Outcomes of elderly patients with organophosphate intoxication.

This study analysed the clinical patterns and outcomes of elderly patients with organophosphate intoxication. A total of 71 elderly patients with organophosphate poisoning were seen between 2008 and 2017. Patients were stratified into two subgroups: survivors (n = 57) or nonsurvivors (n = 14). Chlorpyrifos accounted for 33.8% of the cases, followed by methamidophos (12.7%) and mevinphos (11.3%). Mood, adjustment and psychotic disorder were noted in 39.4%, 33.8% and 2.8% of patients, respectively. All patients were treated with atropine and pralidoxime therapies. Acute cholinergic crisis developed in all cases (100.0%). The complications included respiratory failure (52.1%), aspiration pneumonia (50.7%), acute kidney injury (43.7%), severe consciousness disturbance (25.4%), shock (14.1%) and seizures (4.2%). Some patients also developed intermediate syndrome (15.5%) and delayed neuropathy (4.2%). The nonsurvivors suffered higher rates of hypotension (P < 0.001), shock (P < 0.001) and kidney injury (P = 0.001) than survivors did. Kaplan-Meier analysis indicated that patients with shock suffered lower cumulative survival than did patients without shock (log-rank test, P < 0.001). In a multivariate-Cox-regression model, shock was a significant predictor of mortality after intoxication (odds ratio 18.182, 95% confidence interval 2.045-166.667, P = 0.009). The mortality rate was 19.7%. Acute cholinergic crisis, intermediate syndrome, and delayed neuropathy developed in 100.0%, 15.5%, and 4.2% of patients, respectively.

Association of Dementia-Related Psychosis With Long-term Care Use and Death.

OBJECTIVE: To determine the association of dementia-related psychosis (DRP) with death and use of long-term care (LTC); we hypothesized that DRP would be associated with increased risk of death and use of LTC in patients with dementia. METHODS: A retrospective cohort study was performed. Medicare claims from 2008 to 2016 were used to define cohorts of patients with dementia and DRP. Outcomes were LTC, defined as nursing home stays of >100 consecutive days, and death. Patients with DRP were directly matched to patients with dementia without psychosis by age, sex, race, number of comorbid conditions, and dementia index year. Association of DRP with outcomes was evaluated using a Cox proportional hazard regression model. RESULTS: We identified 256,408 patients with dementia. Within 2 years after the dementia index date, 13.9% of patients developed DRP and 31.9% had died. Corresponding estimates at 5 years were 25.5% and 64.0%. Mean age differed little between those who developed DRP (83.8 ± 7.9 years) and those who did not (83.1 ± 8.7 years). Patients with DRP were slightly more likely to be female (71.0% vs 68.3%) and white (85.7% vs 82.0%). Within 2 years of developing DRP, 16.1% entered LTC and 52.0% died; corresponding percentages for patients without DRP were 8.4% and 30.0%, respectively. In the matched cohort, DRP was associated with greater risk of LTC (hazard ratio [HR] 2.36, 2.29-2.44) and death (HR 2.06, 2.02-2.10). CONCLUSIONS: DRP was associated with a more than doubling in the risk of death and a nearly 2.5-fold increase in risk of the need for LTC.

Antipsychotic use in dementia: the relationship between neuropsychiatric symptom profiles and adverse outcomes.

