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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 4  |  Page : 418-422

Mortality among patients with severe mental disorders from a rural community in South India


Department of Psychiatry, Schizophrenia Research Foundation, Chennai, Tamil Nadu, India

Date of Submission19-Sep-2020
Date of Decision22-Feb-2021
Date of Acceptance16-Mar-2021
Date of Web Publication25-Nov-2021

Correspondence Address:
Vijaya Raghavan
Schizophrenia Research Foundation, R/7A, North Main Road, Anna Nagar West Extension, Chennai - 600 101, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_337_20

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  Abstract 


Background: Even though excess mortality in patients with severe mental disorders (SMD) has been established in many high-income countries, literature on this from the low- and middle-income countries including India is rather scant. Our study seeks to estimate the standardized mortality ratio (SMR) of patients with SMD from a rural community in Tamil Nadu for the years 2011–2015. Materials and Methods: We included patients with SMD from four taluks of Pudukkottai district, Tamil Nadu, during the years 2011–2015. We collected information on a total number of patients with SMD registered, their sociodemographic details, alive/dead status, and cause of death from the clinic registers and patient case records. We used the crude death rates for rural Tamil Nadu for the years 2011–2015 for the calculation of SMR, which is calculated by the formula observed deaths/expected deaths. Results: The SMR of patients with SMD was 3.33, 2.76, 2.11, 1.91, and 1.89 in the years 2011–2015. Of the 74 total deaths in these 5 years, 62 (83.7%) were due to natural causes, while 12.2% died by suicide. Statistically significant differences were observed in age, education, and marital status between patients with SMD who were alive and dead. Conclusion: We observed nearly two-times higher mortality among patients with SMD in rural Tamil Nadu. Further research is needed to examine the reasons for increased mortality among patients with SMD and interventions to reduce this excess mortality.

Keywords: Bipolar disorder, mortality, schizophrenia, severe mental disorders, standardized mortality ratio, suicide


How to cite this article:
Raghavan V, Rao S, Kulandesu A, Karthick S, Gunaselvi S, Senthilkumar S, Rao K, John S, Thara R. Mortality among patients with severe mental disorders from a rural community in South India. Indian J Soc Psychiatry 2021;37:418-22

How to cite this URL:
Raghavan V, Rao S, Kulandesu A, Karthick S, Gunaselvi S, Senthilkumar S, Rao K, John S, Thara R. Mortality among patients with severe mental disorders from a rural community in South India. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Dec 8];37:418-22. Available from: https://www.indjsp.org/text.asp?2021/37/4/418/331136




  Introduction Top


It is well established that patients with severe mental disorders (SMD) (schizophrenia and other psychotic disorders, bipolar disorder, and moderate-to-severe depression with psychotic symptoms) mortality are nearly 10–20 years earlier than the general population.[1] Various studies have also shown a higher and early mortality risk for patients with mental disorders[1],[2] including schizophrenia,[3] bipolar disorder,[4] and depression.[5]

The link between mortality and SMD is complicated as various biological, psychological, and social factors seem to play a role. Mental disorders are one of the most important causes of global burden of diseases, mainly because of the disability caused by them rather than the mortality.[6],[7] Most systematic reviews have shown that the all-cause mortality among SMD is 2–3.5 times higher than the general population.[8],[9] Moreover, recent evidence indicates that this gap is increasing.[2] For example, Saha et al. observed that patients with SMD have benefited less from the progression of improved health care when compared with the general population.[3]

Physical health disorders, especially cardiovascular disorders, respiratory disorders, and cancer account for most of the deaths.[10] Suicide is one of the major un-natural causes of death in persons with severe mental illness.[11] Various other factors such as substance use, noncompliance with medications, lack of insight to seek medical help, and discrimination could also play a significant role.[12] The World Health Organization categorized the risk factors for excess mortality among SMD into three groups as individual factors, health system factors, and social determinants of health factors.[1]

Even though many studies from India have examined the long-term clinical and functional outcomes[13],[14] of persons with SMD, very few have examined mortality as an outcome. Even the existing studies are on schizophrenia and not on other SMD such as bipolar disorder and depression with psychotic symptoms.[13],[15] Hence, the aim of our study was to estimate the standardized mortality ratio (SMR) among patients with SMD from a rural community in south India.


