Vascular Death Tops Suicide After Psychiatric Inpatient Discharge

Megan Brooks

July 30, 2019

Suicide may be the largest single cause of death in the short-term following psychiatric discharge, but vascular disease is the "major" cause of death in this patient population over the medium- and long-term, new research shows.

"The study places the suicide and natural mortality in context" and shows that the physical health of psychiatric patients needs to be taken "seriously," professor Matthew Large, MBBS, University of New South Wales School of Psychiatry, Sydney, Australia, told Medscape Medical News.

"While psychiatrists worry a lot about suicide outcomes, the need to address vascular risk factors such as smoking and blood pressure, and the metabolic side effects of medication that include raised cholesterol, obesity, and diabetes is as, or even more important," said Large.

The study was published online July 20 in Acta Psychiatrica Scandinavica.

Premature Death

To quantify causes of death after inpatient psychiatric care, the researchers combined 71 studies published over 50 years with data on 982,558 patients over almost 15 million person-years.

The pooled natural death rate of 1128 per 100,000 person-years exceeded the pooled unnatural deaths of 479 per 100,000 person-years among studies with varying periods of follow-up.

There was no significant difference in cumulative natural and unnatural death rates at 2 years, but natural deaths significantly exceeded unnatural deaths after that.

Table 1. Natural vs Unnatural Deaths Per 100,000 Person-Years

Years After Discharge

Natural Death

Unnatural Death

P value








< .001




< .001




< .001


Most natural deaths were vascular and most unnatural deaths were suicide. There were nonsignificant differences between cumulative vascular death and suicide rates at 0 to 2 years or 2 to 5 years, but vascular deaths significantly exceeded suicide deaths by 5 to 10 years and over periods of follow-up of more than 10 years.

Table 2. Vascular and Suicide Deaths Per 100,000 Person-Years

Years After Discharge

Vascular Death


P value


















Among studies reporting separate mortality among men and women, men had higher unnatural, suicide, accidental, and gastrointestinal mortality but lower natural mortality than did women.

Overall, the researchers note the findings are in line with other research that found physical health conditions contribute to the majority of premature deaths in patients with severe mental illness.

Opportunity to Intervene

"Our results suggest that there may be opportunities to decrease psychiatric mortality outside of suicide prevention, particularly in the reduction in cardio-metabolic risk factors and treatment of vascular disease," Large and colleagues write.

While the focus of an acute psychiatric admission will "necessarily be on mental wellbeing and safety," a psychiatric admission presents "an opportunity for general medical assessment and cardiovascular risk assessment leading to potentially lifesaving health preventative measures," they add.

"This is an important article," David Roane, MD, chairman, Department of Psychiatry, Lenox Hill Hospital in New York City, told Medscape Medical News.

"It is well known that rates of suicide after psychiatric hospitalization are far higher than in the general population. It is also well known that individuals with severe mental illness (who often require hospitalization) have higher rates of co-morbid medical illness and mortality than is seen in the general population," Roane said.

"This article points to the importance of managing medical conditions in psychiatric patients as intensively as the underlying psychiatric condition," he noted. "As vascular causes of death were the highest, long-term, attention to metabolic syndrome (high blood pressure, elevated blood sugar, cholesterol and triglycerides, obesity) is critical, especially since some psychiatric medications, such as antipsychotics, can contribute to metabolic syndrome," said Roane.

He also noted that studies of inpatient psychiatric facilities specializing in the care of the geriatric population were excluded from the study "reducing the likelihood that the high rate of natural deaths was a function of advanced age."

The study received no funding. Large and Roane have declared no relevant financial relationships.

Acta Psychiatr Scand. Published online July 20, 2019. Abstract

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