Antipsychotic treatments are associated with safety concerns in people with dementia. The authors aimed to investigate whether risk of adverse outcomes related to antipsychotic prescribing differed according to major neuropsychiatric syndromes-specifically psychosis, agitation, or a combination. A cohort of 10,106 patients with a diagnosis of dementia was assembled from a large dementia care database in South East London. Neuropsychiatric symptoms closest to first dementia diagnosis were determined according to the Health of the Nation Outcome Scales' mental and behavioural problem scores and the sample was divided into four groups: 'agitation and psychosis', 'agitation, but no psychosis', 'psychosis, but no agitation', and 'neither psychosis nor agitation'. Antipsychotic prescription in a one-year window around first dementia diagnosis was ascertained as exposure variable through natural language processing from free text. Cox regression models were used to analyse associations of antipsychotic prescription with all-cause and stroke-specific mortality, emergency hospitalisation and hospitalised stroke adjusting for sixteen potential confounders including demographics, cognition, functioning, as well as physical and mental health. Only in the group 'psychosis, but no agitation' (n = 579), 30% of whom were prescribed an antipsychotic, a significant antipsychotic-associated increased risk of hospitalised stroke was present after adjustment (adjusted hazard ratio (HR) 2.16; 95% confidence interval (CI) 1.09-4.25). An increased antipsychotic-related all-cause (adjusted HR 1.14; 95% CI 1.04-1.24) and stroke-specific mortality risk (adjusted HR 1.28; 95% CI 1.01-1.63) was detected in the whole sample, but no interaction between the strata and antipsychotic-related mortality. In conclusion, the adverse effects of antipsychotics in dementia are complex. Stroke risk may be highest when used in patients presenting with psychosis without agitation, indicating the need for novel interventions for this group.

The risk of physical multimorbidity in people with psychotic disorders: A systematic review and meta-analysis.

BACKGROUND: The occurrence of multiple co-occurring chronic health conditions, known as multimorbidity, is associated with decreases in quality of life for patients and poses unique challenges for healthcare systems. Since people with psychotic disorders have an excess of physical health conditions compared to the general population, they may also be at a higher risk for multimorbidity. We conducted a systematic review and meta-analysis to quantify the prevalence and excess risk of multimorbidity among people with psychotic disorders, relative to those without psychosis. METHODS: We searched the MEDLINE, EMBASE, and PsycINFO databases, and conducted forward and backward citation tracing of included studies. Studies published after 1990 were included if they reported the prevalence of multiple chronic physical health conditions among people with psychotic disorders. Data on the prevalence and relative risk of multimorbidity were meta-analyzed using random effects models. RESULTS: Fourteen studies met the inclusion criteria, and eight were included in the meta-analysis. Each study used a different operational definition of multimorbidity, both for the number and types of chronic conditions, which resulted in a wide range in prevalence estimates (16% to 91%). People with psychotic disorders had an increased risk of multimorbidity (RR = 1.69, 95%CI = 1.37,2.08), relative to those without psychosis. CONCLUSIONS: People with psychotic disorders are more likely to experience multimorbidity than those without psychotic disorders. Clinicians treating people with psychosis should closely monitor for a range of physical health conditions. Future research examining multimorbidity among people with psychiatric illness should employ consistent definitions to better enable cross-study comparisons.

Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records.

BACKGROUND: Korea is one of the countries with the highest rate of suicide, while suicidality is known to be closely related to mental illnesses. The study aimed to evaluate the suicide rates in psychiatric patients, to compare it to that of the general population, and to investigate the differences among psychiatric diagnoses and comorbidities. METHODS: Medical records and mortality statistics of psychiatric patients at Seoul National University Hospital from 2003 to 2017 were reviewed. The standardized mortality ratio (SMR) for suicide was calculated to compare the psychiatric patients with the general population. The diagnosis-specific standardized mortality rate and hazard ratio (HR) were adjusted by age, sex, and psychiatric comorbidity (i.e., personality disorder and/or pain disorder). RESULTS: A total of 40,692 survivors or non-suicidal deaths and 597 suicidal death were included. The suicide rate among psychiatric patients was 5.13-fold higher than that of the general population. Psychotic disorder had the highest SMR (13.03; 95% confidence interval [CI], 11.23-15.03), followed by bipolar disorder (10.26; 95% CI, 7.97-13.00) and substance-related disorder (6.78; 95% CI, 4.14-10.47). In survival analysis, psychotic disorder had the highest HR (4.16; 95% CI, 2.86-6.05), which was further increased with younger age, male sex, and comorbidity of personality disorder. CONCLUSION: All psychiatric patients are at a higher risk of suicide compared to the general population, and the risk is highest for those diagnosed with psychotic disorder.

Viewpoint: do antipsychotics protect against early death? A critical view.

