1
Full Professor of Psychiatry, , University of Social Welfare and Rehabilitation Sciences (USWR), Razi
Psychiatric Hospital, Tehran, Iran (Islamic Republic of)
2
Razi Psychiatric Hospital, Tehran, Iran (Islamic Republic of)
Corresponding author details:
Saeed Shoja Shafti
Full Professor of Psychiatry
University of Social Welfare and Rehabilitation Sciences (USWR) Razi Psychiatric Hospital
Tehran,Iran (Islamic Republic of)
Copyright: © 2020 Shafti SS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Introduction: Researchers have consistently reported that people with mental disorders have elevated mortality compared with the general population. In Iran there are not systematic psychiatric case registers that could allow us to study precisely the mortality of psychiatric patients. The aim of the current study was to determine the mortality rate and clinical profile of death in a group of non-western chronic elderly schizophrenic patients.
Methods: Chronic geriatric subdivision of Razi Psychiatric hospital with a capacity around 220 beds (110 for each of male and female elderly patients) had been selected as the specific arena of investigation. For the present retrospective survey, all recorded deceases during the last sixty months (April of 2014-August 2019) in the said senior wards had been included in the current study. Clinical diagnosis, too, was essentially based on ‘Diagnostic and Statistical Manual of Mental Disorders’, 5th edition (DSM-5).
Results: Among eight-hundreds and frothy chronic elderly schizophrenic patients, sixtynine deceases had been registered by the mortality committee of the hospital. As said by results, the annual rate of mortality among elderly schizophrenic patients in the present assessment was around 0.015 (0.15 per 1,000 individuals per year) and 0.017 (0.17 per 1,000 individuals per year) among male and female aged patients, respectively, which were significantly lower than current native crude death rate (p < 0.000). While the age of the expired female patients was significantly more than the died male schizophrenics (p < 0.001), the life expectancy of both male and female expired patients was significantly shorter than the public’s life expectancy (p< 0.000). Besides, in the present evaluation, while cardiac illness was the main leading cause of death among old schizophrenics, reasons like suicide, falls, drug use or tuberculosis, were not applicable at all.
Conclusion: While the rate of mortality among elderly schizophrenics was significantly
lower than public’s crude death rate, age of the deceased female patients was significantly
longer than the male expired patients and life expectancy of both male and female died
patients was significantly lower than native public’s life expectancy. Cardiac disorder, as
well, was the main leading cause of death among aged schizophrenic patients.
Schizophrenia; Rate of Mortality; Geriatric Psychiatry; Life Expectancy; Cause of Death;
Chronic Mental Patients
Researchers have consistently reported that people with mental disorders have elevated
mortality compared with the general population [1,2]. Since then, numerous studies and
reviews have been conducted on the mortality risks of people with a variety of mental
disorders and specific diagnoses [3,4]. The link between mental disorders and mortality
is complicated because most people with mental disorders do not die of their condition;
rather, they die of heart disease and other chronic diseases, infections, suicide, and other
causes [5,6]. Another complicating factor is that mental disorders are associated with risk
factors for mortality [7]. In this regard, people with mental disorders have high rates of
adverse health behaviors, including tobacco smoking, substance use, physical inactivity,
and poor diet [7]. In turn, these behaviors contribute to the high rates of chronic medical
conditions among people with mental disorders [8]. Although schizophrenia is not in itself a
lethal illness, over-mortality among such group of psychiatric patients in comparison to the
reference population has been attested to for a long time [9]. Until the use of antibiotics, this
over-mortality was mainly due to infectious diseases caused by the close quarters in mental
institutions. At the present time this over-mortality is mainly due to suicide but also with a noteworthy mortality by certain natural causes such as respiratory
diseases and cardio-vascular and cerebro-vascular diseases [9]. On
the other hand, old age, or late adulthood, usually refers to the stage of
the life cycle that begins at age 65. Older adults can also be described
as well-old (persons who are healthy) and sick-old (persons who have
an infirmity that interferes with functioning and requires medical or
psychiatric attention) [10]. The health needs of older adults have
grown enormously as the population ages, and geriatric physicians
and psychiatrists play major roles in treating this population [10].
While the leading causes of death among older persons are heart
disease, cancer, and stroke [11]. the National Institute of Mental
Health’s Epidemiologic Catchment Area (ECA) program has found
that the most common mental disorders of old age are depressive
disorders, cognitive disorders, phobias, and alcohol use disorders.
Older adults also have a high risk for suicide and drug-induced
psychiatric symptoms [12]. Meanwhile, elderly persons have a higher
risk for suicide than any other population [13]. In this regard, some
scholars believe that mortality is significantly higher among people
with mental disorders than among the comparison population and
mental disorders rank among the most substantial causes of death
worldwide [1], and mortality risk of the long-stay psychiatric patients
compared with that of the general population was notably higher,
despite ongoing improvements in medical care and facilities [14-16].
