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An epidemiologic study of deaths of psychiatric inpatients
An Epidemiologic Study of Deaths of Psychiatric Inpatients Hideo Shinozaki
T
HERE have previously been several studies of deaths of psychiatric inpatients, mainly in northern European countries and the U.S.‘-” Alstrom,” Odegard,7 and Malzberg* reported that the patients admitted for the first time to mental hospitals have a relative risk of death four to ten times higher than that of the general population and concluded that this was attributable to conditions specifically associated with the hospital facilities and with the hospitalized patient group. The physical conditions of mental hospitals have undergone major changes over time and so have the psychologic and social characteristics of hospitalized patient groups. As a result, factors associated with patients’ deaths have also been subject to changes with this passage of time. From the epidemiologic point of view, studies of psychiatric patients who have died in mental hospitals may therefore raise interesting questions. Using two sources of information, i.e., death certificates and mental hospital discharge records, the author has investigated all psychiatric patients who have died in the mental hospitals of Kanagawa Prefecture for 3 years. These deaths have then been related to total deaths in the general population of the Prefecture in the same period. THE SETTING Kanagawa Prefecture (capital Yokohama City) is a large urban local government area, adjoining the Tokyo metropolitan area. It covers an area of 917 square miles and the population reached almost 5.3 million in 1970. From the viewpoint of psychiatric services, there are 48 mental hospitals, 16 general hospitals which have a psychiatric unit, 1 university medical school, 62 psychiatric clinics, 35 public health centers, and 2 mental health centers. The total number of psychiatric inpatients in these facilities was 10,199 (December 31, 1970). The percentage distribution by diagnosis of these cases is: schizophrenia (64%), alcoholism and drug addiction (8%), manic-depressive psychosis (5%) degenerative psychosis (4%), subnormality (4%), epilepsy (4%), neurosis (3%). syphilitic psychosis (2%), personality disorder (l%), others (5%). For drug addiction there is a special local government mental hospital which has 150 beds and has recently been occupied mostly by alcoholics. Otherwise, alcoholism patients are scattered throughout the remaining mental hospitals. Since subnormality without psychotic features is the responsibility of the education From the Ministry of Health and Welfare, Tokyo. Japan. HideoShinozaki, M.D.: Deputy Head, Planning Division, Public Health Bureau, Ministry ofHealth and Welfare. Tokyo, Japan. Reprint requests should be addressed to Hide0 Shinozaki, M.D., 773-97. Nikaido. Kamakura-Cite. Kanagawa, Japan. ~c> 1976 bv Grune & Stratton, Inc. Comprehenswe Psychiatry. Vol. 17. No. 3 (May/June).
1976
425
HIDE0
426
SHINOZAKI
system, “subnormality” includes subnormality with psychotic syndrome or severe epilepsy. The percentage financial distribution of the hospitalization expenses of these cases is: 47% insurance payments, 27% compulsory hospitalization by mental health law; 25% welfare, and 1% private payment and others. The 48 mental hospitals, among which 7 are public and the rest private, are fairly uniformly distributed throughout the area. Most have approximately 100-200 beds, but a few have approximately 500; the 16 general hospitals which have psychiatric units mostly have outpatient services only, and the total number of psychiatric beds in these hospitals is under 100. The role of the public health center” is primarily as the community health service agency and secondarily as the administrative supervisory agency, with authority delegated by the prefectual governor or city mayor. Each public health center has its own administrative area, containing a population of lOO,OOO-200,000;all community health programs are integrated into its activities. The basic functions, defined by the public health center law, are as follows: health education, vital and health statistics, improvement of nutrition and food sanitation, environmental health, public health nursing, medical social service, laboratory service, mental health, prevention and control of tuberculosis, venereal diseases, and other communicable diseases, maternal and child health, dental hygiene, and other local health programs as required. The 35 public health centers in this area undertaking all these activities, as compared with centers in other prefectures, have particularly emphasized mental health services because the need for tuberculosis treatment has become relatively small. These mental health activities include: (A) a psychiatric case register, covering admissions and discharges, treatment and employment of patients in their homes (however, this is not a complete system); (B) promotion of cooperation between psychiatric facilities, such as mental hospitals, psychiatric clinics, welfare offices, subnormality facilities, geriatric facilities, schools, police, courts, societies of families of psychiatric patients, and A. A. groups, etc.; (C) mental health education for the population; (D) improving associated voluntary activities; (E) mental health consultative clinics by psychiatrists, public health nurses, and psychiatric social workers; (F) home visiting by mental health staff, and (G) legal administration and management under the mental health law. These activities of each public health center are mainly limited to its own administrative area. The main professional personnel of each center consists of three physicians, one part-time dentist and one dental hygienist, three nutritionists, two x-ray technicians, eight laboratory technicians, one pharmacist, one veterinarian, 11 public health nurses, one midwife, one health statistician, one health educator, two social workers, six food inspectors, and six sanitary inspectors. The role of the two mental health centers” is mainly consultation with the public health centers; the main professional personnel of each consists of three psychiatrists, nine psychiatric social workers, two psychologists, and one nurse. All of these facilities are controlled by the local government. MATERIALS
AND METHODS
The details of death certificates and mental hospital discharge records, used as material for this study, are as follows. A death certificate, completed by a doctor under the ICD (International Classification of Diseases) is submitted to the local administrative public health center. A health statistician checks it there and asks the doctor for classification of an incomplete or unclear statement. After that,
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
427
one copy of the certificate
is kept in the public
forwarded
department
to the statistics
are patient’s dental
name, sex, date of birth
death.
site of death,
also submitted hospital
to the administrative
or dies there;
mission,
and death.
name of facility,
hospital
date of discharge
than that of death certiticates Several
other
records
there is no psychiatric The
subjects
Prefecture
prognosis
of the study
or in psychiatric obtained
of psychiatric
are those
beds in general
Investigations qfDeath The subjects chiatric
studied
(recovered,
patients
the period
mental
required
in the public
not improved,
from
health
is the
center
date of ad-
dead).
home ad-
is considered
to be leas
by law. public
home
discharge
health
center.
but
Prefecture. addresses
within
Kanagawa
31. 1970 in mental
in the Prefecture.
hospital
record
is discharged
rate of this record
with
item for XXI-
discharge
name, sex. date of birth,
I, 1968 to December
Their
personal
hospitals
details
were
records.
Certijicates
were those dead psychiatric
home addresses
worker
improved,
patients
also located
and/or
a patient
the whole of Kanagawa
psychiatric
form copy is
additional
hospital
are kept in the administrative
covering
from January
hospitals
from the death certificates
had their
social
are patient’s
name. The reporting
system
cause ofdeath,
whenever
because it is not compulsorily
case register
who died during
center
record
and a computer
The main items of a death certiticate
name. A mental
by a psychiatric
dress. name of next of kin, and hospital
for 5 years,
home address.
health
discharge
or death,
center
government.
and doctor’s
public
this is checked
The main items of a mental
health
of the central
in Kanagawa
patients
who met the following
and (B) site ofdeath
Prefecture.
conditions:
(A) they
ofa psy-
falls under the name
facility.
During
the 3 years
74,600 of uhich criteria.
from
These certificates
September
From
of this study,
were directly
collected
certiticates
issued amounted
i.e., those psychiatric
from all 35 public
to approximately
patients
who met the above
centers
in the Prefecture
health
in
1971.
Investigations
qf Mental
these records,
addresses
1968 to 1970, the death
I143 are the subjects
Hospital Discharge Rec0rd.r
those cases were selected
in kanagawa
Prefecture.
They
who were recorded
amounted
as having died and who had home
to 712 persons
during
the 3 years
from
196X to
1970.
Record Linkage of Death Certificates and Discharge Records Kecords
01’ 1413 persons
were
records
on the same individual.
date of birth, The linked linked. linked
Since,
checked
from
records
death
and linked:
certificates
“record
and 712 persons
linkage”
here
refers
This was done by checking
from
mental
hospital
to the integration
the two records
discharge
of two or more
for patient’s
name. sex.
date of death, and address. cases were 588: 555 from death certiticates however.
were also included
death is an unmistakable in the present
sample,
and I24 from discharge
phenomenon. which therefore
records
could not be
a total of 679 persons who could not he totals
1267 persons.
