Death by homicide, suicide, and other unnatural causes in

people with mental illness: a population-based study

Urara Hiroeh, Louis Appleby, Preben Bo Mortensen, Graham Dunn
School of Psychiatry and Behavioural Sciences, University of Manchester, University
Hospital of South Manchester, Manchester M20 8LR, UK (U Hiroeh MPhil, Prof L Appleby
MD) !epart"ent of Psychiatry, #nstitute for Basic Psychiatric Research, Psychiatric
Hospital in $rhus, Riss%ov, !en"ar% (U Hiroeh) &ational 'entre for Re(ister)*ased
Research, University of $rhus, $rhus ' (Prof P B Mortensen DMedS) and School of
+pide"iolo(y and Statistics, University of Manchester, Manchester (Prof G Dunn PhD)
'orrespondence to, Prof Louis Appleby (e!mail"Louis#Appleby$man#a#u%)
Summary
Introduction
Methods
Results
Discussion
References
Summary
Background People with mental illness are at great risk of suicide, but little is known about
their risk of death from other unnatural causes. No study has commented on their risk of
being ictims of homicide! public concern is pre"occupied with their role as perpetrators. #e
aimed to calculate standardised mortality ratios $SMRs% and directly standardised rate ratios
for death by homicide, suicide, and accident in people admitted to hospital because of mental
illness.
Method #e did a population"based study in which we linked the data for &' '() indiiduals
listed in the Danish Psychiatric *ase Register between +,&- and +,,-, and who died before
Dec -+, +,,-, with data in the Danish National Register of *auses of Death.
Findings +& ),' $'./% patients died from unnatural causes. 0ur results show raised SMRs
for homicide, suicide, and accident for most psychiatric diagnoses irrespectie of se1. 2he all"
diagnosis SMRs for women and men, respectiely, were3 4-' $,./ *I .+&"&&-% and 4(,
$5,-"&.-% for homicide, +-.4 $+-''"+-,+% and +'+' $++)5"+'5+% for suicide, and -+) $-(."
--'% and 544 $55)"5)5% for accident. #e recorded an increased risk of dying by homicide in
men with schi6ophrenia and in indiiduals with affectie psychosis. 2he highest risks of death
by homicide and accident were in alcoholism and drug use, whereas the highest risks of
suicide were in drug use.
Interpretation People with mental disorders, including seere mental illness, are at increased
risk of death by homicide. Strategies to reduce mortality in the mentally ill are correct to
emphasise the high risk of suicide, but they should also focus on other unnatural causes of
death.
Lanet '((+! 3!: '++("+'
Introduction
People with mental disorders hae high rates of suicide, although estimates of risk ary
according to duration of follow"up and in some diagnoses""ie, learning disability and
dementia""high risk has not been seen.
+
2here is less eidence on other kinds of unnatural
mortality, and specific causes of death such as accidents and homicides are fre7uently not
distinguished.
'
Reports on homicide in association with mental illness focus on the mentally ill
as perpetrators rather than ictims,
-,5
and discrimination against the mentally ill is thought to
arise in part from the perception that they are dangerous.
.
8oweer, people with mental
illness are also fre7uently ictims of iolent crime.
4
0ur aim was to ascertain the risk of death
by homicide, suicide, and accident in psychiatric patients.
Methods
#e did a study based on information collected about the Danish population oer '+ years and
entered in two databases3 the Danish Psychiatric *ase Register and the Danish National
Register of *auses of Death. 2he Danish Psychiatric *ase Register is a record of all people
aged +. years and older who hae been admitted to hospital in Denmark with a psychiatric
disorder since +,&-.
&
#e used the uni7ue identification number that eery Danish resident is
assigned to link the data in these two registers. #e thereby identified people on the case
register between +,&- and +,,- who had died on or before Dec -+, +,,-, from suicide
$includes open erdicts%, accident, or homicide. 0pen erdicts are often included in suicide
analyses! without their inclusion, suicide figures are underestimated.
)

#e included the following ariables in our analysis3 se1, age, year of death $for
standardisation%, cause of death, and psychiatric diagnosis at first admission. During the
study, we identified diagnoses and causes of death according to International *lassification of
Diseases, )th edition $I*D)%. 2his coding system changed in +,,-, and subse7uent
diagnoses by I*D+( were not strictly comparable. #e included year of death because of the
ariability by year of death rates between different age groups.
