Death by unnatural causes during childhood and early adulthood in offspring of psychiatric inpatients.

CONTEXT: Offspring of psychiatric inpatients are at higher risk of death from all causes, but their cause-specific risks have not been quantified. OBJECTIVE: To investigate cause-specific deaths at 1 to 25 years in offspring of parents previously admitted as psychiatric inpatients. DESIGN: Population-based cohort study. SETTING: The entire Danish population. PARTICIPANTS: All singleton births (N = 1.38 million) from January 1, 1973, to December 31, 1997, with follow-up to January 1, 1999. Linkage to the national psychiatric register identified all previous parental admissions. MAIN OUTCOME MEASURES: Deaths from all natural causes and all unnatural causes, specifically, accidents, homicides, suicides, and undetermined causes. RESULTS: The highest observed relative risk (RR) was for homicide in young and older children with affected mothers or fathers. Homicides were between 5 and 10 times more likely to occur in this group, according to child's age and whether the mother or father had been admitted. There was previous parental admission in approximately one third of all child homicides. We found no evidence of increased risk of homicide in exposed young adults, but this group had a 2-fold to 3-fold higher risk of suicide. In almost one fourth of the suicides, there was a history of parental admission. Young adults with 2 previously admitted parents were 6 times more likely to kill themselves than were their peers in the general population. Relative risk of suicide or open-verdict deaths by poisoning were higher than for such deaths occurring by other means. CONCLUSIONS: Almost 99% of children studied survived to their mid-20s. However, they were more vulnerable to death from unnatural causes, notably, homicide during childhood and suicide in early adulthood. Further research is needed to establish how parental psychopathology contributes to increased risk of premature death in these offspring.

Mortality risk among offspring of psychiatric inpatients: a population-based follow-up to early adulthood.

OBJECTIVE: The purpose of this article was to estimate relative risks of all-cause mortality associated with parental psychiatric disorder based on offspring age (up to 25 years of age), parental diagnosis, maternal versus paternal disorder, and number of affected parents. METHOD: The study group consisted of all Danish singleton live and stillbirths (N=1.46 million) during 1973-1998, identified using the Central Population Register and Medical Birth Register. Dates of death were recorded with follow-up to Jan. 1, 1999. Parental admission histories since 1969 were obtained from the Psychiatric Central Register. RESULTS: Mortality risks were elevated from birth through early adulthood among offspring of people admitted with any type of psychopathology, although relative risks were attenuated during school attendance years. Effect sizes varied according to offspring ages, the highest being during infancy. The following high-risk subgroups were identified: postneonates with two mentally ill parents, neonates and postneonates whose mothers had alcohol and drug-related disorders, and neonates whose mothers had affective disorders. In general, from the postneonatal period onward, there was no indication that maternal psychopathology is associated with higher offspring mortality risk than paternal disorder. CONCLUSIONS: The greatest number of excess deaths were attributable to alcohol-related disorders, this being the most prevalent paternal diagnostic category and the second most prevalent in mothers. Some findings were unexpected. For example, there was no evidence that mortality risk among offspring of parents with schizophrenia and related disorders was significantly greater than that associated with all other parental psychiatric conditions, whereas the relative risk for neonatal death associated with maternal affective disorders was markedly raised.

Rehabilitative therapies for chronic fatigue syndrome: a secondary mediation analysis of the PACE trial.

BACKGROUND: Cognitive behaviour therapy (CBT) added to specialist medical care (SMC), or graded exercise therapy (GET) added to SMC, are more effective in reducing fatigue and improving physical function than both adaptive pacing therapy (APT) plus SMC and SMC alone for chronic fatigue syndrome. We investigate putative treatment mechanisms. METHODS: We did a planned secondary mediation analysis of the PACE trial comparing SMC alone or SMC plus APT with SMC plus CBT and SMC plus GET for patients with chronic fatigue syndrome. 641 participants were recruited from six specialist chronic fatigue syndrome clinics in the UK National Health Service between March 18, 2005, and Nov 28, 2008. We assessed mediation using the product of coefficients method with the 12 week measure of the mediators and the 52 week measure of the outcomes. The primary outcomes were fatigue measured by the Chalder fatigue scale and physical function measured by the physical function subscale of the SF-36. We included confounder covariates and used treatment by mediator interaction terms to examine differences in mediator-outcome relations by treatment group. FINDINGS: The largest mediated effect for both CBT and GET and both primary outcomes was through fear avoidance beliefs with an effect of larger magnitude for GET (standardised effects ×10, CBT vs APT, fatigue -1.22, 95% CI -0.52 to -1.97, physical function 1.54, 0.86 to 2.31; GET vs APT, fatigue -1.86, -0.80 to -2.89, physical function 2.35, 1.35 to 3.39). Increase in exercise tolerance (6 min walk distance) was a potent mediator of the effect of GET (vs APT, fatigue -1.37, 95% CI -0.76 to -2.21, physical function 1.90, 1.10 to 2.91), but not CBT. INTERPRETATION: Our main finding was that fear avoidance beliefs were the strongest mediator for both CBT and GET. Changes in both beliefs and behaviour mediated the effects of both CBT and GET, but more so for GET. The results support a treatment model in which both beliefs and behaviour play a part in perpetuating fatigue and disability in chronic fatigue syndrome. FUNDING: UK Medical Research Council, Department of Health for England, Scottish Chief Scientist Office, Department for Work and Pensions, National Institute for Health Research (NIHR), NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust, and Institute of Psychiatry, Psychology, and Neuroscience, King's College London.