RESULTS .4
na!,*.res qfPs>schiatric Patienrs who Died in Mental Hospitals
Yearly and monthly Yearl~~/nlonthlv jluctuations and ses/age distribution. fluctuations in the number of psychiatric patients who died in mental hospitals (referred to here as the “deaths in hospital”) are given in Table 1, and their sex/age distribution in Table 2. The annual number of deaths is approximately constant, i.e., 408 in 1968, 439 in 1969, and 420 in 1970. Monthly breakdowns showed a larger number of deaths in July and October of 1968, the monthly mean deaths and mean deviation being 34.0 * 6. In 1969, deaths were high in January and March, mean deaths and deviation being 36.6 f 5.2; in 1970, the number of deaths was particularly large in January, the mean value being 35.0 f 10.1. Monthly fluctuation was greater in 1970. When deaths were analyzed by sex, they were found to be 238 males (58.3%)
428
HIDE0
Table 1. Number
of Deaths in Hospital
1968.-1970
SHINOZAKI
by Year and Month
1968
1969
Jan
153
30
52
71
Feb
95
31
34
30
1970
Mar
129
36
43
50
Apr
95
26
33
36
May Jun
96
33
41
22
79
27
35
17
119
50
37
32
97
29
33
35
71
29
28
14
122
47
41
34
Nov
98
31
29
38
Dee
113
39
33
41
1267
408
439
420
Jul Aug Sept Ott
Total
Table 2.
Number
of Deaths in Hospital
1968-1970
Analyzed
1968
by Year, Sax, and Age 1969
1970
Total 1267
M 713
F 554
Total
M
F
Total
M
F
Total
M
F
408
238
170
439
244
195
420
231
189
(100)
(56.3)
(43.7)
(100)
(58.3)
141.7)
(100)
(44.4)
(100)
(55.0)
(45.0)
lo-19yr
(55.6)
15
9
6
3
3
0
6
2
4
6
4
2
70
40
30
17
8
9
20
11
9
33
21
12
30-39vr
109
71
38
31
24
7
44
27
17
34
20
14
40-49yr
132
84
48
37
22
15
46
31
15
49
31
18
50-59yr
206
130
77
73
44
29
67
45
22
66
40
26
20-29
yr
60-69yr
309
190
121
108
72
36
116
68
48
85
48
37
70+ yr
406
189
234
139
65
74
140
60
80
147
67
80
Parenthetical
figures indicate
Table 3.
Number
Causeof
Death
percentages.
of Deaths in Hospital
(Category
f3)
Analyzed
by Cause of Death and Sex Total
M
F
1267
713
554
25 (2.2)
16
9
50 (4.4)
39
11
34 (3.0)
16
18
9 (0.8)
5
4
166 114.5)
78
88
243 (21.31
140
103
209 (18.3)
107
102
27 (2.41
24
3
8 (0.7)
2
6
120 (10.5)
73
47
Psychosis (B46a)
50 (4.4)
25
25
Accidents
12 (1.0)
11
1
49 (4.3)
32
17
141 (12.2)
66
75
634
509
79
45
Tuberculosis
(l35; 6)
Syphilis and complications Cancer (B19b; Hypertension
(817)
19c; 19f; 19g; 19i) (827)
Heart disease (828;
29)
Brain vascular disease (830) Pneumonia
and bronchitis
(832;
33a)
Liver cirrhosis (637) Nephritis
and nephrosis (838)
Undifferentiated
(845)
(B47; 48~; 48f; 484)
Suicide
(849)
Others
33b; 33~; 34; 35; 36; 46b; 46~;
Bll;
12; 18~; 20; 21; 22; 24; 31;
46e; 46f; 469 Sum
1143
Unknown Parenthetical
124 figures indicate percentages.
(100)
DEATHS
AMONG
PSYCHIATRIC
and 170 females
INPATIENTS
429
(41.7%) in 1968; 244 males (55.6%) and 195 females
(44.4%) in
1969, and 231 males (55.0%) and 189 females (45.0%) in 1970. Male deaths were higher than female in each year. The 3-year combined totals are 713 males (56.3%) and 554 females (43.7%). When analyzed by age, the number of deaths was found to increase with greater age each year. Patients over 60-years-old accounted for 60.5% in 1968, 58.3% in 1969, and 55.2% in 1970. In the 3-year total, 735 persons (or 58.0%) died at the ageof60orover. Causrs of’ death. As already mentioned, the causes of death are described in the death certificates and can be classified in accordance with Category B of the ICD. Table 3 lists the causes of death from the deaths in hospital. The most frequent condition was brain vascular disease, which caused the death of 243 persons (21.3%). The second most common was pneumonia and bronchitis, which caused the death of 209 persons (18.3%). The third was heart disease, causing 166 deaths (14.5%). The remaining conditions include undifferentiated causes (120 persons, 10.5%); syphilis and its complications and psychosis (50 persons, 4.4%); suicide (49 persons, 4.3%; the most common method being hanging which accounted for 40 deaths); cancer (34 persons, 3.0%); liver cirrhosis (27 persons, 2.4%); tuberculosis (25 persons, 2.2%): accidents (12 persons, 1.O%); hypertension (9 persons, 0.8%‘); and nephritis and nephrosis (8 persons, 0.7%). When these causes were analyzed by sex, syphilis and its complications, liver cirrhosis, and accidents were more common in males than in females. It should be noted that in the list given in Table 3, “undifferentiated” cases include senility (45a of Category B), and “others” contain a quite small number of single causes of death. In calculating the death ratio, those 124 persons who could not be linked with death certificates and died of unknown causes were excluded; thus, analyses were made for the remaining 1143 persons. Dearh rates. Rates for the deaths in hospital are given in Table 4. If the death rate is calculated against a hospital population of 1000, it was 40.6 in 1968,41.9 in 1969, and 41.2 in 1970, giving no significant yearly differentiation. Using the concept of a population at risk, the death rates were calculated, using the hospital population (total number of psychiatric patients in residence in mental hospitals as of December 3 1 each year) as the denominator. Comparison qf‘Dearhs in Hospitals and Deaths in the General Popularion The deaths in hospitals were measured against a control, for the period of 3 years from 1968; deaths in the general population of Kanagawa Prefecture (hereinafter referred to as “deaths in the prefecture”) being used as the control. Table 4.
Yearly Hospital
Year
Death
Rates for Deaths in Hospital No.
