research Ethics Committees from Concord Hospital with jurisdiction over inpatient and community mental health services, and the Department of Forensic Medicine within the Coroner’s Office.
Results The demographic details and causes of death for the study group of 109 patients with diagnoses of schizophrenia or related disorder are provided in Table 1. The mean age of death was 46.0 years (45.3 for men; 47.3 for women), compared to the general population life expectancy of 78.7 years for men and 83.5 years for women.18 The average age at first contact with our mental health services was 30.7 years and the average number of years of contact with the mental health service was 14.5 years; 42% of the study patients had an age of onset prior to 26 years of age, 60% were born in Australia, 70% were single or never married, 90% were receiving the Disability Support Pension and 70% had a general practitioner. A post-mortem report was available for 87 of the deaths (80%) during the study period. The causes of death identified by the coroner or listed in the files were: suicide in 55 cases (50.5%) and natural causes (which we imputed to be premature death due to medical illness) in 42 cases (38.5%). Five of the patients were classified as dying from unnatural causes (two victims of violence and one each were by accidental heroin overdose, motor vehicle accident and choking on food); for seven others, the cause of death was undetermined by the coroner (three were found dead due to hypothermia, with high levels of alcohol, two had toxic levels of medications that may have increased post-mortem, one was found at the bottom of stairs and another was classified as undetermined direct causes with no further information). There was no significant gender difference in the study subjects’ death rates from suicide or other causes (Table 1). Classification of death, patient characteristics and current medication are shown in Table 2. Those who died from suicide or unnatural causes tended to be younger. Suicide and death from unnatural causes were associated with fewer person-years lived with mental illness. As seen in Table 2, premature deaths (defined as death before 55 years of age) were higher in patients whom committed suicide (89%), as compared to those whom died of natural causes (52%). The age at onset of illness was not significantly different between the groups having different causes of death. More years living with a mental illness was associated with death from natural causes (imputed death from medical illness). A full data set was available for 107 of the 109 patients with schizophrenia or related psychosis: 12 (11%) had been diagnosed with diabetes
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Australasian Psychiatry 22(2)
Table 1. Demographic variables and causes of death by gender
Mean age at time of death (yrs (SD)) Mean age at first contact or hospitalisation (yrs (SD)) Mean duration of contact with MHS (yrs (SD)) Born in Australiaa (n (%)) Single/never married (n (%)) On pension, unemployed or retired (n (%)) Accommodation (n (%))b Own home Shared Other/boarding house Homeless Has a general practitioner (n (%)) Post mortem completed (n (%)) Cause of death, as per Coroner (n (%)) Natural Unnatural (accidents, acts of violence, etc.) Suicide Undetermined cause
Males (n = 74)
Females (n = 35)
Total (n = 109)
45.3 (13.4) 31.8 (12.3)
47.3 (12.7) 28.3 (10.1)
46.0 (13.2) 30.7 (11.7)
12.8 (11.7)
18.1 (15.4)
14.5 (13.2)
41 (60.3%) 58 (79.5%) 61 (83.6%)
19 (59.4%) 17 (50%) 30 (88.2%)
7 (10%) 28 (40%) 34 (48.6%) 1 (1.4%) 50 (69.4%) 60 (81.1%)
8 (23.5%) 10 (29.4%) 15 (44.1%) 1 (2.9%) 25 (73.5%) 27 (77.1%)
29 (39.2%) 4 (5.4%) 37 (50%) 4 (5.4%)
13 (37.1%) 1 (2.9%) 18 (51.4%) 3 (8.6%)
60 (60%) 75 (70.1%) 91 (85.0%) 15 (14.4%) 38 (36.5%) 49 (47.1%) 2 (1.9%) 75 (70.8%) 87 (79.8%) 42 (38.5%) 5 (4.6%) 55 (50.5%) 7 (6.4%)
aMissing
values for 9 patients. values for 5 patients. MHS: Mental health service; yrs: years bMissing
and 20 (19%) with hypertension, nine (8%) with hepatitis C and none with HIV. The smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes (Table 2). There was a high rate of smoking in the group that died from natural causes, compared with rates in the general population: 61% (of the natural causes group) and 30% (of the suicide group), compared with 21% of males and 18% of females in the general population.19 Morbid obesity (BMI > 35 kg/m2) was higher in the natural causes group (38%), compared with the suicide group (10%). In 107 patients for whom the information was available alcohol was used by 25%, opiates by 17% and seven of these had been treated with methadone. Current drug and alcohol use was reported more often in the patients who committed suicide (51%), compared to those dying of natural causes (15%). Table 2 shows that 19 patients were being treated with clozapine (17.4%). There were 11 people taking clozapine in the group that died from natural causes (27%) and seven amongst the group that committed suicide (14%). We found that 16% were receiving a second generation longacting antipsychotic medication and 34% were receiving a first generation depot antipsychotic medication; 81 were
receiving an oral second generation antipsychotic and only seven subjects, a first generation oral antipsychotic medication. Of those with a diagnosis of schizophrenia or related disorder, 29% had been prescribed an antidepressant, 15% were prescribed valproate, 4% lithium, 13% a benzodiazepine and 5% were taking an anticholinergic agent at the time of death. Those who died from natural causes are shown in Table 3, together with their mean age and BMI at time of death. Nineteen patients (45%) died of heart failure, six (14%) died from smoking-related illnesses (chronic obstructive pulmonary disease, lung cancer) three died from other cancers, four died from cirrhosis of the liver or other alcohol-related illnesses, and three diabetics died from morbid obesity. The other deaths were attributed to: pneumonia, gastric ulcer, sepsis, syphilis and Parkinson’s disease. Except for the two patients dying from pneumonia, the vast majority of these patients died prematurely and 20 (48%) of them died before the age of 55 years. Moreover, most of these patients were significantly overweight and of the 29 patients where height and weight was reported, 45% (n = 13) had a BMI of 30 or more and 11 of these exceeded 35 kg/m2.