In the past 15 years, researchers utilizing prescription databases to assess medication usage have concluded that antipsychotics reduce mortality in patients diagnosed with schizophrenia and other psychotic disorders. These findings stand in contrast to studies in non-psychiatric patients that have found that antipsychotics, because of their adverse effects on physical health, increase the risk of early death. A critical review of the evidence reveals that the worry remains. There is reason to conclude that antipsychotics contribute to the 'mortality gap' between the seriously mentally ill and the general population and that the database studies are plagued with methodological and reporting issues. Most importantly, the database studies tell of mortality rates within a drug-centered paradigm of care, which confounds any comparison of mortality risks when patients are on or off antipsychotics.

Associations of substance use, psychosis, and mortality among people living in precarious housing or homelessness: A longitudinal, community-based study in Vancouver, Canada.

BACKGROUND: The "trimorbidity" of substance use disorder and mental and physical illness is associated with living in precarious housing or homelessness. The extent to which substance use increases risk of psychosis and both contribute to mortality needs investigation in longitudinal studies. METHODS AND FINDINGS: A community-based sample of 437 adults (330 men, mean [SD] age 40.6 [11.2] years) living in Vancouver, Canada, completed baseline assessments between November 2008 and October 2015. Follow-up was monthly for a median 6.3 years (interquartile range 3.1-8.6). Use of tobacco, alcohol, cannabis, cocaine, methamphetamine, and opioids was assessed by interview and urine drug screen; severity of psychosis was also assessed. Mortality (up to November 15, 2018) was assessed from coroner's reports and hospital records. Using data from monthly visits (mean 9.8, SD 3.6) over the first year after study entry, mixed-effects logistic regression analysis examined relationships between risk factors and psychotic features. A past history of psychotic disorder was common (60.9%). Nonprescribed substance use included tobacco (89.0%), alcohol (77.5%), cocaine (73.2%), cannabis (72.8%), opioids (51.0%), and methamphetamine (46.5%). During the same year, 79.3% of participants reported psychotic features at least once. Greater risk was associated with number of days using methamphetamine (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.05-1.24, p = 0.001), alcohol (aOR 1.09, 95% CI 1.01-1.18, p = 0.04), and cannabis (aOR 1.08, 95% CI 1.02-1.14, p = 0.008), adjusted for demographic factors and history of past psychotic disorder. Greater exposure to concurrent month trauma was associated with increased odds of psychosis (adjusted model aOR 1.54, 95% CI 1.19-2.00, p = 0.001). There was no evidence for interactions or reverse associations between psychotic features and time-varying risk factors. During 2,481 total person years of observation, 79 participants died (18.1%). Causes of death were physical illness (40.5%), accidental overdose (35.4%), trauma (5.1%), suicide (1.3%), and unknown (17.7%). A multivariable Cox proportional hazard model indicated baseline alcohol dependence (adjusted hazard ratio [aHR] 1.83, 95% CI 1.09-3.07, p = 0.02), and evidence of hepatic fibrosis (aHR 1.81, 95% CI 1.08-3.03, p = 0.02) were risk factors for mortality. Among those under age 55 years, a history of a psychotic disorder was a risk factor for mortality (aHR 2.38, 95% CI 1.03-5.51, p = 0.04, adjusted for alcohol dependence at baseline, human immunodeficiency virus [HIV], and hepatic fibrosis). The primary study limitation concerns generalizability: conclusions from a community-based, diagnostically heterogeneous sample may not apply to specific diagnostic groups in a clinical setting. Because one-third of participants grew up in foster care or were adopted, useful family history information was not obtainable. CONCLUSIONS: In this study, we found methamphetamine, alcohol, and cannabis use were associated with higher risk for psychotic features, as were a past history of psychotic disorder, and experiencing traumatic events. We found that alcohol dependence, hepatic fibrosis, and, only among participants <55 years of age, history of a psychotic disorder were associated with greater risk for mortality. Modifiable risk factors in people living in precarious housing or homelessness can be a focus for interventions.

Potential gains in life expectancy from reducing amenable mortality among people diagnosed with serious mental illness in the United Kingdom.