of
Rates
of
Deaths
Population
Deaths
1968-1970
30,725
1267
41.2 40.6
(per
in Hospital
10001
1968
10,037
408
1969
10,489
439
41.9
1970
10,199
420
41.2
~____
430
HIDE0
SHINOZAKI
The prefectural population and the deaths in the prefecture were obtained from the Annual Health Statistics Report of Kanagawa Prefecture, while the mental hospital population was obtained from a special Survey of Psychiatric Patients in Kanagawa Prefecture which was carried out in 1969. Since the deaths in hospital included no person aged less than 10, children less than lo-years-old were excluded from the prefectural population, deaths in the prefecture, and hospital population. The sex and age distributions of both the hospital Comparison of death rates. population and prefectual population are given in Table 5. In respect of the sex distribution, the hospital population is divided into 6055 males (57.6%) and 4466 females (42.4%); the prefectural population into 2,240,038 males (51.6%) and 2,097,692 females (48.4%). The male population is larger in both cases. In respect of age distribution, there is a remarkable difference between the hospital and the prefectural populations. In the latter, the twenties are the largest age bracket, with the upper age groups trending downwards gradually. On the other hand, in the hospital population, the thirties are the largest group, with the upper age groups decreasing gradually. The hospital population has only 4.9% in the teens decade. In calculating the death rates for deaths in hospital, the numerator employed was the total number of deaths in hospital during the 3 years 1968-1970. In view of the population at risk, the hospital population as of October 1, 1969 was used as the denominator. Likewise, in the case of deaths in the prefecture, the numerator was total deaths in the prefecture occurring over the 3-year period, 1968-1970, and the denominator was the prefectural population, estimated as of October 1, 1969. The duration used for the death-rate calculation is 3 years. The relative risk is defined as the ratio of hospital/prefectural death rates. It indicates, therefore, how many times the death rate for hospitals is higher than the prefectural overall death rate. Rates of death in hospital were compared with those of death in Kanagawa Prefecture for each sex and age category. The comparison showed that the former was always higher than the latter for both sexes in all the age groups. The relative risks appear in Table 5, which indicates that this is highest in the lo-19 years age group (15.6 for male and 29.9 female). The lowest relative risk is in the forties decade for males (6.0) and at 70 years or older for females (6.4). The relative risk has a downward trend with greater age. The death rate for each sex is 117.8 per 1000 males and 124.1 per 1000 females for deaths in hospital; it is 17.3 per 1000 males and 14.5 per 1000 females for deaths in the prefecture. The relative risk is 6.3 for male and 8.6 for female. Since, however, there is a large difference in sex/age distribution between hospital and prefectural populations, it is necessary to correct the death rates age-specifically. With such a correction, the age-specific death rate for deaths in hospital becomes 118.2 per 1000 males and 107.4 per 1000 females, the relative risk being 6.8 for males and 7.5 for females. Comparison of mean death age. The mean death age is obtained by adding up all the ages of the dead for the year and dividing the sum by the number of deaths. Because of the large differences of sex/age distribution between the hospital and
yr
yr
yr
yr
yr
20-29
30-39
40-49
50-59
60-69
70+ yr
yr
10-19
Total
1196
920
608
1851
1246
675
115
205
347
965
1534
345
223
4464
289
6055
la9
190
130
a4
71
40
9
713
234
121
77
48
38
30
6
554
F
M
M
F
Deaths
in Hospital
Hospital
of
Population
Number
Deaths in Hospital
1643.5
550.7
192.6
67.4
38.4
26.1
31.1
1178
M
112,476 57.187
1141.5
183,486
306,261
499,231
652,633
428,764
2.240,038
M
348.7
126.6
52.2
31.8
31.1
26.9
124.1
F
91,636
125,490
202,362
297,816
456,396
552,613
M
5793
9427
16,259
3367
5230 15,117
2132
1452
969
342
30,314
3443
2583
2116
869
F
of
in Prefecture
Deaths
Number
in Prefecture
38.785
Deaths
by Sex and Age
37 1,379
2,097,692
F
Population
Risk Analyzed
Prefectural
Rates and Relative
Rate
Death
Death
Table 5.
264.3
83.8
28.5
11.2
5.2
3.2
2.0
17.3
M
Death
6.6 6.2
177.4
6.8
6.0
7.4
a.2
15.6
6.8
M
Risk
8.5
F
6.4
7.5
7.6
7.3
9.9
17.3
29.9
Relative
46.2
16.6
7.2
3.2
1.8
0.9
14.5
F
Rate
d
2
2
t
” n
3
3
2
s:
0
8
%
v,
2
g
0
HIDE0
432
SHINOZAKI
prefectural populations, referred to above, the age-specific mean death age was calculated for the deaths in hospital and compared with that value for deaths in the prefecture. The age-specific mean death age was obtained by the following equation:
P ad x PIP VP d x
P/P)
where P = standard population broken down by age groups (in this case, the agebracketed population of Kanagawa Prefecture was estimated as of October 1, 1969); p = population of the sampled group, broken down by age groups (in this case, the age-grouped hospital population, as of October 1, 1969); a = mean age of each bracket, with the exception that the representative value for the group aged 75 or older is set to SO-years-old; and d = number of deaths in each age group. When calculated by the above equation, the age-specific mean death can be fixed at 58.3 (male) and 62.3 (female), for thedeaths in hospital, and 61.2 and 66.2, respectively, for the deaths in the prefecture. Therefore, the male deaths in hospital had a life span about 3 years shorter than that of the male deaths in the prefecture. The life span of female deaths in hospital was about 4 years shorter than that of deaths in the prefecture. In Table 6, the causes of Comparison as to the ranking of “causes of death.” death are ranked for both the deaths in hospital and in the prefecture. The first ranking is occupied by brain vascular disease, common to both groups, amounting to 243 persons (21.3%) for the deaths in hospital and 17,614 persons (25.5%) for the deaths in the prefecture. The second ranking is taken by pneumonia and bronchitis in the case of the deaths in hospital (209 persons, 18.3%), and by cancer in the case of the deaths in the prefecture (13,592 persons, 19.7%).
Table 6.
Number
of Deaths by Cause of Death (Death Number of Deaths in Hospital (1968-1970)
Ratio)
Ranking
Tuberculosis
25 (2.2)
10
Syphilis and complications
50 (4.4)
5
Cancer
34 (3.0)
8
1,620
Ranking
(2.3)
9
89 (0.1) 13,592 1,920
9 (0.8)
Hypertension
of Cause of Death
Number of Deaths in Prefecture (1968-1970) 69,099
1,267
Total
and Ranking
(19.7)
2
(2.81
7 3
Heart disease
166 (14.5)
3
8,540
(12.4)
Brain vascular disease
243 (21.3)
1
17,614
(25.5)
1
Pneumonia
209 (18.3)
2
3,163
(4.6)
6
27 (2.4)
9
1,477
(2.1)
10
and bronchitis
Liver cirrhosis Nephrisis and nephrosis Undifferentiated Psychosis
120 (10.5)
4
50 (4.4)
5
Accidents
12 (1.0)
Suicide
49 (4.3)
Others
141 (12.2)
Sum Unknown Parenthetical
195 (0.3)
8 (0.7)
1143 124 figures indicate percentage.
(100)
7
4,769
(6.9)
4
316 (0.5) 4,755
(6.8)
5
1,633
(2.4)
8
9,416
(13.9)
69,099
( 100) 0
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
433
The third is heart disease, common to both groups, amounting to 166 persons (14.5%) and 8540 persons (12.4%), respectively. The remaining causes of death in hospital are in the following rank order: syphilis and its complications, suicide, cancer, liver cirrhosis, and tuberculosis. Those causes of death in the prefecture are: accidents, pneumonia and bronchitis. hypertension, suicide, tuberculosis, and liver cirrhosis. When ranking of the causes of death is compared between deaths in hospital and deaths in the prefecture, the highest (brain vascular disease) and the third (heart disease) are common to both groups. The second ranking, however. is different in that it is pneumonia and bronchitis in the case of deaths in hospital. but cancer for the deaths in the prefecture. Pneumonia and bronchitis comes as low as sixth for deaths in prefecture, but is ranked high for deaths in hospital. Comparison of death ratesfor each cause ofdeath. Comparison of death rates for each cause of death is given in Table 7 for both sexes and all age groups. This comparison was made for each cause of death, using the relative risk obtained by dividing the sex/age specified death rates of the deaths in hospital by the counterparts of the deaths in prefecture. Brain vascular disease had relative risk values of 5.4 in males and 6.1 in females. Pneumonia and bronchitis recorded the quite high values of 22.8 in males and 33.6 in females. When the relative risk of these diseases is broken down by age groups, the value was highest for males in their thirties and females in their forties, decreasing with greater age in both sexes. Heart disease had relative risk values of 6.2 in males and 10.5 in females. The values for cancer were approximately I .O, e.g., 0.8 in males and 1.4 in females. Compari.von cf deaths caused b>, pneumonia and bronchitis. Many deaths were caused in hospital by pneumonia and bronchitis, and this is an outstanding feature of the deaths in hospital, as compared with deaths in the prefecture. Monthly trends indicate that deaths in the prefecture are considerable in January, then decrease gradually until June and after a temporary peak in July. gradually rise until December, showing a reverse interrelationship with atmospheric temperatures. Such a trend was not observed in the deaths in hospital. However, the age-specific death rate is low in young people, but quite high in the forties or at higher ages. This trend was common to both groups. DISCUSSION
Several reports have been previously presented, mainly by Northern European and American workers, on mortality among psychiatric hospital inpatients. Among these, ijdegard’ conducted a study in Norway of data from 1916 to 1933 and concluded that, in respect of the correlation between duration of hospital stay and death rate, the death rate of newly hospitalized admissions was the highest in the first year of hospital stay, (five or six times greater than that of the general population) and that tuberculosis caused the high death rate, which was irrespective of age and duration of hospital stay. In another study, during the years 1950-1962,“’ making a comparison with the death rate of the general population, Odegard reported that the death rate of psychiatric patients in hospitals tended to decrease parallel with the decrease in the genera1 population’s death rate, that for the age group in their twenties being exceptionally low. Tuberculosis, which had been ranked high in the causes of death.