#e calculated standardised mortality ratios $SMRs% and ,./ *Is by a person"years at risk
method. 9ecause SMRs can ary according to the age structure of the reference population,
making internal comparisons""eg, between dementia and schi6ophrenia""difficult, rate ratios
standardised directly to a common age distribution are sometimes preferable. In our study, the
+,)- Danish population was used to calculate directly standardised rate ratios $DSRRs%, and
where these differ from SMRs they are also reported. 9oth SMRs and DSRRs are reported as
proportions. #e used S2:2: $ersion 4.(% to calculate SMRs.
"esults
;rom +,&- to +,,-, '.& &'( patients were added to the case register3 ++, .5- women and
+-) +&& men. During this period, ', &(' women and 5' .(4 men died, +& ),' $'./% from
unnatural causes $)(,) women and ,&,5 men%. 0f these unnatural deaths, +)+ $+/% were by
homicide, +' ,&& $&-/% by suicide, and 5&-5 $'4/% by accident. 2he table shows the SMRs
and crude rates by diagnosis and se1 for homicide, suicide, and accident. In most diagnostic
groups, there is a high rate of homicide. 2he highest relatie risks were associated with drug
use, alcoholism, personality disorders, schi6ophrenia $men%, and organic psychoses $women%.
0erall, the risk of being a ictim of homicide was increased si1"fold for people with a mental
illness compared with those without. DSRRs were similar to SMRs in most groups, but were
higher in women with alcoholism $DSRR -+&4% or who had dementia $5())%, and in men with
learning disabilities $'(,5% or who were drug users $5+&)%.
Diagnosis #erson- $ause o% death
years &omicide Suicide 'ccident
Number Rate
per
+(((
per
son"
years
SMR
$,./
*I%
Number Rate
per
+(((
per"
son"
years
SMR
$,./
*I%
Number Rate
per
+(((
per"
son"
years
SMR
$,./
*I%
Schi(ophrenia
#omen .5.,. ' (<(5 -5+
$)."
+-4-%
+)) -<55 +()(
$,-4"
+'54%
4' +<+5 ')&
$''5"
-4,%
Men &5.-, & (<(, &-5
$-.("
+.-,%
5(5 .<5' +(&-
$,&-"
++)-%
&( (<,5 '+-
$+4)"
'4,%
'%%ecti)e psychoses=
#omen -(,4-, +( (<(- -'&
$+&4"
4()%
+&(5 .<.( +4((
$+.'4"
+4&)%
-,( +<'4 '+(
$+,("
'-'%
Men +..--& . (<(- -(.
$+'&"
&-'%
+554 ,<-+ +455
$+.4'"
+&-+%
'+. +<-) ''-
$+,."
'.5%
*on-a%%ecti)e psychoses>
#omen +-(-+5 . (<(5 -.5 5.& -<.+ ++(, +&( +<-( '4,
$+5)"
).+%
$+(+'"
+'+.%
$'-+"
-+'%
Men )44,4 5 (<(. -.-
$+-'"
,5(%
.,& 4<), +-)+
$+'&."
+5,4%
++) +<-4 '&-
$'')"
-'&%
*eurosis
#omen '54''4 . (<(' +,&
$)'"
5&'%
)55 -<5- +(()
$,5'"
+(&)%
+&. (<&+ '--
$'(+"
'&(%
Men )5&)' ' (<(' '(5
$.+"
)+4%
-45 5<', )()
$&',"
),.%
)) +<(5 '-'
$+))"
').%
#ersonality disorder?
#omen '(.'++ +, (<(, &)'
$5,,"
+''4%
,5- 5<4( +.4)
$+5&+"
+4&'%
+,4 (<,4 54.
$5(5"
.-.%
Men +)+5(5 +5 (<() .-4
$-++"
,''%
+(&- .<,+ ++,)
$++')"
+'&'%
')& +<.) 5(4
$-4+"
5..%
'lcoholism
#omen 4.)-. +- (<'( +&(5
$,,("
',-.%
--& .<+' +.)4
$+5'."
+&45%
+&. '<44 +-5+
$++.4"
+...%
Men '+((-, '+ (<+( )'+
$.-."
+'.,%
+'+- .<&) +(45
$+((."
++'.%
&'+ -.5- )&&
$)+."
