Kaisa Viilo

Excess mortality among long-stay psychiatric patients in Northern Finland.

Abstract.Background: According to several studies, mortality in psychiatric patients is higher than in the general population, but cause-specific mortality analyses in long-stay psychiatric patients have not been studied very much. Individual follow-ups have been called for in order to identify possible treatment deficiencies and to make recommendations for clinical practices. In this study, mortality of long-stay psychiatric patients has been monitored for the years 1992–2000 and contrasted with that prevalent in the general population. Method: Data on psychiatric patients (N = 253) who were treated without a break for at least 6 months during 1992 in the Department of Psychiatry at Oulu University Hospital were linked with the National Death Register. Standardised mortality rates (SMRs) were determined according to gender, age groups, and different causes of death. Results: Of the total study population, 80.2 % had schizophrenia, 5.1 % other functional psychoses, 9.5 % organic mental disorders, 2.4 % personality disorders and 2.8 % mood disorders. Sixty-nine (27.3 %) of the patients (aged 31–88 years) had died before the end of the year 2000. The all-cause death risk for both males and females was four times that of the general population. The mortality risk was over ten-fold for males and almost 30-fold for females in the youngest age group (25–34 years), with suicides explaining about 75 % of these deaths. SMRs were found to decrease at older age, mortality thus approaching that of the general population. Diseases of the circulatory system were the most common single cause of death in both genders and mortality due to that cause exceeding mortality in the general population nearly 3.6-fold. However, the probability of death was highest (SMR 17.5) in connection with diseases of the digestive system. Increased risks of death due to respiratory complications (SMR 9.3), accidents (SMR 5.1) and neoplasms (SMR 2.1) were also noted. The overall death rates did not differ in relation to social class or professional education. Conclusions: Long-stay psychiatric patients were found to die from the same natural causes as the rest of the general population. However, the 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. Inadequately organised somatic care and the prevailing culture of “non-somatic” treatment in psychiatry were suggested to, at least in part, explain this phenomenon. Attention ought to increasingly focus on somatic examinations and various health educational programmes specially designed for psychiatric patients and involving matters like healthy diet, smoking cessation and physical exercise. These practices should be a regular part of any patients treatment programme. Also, the need to recognise factors associated with a patients psychiatric disorder that could limit that patients ability to communicate somatic symptoms and/or even lead to a refusal by that patient to have somatic diseases treated was seen as essential for providers of psychiatric services.

Cyclic time patterns of death from suicide in northern Finland

BACKGROUNDnTime patterns of suicide have been attributed not only to social and psychological factors but also to direct geophysical effects. Seasonal variations in day length and temperature seem likely to contribute to the timing of the suicide process.nnnMETHODSnWe analysed all suicides (n=1658) committed in a northern province of Finland during a period of 153 months. Daily data on the number of suicides, local weather conditions and geomagnetic storms were compiled and modelled with Poisson regression using the province population as the denominator, and with the means of harmonic series for seasonal variation. Time series analysis of monthly numbers of suicides was carried out using the seasonal-trend decomposition procedure based on loess.nnnRESULTSnMarked fluctuations in the number of suicides occurred during the study period (P=0.01). There was significant seasonal variation in death from suicide (P=0.01), but analysis of the meteorological data showed no evidence of effect on the risk of suicide.nnnLIMITATIONSnAssessment of mental disorder or alcohol consumption was missing, since only data derived from death certificate was available for each case.nnnCONCLUSIONSnThe seasonal effect was significant, but remained modest compared to sex and age as risk factors for suicide. Preventive measures need to be tailored according to time of the year.

Is seasonality of suicides stronger in victims with hospital-treated atopic disorders?

The aim of the present study was to test whether the seasonal distribution of suicides differed between atopic and non-atopic suicide victims. A cross-sectional comparison of the semi-annual and seasonal distribution of suicides was made by using a 13-year database of all suicides (1296 males, 289 females) committed during the years 1988-2000 in the province of Oulu in Northern Finland. During the first half of the year, the proportion of suicides among atopic patients was significantly higher than that linked with non-atopic patients. Of all atopic patients, 72% committed suicide during the first and 28% during the second half of the year. Suicides among victims without any atopic disorders followed a uniform seasonal distribution throughout the year (50 vs. 50%). The exacerbation of an atopic disorder may increase the risk of suicide in spring; something that should be taken note of in clinical work.

Traumatic brain injury, psychiatric disorders and suicide: A population-based study of suicide victims during the years 1988-2004 in Northern Finland

Background: Depression and substance abuse are common among patients with traumatic brain injury (TBI). However, previous studies have not examined the temporal association between psychiatric disorders, TBI and suicide. Objective: To study the prevalence of TBI injury among suicide victims; to determine the association of suicide, psychiatric disorders and TBI severity; and to examine the effect of pre- and post-traumatic psychiatric disorders on their remaining life-time. Methods: This study examined all suicides (nu2009=u20091877) committed during a 16-year period in the province of Oulu, Finland. The information of suicide victims was extracted from the official death certificates and the National Hospital Discharge Registers. Results: TBI was found in 5.5% (nu2009=u2009103) of the victims. Compared to the victims without TBI, those with TBI had significantly more hospital-treated psychiatric and alcohol disorders. If TBI subjects had comorbid psychiatric disorders, the time period between TBI and suicide was under 3 years in ∼u200990% of victims in this suicide population. Conclusions: Seriousness of injury, male gender, older age, being unemployed and presence of psychiatric and alcohol disorders are important to identify as possible predictors for suicidal behaviour in TBI patients. Further studies are required to shed light on interventions aimed at better life management.