yr
yr
50-59
60-69
6.6
6.9 4.2
yr
yr
50-59
60-69 yr 70+ yr
4.1
7.6
37.4
40-49
30-39
yr yr
6.1
5.2
6.5
4.4
5.5
2.8
0
5.4
1 o-29
Female
Total
yr
40-49
vr
yr
70+
yr
lo-29
Total
30-39
Male
Heart
6.2
18.7
9.2
4.8
6.3
5.2
6.1
10.5
38.7
16.8
20.3
7.5
10.1 6.6
9.6
42.4
24.6
36.0
26.3
17.8
33.6
9.4
39.8
56.6
31.8
33.5 24.1
Disease
22.8
Bronchitis
and
Disease
Pneumonia
Brain
VXZlJlZ3r
Relative
319.8
8.5 1.2 19.1 18.9 5.5
187.0 0
10.5
23.7
11.9
83.1
3.5
0
86.3
77.8
0
103.2
13.7
0 0
7.7
9.0
32.5
69.7
205.3
7.9
12.7
22.0
63.0
182.8
41.2
4.0
72.0
45.2
200.5
13.9
16.5
18.0
106.7
205.8
36.3
20.9
61.0
3.7 14.1
267.5
36.8
12.3
Suicide
57.3
Psychosis
40.3
0 720.0
53.8
238.6
and
bv Sex. Aae. and Cause of Death
Complications
Syphilis
Risk Analyzed
14.3
Undifferentiated
Table 7.
1.6
0.9 1.2
0.4
1.8
0
1.4
1.5
0.3
0.4
1.4
0.7
0
0.8
CNlCer
Liver
6.0
6.9
7.0 0
0 3.0 0
17.3
3.7
5.6 7.7
0
0
8.6
14.0
3.4
1.8
6.9
6.3 2.6
3.8
3.0 6.4
0
0
5.2
Tuberculosis
11.7
8.3
Cirrhosis
6.9
7.3
9.4
9.9
14.1
13.9
9.7
5.1
6.0
9.0
4.9
4.4
6.8
5.9
Others
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
435
has decreased in the same manner as for the general population, and disease of the circulatory system has replaced it. He stated, however, that cancer did not have a comparable position with that in the general population. In the present study, no correlation was elicited between death rates and duration of hospital stay, but it was confirmed that the death rate of psychiatric patients in hospital is higher than that for the general population in Kanagawa Prefecture. It was approximately seven times higher, in fact, compared with the age-specific death rate of general population. Brain vascular disease was the most frequent cause of death, followed by respiratory diseases such as pneumonia and bronchitis; death from cancer was low in the list. Innes et al.‘” reported on the deaths of psychiatric patients in Scotland, showing that the rate was more than twice that of the general population. In these causes of death, arteriosclerotic and degenerative heart disease was ranked at the top and respiratory disease the third. The statistics on psychiatric patients who died in hospital in Kentucky, Maryland, and Indiana in the U.S.l-‘” showed that disease of the respiratory system ranked second, and its rate was 21.6% for Kentucky, 8.2% for Maryland, and 2 1.7% for Indiana. In the present study, pneumonia and bronchitis (which is comparable to the above category) was 18.3%, ranking second in the list of causes of death, i.e., the same as in the American study. Yamamoto” reported that one of the epidemiologic features of the death rate for pneumonia and bronchitis was a causal increase when influenza prevailed throughout the country, a causal relationship with the death rate from tuberculosis, a higher death rate in old age, and reciprocity with temperature, i.e., more deaths in colder weather. In the period from 1968 to 1970, when the present investigation was carried out, there was no prevalence of influenza and deaths from tuberculosis were, as in ijdegard study, not frequent, with a ratio as low as 2.2%. No relationship with temperature was observed, as mentioned earlier. A high death rate from pneumonia and bronchitis in old age was observed in this study, where patients over 60 accounted for 58.0% of the total samples. In this study, a life table was not prepared due to the fact that there were no deaths at ages below lo-years-old. In substitution for this, however, a mean death age was calculated. Though this has some defects becuase the samples of the present study do not include ages up to 10 and an age-specific average death rate (weighted by age distribution) was applicable, detailed studies on the number of deaths in the samples relating to the death rate were sufficient. Hence, it was proved that the mean death age of patients who died in hospital is younger compared with that of the general population in the prefecture, i.e., 3 years younger for male and 4 years for female. On the basis of this study, it is suggested that record linkage is a useful method for epidemiologic investigation of chronic psychiatric disorders. MacmahonlX listed five record linkage methods as being essential. One of these is death certificates combined with records of hospitalization. The eighth report of the WHO Expert Committee on Mental Health’” also pointed out the significance of the use of death certificates and hospital statistics. In the present study, there was linkage of death certificates, as records of deaths of psychiatric patients, and mental hospital discharge records, as records
436
HIDE0
SHINOZAKI
of hospital residence. The linkage achieved of death certificates was 51.4%, whereas that on mental hospital discharge records was 82.6%. These, however, would be expected to be loo%, in view of the nature of records of deaths. Due to the fact2” that death certificates are approximately 99.5% complete in Japan, the incompleteness of record linkage in this study must therefore be attributable to the mental hospital discharge records. In spite of such incompleteness, however, this first trial of record linkage as a means of calculating deaths of psychiatric patients in hospital should be a useful contribution to psychiatric epidemiology. ACKNOWLEDGMENT This work was carried out while the author was in Kanagawa Mental Health Center (superintendent, Dr. Ukio Ishihara). and was published in part in the Japanese Journal of Public Health, 19:6455656. 1972. The author would like to thank Dr. Ukio Ishihara for his kind help and Dr. Jack R. Ewalt, Senior Associate Dean for Clinical Affairs, Harvard Medical School for his kind support in collecting the relevant data in U.S. This paper was revised while the author was at the Department of Community Medicine, University of Manchester, England on a World Health Organisation Fellowship. I would like to express my extreme appreciation to Dr. Hugh L. Freeman, Consultant Psychiatrist, Department of Community Medicine, Hope Hospital, Salford and Dr. T. Fryers, Lecturer, Manchester University for editing the paper and their helpful comments on its preparation.
REFERENCES I. Babigian
HM,
Odoroff
CL: The mortality
experience of population with psychiatric illness. Am J Psychiatry 126:470-480, 1969 2. Larson J, Sjorgen T: A methodological, psychiatric and statistical study of large Swedish rural population. Acta Psychiat Neural (Suppl) 89:1--250, 1954 3. Cidegard 0: The excess mortality of the insane. Acta Psychiatr 27:353-367, 1952 4. Malzberg B: Mortality among patients with mental disease in New York civil states hospital. J Insur Med 5:513,1949 5. Pollock HM: What happens to patients with mental diseases during the first year of hospital life? State Hosp Q vol IO, 1925 6. Alstrom CH: Mortality in mental hospitals. Acta Psychiat Neurol (Suppl) 17:24. 1925 7. odegard 0: Mortality in Norwegian mental hospitals from 1916 to 1933. Acta Psychiatr ll:150-161, 1936 8. Malzberg B: Rate of discharge and rates of mortality among first admissions to the New York civil state hospitals. Third paper. Ment Hyg 3716 19-654, 1953 9. ijdegard 0: Mortality in Norwegian mental hospitals 1926-1941. ActaGenet 2:141-173, 1951 10. ijdegard 0: Mortality in Norwegian psychiatric hospitals 1950-1962. Acta Genet 17:137-153, 1967
I I A Brief Report on Public Health Administration in Japan. Ministry of Health and Welfare, Tokyo, 1972. p 4 12. Ishihara U: Annual Health Center, Yokohama, tural Mental Health Center.