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Table 2. Patients who died: classification of death, patient characteristics and medication at the time of death
Age (years) Mean (SD) Range Deaths before the age of 55 (n (%)) Mean age of onset or first contact with health service (years (SD)) Born in Australia (n (%)) Current drug or alcohol use noted in medical record or by Coroner (n (%)) Diabetes mellitus noted in file (n (%)) Taking medication for high blood pressure (n (%)) Body Mass Index2 Mean BMI (kg/m2 (SD)) BMI range (kg/m2) BMI > 35 kg/m2 (n (%)) Long acting injectable medication (n (%))1 1st generation (typicals) 2nd generation (atypicals) Oral medication (n (%)) Typical antipsychotic Clozapine Olanzapine Risperidone Seroquel or other atypical Anticholinergic agent Antidepressant agents Lithium Valproate and/or carbamazepine Benzodiazepines
Natural n = 42
Unnatural n=5
Suicide n = 55
Undetermined n=7
54 (10.6) (34 – 72) 22 (52%) 33.1 (14.9)
37 (13.5) (26 – 60) 4 (80%) 21.2 (2.4)
39 (11.3) (19 – 68) 49 (89%) 29.5 (9.0)
57 (6.0) (44 – 62) 1 (14%) 33.8 (10.5)
21 (57%) 6 (15%)
4 (80%) 3 (60%)
31 (61%) 27 (51%)
4 (57%) 1 (17%)
9 (23%) 12 (30%)
0 (0%) 1 (20%)
2 (4%) 6 (11%)
32 (11.6) 15.6 – 70.0 11 (38%)
32 (3.3) 30.1 – 35.9 1 (33%)
28.4 (6.0) 16.0 – 48.8 5 (10%)
17 (40%) 6 (14%)
3 (60%) 2 (40%)
16 (29%) 8 (15%)
5 (12%) 11 (26%) 9 (21%) 7 (17%) 12 (29%) 1 (2%) 8 (19%) 2 (5%) 6 (14%) 4 (10%)
0 (0%) 0 (0%) 0 (0%) 2 (40%) 3 (60%) 1 (20%) 1 (20%) 0 (0%) 2 (40%) 1 (20%)
2 (4%) 7 (13%) 22 (40%) 11 (20%) 18 (33%) 2 (4%) 18 (33%) 2 (4%) 9 (16%) 9 (16%)
1 (14%) 1 (14%) 22.4 (7.6) 13.7 – 34.7 0 (0%) 1 (14%) 1 (14%) 0 (0%) 1 (14%) 4 (57%) 0 (0%) 1 (14%) 1 (14%) 3 (43%) 0 (0%) 0 (0%) 0 (0%)
1 Patients
could be taking more than one long acting injectable or oral medication. were missing for 22 patients. BMI: Body Mass Index 2 Values
Discussion In this study of mental health patients with a diagnosis of schizophrenia, 42 individuals (38.5%) died from medical conditions and 55 (50%) of them died from suicide. While suicide accounts for the majority of those who died prematurely in this cohort of people using mental health services, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is another threat to life expectancy: death from cardiorespiratory disorders. There was no evidence for a trend in relation to death from a medical condition or death from suicide, for the period examined; however, these
findings highlight the fact that medical conditions closely follow death by suicide as a major cause for premature death in people with schizophrenia. There were no gender differences in death rates from natural causes nor suicide. The suicide group were on average younger than the group that died from natural causes. The average age at time of death was 54 (SD 10.6) years for those who died of natural causes; 52% of these were under the age of 56. Compared with the life expectancy of the general population,18 this represents at least 20 years of life lost for each person. We found that 60% of our study cases were born in Australia, but there was no association between place of
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Australasian Psychiatry 22(2)
Table 3. Causes of death due to natural causes (n = 42) Cause of death due to natural causesa
N
% Male Mean Age (SD)
Mean BMI (SD)
Heart failure or other cardiovascular event
19
79%
Smoking-related illnesses (lung cancer, COPD)
6
50%
Other cancers (bile duct, ovarian, unspecified)
3
0%
34.9 (11.8) 20.0 (4.3) -
Alcohol-related (e.g. cirrhosis of the liver)
4
75%
Diabetes or morbid obesity
3
33%
Respiratory infection (e.g. pneumonia)
2
100%
Other natural causes (Gastric ulcer (n = 2), sepsis, syphilis and Parkinson’s Disease)
5
80%
54.4 (9.8) 55.5 (8.0) 40.3 (5.1) 52.5 (16.8) 57.7 (11.1) 65.5 (9.1) 52.8 (10.1)
34.4 (18.5) 30.3 (8.7) 24 (1.9) 33.8 (7.6)
a Some
patients died from multiple causes. BMI: Body Mass Index; COPD: chronic obstructive pulmonary disease
