Context Despite improvements in mental health services in recent decades, it is unclear whether the risk of mortality in schizophrenia has changed over time. Objective To explore the distribution of standardized mortality ratios (SMRs) for people with schizophrenia. Data Sources Broad search terms were used in MEDLINE, PsychINFO, Web of Science, and Google Scholar to identify all studies that investigated mortality in schizophrenia, published between January 1, 1980, and January 31, 2006. References were also identified from review articles, reference lists, and communication with authors. Study Selection Population-based studies that reported primary data on deaths in people with schizophrenia. Data Extraction Operationalized criteria were used to extract key study features and mortality data. Data Synthesis We examined the distribution of SMRs and pooled selected estimates using random-effects meta-analysis. We identified 37 articles drawn from 25 different nations. The median SMR for all persons for all-cause mortality was 2.58 (10%-90% quantile, 1.18-5.76), with a corresponding random-effects pooled SMR of 2.50 (95% confidence interval, 2.18-2.43). No sex difference was detected. Suicide was associated with the highest SMR (12.86); however, most of the major causes-of-death categories were found to be elevated in people with schizophrenia. The SMRs for all-cause mortality have increased during recent decades (P = .03). Conclusions With respect to mortality, a substantial gap exists between the health of people with schizophrenia and the general community. This differential mortality gap has worsened in recent decades. In light of the potential for second-generation antipsychotic medications to further adversely influence mortality rates in the decades to come, optimizing the general health of people with schizophrenia warrants urgent attention.

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A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time?

https://onlinelibrary.wiley.com/doi/pdf/10.1002/j.2051-5545.2011.tb00014.x

Physical illness in patients with severe mental disorders.I. Prevalence, impact of medications and disparities in health care

Prevalence of the metabolic syndrome in patients with schizophrenia: Baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III.

Background: Major damage to gray and white matter in the prefrontal cortex and autonomic deficits have been found to result in pseudopsychopathic personality in patients with neurological disorders, but it is not known whether people with antisocial personality disorder (APD) in the community who do not have discernable brain trauma also have subtle prefrontal deficits. Methods: Prefrontal gray and white matter volumes were assessed using structural magnetic resonance imaging in 21 community volunteers with APD (APD group) and in 2 control groups, comprising 34 healthy subjects (control group), 26 subjects with substance dependence (substancedependent group), and 21 psychiatric controls. Autonomic activity (skin conductance and heart rate) was also assessed during a social stressor in which participants gave a videotaped speech on their faults. Results: TheAPD group showed an 11.0% reduction in prefrontal gray matter volume in the absence of ostensible brain lesions and reduced autonomic activity during the stressor. These deficits predicted group membership independent of psychosocial risk factors. Conclusions: To our knowledge, these findings provide the first evidence for a structural brain deficit in APD. This prefrontal structural deficit may underlie the low arousal, poor fear conditioning, lack of conscience, and decision-making deficits that have been found to characterize antisocial, psychopathic behavior. Arch Gen Psychiatry. 2000;57:119-127

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/481571/yoa9157.pdf

Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder.

Background
Although expert opinion has asserted that there is an increased risk of violence in individuals with schizophrenia and other psychoses, there is substantial heterogeneity between studies reporting risk of violence, and uncertainty over the causes of this heterogeneity. We undertook a systematic review of studies that report on associations between violence and schizophrenia and other psychoses. In addition, we conducted a systematic review of investigations that reported on risk of homicide in individuals with schizophrenia and other psychoses.

/pdf/schizophrenia-and-violence-systematic-review-and-meta-22vzciv2t3.pdf

Schizophrenia and Violence: Systematic Review and Meta-Analysis

BACKGROUND A relationship exists between mental disorder and offending behaviours but the nature and extent of the association remains in doubt.

METHOD Those convicted in the higher courts of Victoria between 1993 and 1995 had their psychiatric history explored by case linkage to a register listing virtually all contacts with the public psychiatric services.

RESULTS Prior psychiatric contact was found in 25% of offenders, but the personality disorder and substance misuse accounted for much of this relationship. Schizophrenia and affective disorders were also over-represented, particularly those with coexisting substance misuse.

CONCLUSIONS The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse. The risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion.

Serious criminal offending and mental disorder. Case linkage study.

Community care and criminal offending in schizophrenia

BACKGROUND The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner.

METHODS A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both in-patient and community-based services.

RESULTS Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders.

CONCLUSIONS The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.

Sudden death in psychiatric patients.

Background An increased risk of choking associated with antipsychotic medication has been repeatedly postulated. Aims To examine this association in a large number of cases of choking deaths. Method Cases of individuals who had died because of choking were linked with a case register recording contacts with public mental health services. The actual and expected rates of psychiatric disorder and the presence of psychotropic medication in post-mortem blood samples were compared. Results The 70 people who had choked to death were over 20 times more likely to have been treated previously for schizophrenia. They were also more likely to have had a prior organic psychiatric syndrome. The risk for those receiving thioridazine or lithium was. respectively, 92 times and 30 times greater than expected. Other antipsychotic and psychotropic drugs were not over-represented. Conclusions The increased risk of death in people with schizophrenia may be a combination of inherent predispositions and the use of specific antipsychotic drugs. The increased risk of choking in those with organic psychiatric syndromes is consistent with the consequences of compromised neurological competence. Declaration of interest None.

/pdf/choking-deaths-the-role-of-antipsychotic-medication-3vkdepuskd.pdf

Choking deaths: the role of antipsychotic medication.

To justify the indefinite detention of an individual convicted of a serious offence, the High Court of Australia has required expert evidence by a psychiatrist or psychologist to the effect that the individual is likely in the future to commit further serious offences. This article examines whether the rules for admissibility of expert evidence, properly applied, allow any weight to be attached to such predictions. In fact, predictions of future offending are admitted, but are only relied upon where they confirm a court's pre-existing attitudes toward the dangerousness of an individual. It appears that judges are utilising expert evidence to avoid the charge that they are engaging in the arbitrary exercise of power and are acting outside the judicial method. This has significant constitutional implications for the validity of legislative schemes and their compatibility with courts exercising judicial power in accordance with the Australian Constitution.

David Ruschena

Papers

Serious criminal offending and mental disorder. Case linkage study.

Community care and criminal offending in schizophrenia

Sudden death in psychiatric patients.

Choking deaths: the role of antipsychotic medication.

Determining Dangerousness: Whatever Happened to the Rules of Evidence?