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 e-mail: dmitry.krupchenko@gmail.com 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 2014. 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 1994-2014 and alive in the beginning of 2014. 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 2014. 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 1994-2013 with diagnoses of mental disorders (ICD-10, F00-F99) n=452 245 Linking with the mortality registry and cleaning data n=452 111 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 01.01.2014 n=326 495 Excluded: died in 1994-2013 (n=125 616) Applying criteria of diagnoses n=290 579 Excluded: having history of F0x or F7x (n=35 916) Applying criteria of age (15-84 y.o.) n=283 618 <15 y.o. (n=3 966) Excluded: >84 y.o. (n=2 995) FINAL STUDY POPULATION n=283 618 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., 2011. 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., 2011. 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., 2011. 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., 2013. 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., 2013. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet, 382(9904), pp.1575–86 Leon, D.A., Shkolnikov, V.M. & McKee, M., 2009. 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. Copyright © 2018 Logo