The current global economic crisis is expected to produce adverse mental health effects that may increase suicide and alcohol-related death rates in affected countries. In nations with greater social ...safety nets, the health impacts of the economic downturn may be less pronounced. Research indicates that the mental health impact of the economic crisis can be offset by various policy measures. This paper aims to outline how countries can safeguard and support mental health in times of economic downturn. It indicates that good mental health cannot be achieved by the health sector alone. The determinants of mental health often lie outside of the remits of the health system, and all sectors of society have to be involved in the promotion of mental health. Accessible and responsive primary care services support people at risk and can prevent mental health consequences. Any austerity measures imposed on mental health services need to be geared to support the modernization of mental health care provision. Social welfare supports and active labour market programmes aiming at helping people retain or re-gain jobs can counteract the mental health effects of the economic crisis. Family support programmes can also make a difference. Alcohol pricing and restrictions of alcohol availability reduce alcohol harms and save lives. Support to tackle unmanageable debt will also help to reduce the mental health impact of the crisis. While the current economic crisis may have a major impact on mental health and increase mortality due to suicides and alcohol-related disorders, it is also a window of opportunity to reform mental health care and promote a mentally healthy lifestyle.
People with mental disorders evince excess mortality due to natural and unnatural deaths. The relative life expectancy of people with mental disorders is a proxy measure of effectiveness of social ...policy and health service provision.
To evaluate trends in health outcomes of people with serious mental disorders.
We examined nationwide 5-year consecutive cohorts of people admitted to hospital for mental disorders in Denmark, Finland and Sweden in 1987-2006. In each country the risk population was identified from hospital discharge registers and mortality data were retrieved from cause-of-death registers. The main outcome measure was life expectancy at age 15 years.
People admitted to hospital for a mental disorder had a two- to threefold higher mortality than the general population in all three countries studied. This gap in life expectancy was more pronounced for men than for women. The gap decreased between 1987 and 2006 in these countries, especially for women. The notable exception was Swedish men with mental disorders. In spite of the positive general trend, men with mental disorders still live 20 years less, and women 15 years less, than the general population.
During the era of deinstitutionalisation the life expectancy gap for people with mental disorders has somewhat diminished in the three Nordic countries. Our results support further development of the Nordic welfare state model, i.e. tax-funded community-based public services and social protection. Health promotion actions, improved access to healthcare and prevention of suicides and violence are needed to further reduce the life expectancy gap.
Excess mortality among patients with severe mental disorders has not previously been investigated in detail in large complete national populations.
To investigate the excess mortality in different ...diagnostic categories due to suicide and other external causes of death, and due to specific causes in connection with diseases and medical conditions.
In longitudinal national psychiatric case registers from Denmark, Finland, and Sweden, a cohort of 270,770 recent-onset patients, who at least once during the period 2000 to 2006 were admitted due to a psychiatric disorder, were followed until death or the end of 2006. They were followed for 912,279 person years, and 28,088 deaths were analyzed. Life expectancy and standardized cause-specific mortality rates were estimated in each diagnostic group in all three countries.
The life expectancy was generally approximately 15 years shorter for women and 20 years shorter for men, compared to the general population. Mortality due to diseases and medical conditions was increased two- to three-fold, while excess mortality from external causes ranged from three- to 77-fold. Mortality due to diseases and medical conditions was generally lowest in patients with affective disorders and highest in patients with substance abuse and personality disorders, while mortality due to suicide was highest in patients with affective disorders and personality disorders, and mortality due to other external causes was highest in patients with substance abuse.
These alarming figures call for action in order to prevent the high mortality.
Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare ...systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler's method.
The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter.
Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years.
Purpose
To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health.
Methods
Systematic reviews, controlled trials and realist evaluations of ...the last 10 years are reviewed, without age or geographical restrictions.
Results
Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted.
Conclusions
The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate a cross-sectoral approach, and to form partnerships between different government departments, civic society organisations and other stakeholders. This approach is referred to as Mental Health in All Policies and it can be applied to all public policy levels from local policies to supranational.
Summary Background The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to ...establish the long-term contribution of antipsychotic drugs to mortality in such patients. Methods Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5·2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use. Findings Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22·5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio HR 1·41, 95% CI 1·09–1·82), and the lowest risk for clozapine (0·74, 0·60–0·91; p=0·0045 for the difference between clozapine vs perphenazine, and p<0·0001 for all other antipsychotic drugs). Long-term cumulative exposure (7–11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0·81, 0·77–0·84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0·991; 0·985–0·997). Interpretation Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed. Funding Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).
