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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 3  |  Issue : 3  |  Page : 203-206

Age at Death and Causes of Death of Patients Dying in Psychiatric Hospitals: Survey at 15 Hospitals in Tochigi Prefecture, Japan


Department of Psychiatry, Jichi Medical University, Shimotsuke, Japan

Date of Submission22-Nov-2021
Date of Decision07-Dec-2021
Date of Acceptance10-Dec-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Manabu Yasuda
3311-1 Yakushiji, Shimotsuke-shi, Tochigi 329-0498
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_64_21

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  Abstract 


Background: Japan entered an aging society in the late 1990s. The aging of inpatients in psychiatric hospitals has increased the need for medical care, but the actual situation has not been fully investigated. Objectives: We investigated the actual situation of in-hospital deaths through death certificates. Methods: The survey was conducted at 15 of 26 psychiatric hospitals in Tochigi Prefecture, Japan that consented to the survey. We examined the death certificates of patients who died between 1996 and 2015 at these 15 hospitals. The number of the certificates was 2441 (1443 males and 998 females). The number of deaths and the average age of death per year were calculated. Then, we surveyed the data regarding the diagnosis of death described in the death certificates based on the International Classification of Diseases-10. Results: The average age of death was in the 60s from 1996 to 2000 in the first 5 years, but since 2001, it has exceeded 70 years. Respiratory diseases accounted for 40% of the total, cardiovascular diseases for 26%, and malignant neoplasms for 11%. On the other hand, extrinsic death such as suffocation was 4%, and suicide was 1%. Conclusions: The reason of the elevation of death age might be related to the implementation of novel antipsychotics in Japan since 1996 and the establishment of the long-term care insurance system for the elderly in 2000. It is considered that the reasons why respiratory diseases, cardiovascular diseases, and malignant neoplasms occupy the top ranks of death are that these diseases have a high risk of death in the elderly.

Keywords: Care insurance system, death certificates, novel antipsychotics, psychiatric hospitals


How to cite this article:
Yasuda M, Kobayashi T, Sato K, Saito N, Suda S. Age at Death and Causes of Death of Patients Dying in Psychiatric Hospitals: Survey at 15 Hospitals in Tochigi Prefecture, Japan. World Soc Psychiatry 2021;3:203-6

How to cite this URL:
Yasuda M, Kobayashi T, Sato K, Saito N, Suda S. Age at Death and Causes of Death of Patients Dying in Psychiatric Hospitals: Survey at 15 Hospitals in Tochigi Prefecture, Japan. World Soc Psychiatry [serial online] 2021 [cited 2022 Sep 27];3:203-6. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/3/203/333428




  Background Top


Japan entered an aging society in the late 1990s. In Japan, the majority of inpatient psychiatric care is provided in psychiatric hospitals. Compared to other countries, Japan has an outstanding number of long-term hospitalized patients due to mental illness.

About the research conducted in 2006, 320,000 patients have hospitalized in psychiatric hospitals in Japan. 68.8% of them for over one year, and 25% over 10 years.[1],[2]

The aging inpatients in psychiatric hospitals are more likely to age and die there, the need for medical care for them is increasing, but the actual situation has not been fully investigated.

However, we still do not know about the illnesses which lead to death in patients admitted in psychiatric hospitals, and since there are no long-term studies on the causes of their death in Japan, we investigated the status of in-hospital deaths from death certificates.


  Methods Top


We conducted the research at 15 psychiatric hospitals in Tochigi Prefecture, Japan, that agreed to be surveyed. The death certificates of patients who died between 1996 and 2015 at these 15 hospitals were examined. A total number of death certificates were 2441 (1443 for males and 998 for females).

The number of deaths per year and the average age of death were calculated, as well as the average age of death for the entire data set.

Next, we diagnosed the diseases based on the death certificates and according to the World Health Organization International Classification of Diseases-10 Version: 2019 (ICD-10)[3] criteria, and when the cases that were difficult to diagnose, we confirmed the medical records of the psychiatric hospitals surveyed.