birth and cause of death. Drug and alcohol problems are common in this group, and use of alcohol and drugs were often associated with acts of suicide (Table 2). Heroin was the most common means of suicide by overdose, although in some cases it could have been unintentional. About one-quarter of the natural deaths had diabetes and one-third had high blood pressure noted in the file. Almost 40% of those who died from natural causes had a BMI > 35 kg/m2. Heart failure was the most common cause of natural death (n = 19/42 (45%)), followed by smoking-related death (n = 6 (14%)). Many patients dying of heart failure were obese and they had other comorbidities, such as drug and alcohol misuse, diabetes, smoking history or other medical conditions. The study had a number of limitations. We encountered real-world difficulties in accessing data in a health service that relies on paper records and keeps the community and hospital files separate. Data on health risk factors and medical conditions were often not recorded. It is likely that drug, alcohol and smoking rates were under-reported in the files, except when they were a direct cause of death. Only current medications were noted; there was no medication history available. We relied on multiple databases and sometimes these contained conflicting or slightly different information. There was no link to the Coroner’s reports, so these needed to be manually reviewed. Some deaths due to natural causes may have been overlooked, because some consumers may have ceased contact with the mental
health service some years before their death. Additionally, many of the deaths were due to multiple causes (e.g. heart failure due to chronic illnesses), making categorisation of the subject’s cause of death difficult. In some cases, determining whether overdoses were intentional suicides or not was difficult.
What should be done? Lambert13 highlighted that not enough is being done to prevent the increased cardiovascular risk of people with schizophrenia. He points to surveys that show that while metabolic syndrome and other cardio-respiratory risk factors are identified in these patients, they are inadequately treated: ‘knowing’ is not ‘doing’. The failure to translate detection of metabolic risk into effective treatment for people with schizophrenia was a key finding of the Australian National Survey of High Impact Psychosis (SHIP) study.20,21 The barriers that would effectively prevent cardiovascular risk are related to factors in health care systems, health care professionals, and patient and illness factors.22 Most of the barriers to prevention are surmountable. Physical examinations can occur more frequently, provided the right equipment is available and doctors in the psychiatric practice are trained and expected to physically examine patients. Waist measurement, weight and blood pressure can be measured easily. These are key indicators of cardiometabolic risk status.14 Statins, oral hypoglycaemic agents and antihypertensive medications
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O’Connor et al.
are effective agents that can easily be initiated and prescribed in psychiatric settings.13 Psychoeducation about illness can incorporate education about cardiovascular health, including: diet, exercise, oral hygiene and smoking cessation. Community programs can provide opportunities for patients to participate in gymnasium training or other group fitness activities. The variations between patients in relation to response, side effects and impact on metabolic risk factors requires that prescribers take a careful personalised medicine approach.20,23 Changes in policy require system-wide implementation of strategies, such as auditing, structured review processes and monitoring of physical health outcome indicators.13,24 In conclusion, this mortality audit is informative, as it provides a snapshot of the causes of recent deaths and may be used to help plan local health strategies to reduce mortality rates. Although suicides are often thoroughly investigated through the judicious use of root cause analysis,25 deaths from natural causes are likely to go unnoticed by most mental health service providers. The Sydney Mortality audit clearly shows that many patients with schizophrenia are dying prematurely of medical conditions that are preventable or can be managed better, if they were appropriately monitored and adequately treated.