BACKGROUND: To estimate the potential gain in life expectancy from addressing modifiable risk factors for all-cause mortality (excluding suicide and deaths from accidents or violence) across specific serious mental illness (SMI) subgroups, namely schizophrenia, schizoaffective disorders, and bipolar disorders in a Western population. METHODS: We have used relative risks from recent meta-analyses to estimate the population attribution fraction (PAF) due to specific modifiable risk factors known to be associated with all-cause mortality within SMI. The potential gain in life expectancy at birth, age 50 and age 65 years were assessed by estimating the combined effect of modifiable risk factors from different contextual levels (behavioural, healthcare, social) and accounting for the effectiveness of existing interventions tackling these factors. Projections for annual gain in life expectancy at birth during a two-decade was estimated using the Annual Percentage Change (APC) formula. The predicted estimates were based on mortality rates for year 2014-2015. RESULTS: Based on the effectiveness of existing interventions targeting these modifiable risk factors, we estimated potential gain in life expectancy at birth of four (bipolar disorders), six (schizoaffective disorders), or seven years (schizophrenia). The gain in life expectancy at age 50 years was three (bipolar disorders) or five (schizophrenia and schizoaffective disorders) years. The projected gain in life expectancy at age 65 years was three (bipolar disorders) or four (schizophrenia and schizoaffective disorders) years. CONCLUSIONS: The implementation of existing interventions targeting modifiable risk factors could narrow the current mortality gap between the general and the SMI populations by 24% (men) to 28% (women). These projections represent ideal circumstances and without the limitation of overestimation which often comes with PAFs.

Increases in institutionalization, healthcare resource utilization, and mortality risk associated with Parkinson disease psychosis: Retrospective cohort study.

INTRODUCTION: Patients with Parkinson disease (PD) often develop psychosis (P). The association of PDP with death and long-term custodial care (CC) has not been well studied. METHODS: Medicare Parts A, B, and D data, 2007-2015, were used to define cohorts of PD and PDP patients. PD was defined by ≥ 2 ICD-9-CM codes (332.0x) at least 30, but no more than 365, days apart, and PDP by ≥ 2 codes for psychotic symptoms. Outcomes were CC use, defined as nursing home stays of >100 consecutive days, and death. To compare the association of PDP with outcomes, PDP patients were matched to PD patients without psychosis. RESULTS: Within 1 year of PDP diagnosis, 12.1% of PDP patients used CC, versus 3.5% of non-PDP patients 1 year after the matching date; corresponding percentages at 5 years were 25.8% and 10.0%. Cumulative incidence curves for CC and for death differed significantly (P < 0.0001). PDP was associated with RRs of 3.38 (95% CI, 2.93-3.90) for CC and 1.34 (1.23-1.45) for death. Other factors associated with CC were age (3.57, 2.08-6.14, age ≥90 versus ≤70 years) and female sex (1.37, 1.18-1.58). Female sex was associated with a lower RR for death (0.76, 0.70-0.82). Health care utilization and costs were substantially higher for PDP than for non-PDP patients. CONCLUSION: In PD patients, psychosis was associated with a more than 3-fold increased risk of CC and a nearly one-third increased risk of death. Women entered CC more often than men, likely because they lived longer in the setting of PD.

Benefits and harms of antipsychotic drugs in drug-naïve patients with psychosis: A systematic review.

OBJECTIVE: To study the benefits and harms of antipsychotics in drug-naïve patients with psychosis. METHODS: This study is a systematic review and meta-analysis of placebo-controlled trials. MAIN OUTCOME MEASURES: Mortality, activities of daily living, quality of life, core psychiatric events, and relapse and recovery rates. DATA SOURCES: PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), two trial registers and references in potentially eligible articles. DATA EXTRACTION: Two researchers extracted data independently. The outcomes were planned to be meta-analysed using Review Manager based on a fixed effect model. RESULTS: Our searches resulted in 493 unique records of which 447 were clearly not eligible. We read the full text of the 46 potentially eligible articles and found one eligible trial in drug-naïve patients, which was unreliable. It was a Chinese trial comparing olanzapine with placebo in 261 patients with first-episode schizophrenia. After 12 weeks, there was an extremely large difference favouring placebo, but the authors reported the opposite, that olanzapine was effective. CONCLUSIONS: The use of antipsychotics cannot be justified based on the evidence we currently have. Withdrawal effects in the placebo groups make existing placebo-controlled trials unreliable.