We extracted cases with mention of psychiatry disorders in the death certificates of the study participants, classified the psychiatric disorders based on ICD-10, and determined gender differences, and evaluated 1376 cases (826 males and 550 females) that could be confirmed.

Statistical analysis was performed using Excel 365 and EZR.[4]

Informed consent was obtained by posting an opt-out notice on bulletin boards in the hospitals; there was no request for nonparticipation. This study was carried out with the approval of the Clinical Research Ethics Committee of our university.


  Results Top


The average age of death was in the 60s from 1996 to 2000 in the first 5 years, but since 2001, it has exceeded 70 old years and peaked in 2003. Since 2003 it has remained at the 70s [Table 1] and the whole data of average death age was 74.0 ± 13.0.
Table 1: Number of male and female deaths and the average age of death in the 15 psychiatric hospitals-1996-2015

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Data on the diagnosis of death are as follows [Table 2]: Respiratory diseases (J00-J99) accounted for 40% (980/2441), cardiovascular diseases (I00-I99) for 26% (629/2441), and malignant neoplasms (C00-D48) for 11%. On the other hand, deaths from external caused such as asphyxia (V01-Y98 not including X60-X84) were 4% (132/2441), and suicide (X60-X84) was 1% (33/2441).
Table 2: The reasons of the death for 1996-2015

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Of the death certificates surveyed, 1376 cases (826 males and 550 females) mentioned to psychiatric disorders, and the data on psychiatric diagnosis were as follows [Table 3]: The most common disorders were schizophrenia, schizotypal and delusional disorders (F2), 47% (647/1376), followed by organic, including symptomatic, mental disorders and Alzheimer's disease (F0 and G30), 41% (562/1376). Mood disorders (F3), accounted for 4% (60/1376), mental retardation, pervasive development disorder and behavioral and emotional disorders (F7-9) 4% (57/1376), mental and behavioral disorders due to psychoactive substance use (F1) 3% (44/1376).
Table 3: The categories of psychiatry diagnosis in the death certificates

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Neurotic stress-related and somatoform disorders, behavioral syndromes associated with physiological disturbances and physical factors, and disorders of adult personality and behavior (F4-6) accounted for only 1% (6/1376).


  Discussion Top


This study is an attempt to clarify the reality the psychiatric care in Japan through death certificates of psychiatric hospitals in a rural area of Japan.

First, the average age of death at the psychiatric hospitals (74.0 ± 13.0) was lower than the average age of death for the general Japanese population (84.0 years)[5] in a 20-year study, and the data of each 20 years were also lower than those for the general population.

The cause is not clear but given that several papers[6],[7],[8] have reported that the average age at death for patients with schizophrenia is more than 10 years lower than the average age at death for the general population, so the high prevalence of schizophrenia in psychiatric hospitals may be responsible for lowering the average age at death for hospitalized patients.

Secondly, in our study, we found that schizophrenia and dementia were common diseases but mood disorders and neurosis, personality disorders were not common in psychiatric hospital.

In our other research in the psychiatric hospitals,[9] schizophrenia accounted for 63.6%, but mood disorders were only 3.6%.

In Kono's study,[10] the mean residual rate (MRR) of 1784 inpatients with mental illness hospitalized in Japan at 12 months found that dementia was highest MRR (45.6%), followed by schizophrenia (34.9%), whereas depression, bipolar disorder, and alcohol dependence were lower MRR (20%–21%)

His study[10] also found that F4 was as low as 5.2% (92/1784), F5 was 1.8% (33/1784), and F6 was 2.5% (44/1784). F4-F6 was 9.5% (169/1784) as a whole and the MRR at 12 months was as low as that of mood disorders and alcohol dependence.

These studies[9],[10] showed that most patients whom death certificates recorded at psychiatric hospitals were in long-term hospitalizations over years, such as patients with schizophrenia or dementia, and some research[1],[2],[11] pointed out that schizophrenia and dementia were difficult to care for at home or at a care health facility.

So that, patients with mood disorders or anxiety, personality disorders are thought to rarely be hospitalized over a year, and so they have few death outcomes at psychiatric hospitals.