But there are other scholars as well, who believe that standardized
mortality ratios are lowest in geriatric psychiatric patients [17] and
the ostensible over-mortality tends to disappear in elderly subjects
[18]. Also with regard to leading causes of death, while some of
researchers believe that long-stay psychiatric patients were found to
die from the same natural causes as the rest of the general population
[11,16]. Others accentuate on more specific causes [19,20]. In Iran
there are not systematic psychiatric case registers that could allow
us to study precisely the mortality of psychiatric patients. So, the
aim of the current study was to determine the mortality rate and
clinical profile of death in a group of non-western chronic elderly
schizophrenic patients.
Razi psychiatric hospital in south of capital city of Tehran, as one of the largest and oldest public psychiatric hospitals in the Middle East, which has been established formally in 1917 and with a capacity around 1375 active beds, had been selected as the field of study in the present retrospective assessment. Moreover, amongst its separate existent sections, chronic geriatric subdivision of the hospital with a capacity around 220 beds (110 for each of male and female elderly patients) had been selected as the specific arena of investigation. So for survey, all recorded deceases during the last sixty months (April of 2014-August 2019) in the said senior wards had been included in the current study. Clinical diagnosis, too, was essentially based on ‘Diagnostic and Statistical Manual of Mental Disorders’, 5th edition (DSM-5) [21].
Statistical Analysis
‘t-test’ and ‘comparison of proportions’ had been used as arithmetic
formularies for valuation of data. Statistical significance, as well, had
been defined as p value ≤ 0.05. Med Calc Statistical Software version
15.2 was used as statistical software tool for analysis.
Among eight-hundreds and frothy elderly schizophrenic patients
hospitalized in the chronic geriatric section of Razi psychiatric
hospital (n = 505 & n = 335, for male and female aged patients,
respectively), during the last sixty-four months, sixty-nine deceases
(thirty-nine deaths among male patients, and thirty expiries among
female patients) had been registered by the mortality committee of
the hospital. As said by results, the annual rate of mortality among
elderly psychiatric patients in the present assessment was around
0.015 (0.15 per 1,000 individuals per year) and 0.017 (0.17 per
1,000 individuals per year) among male and female elderly patients,
respectively, which could not show any significant gender-based
difference, incidentally (z = -0.6370, p-< 0.52, CI 95% = -0.05, 0.02).
Nevertheless, they were significantly lower than the current native
crude death rate (4.84 deaths / 1000 population) (z = 6.09, p<0.000,
CI 95% = 0.005, 0.002). On the other hand, the mean ± standard
deviation (SD) of the age of the deceased patients were around 68.2 ±
6.81 and 73.57 ± 6.82 for male & female patients, respectively, which
could well reveal a significant gender-based difference, by the way
(t = 3.245 , probability < 0.001, CI 95% = 2.07, 8.67). Furthermore,
in comparison with the life expectancy in Iran, based on the latest
WHO data published in 2018, which was around 74.6 and 76.9 for
male & female persons, respectively, and 75.7, as total, findings of the
present assessment displayed a significant shortening of life among
both male and female aged patients (t = 21.11, p < 0.000, CI 95% =
5.81, 6.99, and t = 8.93, p < 0.000, CI 95% = 2.60, 4.06, respectively).
With regard to leading causes of death, results of the present
assessment had exposed that cardiac disorders, in total, was the main
leading cause of death among aged schizophrenic patients (Table
1). Regarding other causes of death, like stroke, lower respiratory
infections, chronic obstructive pulmonary disease, and malignancy,
the present ranking was rather roughly in concurrence with the
national or universal data, may be due to preventable problems like
electrolyte imbalance or aspiration \ asphyxiation, which demands
more medical cautiousness or monitoring. Moreover, with regard to
malignancy, trachea, bronchus or lung cancers was evident in only
two male cases, and the rest included stomach, pancreas and brain
cancers, as well as lymphoma. Likewise, causes like violence, suicide, road traffic accidents, falls, fires, drug use, tuberculosis, drowning,
epilepsy, and Parkinson’s disease were not applicable at all, in the
present evaluation.
While mental disorders are supposed to be associated with an
elevated risk of premature mortality [1], inadequately organized
somatic care and the prevailing culture of “non-somatic” treatment
in psychiatry were suggested to, at least in part, explain this
phenomenon [16]. Such a problem, also, maybe can be exacerbated
by the shift in psychiatric care from inpatient facilities to community
settings, jails, and prisons in recent decades [22]. Evidence from
national registry studies indicates that this mortality risk is especially
high soon after discharge from inpatient psychiatric services [23,24].