Report of Mental Kanagawa Prefec1970, p 139
13. lnnes G, Millar WM: Mortality among psychiatric patients. Scott Med J 15:143-148, 1970 14. Statistical Report of State Mental Hospitals and Institutions for the Retarded, Fiscal 69-70. Kentucky Department of Mental Health, Frankfort, Ky, 1970 IS. Annual Statistical Report of State Mental Hospitals. Maryland Department of Health and Mental Hygiene, Baltimore, 1968 16. Indiana
Mental
Year 1967. Department dianapolis, 1967 17. Yamamoto Tokyo, Bunkodo,
Hospital
Statistics,
of Mental
S: Details 1970, p 230
of
18. Macmahon B, Pugh TF: Principles and Methods. Boston, 1970, pp 95-99 19. Epidemiology of Mental Techn Rep Ser 185:lO. Geneva,
Fiscal
Health,
In-
Epidemiology. EpidemiologyLittle, Brown,
Disorders. 1960
WHO
20. Tachikawa K: New Health Statistics. Tokyo, Daiichi-Schuppan, 1970, p 504
T
HERE have previously been several studies of deaths of psychiatric inpatients, mainly in northern European countries and the U.S.‘-” Alstrom,” Odegard,7 and Malzberg* reported that the patients admitted for the first time to mental hospitals have a relative risk of death four to ten times higher than that of the general population and concluded that this was attributable to conditions specifically associated with the hospital facilities and with the hospitalized patient group. The physical conditions of mental hospitals have undergone major changes over time and so have the psychologic and social characteristics of hospitalized patient groups. As a result, factors associated with patients’ deaths have also been subject to changes with this passage of time. From the epidemiologic point of view, studies of psychiatric patients who have died in mental hospitals may therefore raise interesting questions. Using two sources of information, i.e., death certificates and mental hospital discharge records, the author has investigated all psychiatric patients who have died in the mental hospitals of Kanagawa Prefecture for 3 years. These deaths have then been related to total deaths in the general population of the Prefecture in the same period. THE SETTING Kanagawa Prefecture (capital Yokohama City) is a large urban local government area, adjoining the Tokyo metropolitan area. It covers an area of 917 square miles and the population reached almost 5.3 million in 1970. From the viewpoint of psychiatric services, there are 48 mental hospitals, 16 general hospitals which have a psychiatric unit, 1 university medical school, 62 psychiatric clinics, 35 public health centers, and 2 mental health centers. The total number of psychiatric inpatients in these facilities was 10,199 (December 31, 1970). The percentage distribution by diagnosis of these cases is: schizophrenia (64%), alcoholism and drug addiction (8%), manic-depressive psychosis (5%) degenerative psychosis (4%), subnormality (4%), epilepsy (4%), neurosis (3%). syphilitic psychosis (2%), personality disorder (l%), others (5%). For drug addiction there is a special local government mental hospital which has 150 beds and has recently been occupied mostly by alcoholics. Otherwise, alcoholism patients are scattered throughout the remaining mental hospitals. Since subnormality without psychotic features is the responsibility of the education From the Ministry of Health and Welfare, Tokyo. Japan. HideoShinozaki, M.D.: Deputy Head, Planning Division, Public Health Bureau, Ministry ofHealth and Welfare. Tokyo, Japan. Reprint requests should be addressed to Hide0 Shinozaki, M.D., 773-97. Nikaido. Kamakura-Cite. Kanagawa, Japan. ~c> 1976 bv Grune & Stratton, Inc. Comprehenswe Psychiatry. Vol. 17. No. 3 (May/June).
1976
425
HIDE0
426
SHINOZAKI
system, “subnormality” includes subnormality with psychotic syndrome or severe epilepsy. The percentage financial distribution of the hospitalization expenses of these cases is: 47% insurance payments, 27% compulsory hospitalization by mental health law; 25% welfare, and 1% private payment and others. The 48 mental hospitals, among which 7 are public and the rest private, are fairly uniformly distributed throughout the area. Most have approximately 100-200 beds, but a few have approximately 500; the 16 general hospitals which have psychiatric units mostly have outpatient services only, and the total number of psychiatric beds in these hospitals is under 100. The role of the public health center” is primarily as the community health service agency and secondarily as the administrative supervisory agency, with authority delegated by the prefectual governor or city mayor. Each public health center has its own administrative area, containing a population of lOO,OOO-200,000;all community health programs are integrated into its activities. The basic functions, defined by the public health center law, are as follows: health education, vital and health statistics, improvement of nutrition and food sanitation, environmental health, public health nursing, medical social service, laboratory service, mental health, prevention and control of tuberculosis, venereal diseases, and other communicable diseases, maternal and child health, dental hygiene, and other local health programs as required. The 35 public health centers in this area undertaking all these activities, as compared with centers in other prefectures, have particularly emphasized mental health services because the need for tuberculosis treatment has become relatively small. These mental health activities include: (A) a psychiatric case register, covering admissions and discharges, treatment and employment of patients in their homes (however, this is not a complete system); (B) promotion of cooperation between psychiatric facilities, such as mental hospitals, psychiatric clinics, welfare offices, subnormality facilities, geriatric facilities, schools, police, courts, societies of families of psychiatric patients, and A. A. groups, etc.; (C) mental health education for the population; (D) improving associated voluntary activities; (E) mental health consultative clinics by psychiatrists, public health nurses, and psychiatric social workers; (F) home visiting by mental health staff, and (G) legal administration and management under the mental health law. These activities of each public health center are mainly limited to its own administrative area. The main professional personnel of each center consists of three physicians, one part-time dentist and one dental hygienist, three nutritionists, two x-ray technicians, eight laboratory technicians, one pharmacist, one veterinarian, 11 public health nurses, one midwife, one health statistician, one health educator, two social workers, six food inspectors, and six sanitary inspectors. The role of the two mental health centers” is mainly consultation with the public health centers; the main professional personnel of each consists of three psychiatrists, nine psychiatric social workers, two psychologists, and one nurse. All of these facilities are controlled by the local government. MATERIALS
AND METHODS
The details of death certificates and mental hospital discharge records, used as material for this study, are as follows. A death certificate, completed by a doctor under the ICD (International Classification of Diseases) is submitted to the local administrative public health center. A health statistician checks it there and asks the doctor for classification of an incomplete or unclear statement. After that,
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
427
one copy of the certificate
is kept in the public
forwarded
department
to the statistics
are patient’s dental
name, sex, date of birth
death.
site of death,
also submitted hospital
to the administrative
or dies there;
mission,
and death.
name of facility,
hospital
date of discharge
than that of death certiticates Several
other
records
there is no psychiatric The
subjects
Prefecture
prognosis
of the study
or in psychiatric obtained
of psychiatric
are those
beds in general
Investigations qfDeath The subjects chiatric
studied
(recovered,
patients
the period
mental
required
in the public
not improved,
from
health
is the
center
date of ad-
dead).
home ad-
is considered
to be leas
by law. public
home
discharge
health
center.
but
Prefecture. addresses
within
Kanagawa
31. 1970 in mental
in the Prefecture.
hospital
record
is discharged
rate of this record
with
item for XXI-
discharge
name, sex. date of birth,
I, 1968 to December
Their
personal
hospitals
details
were
records.
Certijicates
were those dead psychiatric
home addresses
worker
improved,
patients
also located
and/or
a patient
the whole of Kanagawa
psychiatric
form copy is
additional
hospital
are kept in the administrative
covering
from January
hospitals
from the death certificates
had their
social
are patient’s
name. The reporting
system
cause ofdeath,
whenever
because it is not compulsorily
case register
who died during
center
record
and a computer
The main items of a death certiticate
name. A mental
by a psychiatric
dress. name of next of kin, and hospital
for 5 years,
home address.
health
discharge
or death,
center
government.
and doctor’s
public
this is checked
The main items of a mental
health
of the central
in Kanagawa
patients
who met the following
and (B) site ofdeath
Prefecture.
conditions:
(A) they
ofa psy-
falls under the name
facility.
During
the 3 years
74,600 of uhich criteria.
from
These certificates
September
From
of this study,
were directly
collected
certiticates
issued amounted
i.e., those psychiatric
from all 35 public
to approximately
patients
who met the above
centers
in the Prefecture
health
in
1971.
Investigations
qf Mental
these records,
addresses
1968 to 1970, the death
I143 are the subjects
Hospital Discharge Rec0rd.r
those cases were selected
in kanagawa
Prefecture.
They
who were recorded
amounted
as having died and who had home
to 712 persons
during
the 3 years
from
196X to
1970.
Record Linkage of Death Certificates and Discharge Records Kecords
01’ 1413 persons
were
records
on the same individual.
date of birth, The linked linked. linked
Since,
checked
from
records
death
and linked:
certificates
“record
and 712 persons
linkage”
here
refers
This was done by checking
from
mental
hospital
to the integration
the two records
discharge
of two or more
for patient’s
name. sex.
date of death, and address. cases were 588: 555 from death certiticates however.
were also included
death is an unmistakable in the present
sample,
and I24 from discharge
phenomenon. which therefore
records
could not be
a total of 679 persons who could not he totals
1267 persons.
