Strikingly High Death Rate in Early Psychosis a Wake-up Call

April 19, 2017

The death rate for young people who suffer a first episode of psychosis (FEP) is 24 times greater than that of their peers in the general population in the year following the episode, a new study suggests.

This finding is "striking," lead investigator Michael Schoenbaum, PhD, of the National Institute of Mental Health in Bethesda, Maryland, told Medscape Medical News.

"We know that people with serious mental illness don't live as long as other people. We expected there to be elevated mortality compared to a general population, but we did not expect necessarily to see excess mortality on the scale that we found. We were really blown away," said Dr Schoenbaum.

 
We were really blown away. Dr Michael Schoenbaum
 

The study also found "surprisingly" low rates of medical oversight and only modest involvement with psychosocial treatment providers after FEP.

This study is a "wake-up call telling us that young people experiencing psychosis need intensive, integrated clinical and psychosocial supports," said Dr Schoenbaum in a news release.

The study was published online April 7 in the Schizophrenia Bulletin.

Monumental Mortality Risk

The researchers examined 12-month mortality and patterns of treatment among 5488 commercially insured individuals aged 16 to 30 years who experienced an incident episode of psychosis in 2008-2009.

Under the "most conservative assumptions," the mortality rate 12 months after FEP was about 24 times greater than the rate in the general age-matched US population (2.0%, or 1968 per 100,000, vs <0.1%, or 89 per 100,000), they report.

The 12-month mortality rate after FEP was "up to 7372 per 100,000, some 89 times the corresponding general population rate," they say.

"In the general population, only individuals over 70 years of age have all-cause 12-month mortality approaching the rates we observed among young psychosis patients," they note in their article.

Mortality after FEP varied by age, with higher rates seen in those with incident psychosis after age 25 relative to those who experienced FEP from the ages of 16 to 20.

Among 1357 FEP patients included in the healthcare service utilization cohort, 61% did not receive any antipsychotic medications, and 41% received no individual psychotherapy in the year after FEP. Nearly two thirds (62%) had at least one hospital stay and/or emergency department visit in the year after FEP.

Patients who died within 12 months of FEP had more hospitalizations than survivors and more ED visits, but their use of medication and psychotherapy was lower, the study found.

Dr Schoenbaum noted that healthcare billing data used in this study cannot assess the quality of care at the individual level. "But for the group as a whole, if you compare the patterns of care that we saw to the clinical practice recommendations on how to treat people with psychosis, or the recommendations from recent trials about what effective care looks like, what these people received fell far short of that, on average. We aren't doing well enough. We have to do better," he said.

The findings highlight the importance of tracking mortality in individuals with mental illness, Dr Schoenbaum said.

"In cancer, people have been tracking survival in tumor registries for decades. In cardiac surgery, we track survival. There is no behavioral health setting where we do that," he noted.

 
What we are doing now is not working. Dr Oliver Freudenreich
 

Many Go Untreated

Reached for comment, Oliver Freudenreich, MD, director of the First Episode and Early Psychosis Program at the Massachusetts General Hospital in Boston, said the study highlights a need for a paradigm shift in the management of FEP.

"What this study shows is that what we are doing now is not working for this population. The idea that psychosis is kind of a psychological affliction where you need a little bit of therapy is really wrong in my mind. This is a serious disorder that comes with mortality, and I believe in my clinical experience this is a clear and direct result of being untreated," Dr Freudenreich told Medscape Medical News.

"We do have treatments for psychosis that work," he added. "As a conservative estimate, two thirds of young adults who take antipsychotics after a first episode of psychosis will likely be symptom free after this episode." With continued antipsychotic treatment, the odds are "good" that the patient will not have another episode, Dr Freudenreich said.

"Long-acting injectables, for example, in this group of patients have clearly been shown to work much better than oral pills, and yet we haven't developed a treatment system with proactive coordinated specialty care teams that really makes this kind of treatment the standard of care," he noted.

The study was funded by the National Institute of Mental Health. The authors have disclosed no relevant financial relationships. Dr Freudenreich is a consultant for Janssen Pharmaceuticals, has received honoraria from Neurocrine Biosciences and Global Medical Education, a research grant from Avanir Pharmaceuticals, and royalties from Wolters-Kluwer.

Schizophr Bull. Published online April 7, 2017. Abstract

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