Mortality and Medical Comorbidity in the Severely Mentally Ill.

BACKGROUND: Mentally ill patients die on average 10 years earlier than the general population, largely due to general medical disorders. This study is the first to explore in a large German sample the prevalence, mortality, and medical comorbidity in pa- tients with severe mental illness (SMI). The patients were affected by borderline personality disorder (BPD), psychotic disorders, bipolar disorder, or severe unipolar depression. METHODS: Our database consists of billing data from all adults with statutory health insurance in Germany. Twelve-month administrative SMI prevalence and medical comorbidity were estimated using cross-sectional data from 2016 (age ≥ 18; N = 59 561 310). Two-year mortality was established longitudinally in a randomly selected subset of the billing data (most recent mortality information available for 2012 to 2014; 2012: n = 15 590 107). RESULTS: Severe unipolar depression had the highest prevalence (2.01%), followed by psychotic disorders (1.25%), BPD (0.34%), and bipolar disorder (0.29%). While the prevalence of malignant neoplasms showed moderate deviations from reference values [severe unipolar depression: OR = 1.30 (95% CI = 1.29; 1.31), BPD: OR = 1.11 (1.09; 1.14), psychotic dis- orders: OR = 0.90 (0.89; 0.90), bipolar disorder: OR = 1.07 (1.06; 1.09)], other disease groups (infectious, endocrine/nutritional/ metabolic, circulatory, respiratory) were substantially elevated in all categories of SMI. Mortality rates for psychotic disorders, BPD, bipolar disorder, and severe unipolar depression were increased (OR = 2.38 [95% CI=2.32; 2.44], 2.30 [2.08; 2.54], 1.52 [1.42; 1.62], and 1.40 [1.37; 1.44], respectively), with a loss of 2.6 to 12.3 years, depending on age, sex, and SMI. CONCLUSION: Mortality is substantially elevated in all SMI patients. The results underline the need to remove barriers to adequate general medical care, both on the patient and the provider side, to reduce excess mortality.

The iHOPE-20 study: mortality in first episode psychosis-a 20-year follow-up of the Dublin first episode cohort.

PURPOSE: Increased mortality rates have been found in those with a diagnosis of psychosis; studies suggest a shortened life expectancy of up to 20 years less than that of the general population. This study aimed to investigate the mortality of a first episode psychosis cohort at 20-year follow-up, compare it to that of the general Irish population, and explore whether the mortality gap has changed over time. METHODS: 171 individuals diagnosed with a first episode psychosis identified between 1995 and 1999 in a community mental health service were traced. Mortality was established by matching death certificates to deceased cohort members (using name, age at date of death, and address at date of death). Date of first presentation to service was used as date of entry point and date of death or end of follow-up as the end point. RESULTS: Of the 171 cases there were 20 deaths during follow-up. Nine deaths were attributed to natural causes; 7 to unnatural causes; and 4 were unknown. Comparing standardised mortality rates at 20-year follow-up to those at 12 year showed a reduction in rates over time. CONCLUSION: Findings suggest that the mortality gap in people with schizophrenia and other psychoses remains high, especially in young males.

Medication, hospitalizations and mortality in 5 years after first-episode psychosis in a Swedish nation-wide cohort.

AIM: To investigate medication, rehospitalizations and mortality after first-episode hospital-treated psychosis. METHODS: A population-based nation-wide cohort (n = 2488) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Cases were followed for up to 5 years after the first psychosis hospitalization with regard to mortality, hospitalizations and dispensations of antipsychotics and benzodiazepines. RESULTS: The proportion of patients dispensing antipsychotics decreased from 80% year 1 after first discharge to 55% year 5. The proportion of patients having episodes of inpatient care also decreased year by year from 46% year 1 to 27% year 5. Of 863 cases with 5 years of observation time 41% had dispensations of antipsychotics every year; 21% had no dispensation of antipsychotics or hospitalization after the first year. The cumulative 5-year mortality was 3.9%. Cumulative suicide mortality was 2.4%. Incidence of suicide was highest in the first year. Male gender, benzodiazepines, recent hospital-discharge and self-harm were identified as risk factors for suicide. CONCLUSIONS: The proportion of cases dispensing antipsychotics decreases year by year after first discharge. Mortality and rates of rehospitalization also decrease year by year from high levels the first year.