RESULTS .4
na!,*.res qfPs>schiatric Patienrs who Died in Mental Hospitals
Yearly and monthly Yearl~~/nlonthlv jluctuations and ses/age distribution. fluctuations in the number of psychiatric patients who died in mental hospitals (referred to here as the “deaths in hospital”) are given in Table 1, and their sex/age distribution in Table 2. The annual number of deaths is approximately constant, i.e., 408 in 1968, 439 in 1969, and 420 in 1970. Monthly breakdowns showed a larger number of deaths in July and October of 1968, the monthly mean deaths and mean deviation being 34.0 * 6. In 1969, deaths were high in January and March, mean deaths and deviation being 36.6 f 5.2; in 1970, the number of deaths was particularly large in January, the mean value being 35.0 f 10.1. Monthly fluctuation was greater in 1970. When deaths were analyzed by sex, they were found to be 238 males (58.3%)
428
HIDE0
Table 1. Number
of Deaths in Hospital
1968.-1970
SHINOZAKI
by Year and Month
1968
1969
Jan
153
30
52
71
Feb
95
31
34
30
1970
Mar
129
36
43
50
Apr
95
26
33
36
May Jun
96
33
41
22
79
27
35
17
119
50
37
32
97
29
33
35
71
29
28
14
122
47
41
34
Nov
98
31
29
38
Dee
113
39
33
41
1267
408
439
420
Jul Aug Sept Ott
Total
Table 2.
Number
of Deaths in Hospital
1968-1970
Analyzed
1968
by Year, Sax, and Age 1969
1970
Total 1267
M 713
F 554
Total
M
F
Total
M
F
Total
M
F
408
238
170
439
244
195
420
231
189
(100)
(56.3)
(43.7)
(100)
(58.3)
141.7)
(100)
(44.4)
(100)
(55.0)
(45.0)
lo-19yr
(55.6)
15
9
6
3
3
0
6
2
4
6
4
2
70
40
30
17
8
9
20
11
9
33
21
12
30-39vr
109
71
38
31
24
7
44
27
17
34
20
14
40-49yr
132
84
48
37
22
15
46
31
15
49
31
18
50-59yr
206
130
77
73
44
29
67
45
22
66
40
26
20-29
yr
60-69yr
309
190
121
108
72
36
116
68
48
85
48
37
70+ yr
406
189
234
139
65
74
140
60
80
147
67
80
Parenthetical
figures indicate
Table 3.
Number
Causeof
Death
percentages.
of Deaths in Hospital
(Category
f3)
Analyzed
by Cause of Death and Sex Total
M
F
1267
713
554
25 (2.2)
16
9
50 (4.4)
39
11
34 (3.0)
16
18
9 (0.8)
5
4
166 114.5)
78
88
243 (21.31
140
103
209 (18.3)
107
102
27 (2.41
24
3
8 (0.7)
2
6
120 (10.5)
73
47
Psychosis (B46a)
50 (4.4)
25
25
Accidents
12 (1.0)
11
1
49 (4.3)
32
17
141 (12.2)
66
75
634
509
79
45
Tuberculosis
(l35; 6)
Syphilis and complications Cancer (B19b; Hypertension
(817)
19c; 19f; 19g; 19i) (827)
Heart disease (828;
29)
Brain vascular disease (830) Pneumonia
and bronchitis
(832;
33a)
Liver cirrhosis (637) Nephritis
and nephrosis (838)
Undifferentiated
(845)
(B47; 48~; 48f; 484)
Suicide
(849)
Others
33b; 33~; 34; 35; 36; 46b; 46~;
Bll;
12; 18~; 20; 21; 22; 24; 31;
46e; 46f; 469 Sum
1143
Unknown Parenthetical
124 figures indicate percentages.
(100)
DEATHS
AMONG
PSYCHIATRIC
and 170 females
INPATIENTS
429
(41.7%) in 1968; 244 males (55.6%) and 195 females
(44.4%) in
1969, and 231 males (55.0%) and 189 females (45.0%) in 1970. Male deaths were higher than female in each year. The 3-year combined totals are 713 males (56.3%) and 554 females (43.7%). When analyzed by age, the number of deaths was found to increase with greater age each year. Patients over 60-years-old accounted for 60.5% in 1968, 58.3% in 1969, and 55.2% in 1970. In the 3-year total, 735 persons (or 58.0%) died at the ageof60orover. Causrs of’ death. As already mentioned, the causes of death are described in the death certificates and can be classified in accordance with Category B of the ICD. Table 3 lists the causes of death from the deaths in hospital. The most frequent condition was brain vascular disease, which caused the death of 243 persons (21.3%). The second most common was pneumonia and bronchitis, which caused the death of 209 persons (18.3%). The third was heart disease, causing 166 deaths (14.5%). The remaining conditions include undifferentiated causes (120 persons, 10.5%); syphilis and its complications and psychosis (50 persons, 4.4%); suicide (49 persons, 4.3%; the most common method being hanging which accounted for 40 deaths); cancer (34 persons, 3.0%); liver cirrhosis (27 persons, 2.4%); tuberculosis (25 persons, 2.2%): accidents (12 persons, 1.O%); hypertension (9 persons, 0.8%‘); and nephritis and nephrosis (8 persons, 0.7%). When these causes were analyzed by sex, syphilis and its complications, liver cirrhosis, and accidents were more common in males than in females. It should be noted that in the list given in Table 3, “undifferentiated” cases include senility (45a of Category B), and “others” contain a quite small number of single causes of death. In calculating the death ratio, those 124 persons who could not be linked with death certificates and died of unknown causes were excluded; thus, analyses were made for the remaining 1143 persons. Dearh rates. Rates for the deaths in hospital are given in Table 4. If the death rate is calculated against a hospital population of 1000, it was 40.6 in 1968,41.9 in 1969, and 41.2 in 1970, giving no significant yearly differentiation. Using the concept of a population at risk, the death rates were calculated, using the hospital population (total number of psychiatric patients in residence in mental hospitals as of December 3 1 each year) as the denominator. Comparison qf‘Dearhs in Hospitals and Deaths in the General Popularion The deaths in hospitals were measured against a control, for the period of 3 years from 1968; deaths in the general population of Kanagawa Prefecture (hereinafter referred to as “deaths in the prefecture”) being used as the control. Table 4.
Yearly Hospital
Year
Death
Rates for Deaths in Hospital No.