Third, when the causes of death were examined in this survey, respiratory diseases were the most common at 40%, followed by cardiovascular diseases at 26% and malignant neoplasms at 11%.

In Capasso's study,[12] the causes of death in schizophrenia patients were cardiovascular disease (29%), lung disease (26%), and malignant neoplasms excluding lung cancer (10%), and these three diseases accounted for more than half of the causes of death. The mean survival rate after diagnosis was 34.8 years for men and 38.7 years for women.

Degerskär and Englund research[13] showed that the two most frequent causes of death in the dementia population were pneumonia (34.3%) and acute myocardial infarction (30.4%).

In his study,[13] the neoplasm was only 1.9%, but the proportion was higher than that of other diseases without respiratory and cardiovascular diseases.

So that, these three diseases are possible to the so-called diseases of the middle-aged and elderly, a result that is to be expected in psychiatric hospitals in Japan, where the population is now considered to be aging.

In fact the section on psychiatric disorders,the percentage of organic brain psychiatric disorders and dementia (F0, G30) was 41%. It was more likely to affect the elderly as high as schizophrenia, schizotypal and delusional disorder (F2).

These results may be due to the introduction of long-term care insurance system in 2000,[14] which led to the admission to psychiatric hospitals of elderly patients at high risk for respiratory and cardiovascular diseases, malignant neoplasms with psychiatric disorders, and although it is not certain, the adverse effects of anti-psychiatric drugs.

Kinoshita's research[11] pointed out that among many psychiatric hospitals, the introduction of long-term care insurance system was a good chance to survive and increase revenue, so they were willing to admit dementia patients to psychiatric hospitals or to connect their outpatient visits and related facilities.

On the other hand, there were a certain number of patients who died from factors other than illness, such as suicide, aspiration, and asphyxia.

As for suicide, it is difficult to speculate on the cause, as it is likely to be influenced by the mental state of the person who committed suicide, but as for aspiration and asphyxia, antipsychotic drugs may have an effect. Although many psychiatric hospitals in Japan are making efforts to prevent such suicide, aspiration, and asphyxia, the problem still has room for improvement.

Finally, the average age of death since the survey began in 1996 was <70 years old, but in the three years from 2001 to 2003, the average age of death increased by more than seven years. Possible reasons for the rapid change include the introduction of the long-term care insurance system as well as the favorable impact of novel antipsychotics that came into use in Japan between 1996 and 2001, such as risperidone (1996),[15] olanzapine (2001),[16] and quetiapine (2001).[16] Unlike conventional antipsychotics, these newer antipsychotics are less likely to cause extrapyramidal symptoms and cardiac dysfunction,[17] and their use in psychiatric hospitals over the years may have increased the average age of death.


  Conclusions Top


The death certificate showed that the average age of death of patients who died in psychiatric hospitals was shorter than the average age of death of the general population and that respiratory diseases, cardiovascular diseases, and malignant neoplasms, which considered to be common among middle-aged and elderly people, were the common causes of death.

The increase in the age of death is thought to be related to the introduction of novel antipsychotics in 1996 and the introduction of the long-term care insurance system in 2000.

Respiratory diseases, cardiovascular diseases, and malignant neoplasms are at the top of death rankings because these diseases have a high risk of death in the elderly.[13]

Limitation

The limitation of this study is that it was based on death certificates, so we could not mention the complications and the usage of psychotropic drugs of each patient at the time of death.

In addition, we could not statistically test the relationship between the cause of death and the psychiatric diagnosis and there were a significant number of death certificated that did not mention the psychiatric diagnosis.

Psychiatrists in Japan often do not record psychiatric diseases on death certificates. Because some patients' family and doctors feel sorry for recording psychiatric disorders on death certificates, that is “stigma.”

Acknowledgments

We would like to express our deepest gratitude to the staff at the 15 psychiatric hospitals in Tochigi Prefecture who cooperated in the study.