[Increased somatic morbidity in patients with severe mental illness]. / Markant somatisk översjuklighet vid allvarlig psykisk sjukdom.

Patients with severe mental illness suffer an increased somatic mortality and morbidity from cardiovascular disease, diabetes and cancer. Furthermore, they are less likely to have adequate diagnostic and therapeutic procedures for somatic disorders. Life style issues, side effects of pharmacotherapy, cognitive impairment and suboptimal organization of the health care system all contribute. In total, a challenging situation that has to be addressed by the health care system. In Region Västra Götaland, Sweden, new medical routines for psychiatric patients are currently implemented. All patients should be offered an annual medical somatic checkup, including blood tests and ECG, and be advised about their life style, i.e. diet, exercise, smoking and alcohol. At the Department of psychosis, Sahlgrenska University Hospital, Göteborg, Sweden, a new permanent position as senior consultant in internal medicine/liaison physician has been established.

Relationship between incidence and prevalence in psychotic disorders: An incidence-prevalence-mortality model.

OBJECTIVES: Incidence-prevalence-mortality (IPM) models have been developped to estimate incidence or prevalence when one of these two measures is unavailable. We aimed to test the consistency of an IPM model of psychotic disorders on a recent incidence-prevalence couple dataset and to identify potential causes of inconsistency by applying the model to (a) the whole population, (b) female and male subgroups, (c) migrant subgroups, and (d) psychotic disorders with age at onset (AAO) between 18 and 24 (18-24 AAO). METHODS: We modelled prevalence (MP) using incidence data and the expected mortality and remission values. We then compared the MP to the observed prevalence (OP). RESULTS: In the whole population, the model significantly underestimated the prevalence (MP = 3.30, 95% CI [2.97, 3.66]; OP = 4.98, 95% CI [4.58, 5.41]). The results were similar for the two genders. In the migrants group, results were in the opposite direction, the model significantly overestimating the prevalence. Finally, in the 18-24 AAO subgroup, the model performed well, with OP and MP not significantly different. CONCLUSION: These results suggest that standard IPM models do not perform well for psychotic disorders and more complex models taking into account the heterogeneity of the sample (in terms of remission, mortality, population movements, etc.) need to be developed.

Correlates of risk factors for reduced life expectancy in schizophrenia: Is it possible to develop a predictor profile?

Patients with schizophrenia have significantly greater mortality rates than the general population, with an estimated reduced lifespan of 10-20 years. We previously reported on a link between impairment in cognition and premature death in a prospective 20-year study. Patients who had died prematurely showed neurocognitive impairment in nine different cognitive tests compared to those who did not. Based on those findings, in this study the surviving patients in the cohort were divided into three different groups based on neurocognitive impairment and compared on symptom severity including remission status, RAND-36, weight and BMI at onset of illness and baseline of the study, and medical/physical symptomatology (i.e., blood pressure, symptom awareness, vertigo and orthostatic symptoms). Differences were most prominent between the cognitively unimpaired and severely cognitively impaired (SCI) groups, with remission, negative symptoms, general symptoms and PANSS total scores differing. For SF-36 (RAND) Physical functioning and Role limitations due to physical health subscales the SCI were worst. The findings indicate that greater impairments in cognitive ability during the illness are associated with several potential indicators of risk for early mortality. Together these factors may be of guidance for establishing an algorithm to detect patients at risk of premature death early in their illness.

Long-term antipsychotic polypharmacy prescribing in secondary mental health care and the risk of mortality.