  Materials and Methods Top


Study setting

This study was a part of Schizophrenia Research Foundation (SCARF) TElepsychiatry in Pudukkottai (STEP) program initiated in 2010 at Pudukkottai district of Tamil Nadu. The details of the case identification and treatment through telepsychiatry are described elsewhere.[14],[16] Briefly, the researchers and trained community level workers used key informant method for the identification of person with mental disorders from the community. The key informants were residents of the same locality who had intimate knowledge about their community. After identification, a qualified psychiatrist used The Mini International Neuropsychiatric Interview[17] to confirm the diagnosis and recruited into the program after informed consent. The recruited participants were treated with psychopharmacological and psychosocial interventions delivered to them free of cost. Monthly clinical assessments and treatment were provided through telepsychiatry setup, as explained above. The participants and their family members were provided continued care through the community level workers and social workers. The participants were also given the choice to seek mental health care from other mental health professionals/facility, if they desired. Even when the participants were receiving medical treatment from others, community level workers continued to provide psychosocial interventions and maintained contact through monthly home visits and telephone calls.

Participants

We included patients with SMD into the study. Here, SMD will include patients with schizophrenia, bipolar disorder, or depression with psychotic symptoms. We excluded patients who did not give informed consent to be a part of the study.

Mortality data

For the SMD patients' mortality data, STEP research team was constantly in communication with the participants and their family members and information regarding mortality was updated immediately after any death. The cause of death was ascertained during the interview with the family members and other corroborative evidence provided by the family members. Hospital records when available were also used.

General population mortality rates were obtained from the census available from the civil registration system of the Government of Tamil Nadu.[18] Here, crude death rates (CDRs) of the rural population of Tamil Nadu for the particular years were used as district-specific CDRs were not available.

Ethical considerations

The study was approved by the Institutional Ethics Committee of the SCARF, Chennai. Treatment was made available through telepsychiatry and medications were provided free of charge for all patients needing treatment along with psychosocial interventions.

Statistical analysis

We calculated the SMR using the formula, SMR = observed deaths/expected deaths for that year. We used the CDR for rural Tamil Nadu of the years 2011–2015 to calculate the expected deaths among our sample. To obtain the expected deaths, we multiplied the number of patients with SMD in that particular year with the CDR of the same year. After this, we used the observed deaths and expected deaths obtained to calculate the SMR using OpenEpi.[19] The statistical analysis was done using SPSS 20.0 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Sociodemographic variables were represented as frequency and percentages or mean and standard deviation. Chi-square test and t-test were used to compare between the two groups of alive and dead patients with SMD. We set the level of significance at P < 0.05.


  Results Top


In the years between 2011 and 2015, there were 74 deaths in the patient population. [Table 1] shows the regarding the SMRs for these years separately. The SMR for SMD in 2011 was 3.33, 2012 was 2.76, 2013 was 2.11, 2014 was 1.91, and 2015 was 1.89. [Table 2] provides details regarding the causes of mortality in patients and they indicate 83% of natural deaths and 18% of un-natural deaths between the years 2011 and 2015. Within the unnatural causes of mortality, most of the death were due to completed suicide. The average SMR for all the 4 years was 2.4, indicating about 2-fold excess mortality among patients with SMD. The rate of death by suicide accounts for 12.2% of the total patient population. [Table 3] indicates the association between the sociodemographic and mortality rates among the patients in 4 years. The difference between the two groups is statistically significant when categorized by age, education, and marital status but not with gender. The mean age for dead patients with SMD was 52.5 as opposed to 42.72 for patients who are alive. Similarly, the education span (in years) for the former group was 4.82, while the span for the patients who are still alive was 6.64. Patients who were alive were younger and educated for a longer time period than the deceased.
Table 1: Standardized mortality ratio of patients with severe mental disorders for the years 2011-2015

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Table 2: Frequency and percentage of causes of death among patients with severe mental disorders

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Table 3: Association between socio-demographic variables and mortality among patients with severe mental disorders

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  Discussion Top


Our results indicate that the patients with SMD have nearly two times higher mortality rate when compared with general population. Even though the results show a SMR of 3.3 and 2.7 in the 1st 2 years of the study, SMR has stabilized after that and remained around 2. This variation could be due to the fluctuations in the number of patients in the cohort during the initial years which had stabilized after 2 years into the study. Similar results were observed in previous studies from India. For example, Bagewadi et al.[15] concluded that there is a 2-fold increase in excess mortality in schizophrenia in Thirthahalli, South India. The results of our study and that of few other Indian studies[13],[15] are comparable with the SMR of developed parts of the world with an average SMR around 2.15.[20]

A longitudinal study conducted by Thara concluded that the global functioning of a patient with schizophrenia approximated results from developing countries and much better performance in comparison to developed countries.[21] A recent meta-analysis by Liu et al.,[1] which examined mortality estimates of persons with SMD from different ethnic population reported an SMR to be 2.6. A study from Bali estimated that the SMR was 4.85 indicating premature deaths over 17 years.[22] A study from Ethiopia, a low-income country had comparable rates. These results indicate that the mortality in persons with SMD is clearly higher than that of the general population around the world and with different ethnic populations.[23]

