20 Apr 2017
by Pat McCaffrey
Young people who experience psychosis have a dramatically increased rate of death in the short term, reports a new study from Michael Schoenbaum and colleagues at the National Institute of Mental Health in Bethesda, Maryland. In an analysis of insurance claims information and linked mortality data on people aged 16-30, Schoenbaum and coworkers discovered that death rates in the year following a first episode of psychosis (FEP) soar to at least 24 times higher than for the same age in the general population. At the same time, most patients received limited and suboptimal care, the data show. The study was published online April 6 in Schizophrenia Bulletin.
"This study identifies two important problems—early mortality and big gaps in the quality of care,” said Benjamin Druss of Emory University in Atlanta, Georgia, who was not involved in the study. “It's a wakeup call for the field and for policymakers that they need to pay close attention to the time around incident diagnosis, which is clearly a very high-risk period,” Druss told SRF.
It’s known that adults with serious mental illness lose about a decade of life due to medical issues such as heart disease and diabetes, and suicide. The new study is one of the few to look at mortality associated with the onset of psychosis in young people, and the only one to look at mortality and care patterns after an incident of psychosis in the United States.
For the analysis, the authors used data from the Multi-Payer Claims Database pilot, a collection of insurance enrollment information and healthcare claims covering 63.4 million commercially insured Americans. The original goal of the study was to get a better picture of usual care after a first episode of psychosis in young people, in support of the RAISE (Recovery After an Initial Schizophrenia Episode) trials, which aimed to improve care for FEP (see SRF news here and here). The insurance data came with a bonus: Linkage to Social Security Administration death records gave the investigators a look at not only medical conditions and care, but also outcome in terms of mortality in the cohort.
In the study, Schoenbaum’s team identified 5,488 people age 16-30 with a first diagnosis of psychosis, of whom 108, or 2 percent died in the 12 months following diagnosis. The standardized mortality rate (1,968 deaths per 100,000 people) was 24 times greater than the rate in the general population of the same age (89 per 100,000, or < 0.1 percent). Mortality increased with age at first episode: In those over 25 years old, mortality was 54 times that of the general population.
“We expected to see somewhat higher mortality, but we were blown away by the scale—we did not expect to see more than 20 times higher mortality,” Schoenbaum told SRF. The death rate observed in young people is comparable to that seen in people over 70 in the US, he said.
Despite the toll, many of the cohort appeared to receive limited care: 61 percent of the patients filled no prescriptions for antipsychotic drugs, and 41 percent received no individual psychotherapy. Nearly two-thirds (62 percent) had at least one hospitalization or emergency room visit in the year after diagnosis. “Most get something, but very few get what we hope and expect they would get,” said Schoenbaum.
The researchers cannot say how the young people are dying, because Social Security records do not specify cause of death. “The most plausible explanation is that deaths are due mainly to suicide and accidents, but at a higher rate than the general population. I would not be surprised if we saw increased suicide, but we don’t know that,“ said Schoenbaum.
Druss agrees that it will be important to know causes of death “to understand better the pathways to mortality, the specific risk factors for death, and the best ways of intervening.”
The study reinforces the importance of intensive, comprehensive care in this young population, said Schoenbaum, and also argues for tracking mortality as an outcome. He hopes to see similar studies from other groups in different cohorts, including longer, multiyear follow-up.