of
Rates
of
Deaths
Population
Deaths
1968-1970
30,725
1267
41.2 40.6
(per
in Hospital
10001
1968
10,037
408
1969
10,489
439
41.9
1970
10,199
420
41.2
~____
430
HIDE0
SHINOZAKI
The prefectural population and the deaths in the prefecture were obtained from the Annual Health Statistics Report of Kanagawa Prefecture, while the mental hospital population was obtained from a special Survey of Psychiatric Patients in Kanagawa Prefecture which was carried out in 1969. Since the deaths in hospital included no person aged less than 10, children less than lo-years-old were excluded from the prefectural population, deaths in the prefecture, and hospital population. The sex and age distributions of both the hospital Comparison of death rates. population and prefectual population are given in Table 5. In respect of the sex distribution, the hospital population is divided into 6055 males (57.6%) and 4466 females (42.4%); the prefectural population into 2,240,038 males (51.6%) and 2,097,692 females (48.4%). The male population is larger in both cases. In respect of age distribution, there is a remarkable difference between the hospital and the prefectural populations. In the latter, the twenties are the largest age bracket, with the upper age groups trending downwards gradually. On the other hand, in the hospital population, the thirties are the largest group, with the upper age groups decreasing gradually. The hospital population has only 4.9% in the teens decade. In calculating the death rates for deaths in hospital, the numerator employed was the total number of deaths in hospital during the 3 years 1968-1970. In view of the population at risk, the hospital population as of October 1, 1969 was used as the denominator. Likewise, in the case of deaths in the prefecture, the numerator was total deaths in the prefecture occurring over the 3-year period, 1968-1970, and the denominator was the prefectural population, estimated as of October 1, 1969. The duration used for the death-rate calculation is 3 years. The relative risk is defined as the ratio of hospital/prefectural death rates. It indicates, therefore, how many times the death rate for hospitals is higher than the prefectural overall death rate. Rates of death in hospital were compared with those of death in Kanagawa Prefecture for each sex and age category. The comparison showed that the former was always higher than the latter for both sexes in all the age groups. The relative risks appear in Table 5, which indicates that this is highest in the lo-19 years age group (15.6 for male and 29.9 female). The lowest relative risk is in the forties decade for males (6.0) and at 70 years or older for females (6.4). The relative risk has a downward trend with greater age. The death rate for each sex is 117.8 per 1000 males and 124.1 per 1000 females for deaths in hospital; it is 17.3 per 1000 males and 14.5 per 1000 females for deaths in the prefecture. The relative risk is 6.3 for male and 8.6 for female. Since, however, there is a large difference in sex/age distribution between hospital and prefectural populations, it is necessary to correct the death rates age-specifically. With such a correction, the age-specific death rate for deaths in hospital becomes 118.2 per 1000 males and 107.4 per 1000 females, the relative risk being 6.8 for males and 7.5 for females. Comparison of mean death age. The mean death age is obtained by adding up all the ages of the dead for the year and dividing the sum by the number of deaths. Because of the large differences of sex/age distribution between the hospital and
yr
yr
yr
yr
yr
20-29
30-39
40-49
50-59
60-69
70+ yr
yr
10-19
Total
1196
920
608
1851
1246
675
115
205
347
965
1534
345
223
4464
289
6055
la9
190
130
a4
71
40
9
713
234
121
77
48
38
30
6
554
F
M
M
F
Deaths
in Hospital
Hospital
of
Population
Number
Deaths in Hospital
1643.5
550.7
192.6
67.4
38.4
26.1
31.1
1178
M
112,476 57.187
1141.5
183,486
306,261
499,231
652,633
428,764
2.240,038
M
348.7
126.6
52.2
31.8
31.1
26.9
124.1
F
91,636
125,490
202,362
297,816
456,396
552,613
M
5793
9427
16,259
3367
5230 15,117
2132
1452
969
342
30,314
3443
2583
2116
869
F
of
in Prefecture
Deaths
Number
in Prefecture
38.785
Deaths
by Sex and Age
37 1,379
2,097,692
F
Population
Risk Analyzed
Prefectural
Rates and Relative
Rate
Death
Death
Table 5.
264.3
83.8
28.5
11.2
5.2
3.2
2.0
17.3
M
Death
6.6 6.2
177.4
6.8
6.0
7.4
a.2
15.6
6.8
M
Risk
8.5
F
6.4
7.5
7.6
7.3
9.9
17.3
29.9
Relative
46.2
16.6
7.2
3.2
1.8
0.9
14.5
F
Rate
d
2
2
t
” n
3
3
2
s:
0
8
%
v,
2
g
0
HIDE0
432
SHINOZAKI
prefectural populations, referred to above, the age-specific mean death age was calculated for the deaths in hospital and compared with that value for deaths in the prefecture. The age-specific mean death age was obtained by the following equation:
P ad x PIP VP d x
P/P)
where P = standard population broken down by age groups (in this case, the agebracketed population of Kanagawa Prefecture was estimated as of October 1, 1969); p = population of the sampled group, broken down by age groups (in this case, the age-grouped hospital population, as of October 1, 1969); a = mean age of each bracket, with the exception that the representative value for the group aged 75 or older is set to SO-years-old; and d = number of deaths in each age group. When calculated by the above equation, the age-specific mean death can be fixed at 58.3 (male) and 62.3 (female), for thedeaths in hospital, and 61.2 and 66.2, respectively, for the deaths in the prefecture. Therefore, the male deaths in hospital had a life span about 3 years shorter than that of the male deaths in the prefecture. The life span of female deaths in hospital was about 4 years shorter than that of deaths in the prefecture. In Table 6, the causes of Comparison as to the ranking of “causes of death.” death are ranked for both the deaths in hospital and in the prefecture. The first ranking is occupied by brain vascular disease, common to both groups, amounting to 243 persons (21.3%) for the deaths in hospital and 17,614 persons (25.5%) for the deaths in the prefecture. The second ranking is taken by pneumonia and bronchitis in the case of the deaths in hospital (209 persons, 18.3%), and by cancer in the case of the deaths in the prefecture (13,592 persons, 19.7%).
Table 6.
Number
of Deaths by Cause of Death (Death Number of Deaths in Hospital (1968-1970)
Ratio)
Ranking
Tuberculosis
25 (2.2)
10
Syphilis and complications
50 (4.4)
5
Cancer
34 (3.0)
8
1,620
Ranking
(2.3)
9
89 (0.1) 13,592 1,920
9 (0.8)
Hypertension
of Cause of Death
Number of Deaths in Prefecture (1968-1970) 69,099
1,267
Total
and Ranking
(19.7)
2
(2.81
7 3
Heart disease
166 (14.5)
3
8,540
(12.4)
Brain vascular disease
243 (21.3)
1
17,614
(25.5)
1
Pneumonia
209 (18.3)
2
3,163
(4.6)
6
27 (2.4)
9
1,477
(2.1)
10
and bronchitis
Liver cirrhosis Nephrisis and nephrosis Undifferentiated Psychosis
120 (10.5)
4
50 (4.4)
5
Accidents
12 (1.0)
Suicide
49 (4.3)
Others
141 (12.2)
Sum Unknown Parenthetical
195 (0.3)
8 (0.7)
1143 124 figures indicate percentage.
(100)
7
4,769
(6.9)
4
316 (0.5) 4,755
(6.8)
5
1,633
(2.4)
8
9,416
(13.9)
69,099
( 100) 0
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
433
The third is heart disease, common to both groups, amounting to 166 persons (14.5%) and 8540 persons (12.4%), respectively. The remaining causes of death in hospital are in the following rank order: syphilis and its complications, suicide, cancer, liver cirrhosis, and tuberculosis. Those causes of death in the prefecture are: accidents, pneumonia and bronchitis. hypertension, suicide, tuberculosis, and liver cirrhosis. When ranking of the causes of death is compared between deaths in hospital and deaths in the prefecture, the highest (brain vascular disease) and the third (heart disease) are common to both groups. The second ranking, however. is different in that it is pneumonia and bronchitis in the case of deaths in hospital. but cancer for the deaths in the prefecture. Pneumonia and bronchitis comes as low as sixth for deaths in prefecture, but is ranked high for deaths in hospital. Comparison of death ratesfor each cause ofdeath. Comparison of death rates for each cause of death is given in Table 7 for both sexes and all age groups. This comparison was made for each cause of death, using the relative risk obtained by dividing the sex/age specified death rates of the deaths in hospital by the counterparts of the deaths in prefecture. Brain vascular disease had relative risk values of 5.4 in males and 6.1 in females. Pneumonia and bronchitis recorded the quite high values of 22.8 in males and 33.6 in females. When the relative risk of these diseases is broken down by age groups, the value was highest for males in their thirties and females in their forties, decreasing with greater age in both sexes. Heart disease had relative risk values of 6.2 in males and 10.5 in females. The values for cancer were approximately I .O, e.g., 0.8 in males and 1.4 in females. Compari.von cf deaths caused b>, pneumonia and bronchitis. Many deaths were caused in hospital by pneumonia and bronchitis, and this is an outstanding feature of the deaths in hospital, as compared with deaths in the prefecture. Monthly trends indicate that deaths in the prefecture are considerable in January, then decrease gradually until June and after a temporary peak in July. gradually rise until December, showing a reverse interrelationship with atmospheric temperatures. Such a trend was not observed in the deaths in hospital. However, the age-specific death rate is low in young people, but quite high in the forties or at higher ages. This trend was common to both groups. DISCUSSION
Several reports have been previously presented, mainly by Northern European and American workers, on mortality among psychiatric hospital inpatients. Among these, ijdegard’ conducted a study in Norway of data from 1916 to 1933 and concluded that, in respect of the correlation between duration of hospital stay and death rate, the death rate of newly hospitalized admissions was the highest in the first year of hospital stay, (five or six times greater than that of the general population) and that tuberculosis caused the high death rate, which was irrespective of age and duration of hospital stay. In another study, during the years 1950-1962,“’ making a comparison with the death rate of the general population, Odegard reported that the death rate of psychiatric patients in hospitals tended to decrease parallel with the decrease in the genera1 population’s death rate, that for the age group in their twenties being exceptionally low. Tuberculosis, which had been ranked high in the causes of death.