Death from natural causes accounted for 84% and unnatural causes for 16%. Many other studies from low-income countries have found that most deaths are due to natural illness.[21],[22],[23] Meta-analyses conducted in high-income countries identified cardiovascular diseases as a cause of death in patients with SMD.[24] Reduced survival rates causes are undetermined as most patients died from natural causes specifically from cardiovascular disease as reported by the family member, but there was a large number of deaths unreported and unspecified as unnatural causes and family members may have felt stigmatized to report it as possibly suicide. In Japan, the SMR found to be 7.38 for suicide among patients with SMD.[12] Suicide is one of the leading causes for premature deaths in SMD, with reported percentage of completed suicides ranging between 60% and 98% of all suicides.[25]

While the rate of suicide was 12.2% in our study, we have reason to believe that more deaths due to suicide may be unreported fearing legal complications and stigma. In general, India especially Tamil Nadu has a higher suicide rate. Even though this trend could have been a reflection in the study population, high SMR is a signal for prompt action to reduce and prevent self-injurious behavior. The previous study indicates that the common risk factors for suicides in low-income settings are current mental illness, previous history of suicide attempt, low socioeconomic status, and poverty, and sociocultural characteristics.[26] In a systematic review, Iemmi et al. showed a consistent trend that poverty (including worse economic status, diminished wealth, and unemployment) is associated with suicidal ideations and behaviors.[27]

These results are indicative of the access to care being provided by the STEP program in a country where generally access to psychiatric care is limited and discriminating. Even in countries with high-quality access to health care, specifically Scandinavian countries, the mortality ratio is high and have only partially decreased.[28] There could be detrimental lifestyles led, comorbidities, and side effects as a result of the psychiatric medications prescribed. Risk factors such as smoking, alcohol and substance dependence, poor diet and lack of physical activity, with a diagnosis of undetected diabetes mellitus, respiratory and circulatory system diseases could be leading causes for higher death rates in patients with severe mental illnesses.

The major strengths of the current study are that four entire taluks from a district were included, the persons with SMD were followed up in the community, and continuous monitoring of the cohort was ensured by regular monthly visits by community level workers along with telephonic contacts.

The current study has few major limitations. The cause of death could not be clearly ascertained by the physician. We had to rely on reports from the family members and death certificates (in few cases). Even though the nature of death (natural or unnatural) could be identified, the lack of reliable information on the exact cause of mortality hindered the presentation of cause-specific mortality ratios in this cohort. Moreover, as the information on suicide and self-harm were not always volunteered, the number of suicides recorded here may be an underestimate. The age- and sex-specific SMR for persons with SMD was calculated using the state data for Tamil Nadu as the same is not available for the specific taluks.


  Conclusion Top


Patients with serious mental illness experience a high burden of mortality. The SMR of serious mental illness in a low-income rural community in South India is two times more than that of the general population. This mortality includes 84% of natural deaths and reduction of this burden will require a focus on a comprehensive access to general physical care to curb and manage physical and psychiatric comorbidities in this rural community.

Acknowledgment

We acknowledge the hard work of all our community based staff.

Financial support and sponsorship

SCARF TElepsychiatry in Pudukottai (STEP) Program was funded by Tata Education Trust of the Sir Dorabji Tata Trust and the Allied Trusts.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Liu NH, Daumit GL, Dua T, Aquila R, Charlson F, Cuijpers P, et al. Excess mortality in persons with severe mental disorders: A multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry 2017;16:30-40.  Back to cited text no. 1
    
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Roshanaei-Moghaddam B, Katon W. Premature mortality from general medical illnesses among persons with bipolar disorder: A review. Psychiatr Serv 2009;60:147-56.  Back to cited text no. 4
    
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Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86.  Back to cited text no. 7
    
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Ringen PA, Engh JA, Birkenaes AB, Dieset I, Andreassen OA. Increased mortality in schizophrenia due to cardiovascular disease – A non-systematic review of epidemiology, possible causes, and interventions. Front Psychiatry 2014;5:137.  Back to cited text no. 8
    
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Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry 2015;72:334-41.  Back to cited text no. 9
    
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Kondo S, Kumakura Y, Kanehara A, Nagato D, Ueda T, Matsuoka T, et al. Premature deaths among individuals with severe mental illness after discharge from long-term hospitalisation in Japan: A naturalistic observation during a 24-year period. BJPsych Open 2017;3:193-5.  Back to cited text no. 12
    
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[PUBMED]  [Full text]  
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Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.  Back to cited text no. 17
    
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Government of Tamil Nadu. Birth and Death Registrars under Civil Registration System in Tamil Nadu; 2020. Available from: https://tn.data.gov.in/catalog/birth and death registrars under civil registration-system tamil nadu#web_catalog_tabs_block_10. [Last accessed on 2020 Aug 18].  Back to cited text no. 18
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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