Influence of environmental factors in higher risk of sudden infant death syndrome linked with parental mental illness.

CONTEXT: Since national risk reduction campaigns have been conducted, sudden infant death syndrome (SIDS) has become increasingly concentrated among disadvantaged families, including those affected by mental illness. However, causal mechanisms specific to this group are poorly understood. OBJECTIVES: To estimate relative risk and compare risk factor prevalence in infants with and without parental psychiatric inpatient history, and to explore effect modification after the 1992 Swedish risk reduction campaign. DESIGN: National birth cohort. Parental psychiatric admissions, maternal prenatal smoking, obstetric and social risk factors, and cause-specific infant death were ascertained via linkage between national registers. SETTING: The Swedish population, 1978 through 2004. PARTICIPANTS: All singleton live births (N = 2.5 million). MAIN OUTCOME MEASURE: Incidence of SIDS. RESULTS: Risk of SIDS was higher with a history of parental inpatient care, especially if both parents were admitted with any mental illness (odds ratio, 6.8; 95% confidence interval, 4.7-10.0), or if the mother (6.5; 4.9-8.7) or both parents (9.5; 5.5-16.4) had an alcohol/drug disorder. A 2-fold higher risk was also seen if the mother or father was admitted with any psychiatric illness other than alcohol or other drug disorders. Elevated risk persisted even if the last maternal inpatient episode had occurred 5 or more years before the infant's birth. After the national campaign, risk factor prevalence (especially maternal antenatal smoking) remained high in this population, and relative risks therefore increased. During 1992 through 2004, smoking and individual social adversity measures jointly accounted for approximately half the excess risk linked with maternal psychiatric inpatient history, whereas the confounding effects of obstetric factors were minimal. CONCLUSIONS: Tailored approaches are needed to ensure that standard safety advice is effectively communicated to these vulnerable families. In particular, mentally ill pregnant women should be encouraged and better supported to stop smoking. Families with 2 affected parents require particularly strong support. A clearer understanding is needed as to why high risk factor prevalence persists among these parents.

Risk of sudden infant death syndrome with parental mental illness.

CONTEXT: Sudden infant death syndrome is the leading cause of postneonatal death in developed countries. Little is known about risks linked with parental mental illness per se or how such risks are modified by specific psychiatric conditions and by maternal vs paternal psychopathological abnormalities. OBJECTIVE: To investigate cause-specific postneonatal death, including sudden infant death syndrome, in infants whose parents had been admitted as psychiatric inpatients. DESIGN: National cohort study. SETTING: The entire Danish population. Patients All of the singleton live births registered from January 1, 1973, to December 31, 1998. Linkage to the national psychiatric register enabled identification of all of the parental admissions from April 1, 1969, onward. MAIN OUTCOME MEASURE: All of the cases of sudden infant death syndrome in the postneonatal period classified via national mortality registration between January 1, 1973, and December 31, 1998. RESULTS: Psychiatric admission history in either parent doubled the risk of sudden infant death syndrome, but there was no difference in risk whether infants were exposed to maternal or paternal admission. Risk was particularly high if both parents had been admitted for any psychiatric disorder (relative risk, 6.9; 95% confidence interval, 4.1-11.6). Among specific parental disorders, the greatest risk was associated with admission for alcohol- or drug-related disorders (mothers: relative risk, 5.0; 95% confidence interval, 3.4-7.5; fathers: relative risk, 2.5; 95% confidence interval, 1.7-3.8). Contrary to prior expectation, parental schizophrenia and related disorders did not confer higher risks than other parental disorders that resulted in admission. CONCLUSIONS: Infants whose parents have been admitted for psychiatric treatment are at greater risk for sudden infant death syndrome. However, risks may be lower than previously thought with maternal schizophrenia and related disorders. Clinicians should be aware of particularly high risks if both parents have received any psychiatric inpatient treatment or if either parent (but the mother especially) was admitted with an alcohol- or drug-related disorder.