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Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999-2006

BMJ 2011; 343 doi: (Published 13 September 2011) Cite this as: BMJ 2011;343:d5422
  1. Uy Hoang, academic clinical fellow1,
  2. Robert Stewart, clinical reader2,
  3. Michael J Goldacre, professor of public health1
  1. 1Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford OX3 7LF, UK
  2. 2Institute of Psychiatry, King’s College London, London SE5 8AF
  1. Correspondence to: U Hoang uy.hoang{at}
  • Accepted 8 August 2011


Objective To investigate whether the mortality gap has reduced in recent years between people with schizophrenia or bipolar disorder and the general population.

Design Record linkage study.

Setting English hospital episode statistics and death registration data for patients discharged 1999-2006.

Participants People discharged from inpatient care with a diagnosis of schizophrenia or bipolar disorder, followed for a year after discharge.

Main outcome measures Age standardised mortality ratios at each time, comparing the mortality in people with schizophrenia or bipolar disorder with mortality in the general population. Poisson test of trend was used to investigate trend in ratios over time.

Results By 2006 standardised mortality ratios in the psychiatric cohorts were about double the population average. The mortality gap widened over time. For people discharged with schizophrenia, the ratio was 1.6 (95% confidence interval 1.5 to 1.8) in 1999 and 2.2 (2.0 to 2.4) in 2006 (P<0.001 for trend). For bipolar disorder, the ratios were 1.3 (1.1 to 1.6) in 1999 and 1.9 (1.6 to 2.2) in 2006 (P=0.06 for trend). Ratios were higher for unnatural than for natural causes. About three quarters of all deaths, however, were certified as natural, and increases in ratios for natural causes, especially circulatory disease and respiratory diseases, were the main components of the increase in all cause mortality.

Conclusions The total burden of premature deaths from natural causes in people with schizophrenia or bipolar disorder is substantial. There is a need for better understanding of the reasons for the persistent and increasing gap in mortality between discharged psychiatric patients and the general population, and for continued action to target risk factors for both natural and unnatural causes of death in people with serious mental illness.


  • Contributors: UH and MG were responsible for the conception and design of this study. UH analysed the data. All authors were involved in the interpretation of data, drafting the article, and approval of the final manuscript. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. UH is guarantor.

  • Funding: This work was funded in part by the English National Institute for Health Research. RS is funded by the NIHR Specialist Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s College London. UH is an academic clinical fellow at the Oxford University Clinical Academic Graduate School and the Oxford School of Public Health. The work of the authors is independent from the funders of this research. The funders were not involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The current work programme of analysis using the linked datasets held at the unit of health-care epidemiology was approved by an ethics committee of the NHS central office for research (reference No 04/Q2006/176).

  • Data sharing: Hospital Episodes Statistics and mortality data can be obtained through the NHS Information Centre and the Office for National Statistics, respectively. More detailed aggregated statistical tables than those shown in this paper are available from the corresponding author.

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