7. Hiroeh U, Kapur N, Webb R, et al. Deaths from natural causes in people with mental illness: A cohort study. J Psychosomatic Res 2008; 64: 275–283. 8. Kisely S. Cancer-related mortality in people with mental illness. J Am Med Ass Psychiatry 2013; 70: 209–217. 9. Dutta R, Murray R, Allardyce J, et al. Mortality in first contact psychosis patients in the UK: A cohort study. Psychol Med 2011; 42: 1649–1661. 10. Honkonen H, Mattila AK, Lehtinen K, et al. Mortality of Finnish acute psychiatric hospital patients. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 660–666. 11. De Oliveira C, Watt R and Hamer M. Toothbrushing, inflammation and cardiovascular disease: Results from Scottish Health Survey. Brit Med J 2010; 340:c2451doi:10.1136/ bmj.c2451: 1–6. 12. Kalucy M, Grunstein R, Lambert T, et al. Obstructive sleep apnoea and schizophrenia - A research agenda. Sleep Med Rev 2012; 17: 357–365. 13. Lambert TJR and Newcomer JW. Are cardiometabolic complications of schizophrenia still neglected? Barriers to care. Med J Austral 2009; 190: S39–42. 14. Lambert TJR. The medical care of people with psychosis. Med J Austral 2009; 190: 171–172. 15. De Hert M, Correll CU and Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophren Res 2010; 117: 68–74. 16. Joukamaa M, Heliovaara M, Knekt P, et al. Schizophrenia, neuroleptic medication and mortality. Brit J Psychiatry 2006; 188: 122–127. 17. Stahl SM, Mignon L and Meyer JM. Which comes first antipsychotic treatment or cardiometabolic risk? Acta Psychiatrica Scand 2009; 119: 171–179. 18. Australian Institute of Health and Welfare. Australian life expectancy, www.aihw.gov. au/australian-trends-in-life-expectancy/ (2011, accessed 15 September 2013).
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
19. Australian Institute of Health and Welfare. Tobacco smoking. Information and statistics, 2013. Canberra: Australian Government. 20. Galletly C. People living with psychosis: The good news and the bad news. Austral NZ J Psychiatry 2012; 46: 803–807.
References 1. Saha S, Chant D and McGrath J. A systematic review of mortality in schizophrenia. Arch Gen Psychiatry 2007; 64: 1123–1131. 2. Martin RL, Cloninger CR, Guze SB, et al. Mortality in a follow-up of 500 psychiatric outpatients. Arch Gen Psychiatry 1985; 42: 47–54. 3. Hennekens CH. Increasing global burden of cardiovascular disease in general populations and in patients with schizophrenia. J Clin Psychiatry 2007; 68: 4–7. 4. Brown S, Inskip H and Barraclough B. Causes of the excess mortality in schizophrenia. Brit J Psychiatry 2000; 177: 212–217. 5. Allebeck P. Schizophrenia: A life-shortening disease. Schizophren Bull 1989; 15: 81–89. 6. Colton CW and Manderscheid RW. Congruencies in mortality rates, years of life lost and causes of death in public mental health clients in eight states. Prevent Chronic Dis 2006; 3: A42.
21. Morgan VA, Waterreus A, Jablensky A, et al. People living with psychotic illness in 2010: The second Australian national survey of psychosis. Austral NZ J Psychiatry 2012; 46: 735–752. 22. Lambert TJR, Velakoulis D and Pantelis C. Medical comorbidity in schizophrenia. Med J Austral 2003; 178: S67–70. 23. Baptista T. Cardiometabolic risk factors in people with pscyhotic disorders: The second Australian survey of psychosis: Going back to the foundations. Austral NZ J Psychiatry 2012; 46: 901–907. 24. Lawrence D, Hancock K and Kisley S. The gap in life expectancy from preventable illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. Brit Med J Online 2013; 346: 1–14. doi: 10.1136/bmj.f2539 (Published 22 May 2013) 25. Vine R and Mulder C. After an inpatient suicide: The aim and outcome of review mechanisms Australas Psychiatry 2013; 21: 359–364.
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APY22210.1177/1039856213519690Australasian PsychiatryO’Connor et al.
AP
Psychiatric services
The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do?
Australasian Psychiatry 2014, Vol 22(2) 154–159 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856213519690 apy.sagepub.com
Nick O’Connor Clinical Director, North Shore Ryde Mental Health Service, St Leonards, NSW, and; Clinical Senior Lecturer, Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia
Glenn E Hunt Associate Professor, Discipline of Psychiatry, University of Sydney, Sydney, NSW, and; Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Maureen O’Hara-Aarons Research Assistant, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Allan Hall Director of Clinical Governance, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
Jeff Snars Clinical Director, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia Victor Storm Area Director of Mental Health, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, and; Conjoint Associate Professor, University of Western Sydney, Sydney, NSW, Australia
Tim Lambert Professor of Psychiatry, Concord Clinical School, Concord, and; Brain and Mind Research Institute (BMRI), University of Sydney, Sydney, NSW, Australia
Abstract Objectives: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 – 2010. Methods: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. Results: The mean age of death for men was 45 years and for women, 47 years, compared to the general population’s male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m2) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). Conclusions: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation. Keywords: antipsychotics, heart disease, metabolic syndrome, mortality, obesity, premature death, quality of life, schizophrenia, suicide
P
eople with schizophrenia are dying at younger ages than their general population counterparts, even when suicide deaths are excluded.1–8 The main contributors are cardiac and respiratory9 disease: the contributors to this risk are multiple and complex. For example, one study shows that coercive treatment may be associated with increased mortality rates10 and hitherto unsuspected factors, such as poor dental hygiene and obstructive sleep apnoea, may play a role in cardiac events.11,12 Lambert13,14 summarised a number of
possible contributors that increase cardiovascular morbidity: the rates of obesity, metabolic syndrome, diabetes, dyslipidaemia and smoking are increased in people
Corresponding author: Nick O’Connor, North Shore Ryde Mental Health Service and; University of Sydney, Level 1 Community Health Centre, 2C Herbert Street, Saint Leonards, NSW 2065, Australia. Email: [email protected]
154 Downloaded from apy.sagepub.com at UNIV OF ILLINOIS URBANA on March 10, 2015
O’Connor et al.