Sedative Drug Use in the Home-Dwelling Elderly

BACKGROUND The elderly use more sedatives than other populations. Reports on the sedative load of drugs and their associations with health items are scarce. OBJECTIVE To investigate the prevalence of sedatives and drugs with sedative properties and the associations between those drugs and demographic or health items in the home-dwelling elderly in a cross-sectional community survey. METHODS Information was obtained from 1197 persons (43% men) aged ue42164 years in the Finnish municipality of Lieto in 1998–1999. The brand names of the prescription drugs taken by each interviewee during one week prior to the interview were recorded. The classification created in a previous study, where the drugs used in Finland were divided into 4 groups by their sedative properties, was utilized to determine associations with health items. RESULTS A total of 88% (n = 1056) of the participants used some drug. Forty percent (n = 422 persons) of the drug users took sedatives or drugs with sedative properties. The oldest individuals (ue42180 y), women, those with low education, smokers, those with poor self-perceived health, people with dementia and mobility problems, and especially those with depression had an independent association with the simultaneous use of many (ue4212) sedatives or drugs with sedative properties. CONCLUSIONS In a population of home-dwelling elderly patients, abundant sedative drug use was common and especially associated with high age, female gender, poor basic education, poor health habits (eg, smoking), depression, dementia, or impaired mobility. Users also had poor self-perceived health. The need to further develop the classification will be a major challenge, and the classification needs to be updated every year. More studies are needed in this field.

Lifetime prevalences of physical diseases and mental disorders in young suicide victims

Objective: Evaluation was done of a possible link between psychiatric and physical illnesses in suicide victims 25 years of age or younger. Methods: This was a follow-up study based on a 13-year database (n = 1,585) of all suicides committed during the years 1988 to 2000 in northern Finland with linkage to national hospital discharge registers. The setting for the study was the province of Oulu, located in northern Finland. Subjects comprised 202 male and 27 female suicide victims aged 25 years or less. Results: Despite the young age of the suicide victims, lifetime prevalence of physical illness was about 70% in both males and females. In relation to mental disorders, female suicide victims were affected significantly more (45%) than their male counterparts (21%). About 27% of the subjects with physical illnesses had also suffered from mental disorders, but the respective proportion among those without any physical illness was only 7%. An increased prevalence of mental disorders was found in victims with diseases of the skin and subcutaneous tissues, musculoskeletal, respiratory, and digestive systems. Furthermore, increased incidences of mental disorders were also noticed in connection with injuries, poisonings, and symptoms or signs of infectious diseases. Prevalence of mental disorders in these physical disease categories varied from 25% to 44%. Conclusion: We recommend a greater attention to young people with physical illnesses and other symptoms in the hope that such screening may lead to an early recognition of psychiatric disorders and suicidal tendencies. FHDR = Finnish Hospital Discharge Register; ICD = International Classification of Diseases.

Avoidable mortality in long-stay psychiatric patients of Northern Finland

The aim of the present study was to examine mortality due to avoidable and unavoidable causes, unnatural deaths, and mortality possibly related to the use of psychotropic drugs. Mortality of 253 long-stay psychiatric patients from Northern Finland were monitored over a 9-year period and characterized according to standardized mortality rates (SMRs). Deaths due to avoidable causes included about 30% of all deaths, SMRs being 1.9 times (males) and 3.2 times (females) higher than those of the general population. The risk of unnatural deaths was also elevated, with SMRs amounting to 3.9 in males and 8.5 in females. An increased mortality risk, possibly related to the use of psychotropic drugs, was noticed. The physical care of long-stay psychiatric patients seems not to reach the same level that the general population enjoys. Continuous attention to the physical health of psychiatric patients is important, but new strategies and specific intervention methods should not be neglected. The concept of “avoidable mortality” is a useful, but rarely used indicator of the quality of the medical care in psychiatric populations. However, the concept needs regular updates from the whole field of medicine. From the psychiatric point of view, it was suggested that suicides be regarded as avoidable deaths.

Alcohol-Related Suicides in Victims with a History of Hospital-Treated Depression

Victims of suicides are frequently known to have suffered from depression and alcohol-related disorders, but whether these disorders exert different impacts on the period of survival following last hospitalizations have remained unknown. We surveyed 1,585 suicide victims from northern Finland and assigned them to one of three groups, based on lifetime history of depression, alcohol-related disorders, and both together. We then compared survival times in the three groups. Survival times in depressed alcoholic and non-alcoholic males were significantly shorter than those of males with alcohol-related disorders alone. Depressed but non-alcoholic suicide victims had more commonly used violent methods, had less often been under the influence of alcohol, and had had more psychotic disorders than the rest. It is apparently important in clinical practice to recognize the increased risk of suicide soon after hospital discharge not only in depressed patients, but also in those with a history of both depression and alcohol-related disorders.