Elderly patients have more concomitant, chronic, and multiple
medical problems and take more medications than younger adults
[25]; many of these medications can influence their mental status
[26]. Back to our discussion and with respect to the mortality rate,
our conclusion was somewhat in accord with the outcomes of Ran et
al., who supposed that standardized mortality ratios were highest in
young subjects and the lowest in geriatric subjects [17]. But, instead,
it was not in agreement with the inferences of Lim et al. [14], Hewer
et al. [15], and Räsänen et al. [16], who assumed that the mortality
risk of the long-stay psychiatric patients compared with that of
the general population was notably higher. Furthermore, it was in
partial agreement with Bralet et al., who said that though the average
mortality in schizophrenia is twice higher than among the population,
this over-mortality is highest among the 20-40 years range of age and
added risk tends to disappear after 60 years [18]. So the reports of
Walker et al. [1] that mortality is significantly higher among people
with mental disorders than among the comparison population and
mental disorders rank among the most substantial causes of death
worldwide may demand reconsideration. Also, while in the present
assessment and with respect to mortality rate there was not any
meaningful difference between old male and female psychiatric
patients, this finding was not in harmony with the deduction
of Tabbane et al., who stated that the supposed over-mortality
concerned only schizophrenic male patients whereas schizophrenic
females did not have an over-mortality [19]. In addition, while a
substantial difference was evident between male and female old
patients as regards the age of death, which was significantly longer on
behalf of female patients, the latter finding is coherent with the fact
that on average, women live longer than men [11], and may highlight
some kind of biological vulnerability, which demands further genderbased clinical investigations. Moreover, with respect to gender-based
mortality rate, our verdict was not compatible with the assumptions
of Gausset et al. [27], who supposed that among severe mental
patients, mortality rates are higher for men than women. Similarly,
as regards life expectancy, outcomes of the current evaluation, which
showed a significant shortening of life among elderly male and
female schizophrenic patients, were consistent with the findings of
Zgueb et al. [28], who stated that young psychiatric inpatients seem
to be at high risk of premature death and Zubenko et al. [29], who
supposed that the mental disorders of late life have a significant
negative impact on the survival of older psychiatric patients. With
regard to leading causes of death, results of the present assessment
had exposed that cardiac disorders, in total, was the main leading
cause of death among geriatric patients, which was in agreement
with the conclusions of Trollor et al. [11] and Räsänen et al. [16],
who believed that long-stay psychiatric patients were found to die
from the same natural causes as the rest of the general population.
Regarding other causes of death, the present ranking was rather
roughly in concurrence with the findings of Lim et al. [14], Hewer
et al. [15], Tabbane et al. [19], and Abiodun OA [20]. Such a variance
maybe is a bit due to preventable problems like electrolyte imbalance
or aspiration \ asphyxiation, which had occupied the second ranking,
among all causes of death and demands more medical cautiousness
or monitoring. Also, with respect to infection and pneumonia, our
results were not consistent with the assumptions of Lim et al. [14], and Abiodun OA [20], who had declared, in general, infection and
pneumonia as the most important causes of death. The later finding,
perhaps, could be attributed to proper scrubbing and ventilation,
which may well reduce the risk of infections. But, regarding sudden
cardiac death our conclusion was somewhat compatible with the
finding of Abiodun OA, who had found sudden unexplained deaths
in a noticeable number of cases [20]. Also, in opposite to Walker et
al. [1] and Bralet et al. [18], unnatural causes, like suicide, did not
have any place among main causes of death in our study. Nonetheless,
as regards the role of malignancy, it was rather in harmony with the
statement of Tabbane et al., who thought that cancer mortality in
schizophrenic patients is still debated [19]. In general, at all times
a pretreatment medical evaluation, plus periodic exams, based on
standard protocols, is essential [30]. For example, any changes in
blood pressure and pulse rate and other side effects should be watched
[31]. Attention ought to increasingly focus on somatic examinations
and various health educational programs specially designed for
psychiatric patients and involving matters like healthy diet, smoking
cessation and physical exercise [32]. Anyhow, the importance of
mortality studies remains twofold: they are a good indicator of the
quality of health care policy, and also they enable the formulation of
research hypotheses to be made if you point out specific causes of
death in a sub-group like schizophrenics compared to the general
population [33]. For patients hospitalized with psychiatric disorders,
the time shortly after discharge is the period in which they are at the
highest risk for premature death from a variety of causes. Clinicians
should keep these patients safe by serving as a liaison between
primary and secondary health care services to ensure patients are
receiving holistic care that meets their physical and mental health
needs as well as addresses their psychosocial problems. Mental
health facilities and their partner agencies need to work proactively
and in unison to determine the risks likely to reemerge or become
exacerbated at discharge and to provide extra support to ameliorate
the greatly elevated risk of unnatural death [22]. Identifying risk
factors for deaths in psychiatric hospitals highlights needed changes
in psychiatric management strategies taking into account the
patient’s characteristics as well as the drugs’ safety profile. Further
studies with larger samples are needed to better highlight risk factors
for premature death in psychiatric inpatients. Identifying such risk
factors is necessary to develop efficient preventive strategies [28].
While the rate of mortality among elderly schizophrenics was
significantly lower than public’s crude death rate, age of the deceased
emale patients was significantly longer than the male expired
patients and life expectancy of both male and female died patients
was significantly lower than native public’s life expectancy. Cardiac
disorder, as well, was the main leading cause of death among aged
schizophrenic patients.
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