with schizophrenia; lack of exercise may play a significant role in reducing life expectancy. There is some contention about how much their neuroleptic treatment may contribute to increased nonsuicide mortality rates in people with schizophrenia.15 Joukamaa et al.16 found a graded relationship between the number of neuroleptic medications prescribed and mortality in those with schizophrenia. Stahl et al.17 describe a ‘metabolic highway’ by which neuroleptic medications may exert more rapid development of the stages that precede cardiovascular events and premature death, such as: rapid weight gain, elevated triglyceride levels and insulin resistance. The current study used a clinical audit tool to determine if it could be used to monitor early deaths and their causes, in a defined catchment area. This article reports the results for patients with schizophrenia and related psychoses, using clinical and incident managementrelated documentation; including, where available, the post-mortem reports of people who died whilst a client of a large metropolitan mental health service, in the period from 1 January 2005 to 31 December 2010.
Methods All mental health clients who died during the study period (1 January 2005 to 31 December 2010) were identifiable if known to the mental health service, because of a mandatory reporting procedure that has been in place in New South Wales (NSW) since the mid-1990s. On a centralised database, we identified a total of 175 mental health service users whom died in the period, within the Sydney Local Health District catchment area. Sydney Local Health District provides mental health services to approximately 390,316 people aged 18–64 years, in both central and inner western metropolitan Sydney; and for this study, we also included adult deaths from the Bankstown Mental Health Service, which serves a population of 110,990 in South Western Sydney. Of the 175 registered deaths, 109 (62% of the total) had a diagnosis of schizophrenia or a related disorder (schizoaffective disorder, first episode psychosis or drug-related psychosis). These patients with schizophrenia were selected because they comprised the largest diagnostic group and most, if not all, would have taken neuroleptic medications for extended periods. An audit tool, the Mental Health Client Mortality Audit Tool, containing 26 questions, was developed for the purpose of the audit. The questions examined demographic factors (sex, age and living arrangements), psychiatric history (first admission to hospital or community visit, diagnosis and number of hospitalisations), risk factors for somatic ill health (Body Mass Index (BMI), smoking status, diabetes, hypertension and past medical history), current medications, drug and alcohol use, recent primary health and mental health service contacts, and the cause of death. An experienced registered nurse with a back-
ground in general and mental health nursing undertook the audit, which included examining electronic medical records stored on a secure server, hospital and community files, and when available, Coroner’s reports. Ethics approval was obtained from the Human Research Ethics Committees from Concord Hospital with jurisdiction over inpatient and community mental health services, and the Department of Forensic Medicine within the Coroner’s Office.