Financial support and sponsorship

This study was funded by a KAKENHI Grant-in-Aid for Scientific Research (No. 16K09182).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Koyama A, Tatemori H, Kohno T, Takeshma T. An index of discharge excluding death and transfer to other hospitals or beds for long-stay inpatients from psychiatric hospitals. Jpn J Public Health 2011;58:40-6.  Back to cited text no. 1
    
2.
Ministry of Health, Labor and Welfare. Overview of Medical facility (dynamic) Survey of Japan, June 30,2006. Available from: https.//www.mhlw.go.jp/toukei/saikin/hw/iryosd/06/dl/data.pdf (in Japanese).[Last retrieved on 2021 Dec 07].  Back to cited text no. 2
    
3.
WHO. International Statistical Classification of Diseases and Related Health Problems 10th Revision. 2019: WHO; Geneve.Available from: https://icd.who.int/browse10/2019/en. [Last accessed on 2021 Aug 17].  Back to cited text no. 3
    
4.
Kanda Y. Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transplant 2013;48:452-8.  Back to cited text no. 4
    
5.
The World Bank Data. Life Expectancy at Birth, Total (years). Available from: https://data.worldbank.org/indicator/SP.DYN.LE00.IN. [Last accessed on 2020 Jul 09].  Back to cited text no. 5
    
6.
Kondo S, Kumakura Y, Kanehara A, Nagato D, Ueda T, Matsuoka T, et al. Premature deaths among individuals with severe mental illness after discharge from long-term hospitalisation in Japan: A naturalistic observation during a 24-year period. BJPsych Open 2017;3:193-5.  Back to cited text no. 6
    
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Laursen TM, Wahlbeck K, Hällgren J, Westman J, Ösby U, Alinaghizadeh H, et al. Life expectancy and death by diseases of the circulatory system in patients with bipolar disorder or schizophrenia in the Nordic countries. PLoS One 2013;8:e67133.  Back to cited text no. 7
    
8.
Mortensen PB, Juel K. Mortality and causes of death in first admitted schizophrenic patients. Br J Psychiatry 1993;163:183-9.  Back to cited text no. 8
    
9.
Yasuda M, Kobayashi T, Sato K, Saito N, Suda S. A prospective research of in- hospital death at psychiatric hospitals – A two year survey of 20 Tochigi prefecture hospitals. Jpn J Psychiatry 2020;25:507-14.  Back to cited text no. 9
    
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Kono T, Shiraishi H, Tachimori H, Koyamas A, Naganuma Y, Takeshima T. Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals. Psychiatria et Neurologia Japonica 2012;114:764-81.  Back to cited text no. 10
    
11.
Kinoshita K. Issues facing families of patients with dementia and support systems for those families as revealed by a survey of members of families with a member in a psychiatric hospital. Bull Nayoro City Univ 2016;10:79-86.  Back to cited text no. 11
    
12.
Capasso RM, Lineberry TW, Bostwick JM, Decker PA, St. Sauver J. Mortality in schizophrenia and schizoaffective disorder: An Olmsted county, Minnesota cohort: 1950-2005. Schizophr Res 2008;98:287-94.  Back to cited text no. 12
    
13.
Degerskär AN, Englund EM. Cause of death in autopsy-confirmed dementia disorders. Eur J Neurol 2020;27:2415-21.  Back to cited text no. 13
    
14.
Ministry of Health, Labor and Welfare. Long-Term Care, Health and Welfare Services for the Elderly. Available from: https://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/ltcisj_e.pdf. [Last accessed on 2021 Sep 02].  Back to cited text no. 14
    
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Phamaceuticals and Medical Devices Agency. (in Japanese) Available from: https://www.pmda.go.jp/PmdaSearch/iyakuDetail/GeneralList/1179038. [Last accessed on 2021 Oct 09].  Back to cited text no. 15
    
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Phamaceuticals and Medical Devices Agency. (in Japanese) Available from: https://www.pmda.go.jp/review-services/drug-reviews/review-information/p-drugs/0024.html. [Last accessed on 2021 Oct 09].  Back to cited text no. 16
    
17.
Liperoti R, Gambassi G, Lapane KL, Chiang C, Pedone C, Mor V, et al. Conventional and atypical antipsychotics and the risk of hospitalization for ventricular arrhythmias or cardiac arrest. Arch Intern Med 2005;165:696-701.  Back to cited text no. 17
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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