yr
yr
50-59
60-69
6.6
6.9 4.2
yr
yr
50-59
60-69 yr 70+ yr
4.1
7.6
37.4
40-49
30-39
yr yr
6.1
5.2
6.5
4.4
5.5
2.8
0
5.4
1 o-29
Female
Total
yr
40-49
vr
yr
70+
yr
lo-29
Total
30-39
Male
Heart
6.2
18.7
9.2
4.8
6.3
5.2
6.1
10.5
38.7
16.8
20.3
7.5
10.1 6.6
9.6
42.4
24.6
36.0
26.3
17.8
33.6
9.4
39.8
56.6
31.8
33.5 24.1
Disease
22.8
Bronchitis
and
Disease
Pneumonia
Brain
VXZlJlZ3r
Relative
319.8
8.5 1.2 19.1 18.9 5.5
187.0 0
10.5
23.7
11.9
83.1
3.5
0
86.3
77.8
0
103.2
13.7
0 0
7.7
9.0
32.5
69.7
205.3
7.9
12.7
22.0
63.0
182.8
41.2
4.0
72.0
45.2
200.5
13.9
16.5
18.0
106.7
205.8
36.3
20.9
61.0
3.7 14.1
267.5
36.8
12.3
Suicide
57.3
Psychosis
40.3
0 720.0
53.8
238.6
and
bv Sex. Aae. and Cause of Death
Complications
Syphilis
Risk Analyzed
14.3
Undifferentiated
Table 7.
1.6
0.9 1.2
0.4
1.8
0
1.4
1.5
0.3
0.4
1.4
0.7
0
0.8
CNlCer
Liver
6.0
6.9
7.0 0
0 3.0 0
17.3
3.7
5.6 7.7
0
0
8.6
14.0
3.4
1.8
6.9
6.3 2.6
3.8
3.0 6.4
0
0
5.2
Tuberculosis
11.7
8.3
Cirrhosis
6.9
7.3
9.4
9.9
14.1
13.9
9.7
5.1
6.0
9.0
4.9
4.4
6.8
5.9
Others
DEATHS
AMONG
PSYCHIATRIC
INPATIENTS
435
has decreased in the same manner as for the general population, and disease of the circulatory system has replaced it. He stated, however, that cancer did not have a comparable position with that in the general population. In the present study, no correlation was elicited between death rates and duration of hospital stay, but it was confirmed that the death rate of psychiatric patients in hospital is higher than that for the general population in Kanagawa Prefecture. It was approximately seven times higher, in fact, compared with the age-specific death rate of general population. Brain vascular disease was the most frequent cause of death, followed by respiratory diseases such as pneumonia and bronchitis; death from cancer was low in the list. Innes et al.‘” reported on the deaths of psychiatric patients in Scotland, showing that the rate was more than twice that of the general population. In these causes of death, arteriosclerotic and degenerative heart disease was ranked at the top and respiratory disease the third. The statistics on psychiatric patients who died in hospital in Kentucky, Maryland, and Indiana in the U.S.l-‘” showed that disease of the respiratory system ranked second, and its rate was 21.6% for Kentucky, 8.2% for Maryland, and 2 1.7% for Indiana. In the present study, pneumonia and bronchitis (which is comparable to the above category) was 18.3%, ranking second in the list of causes of death, i.e., the same as in the American study. Yamamoto” reported that one of the epidemiologic features of the death rate for pneumonia and bronchitis was a causal increase when influenza prevailed throughout the country, a causal relationship with the death rate from tuberculosis, a higher death rate in old age, and reciprocity with temperature, i.e., more deaths in colder weather. In the period from 1968 to 1970, when the present investigation was carried out, there was no prevalence of influenza and deaths from tuberculosis were, as in ijdegard study, not frequent, with a ratio as low as 2.2%. No relationship with temperature was observed, as mentioned earlier. A high death rate from pneumonia and bronchitis in old age was observed in this study, where patients over 60 accounted for 58.0% of the total samples. In this study, a life table was not prepared due to the fact that there were no deaths at ages below lo-years-old. In substitution for this, however, a mean death age was calculated. Though this has some defects becuase the samples of the present study do not include ages up to 10 and an age-specific average death rate (weighted by age distribution) was applicable, detailed studies on the number of deaths in the samples relating to the death rate were sufficient. Hence, it was proved that the mean death age of patients who died in hospital is younger compared with that of the general population in the prefecture, i.e., 3 years younger for male and 4 years for female. On the basis of this study, it is suggested that record linkage is a useful method for epidemiologic investigation of chronic psychiatric disorders. MacmahonlX listed five record linkage methods as being essential. One of these is death certificates combined with records of hospitalization. The eighth report of the WHO Expert Committee on Mental Health’” also pointed out the significance of the use of death certificates and hospital statistics. In the present study, there was linkage of death certificates, as records of deaths of psychiatric patients, and mental hospital discharge records, as records
436
HIDE0
SHINOZAKI
of hospital residence. The linkage achieved of death certificates was 51.4%, whereas that on mental hospital discharge records was 82.6%. These, however, would be expected to be loo%, in view of the nature of records of deaths. Due to the fact2” that death certificates are approximately 99.5% complete in Japan, the incompleteness of record linkage in this study must therefore be attributable to the mental hospital discharge records. In spite of such incompleteness, however, this first trial of record linkage as a means of calculating deaths of psychiatric patients in hospital should be a useful contribution to psychiatric epidemiology. ACKNOWLEDGMENT This work was carried out while the author was in Kanagawa Mental Health Center (superintendent, Dr. Ukio Ishihara). and was published in part in the Japanese Journal of Public Health, 19:6455656. 1972. The author would like to thank Dr. Ukio Ishihara for his kind help and Dr. Jack R. Ewalt, Senior Associate Dean for Clinical Affairs, Harvard Medical School for his kind support in collecting the relevant data in U.S. This paper was revised while the author was at the Department of Community Medicine, University of Manchester, England on a World Health Organisation Fellowship. I would like to express my extreme appreciation to Dr. Hugh L. Freeman, Consultant Psychiatrist, Department of Community Medicine, Hope Hospital, Salford and Dr. T. Fryers, Lecturer, Manchester University for editing the paper and their helpful comments on its preparation.
REFERENCES I. Babigian
HM,
Odoroff
CL: The mortality
experience of population with psychiatric illness. Am J Psychiatry 126:470-480, 1969 2. Larson J, Sjorgen T: A methodological, psychiatric and statistical study of large Swedish rural population. Acta Psychiat Neural (Suppl) 89:1--250, 1954 3. Cidegard 0: The excess mortality of the insane. Acta Psychiatr 27:353-367, 1952 4. Malzberg B: Mortality among patients with mental disease in New York civil states hospital. J Insur Med 5:513,1949 5. Pollock HM: What happens to patients with mental diseases during the first year of hospital life? State Hosp Q vol IO, 1925 6. Alstrom CH: Mortality in mental hospitals. Acta Psychiat Neurol (Suppl) 17:24. 1925 7. odegard 0: Mortality in Norwegian mental hospitals from 1916 to 1933. Acta Psychiatr ll:150-161, 1936 8. Malzberg B: Rate of discharge and rates of mortality among first admissions to the New York civil state hospitals. Third paper. Ment Hyg 3716 19-654, 1953 9. ijdegard 0: Mortality in Norwegian mental hospitals 1926-1941. ActaGenet 2:141-173, 1951 10. ijdegard 0: Mortality in Norwegian psychiatric hospitals 1950-1962. Acta Genet 17:137-153, 1967
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13. lnnes G, Millar WM: Mortality among psychiatric patients. Scott Med J 15:143-148, 1970 14. Statistical Report of State Mental Hospitals and Institutions for the Retarded, Fiscal 69-70. Kentucky Department of Mental Health, Frankfort, Ky, 1970 IS. Annual Statistical Report of State Mental Hospitals. Maryland Department of Health and Mental Hygiene, Baltimore, 1968 16. Indiana
Mental
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of
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Fiscal
Health,
In-
Epidemiology. EpidemiologyLittle, Brown,
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20. Tachikawa K: New Health Statistics. Tokyo, Daiichi-Schuppan, 1970, p 504