Results The demographic details and causes of death for the study group of 109 patients with diagnoses of schizophrenia or related disorder are provided in Table 1. The mean age of death was 46.0 years (45.3 for men; 47.3 for women), compared to the general population life expectancy of 78.7 years for men and 83.5 years for women.18 The average age at first contact with our mental health services was 30.7 years and the average number of years of contact with the mental health service was 14.5 years; 42% of the study patients had an age of onset prior to 26 years of age, 60% were born in Australia, 70% were single or never married, 90% were receiving the Disability Support Pension and 70% had a general practitioner. A post-mortem report was available for 87 of the deaths (80%) during the study period. The causes of death identified by the coroner or listed in the files were: suicide in 55 cases (50.5%) and natural causes (which we imputed to be premature death due to medical illness) in 42 cases (38.5%). Five of the patients were classified as dying from unnatural causes (two victims of violence and one each were by accidental heroin overdose, motor vehicle accident and choking on food); for seven others, the cause of death was undetermined by the coroner (three were found dead due to hypothermia, with high levels of alcohol, two had toxic levels of medications that may have increased post-mortem, one was found at the bottom of stairs and another was classified as undetermined direct causes with no further information). There was no significant gender difference in the study subjects’ death rates from suicide or other causes (Table 1). Classification of death, patient characteristics and current medication are shown in Table 2. Those who died from suicide or unnatural causes tended to be younger. Suicide and death from unnatural causes were associated with fewer person-years lived with mental illness. As seen in Table 2, premature deaths (defined as death before 55 years of age) were higher in patients whom committed suicide (89%), as compared to those whom died of natural causes (52%). The age at onset of illness was not significantly different between the groups having different causes of death. More years living with a mental illness was associated with death from natural causes (imputed death from medical illness). A full data set was available for 107 of the 109 patients with schizophrenia or related psychosis: 12 (11%) had been diagnosed with diabetes
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Table 1. Demographic variables and causes of death by gender
Mean age at time of death (yrs (SD)) Mean age at first contact or hospitalisation (yrs (SD)) Mean duration of contact with MHS (yrs (SD)) Born in Australiaa (n (%)) Single/never married (n (%)) On pension, unemployed or retired (n (%)) Accommodation (n (%))b Own home Shared Other/boarding house Homeless Has a general practitioner (n (%)) Post mortem completed (n (%)) Cause of death, as per Coroner (n (%)) Natural Unnatural (accidents, acts of violence, etc.) Suicide Undetermined cause
Males (n = 74)
Females (n = 35)
Total (n = 109)
45.3 (13.4) 31.8 (12.3)
47.3 (12.7) 28.3 (10.1)
46.0 (13.2) 30.7 (11.7)
12.8 (11.7)
18.1 (15.4)
14.5 (13.2)
41 (60.3%) 58 (79.5%) 61 (83.6%)
19 (59.4%) 17 (50%) 30 (88.2%)
7 (10%) 28 (40%) 34 (48.6%) 1 (1.4%) 50 (69.4%) 60 (81.1%)
8 (23.5%) 10 (29.4%) 15 (44.1%) 1 (2.9%) 25 (73.5%) 27 (77.1%)
29 (39.2%) 4 (5.4%) 37 (50%) 4 (5.4%)
13 (37.1%) 1 (2.9%) 18 (51.4%) 3 (8.6%)
60 (60%) 75 (70.1%) 91 (85.0%) 15 (14.4%) 38 (36.5%) 49 (47.1%) 2 (1.9%) 75 (70.8%) 87 (79.8%) 42 (38.5%) 5 (4.6%) 55 (50.5%) 7 (6.4%)
aMissing
values for 9 patients. values for 5 patients. MHS: Mental health service; yrs: years bMissing
and 20 (19%) with hypertension, nine (8%) with hepatitis C and none with HIV. The smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes (Table 2). There was a high rate of smoking in the group that died from natural causes, compared with rates in the general population: 61% (of the natural causes group) and 30% (of the suicide group), compared with 21% of males and 18% of females in the general population.19 Morbid obesity (BMI > 35 kg/m2) was higher in the natural causes group (38%), compared with the suicide group (10%). In 107 patients for whom the information was available alcohol was used by 25%, opiates by 17% and seven of these had been treated with methadone. Current drug and alcohol use was reported more often in the patients who committed suicide (51%), compared to those dying of natural causes (15%). Table 2 shows that 19 patients were being treated with clozapine (17.4%). There were 11 people taking clozapine in the group that died from natural causes (27%) and seven amongst the group that committed suicide (14%). We found that 16% were receiving a second generation longacting antipsychotic medication and 34% were receiving a first generation depot antipsychotic medication; 81 were
receiving an oral second generation antipsychotic and only seven subjects, a first generation oral antipsychotic medication. Of those with a diagnosis of schizophrenia or related disorder, 29% had been prescribed an antidepressant, 15% were prescribed valproate, 4% lithium, 13% a benzodiazepine and 5% were taking an anticholinergic agent at the time of death. Those who died from natural causes are shown in Table 3, together with their mean age and BMI at time of death. Nineteen patients (45%) died of heart failure, six (14%) died from smoking-related illnesses (chronic obstructive pulmonary disease, lung cancer) three died from other cancers, four died from cirrhosis of the liver or other alcohol-related illnesses, and three diabetics died from morbid obesity. The other deaths were attributed to: pneumonia, gastric ulcer, sepsis, syphilis and Parkinson’s disease. Except for the two patients dying from pneumonia, the vast majority of these patients died prematurely and 20 (48%) of them died before the age of 55 years. Moreover, most of these patients were significantly overweight and of the 29 patients where height and weight was reported, 45% (n = 13) had a BMI of 30 or more and 11 of these exceeded 35 kg/m2.
