Substance Abuse and Excessive Mortality Among Forensic Psychiatric Patients: A Finnish Nationwide Cohort Study

Abstract

Background: Forensic psychiatric patients are known to have reduced life expectancy. The aim of this study was to explore to what extent substance abuse disorders account for this increased mortality. Methods: Data up to December 31, 2016 for mortality (causes of death register) and substance abuse (forensic psychiatric examinations) were collected for all of the 950 patients committed to involuntary forensic psychiatric hospital care in Finland during 1980–2009 and discharged no later than December 31, 2016. Patients were then classified as suffering or not suffering from substance abuse disorders and their causes of death were examined. The standardized mortality ratio was then calculated for these groups on the basis of sex-, age-, and calendar-period-specific mortality rates for the general Finnish population. Results: During the follow-up time (mean 13.4 years), 354 (320 men, 34 women) patients died, resulting in a standardized mortality ratio of 3.5. The standardized mortality ratio for the patients with a history of substance abuse disorders was 4.1 compared to 2.8 for those with no such history. Among men, but not women, the age-adjusted proportion of death was significantly higher for those with a history of substance abuse disorders. In addition, in patients with a history of substance abuse disorders, the male age-adjusted competing risk of mortality was higher for unnatural causes, but not natural causes. Furthermore, a prominent proportion (16%) of all deaths and a majority of the accidental deaths (64%) occurred under the influence of some substance. Conclusions: Substance abuse is a major factor causing excessive mortality among forensic psychiatric patients. The management of substance abuse problems should be one cornerstone of the treatment of patients with both severe mental disorders and substance abuse disorders during their time in hospital and this should be extended to outpatient care.

Duration of forensic psychiatric care and subsequent criminal recidivism in individuals sentenced in Sweden between 2009 and 2019

“…Additionally, international comparisons between legal and clinical approaches to treatment and their effect on risk of relapse in crime are warranted, as criminal recidivism in mentally ill offenders appears to differ considerably between countries. Finally, a more detailed and comprehensive analysis of specific aspects of forensic psychiatric care ( 29 , 30 ) and aftercare ( 31 , 32 )—which, at the same time, takes into consideration patient characteristics ( 33 – 35 )—in relation to subsequent recidivism could also provide guidance for clinicians in their daily practice, as well as for policymakers engaged in deliberations on legal treatment of mentally ill offenders.…”

Morbidity and mortality in schizophrenia with comorbid substance use disorders

“… 37 However, an underestimation of the prevalence of SUD cannot be ruled out, as SUD are often underdiagnosed. 38 Underdiagnosis in clinical care may be related to under‐reporting, 39 but also to substance‐induced symptoms, such as anxiety, depression and psychosis not being recognized as such. 40 Clinicians may also be hesitant to diagnose SUD out of fear that patients will stop coming to their scheduled schizophrenia outpatient visits.…”

Mortality Among Patients Discharged From an Acute Psychiatric Department: A 5-Year Prospective Study

“…The standardized mortality ratio (SMR) in psychiatric populations has varied from being 1-fold to 20fold higher than in the general population, depending on psychiatric diagnosis, patient population, and causes of death (6)(7)(8). Most psychiatric diagnoses carry an elevated mortality risk (4,9,10), and the highest risk of premature death has been found among patients with substance use disorders (3,5,7,11,12) or organic mental disorders (13,14).…”