OBJECTIVES: To investigate the association between long-term antipsychotic polypharmacy use and mortality; and determine whether this risk varies by cause of death and antipsychotic dose. METHODS: Using data from a large anonymised mental healthcare database, we identified all adult patients with serious mental illness (SMI) who had been prescribed a single antipsychotic or polypharmacy, for six or more months between 2007 and 2014. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical factors and smoking, to examine the association between APP use and the risk of death. RESULTS: We identified 10 945 adults with SMI who had been prescribed long-term antipsychotic monotherapy (76.9%) or APP (23.1%). Patients on long-term APP had a small elevated risk of mortality, which was significant in some but not all models. The adjusted hazard ratios for death from natural and unnatural causes associated with APP were 1.2 (0.9-1.4, P = 0.111) and 1.1 (0.7-1.9, P = 0.619) respectively. The strengths of the associations between APP and mortality outcomes were similar after further adjusting for % BNF antipsychotic dose (P = 0.031) or olanzapine equivalence (P = 0.088). CONCLUSION: The findings suggest that the effect of long-term APP on mortality is not clear-cut, with limited evidence to indicate an association, even after controlling for the effect of dose.

Increased mortality among people with schizophrenia and other non-affective psychotic disorders in the community: A systematic review and meta-analysis.

INTRODUCTION: There is increasing evidence of excess mortality in schizophrenia but less information on other non-affective psychoses. We therefore generated standardised mortality ratios (SMRs) for community-dwelling people with schizophrenia and other non-affective psychoses, relative to the general population, and examined changes to the SMR over time. METHODS: We conducted a systematic review in which Pubmed, CINAHL, EMBASE, Google Scholar and PsycINFO were searched for publications that reported SMRs for all-cause mortality among community-dwelling people with schizophrenia and psychotic disorders. Meta-analyses of SMRs were conducted, pooled across genders and then separately by gender. Sub-group analyses were conducted for diagnostic group, global region, decade and risk of study bias. RESULTS: We were able to include 34 studies covering 1,724,906 participants. The gender pooled SMR for schizophrenia and psychotic disorders was 3.08 (95%CI 2.88-3.31). Schizophrenia and broader psychotic disorders had similar SMRs. Stratification by decade of observation suggests that the difference in SMR is not declining and may possibly be widening. Analyses showed high levels of heterogeneity. CONCLUSIONS: The appearance of a static or widening mortality gap over time between people with schizophrenia and psychotic disorders and the general population is of concern. However, whether it is an increase over time is unclear, as there are insufficient studies to confirm this.

Effectiveness of Early Psychosis Intervention: Comparison of Service Users and Nonusers in Population-Based Health Administrative Data.

OBJECTIVE: Early psychosis intervention (EPI) programs improve clinical and functional outcomes for people with first-episode psychosis. Less is known about the impact of these programs on the larger health care system. The authors sought to compare indicators of health service use, self-harm, suicide, and mortality between people with first-episode psychosis who were using EPI services and a propensity-matched group of concurrent control subjects who were not accessing EPI services. METHOD: A retrospective cohort of incident cases of nonaffective psychosis in the catchment area of the Prevention and Early Intervention Program for Psychoses in London, Ontario, between 1997 and 2013 was constructed using health administrative data. This cohort was linked to primary data from the same program to identify people who used EPI services. Outcomes for people who used EPI services and those who did not were compared using Cox proportional hazards models. RESULTS: People who used EPI services had substantially lower rates of all-cause mortality in the 2-year period after EPI program admission (hazard ratio=0.24, 95% CI=0.11-0.53), although a significant difference in self-harm (hazard ratio=0.86, 95% CI=0.18-4.24) and suicide (hazard ratio=0.73, 95% CI=0.29-1.80) between the two groups was not observed. Those who used EPI services also had lower rates of emergency department presentation (hazard ratio=0.71, 95% CI=0.60-0.83) but higher rates of hospitalization (hazard ratio=1.42, 95% CI=1.18-1.71). These benefits were not observed after 2 years, when EPI care is typically stepped down to medical management. CONCLUSIONS: People with first-episode psychosis who used EPI services had mortality rates that were four times lower than those with first-episode psychosis who did not use these services, as well as better outcomes across several health care system indicators. These findings support the effectiveness of EPI services for the treatment of first-episode psychosis in the larger context of the overall health care system.