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Table 2. Patients who died: classification of death, patient characteristics and medication at the time of death
Age (years) Mean (SD) Range Deaths before the age of 55 (n (%)) Mean age of onset or first contact with health service (years (SD)) Born in Australia (n (%)) Current drug or alcohol use noted in medical record or by Coroner (n (%)) Diabetes mellitus noted in file (n (%)) Taking medication for high blood pressure (n (%)) Body Mass Index2 Mean BMI (kg/m2 (SD)) BMI range (kg/m2) BMI > 35 kg/m2 (n (%)) Long acting injectable medication (n (%))1 1st generation (typicals) 2nd generation (atypicals) Oral medication (n (%)) Typical antipsychotic Clozapine Olanzapine Risperidone Seroquel or other atypical Anticholinergic agent Antidepressant agents Lithium Valproate and/or carbamazepine Benzodiazepines
Natural n = 42
Unnatural n=5
Suicide n = 55
Undetermined n=7
54 (10.6) (34 – 72) 22 (52%) 33.1 (14.9)
37 (13.5) (26 – 60) 4 (80%) 21.2 (2.4)
39 (11.3) (19 – 68) 49 (89%) 29.5 (9.0)
57 (6.0) (44 – 62) 1 (14%) 33.8 (10.5)
21 (57%) 6 (15%)
4 (80%) 3 (60%)
31 (61%) 27 (51%)
4 (57%) 1 (17%)
9 (23%) 12 (30%)
0 (0%) 1 (20%)
2 (4%) 6 (11%)
32 (11.6) 15.6 – 70.0 11 (38%)
32 (3.3) 30.1 – 35.9 1 (33%)
28.4 (6.0) 16.0 – 48.8 5 (10%)
17 (40%) 6 (14%)
3 (60%) 2 (40%)
16 (29%) 8 (15%)
5 (12%) 11 (26%) 9 (21%) 7 (17%) 12 (29%) 1 (2%) 8 (19%) 2 (5%) 6 (14%) 4 (10%)
0 (0%) 0 (0%) 0 (0%) 2 (40%) 3 (60%) 1 (20%) 1 (20%) 0 (0%) 2 (40%) 1 (20%)
2 (4%) 7 (13%) 22 (40%) 11 (20%) 18 (33%) 2 (4%) 18 (33%) 2 (4%) 9 (16%) 9 (16%)
1 (14%) 1 (14%) 22.4 (7.6) 13.7 – 34.7 0 (0%) 1 (14%) 1 (14%) 0 (0%) 1 (14%) 4 (57%) 0 (0%) 1 (14%) 1 (14%) 3 (43%) 0 (0%) 0 (0%) 0 (0%)
1 Patients
could be taking more than one long acting injectable or oral medication. were missing for 22 patients. BMI: Body Mass Index 2 Values
Discussion In this study of mental health patients with a diagnosis of schizophrenia, 42 individuals (38.5%) died from medical conditions and 55 (50%) of them died from suicide. While suicide accounts for the majority of those who died prematurely in this cohort of people using mental health services, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is another threat to life expectancy: death from cardiorespiratory disorders. There was no evidence for a trend in relation to death from a medical condition or death from suicide, for the period examined; however, these
findings highlight the fact that medical conditions closely follow death by suicide as a major cause for premature death in people with schizophrenia. There were no gender differences in death rates from natural causes nor suicide. The suicide group were on average younger than the group that died from natural causes. The average age at time of death was 54 (SD 10.6) years for those who died of natural causes; 52% of these were under the age of 56. Compared with the life expectancy of the general population,18 this represents at least 20 years of life lost for each person. We found that 60% of our study cases were born in Australia, but there was no association between place of
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Table 3. Causes of death due to natural causes (n = 42) Cause of death due to natural causesa
N
% Male Mean Age (SD)
Mean BMI (SD)
Heart failure or other cardiovascular event
19
79%
Smoking-related illnesses (lung cancer, COPD)
6
50%
Other cancers (bile duct, ovarian, unspecified)
3
0%
34.9 (11.8) 20.0 (4.3) -
Alcohol-related (e.g. cirrhosis of the liver)
4
75%
Diabetes or morbid obesity
3
33%
Respiratory infection (e.g. pneumonia)
2
100%
Other natural causes (Gastric ulcer (n = 2), sepsis, syphilis and Parkinson’s Disease)
5
80%
54.4 (9.8) 55.5 (8.0) 40.3 (5.1) 52.5 (16.8) 57.7 (11.1) 65.5 (9.1) 52.8 (10.1)
34.4 (18.5) 30.3 (8.7) 24 (1.9) 33.8 (7.6)
a Some
patients died from multiple causes. BMI: Body Mass Index; COPD: chronic obstructive pulmonary disease
birth and cause of death. Drug and alcohol problems are common in this group, and use of alcohol and drugs were often associated with acts of suicide (Table 2). Heroin was the most common means of suicide by overdose, although in some cases it could have been unintentional. About one-quarter of the natural deaths had diabetes and one-third had high blood pressure noted in the file. Almost 40% of those who died from natural causes had a BMI > 35 kg/m2. Heart failure was the most common cause of natural death (n = 19/42 (45%)), followed by smoking-related death (n = 6 (14%)). Many patients dying of heart failure were obese and they had other comorbidities, such as drug and alcohol misuse, diabetes, smoking history or other medical conditions. The study had a number of limitations. We encountered real-world difficulties in accessing data in a health service that relies on paper records and keeps the community and hospital files separate. Data on health risk factors and medical conditions were often not recorded. It is likely that drug, alcohol and smoking rates were under-reported in the files, except when they were a direct cause of death. Only current medications were noted; there was no medication history available. We relied on multiple databases and sometimes these contained conflicting or slightly different information. There was no link to the Coroner’s reports, so these needed to be manually reviewed. Some deaths due to natural causes may have been overlooked, because some consumers may have ceased contact with the mental
health service some years before their death. Additionally, many of the deaths were due to multiple causes (e.g. heart failure due to chronic illnesses), making categorisation of the subject’s cause of death difficult. In some cases, determining whether overdoses were intentional suicides or not was difficult.