Abstract Background Clozapine is the drug of choice for patients with unsatisfactory response to routine antipsychotic treatment. Polypharmacy is widely used among patients having clozapine-resistant ...schizophrenia, although no solid evidence exists for any effective augmentation therapy for this patient population. We aimed to study the efficacy of lamotrigine in the treatment of clozapine-resistant schizophrenia. Method We conducted electronic searches of the Cochrane PsiTri database, the Website of metaRegister of Controlled Trials, including NIH ClinicalTrials.gov, and a clinical trial register by the manufacturer of lamotrigine (GlaxoSmithKline). All randomized placebo-controlled studies on patients receiving clozapine were included in the analysis. The primary outcome measure was a total score for symptoms of psychosis, and the secondary outcome measures were scores for positive and negative symptoms of psychosis. For continuous and binary data, standardized mean differences (SMD), and odds ratios (OR) and the number needed to treat (NNT) were calculated, respectively. Results Five trials with 10 to 24 weeks duration and total of 161 randomized clozapine patients were included in the meta-analysis. Lamotrigine was superior to placebo augmentation in both the primary outcome measure (SMD 0.57, 95%CI 0.25–0.89, p < 0.001; OR 0.19, 95%CI 0.09–0.43, p < 0.001; NNT 4, 95%CI 3–6) and secondary outcome measures (SMD 0.34, 95%CI 0.02–0.65 for positive symptoms, SMD 0.43, 95%CI 0.11–0.75 for negative symptoms). Conclusions This meta-analysis suggests that lamotrigine augmentation may be an effective treatment for patients with clozapine-resistant schizophrenia. A substantial proportion of these most severely ill patients appeared to obtain clinically meaningful benefit from this combination treatment.
Summary Background In many countries, psychiatric services have been reformed by reducing the size of hospitals and developing community mental-health services. We investigated this reform by ...assessing the relation between suicide risk and different ways of organising mental-health services. Methods We did a nationwide comprehensive survey of Finnish adult mental-health service units between Sept 1, 2004, and March 31, 2005. From health-care or social-care officers of 428 municipalities, we asked for information, classified according to the European service mapping schedule, about adult mental-health services. For each municipality, we measured age-adjusted and sex-adjusted suicide risk, pooled between 2000 and 2004, and then adjusted for register-derived socioeconomic factors. Findings A wide variety of outpatient services (relative risk RR 0·92, 95% CI 0·87–0·96), prominence of outpatient versus inpatient services (0·93, 0·89–0·97), and 24-h emergency services (0·84, 0·75–0·92) were associated with decreased death rates from suicide. However, after adjustment for socioeconomic factors, only the prominence of outpatient services was associated with low suicide rate (0·94, 0·90–0·98). We replicated this finding even after adjustment for organisational changes and inpatient treatment. Interpretation Well-developed community mental-health services are associated with lower suicide rates than are services oriented towards inpatient treatment provision. These data are consistent with the idea that population mental health can be improved by use of multifaceted, community-based, specialised mental-health services. Funding Academy of Finland.
The clearest advantage of new generation, atypical antipsychotics is a reduced risk of extrapyramidal side-effects (EPS), compared with conventional compounds. These findings might have been biased ...by the use of the high-potency antipsychotic haloperidol as a comparator in most of the trials. We aimed to establish whether the new drugs induce fewer EPS than low-potency conventional antipsychotics.
We did a meta-analysis of all randomised controlled trials in which new generation antipsychotics had been compared with low-potency (equivalent or less potent than chlorpromazine) conventional drugs. We included studies that met quality criteria A or B in the Cochrane Collaboration Handbook, and assessed quality with the Jadad scale. The primary outcome of interest was the number of patients who had at least one EPS. We used risk differences and 95% CIs as measures of effect size.
We identified 31 studies with a total of 2320 participants. Of the new generation drugs, only clozapine was associated with significantly fewer EPS (RD=-0.15, 95% CI -0.26 to -0.4, p=0.008) and higher efficacy than low-potency conventional drugs. Reduced frequency of EPS seen with olanzapine was of borderline significance (-0.15, -0.31 to -0.01, p=0.07). Only one inconclusive trial of amisulpride, quetiapine, and risperidone and no investigations of ziprasidone and sertindole were identified, but some evidence indicates that zotepine and remoxipride do not lead to fewer EPS than low-potency antipsychotics. Mean doses less than 600 mg/day of chlorpromazine or its equivalent had no higher risk of EPS than new generation drugs. As a group, new generation drugs were moderately more efficacious than low-potency antipsychotics, largely irrespective of the comparator doses used.
Optimum doses of low-potency conventional antipsychotics might not induce more EPS than new generation drugs. Potential advantages in efficacy of the new generation drugs should be a factor in clinical treatment decisions to use these rather than conventional drugs.
Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service ...provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help‐seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high‐risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population‐based mental health interventions asks for actions for putting evidence into practice.
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