Centre for Mental Health & Safety, The University of Manchester and Manchester Academic Health Sciences Centre, Manchester, United Kingdom.
Centre for Integrated Register-Based Research and National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark.
J Clin Psychiatry. 2018 Oct 2;79(6):17m11809. doi: 10.4088/JCP.17m11809.
Persons discharged from inpatient psychiatric units are at greatly elevated risk of dying unnaturally. We conducted a comprehensive examination of specific causes of unnatural death post-discharge in a national register-based cohort.
A cohort of 1,683,645 Danish residents born 1967-1996 was followed from their 15th birthday until death, emigration, or December 31, 2011, whichever came first. Survival analysis techniques were used to estimate incidence rate ratios (IRRs) comparing risk for persons with and without psychiatric admission history in relation to (a) suicide method, (b) accidental death type, (c) fatal poisoning type, and (d) homicide.
More than half (52.5%, n = 711) of all unnatural deaths post-discharge were fatal poisonings, compared with less than a fifth (17.0%, n = 1,012) among persons in the general population not admitted. Just 6.8% (n = 92) of all unnatural deaths post-discharge were due to transport accidents-the most common unnatural death type in the general population (53.4%, n = 3,184). Suicide risk was 32 times higher among discharged patients (IRR 32.3; 95% CI, 29.2-35.8) and was even higher during the first year post-discharge (IRR 70.4; 95% CI, 59.7-83.0). Among the suicide methods examined, relative risk values were significantly larger for intentional self-poisoning (IRR 40.8; 95% CI, 33.9-49.1) than for "violent" suicide methods (IRR 29.4; 95% CI, 26.1-33.2). The greatest relative risk observed was for fatal poisoning (irrespective of intent) by psychotropic medication (IRR 93.7; 95% CI, 62.5-140.5). The highest post-discharge mortality rate was for accidental self-poisoning among persons diagnosed with a psychoactive substance abuse disorder: 290.1 per 100,000 person-years.
Closer liaison between inpatient services and community care, more effective early treatment for comorbid substance abuse, enhanced psychosocial assessment following self-harm, and tighter medication surveillance could decrease risk of unnatural death post-discharge.
从住院精神病病房出院的患者的非自然死亡风险大大增加。我们在全国登记的队列研究中全面检查了出院后非自然死亡的具体原因。
该队列包括 1967 年至 1996 年出生的 1683645 名丹麦居民，从他们 15 岁生日开始随访，直至死亡、移民或 2011 年 12 月 31 日，以先发生者为准。生存分析技术用于比较有和无精神病住院史的患者的风险，以评估自杀方法、意外死亡类型、致命中毒类型和故意杀人的发病率比（IRR）。
超过一半（52.5%，n=711）的出院后非自然死亡是致命中毒，而一般人群中未住院的人中不到五分之一（17.0%，n=1012）。只有 6.8%（n=92）的出院后非自然死亡是由于交通意外造成的，而交通意外是一般人群中最常见的非自然死亡类型（53.4%，n=3184）。出院患者的自杀风险高 32 倍（IRR 32.3；95%CI，29.2-35.8），出院后第一年的自杀风险更高（IRR 70.4；95%CI，59.7-83.0）。在所检查的自杀方法中，故意自我中毒（IRR 40.8；95%CI，33.9-49.1）的相对风险值明显高于“暴力”自杀方法（IRR 29.4；95%CI，26.1-33.2）。观察到的最大相对风险是精神药物（IRR 93.7；95%CI，62.5-140.5）的致命中毒（不论意图如何）。诊断为精神活性物质滥用障碍的患者意外自我中毒的出院后死亡率最高：每 10 万人年 290.1 人。
加强住院服务与社区护理之间的联系、更有效的早期共病物质滥用治疗、伤害后更有效的心理社会评估以及更严格的药物监测可以降低出院后非自然死亡的风险。