What should be done? Lambert13 highlighted that not enough is being done to prevent the increased cardiovascular risk of people with schizophrenia. He points to surveys that show that while metabolic syndrome and other cardio-respiratory risk factors are identified in these patients, they are inadequately treated: ‘knowing’ is not ‘doing’. The failure to translate detection of metabolic risk into effective treatment for people with schizophrenia was a key finding of the Australian National Survey of High Impact Psychosis (SHIP) study.20,21 The barriers that would effectively prevent cardiovascular risk are related to factors in health care systems, health care professionals, and patient and illness factors.22 Most of the barriers to prevention are surmountable. Physical examinations can occur more frequently, provided the right equipment is available and doctors in the psychiatric practice are trained and expected to physically examine patients. Waist measurement, weight and blood pressure can be measured easily. These are key indicators of cardiometabolic risk status.14 Statins, oral hypoglycaemic agents and antihypertensive medications
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are effective agents that can easily be initiated and prescribed in psychiatric settings.13 Psychoeducation about illness can incorporate education about cardiovascular health, including: diet, exercise, oral hygiene and smoking cessation. Community programs can provide opportunities for patients to participate in gymnasium training or other group fitness activities. The variations between patients in relation to response, side effects and impact on metabolic risk factors requires that prescribers take a careful personalised medicine approach.20,23 Changes in policy require system-wide implementation of strategies, such as auditing, structured review processes and monitoring of physical health outcome indicators.13,24 In conclusion, this mortality audit is informative, as it provides a snapshot of the causes of recent deaths and may be used to help plan local health strategies to reduce mortality rates. Although suicides are often thoroughly investigated through the judicious use of root cause analysis,25 deaths from natural causes are likely to go unnoticed by most mental health service providers. The Sydney Mortality audit clearly shows that many patients with schizophrenia are dying prematurely of medical conditions that are preventable or can be managed better, if they were appropriately monitored and adequately treated.
7. Hiroeh U, Kapur N, Webb R, et al. Deaths from natural causes in people with mental illness: A cohort study. J Psychosomatic Res 2008; 64: 275–283. 8. Kisely S. Cancer-related mortality in people with mental illness. J Am Med Ass Psychiatry 2013; 70: 209–217. 9. Dutta R, Murray R, Allardyce J, et al. Mortality in first contact psychosis patients in the UK: A cohort study. Psychol Med 2011; 42: 1649–1661. 10. Honkonen H, Mattila AK, Lehtinen K, et al. Mortality of Finnish acute psychiatric hospital patients. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 660–666. 11. De Oliveira C, Watt R and Hamer M. Toothbrushing, inflammation and cardiovascular disease: Results from Scottish Health Survey. Brit Med J 2010; 340:c2451doi:10.1136/ bmj.c2451: 1–6. 12. Kalucy M, Grunstein R, Lambert T, et al. Obstructive sleep apnoea and schizophrenia - A research agenda. Sleep Med Rev 2012; 17: 357–365. 13. Lambert TJR and Newcomer JW. Are cardiometabolic complications of schizophrenia still neglected? Barriers to care. Med J Austral 2009; 190: S39–42. 14. Lambert TJR. The medical care of people with psychosis. Med J Austral 2009; 190: 171–172. 15. De Hert M, Correll CU and Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophren Res 2010; 117: 68–74. 16. Joukamaa M, Heliovaara M, Knekt P, et al. Schizophrenia, neuroleptic medication and mortality. Brit J Psychiatry 2006; 188: 122–127. 17. Stahl SM, Mignon L and Meyer JM. Which comes first antipsychotic treatment or cardiometabolic risk? Acta Psychiatrica Scand 2009; 119: 171–179. 18. Australian Institute of Health and Welfare. Australian life expectancy, www.aihw.gov. au/australian-trends-in-life-expectancy/ (2011, accessed 15 September 2013).
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
19. Australian Institute of Health and Welfare. Tobacco smoking. Information and statistics, 2013. Canberra: Australian Government. 20. Galletly C. People living with psychosis: The good news and the bad news. Austral NZ J Psychiatry 2012; 46: 803–807.
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