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Original Investigation
March 2018

Mortality Rates After the First Diagnosis of Psychotic Disorder in Adolescents and Young Adults

Author Affiliations
  • 1Kaiser Permanente Washington Health Research Institute, Seattle, Washington
  • 2Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
  • 3Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
  • 4Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
  • 5Division of Research (Emeritus), Kaiser Permanente Northern California, Oakland
JAMA Psychiatry. 2018;75(3):254-260. doi:10.1001/jamapsychiatry.2017.4437
Key Points

Question  How does the risk of death increase after the first diagnosis of a psychotic disorder?

Findings  In this population-based cohort study of 11 713 individuals aged 16 to 30 years with first diagnosis of a psychotic disorder, overall mortality was 54.6 per 10 000 compared with 6.7 per 10 000 among health system outpatients. Injuries and poisonings accounted for half of all mortality among patients with psychotic disorders.

Meaning  The 3-year period after first diagnosis of a psychotic disorder may be a high-risk time for suicide and other deaths due to injury or poisoning.

Abstract

Importance  Individuals with psychotic disorders have increased mortality, and recent research suggests a marked increase shortly after diagnosis.

Objective  To use population-based data to examine overall and cause-specific mortality after first diagnosis of a psychotic disorder.

Design, Setting, and Participants  This cohort study used records from 5 integrated health systems that serve more than 8 million members in 5 states. Members aged 16 through 30 years who received a first lifetime diagnosis of a psychotic disorder from September 30, 2009, through September 30, 2015, and 2 comparison groups matched for age, sex, health system, and year of diagnosis were selected from all members making an outpatient visit (general outpatient group) and from all receiving a first diagnosis of unipolar depression (unipolar depression group).

Exposures  First recorded diagnosis of schizophrenia, schizoaffective disorder, mood disorder with psychotic symptoms, or other psychotic disorder in any outpatient, emergency department, or inpatient setting.

Main Outcomes and Measures  Death within 3 years after the index diagnosis or visit date, ascertained from health system electronic health records, insurance claims, and state mortality records.

Results  A total of 11 713 members with first diagnosis of a psychotic disorder (6976 [59.6%] men and 4737 [40.4%] women; 2368 [20.2%] aged 16-17 and 9345 [79.8%] aged 18-30 years) were matched to 35 576 outpatient service users and 23 415 members with a first diagnosis of unipolar depression. During the year after the first diagnosis, all-cause mortality was 54.6 (95% CI, 41.3-68.0) per 10 000 in the psychotic disorder group compared with 20.5 (95% CI, 14.7-26.3) per 10 000 in the unipolar depression group and 6.7 (95% CI, 4.0-9.4) per 10 000 in the general outpatient group. After adjustment for race, ethnicity, and preexisting chronic medical conditions, the relative hazard of death in the psychotic disorder group compared with the general outpatient group was 34.93 (95% CI, 8.19-149.10) for self-inflicted injury or poisoning and 4.67 (95% CI, 2.01-10.86) for other type of injury or poisoning. Risk of death due to heart disease or diabetes did not differ significantly between the psychotic disorder and the general outpatient groups (hazard ratio, 0.78; 95% CI, 0.15-3.96). Between the first and third years after diagnosis, all-cause mortality in the psychotic disorder group decreased from 54.6 to 27.1 per 10 000 persons and injury and poisoning mortality decreased from 30.6 to 15.1 per 10 000 persons. Both rates, however, remained 3 times as high as in the general outpatient group (9.0 per 10 000 for all causes; 4.8 per 10 000 for injury or poisoning).

Conclusions and Relevance  Increases in early mortality underscore the importance of systematic intervention for young persons experiencing the first onset of psychosis. Clinicians should attend to the elevated suicide risk after the first diagnosis a psychotic disorder.

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