Historical data have always been focusing on over-estimating the rate of unnatural deaths in inpatient populations with SMD (suicide, accidents, and homicides). It is known that the mortality gap cannot be attributed to this alone [10]. The linked data from mental and physical health services reported that the excess deaths were attributable to physical illnesses in over three-quarters of cases [10]. More attentive checks for psychiatric patient’s physical illness, side effects of medications, and suicidal tendencies can take mortality rates to lower limits.
In this study, retrospective data analysis for 17,562 patient files, admitted to ASUIP during this period, revealed a mortality rate of 0.32%. 56.5% of the reported death cases were female patients. The general mortality rate in Egypt in the same period between 1990 and 2013 was 6.2 to 6.9 per 1000 population [11]. In other words, in this study mortality rate was nearly half the national reported average by the National Center for Health Statistics (NCHS) Public Health Surveillance, Population demographic reports 2015 [12].
Hewer and his colleagues reported higher inpatient mortality rates (1.38%) in German psychiatric hospitals [13]. Khamker and his colleagues reported near figure (1.47%) in a South African psychiatric hospital [14]. Although persons with SMD are dying younger than the general population globally, there is an emerging consensus that the majority of excess mortality is due to poor physical health, with cardiovascular disease as the primary cause of death [15].
Applying high standards and best practice guidelines in assessment and monitoring patients’ physical and mental conditions as in the case of ASUIP, in addition to the restricting admission criteria excluding organic mental disorders unless well investigated and controlled, kept inpatients mortality rates to lower limits.
Rare studies were directed toward the analysis of mortality rates differences between long and short-stay mental health hospitals, but considering that ASUIP is a short-stay hospital, excluded other involved mortality causes related to long hospital admissions.
In agreement with other studies showed higher death rates in younger patients (42.2 ± 14.7) years [16,17,18]. Nevertheless, it came to the contrary to other studies that reported higher mortality in older age groups 50 and 70 years, respectively [14, 13]. This variation could be attributed to the younger age of admission in ASUIP versus older age ranges of patients, with organic mental diseases in other studied settings. This age range was much younger than the mean age of death in general population as general mortality rate in Egypt in 2013 was 70.8 years [19].
In this study, the number of admitted female patients in ASUIP was less than half the number of admitted males during the same period. Despite the data showed no statistically significant differences in both sexes in clinical variables, female patients had a higher mortality rate 6/1000 versus 2/1000 in males. Similarly, other studies reported slightly higher female mortality rates [13, 17, 20]. However, other studies failed to find differences among females and males [16] or even found a reversed male-female ratio with more reported male mortality [14].
The mean duration of hospitalization in ASUIP was 11.5± 14.7 days, with a range of 1–90 days. In contrast, previous studies reported that a more extended admission period was associated with inpatient death incidence. However, it is worth mentioning that Khamker and colleague’s study reported that 25% of the death incidence occurred in the first month of admission [14].
Major depression (32.6%) followed by schizophrenia (30.4%) were the most frequent diagnoses with reported mortality, while substance use disorder was least frequent in the current study. Similar findings were detected in West Africa institute, in their cohort, schizophrenia (26%), and major depression (25%) constituted the main psychiatric diagnoses at the time of admission [17]. Hewer and his colleagues found that organic mental disorder had a high mortality risk [13].
Natural causes were the primary etiology of death among psychiatric patients, and their rates differ in different studies [14]. Consistently, in this study, natural death causes were responsible for all cases with a known and unknown causes. Cardiac complications were implicated in most of the death reports, followed by cerebrovascular accidents. Other death causes, which include renal failure, respiratory complications, bleeding, metabolic problems, septicemia, and drug intoxication, were involved in more than a quarter of the morality. Cases of patients who died without reporting any new medical complications in the last week before death or died before proper medical examination and investigation were counted as a separate group not under cardiac death causes group, despite that the registered cause of death in their death report was a sudden circulatory system failure. Sudden or unknown causes of death were reported in 41.3% of the sample. The high rate of disturbed vital data reported in the current study may raise the question about cardiac causes as a possible hidden cause of death in those cases [21, 22].
Cardiovascular causes were the most reported natural cause of death in psychiatric inpatients in previous different studies [16, 23]. Increased risk of cardiovascular diseases in psychiatric patients could be explained as a result of the use of antipsychotic drugs, psychosocial deprivation, and sedentary lifestyle as excessive smoking and physical inactivity [14, 21, 22]. Furthermore, cardiovascular causes could be the leading cause of sudden unknown deaths of psychiatric patients [24]. Interestingly, the main known causes of mortality in psychiatric inpatients differ in different populations. Different death causes can explain part of that in a particular general population, as in the case of inconvenient socioeconomic factors and level of medical care in some communities and prevalence of infections or other endemic diseases in others. Infections were the most common natural cause of death in Singapore, South, and West Africa studies [14, 17, 20].
Remarkably, unnatural causes of mortality, such as suicide and injuries, were not reported in the current study. In contrast, suicide was the main unnatural cause reported by other studies [16]. Factors as the close follow-up of patients, short-stay hospitalization, proper medical care, and use of ECT could explain this finding.
The present study had some limitations, including incomplete files during registration, difficulty to access, and the improper documentation of some critical clinical data in patients’ medical records, a high percentage of unknown death causes. The absence of essential comparative statistics data in this study was due to the lack of information about mortality patterns in patients with mental illness in the Egyptian community and in the Arab countries. This limitation should direct mental health planners and other stakeholders’ efforts toward extensive epidemiological research projects, and the adoption of more functional registration systems. In addition to applying best practice guidelines in providing medical and mental health services to this population.