,55%
Drug use
#omen -,((, & (<+) +.4'
$&5."
-'&&%
'&( 4<,' '-,&
$'+')"
'&(+%
+-' -<-) +55.
$+'+,"
+&+5%
Men -,,+( +5 (<-. '5.,
$+5.4"
5+.'%
5.( ++<') '54(
$''5-"
'4,)%
--( )<'& '(-5
$+)'4"
''4.%
+rganic psychoses@
#omen 4-(54 , (<+5 +-.+
$&(-"
'.,&%
'), 5<.) +54+
$+-('"
+4-,%
+5( '<'' -&(
$-+-"
5-4%
Men 4(.,' + (<(' +-)
$+,"
,&)%
-4- .<,, ++-,
$+(')"
+'4-%
'(, -<5. .-4
$54)"
4+-%
DementiaA
#omen .(&4& + (<(' '5(
$-5"
+&(+%
&- +<55 5.'
$-.,"
.4,%
5-( )<5& -(-
$'&."
---%
Men -4'&+ + (<(- -4-
$.+"
'.&4%
,' '<.5 -)'
$-++"
54)%
-') ,<(5 54-
$5+4"
.+4%
,earning disability--
#omen +'''( + (<() &(&
$+(("
.(+)%
+. +<'- 5-'
$'4("
&+4%
+5 +<+. 4--
$-&."
+(&(%
Men +-+,) + (<() .&+
$)+"
5(.4%
'( +<.' -+5
$'(-"
5)&%
'' +<4& 5()
$'4)"
4+,%
+ther non-psychotic conditions==
#omen '+',.4 '- (<++ ,((
$.,)"
)+& -<)5 +5-,
$+-55"
+)' (<). -'+
$'&&"
+-.5% +.5+% -&+%
Men +&4.,( +4 (<(, 455
$-,5"
+(.'%
+(+) .<&4 +'-'
$++.,"
+-+(%
')( +<., -4(
$-'("
5(5%
.otal
#omen '--'.)5 ,. (<(& 4-'
$.+&"
&&-%
.,-& 5<'& +-.4
$+-''"
+-,+%
'(44 +<5, -+)
$-(."
--'%
Men 5&)&+4- )4 (<() 4(,
$5,-"
&.-%
&(5( 4<', +'+'
$++)5"
+'5+%
'44) '<-) 544
$55)"
5)5%
=Includes manic depressie psychoses and certain reactie psychoses $I*D)3 ',)<(-, ',)<+,%!
>Includes certain reactie psychoses $I*D)3 ',&, ',)<+,"',)-,% and other non"classifiable
psychoses $I*D)3 ',)<,,, ',,%! ?Includes psychopathy! @Includes psychoses due to syphilis in
the central nerous system $*NS%, psychoses and non"psychotic conditions associated with
epilepsy, and psychoses and non"psychotic conditions associated with other physical illness!
APresenile and senile psychoses and psychoses associated with ascular disorders in the *NS
$mostly ascular dementia%! BBCisted as mental retardation! ==Cisted as other diagnosis in Danish
Psychiatric *are register.
Standardised mortality ratios /SM"s0 %or homicide, suicide, and accident, by diagnostic
category
Risk of committing suicide was raised for both se1es in all diagnostic categories. Patients with
alcoholism who were drug users, or who had affectie psychoses or personality disorders
were most at risk. 2hose least likely to commit suicide were patients with learning disabilities
or dementia. 0erall there was at least a +'"fold increase in risk in both se1es. DSRRs were
similar to SMRs in most groups, but were higher in patients with affectie psychoses $women
'-'', men '',,%, dementia $+)+', )5(%, and other non"psychotic conditions $'--), '+,,%.
+(.. men $+./% and &&, women $+-/% in the suicide sample receied open erdicts.
D1cluding these patients from analyses made little difference to the SMRs e1cept in the drug
use $women +4 -&&, men +- &',% and alcoholism groups $+' ,&4, ,.+&%.
2he risk of accidental death was also raised irrespectie of diagnosis. 2he highest risks were
in drug use and alcoholism. 0erall, there was a three"fold increase in risk in women and a
higher than four"fold increase in men. DSRRs were generally similar to SMRs but were lower
in women with alcoholism $4,5% and men who were drug users $++.-%.
Discussion
0ur results indicate high rates of death from homicide, suicide, and accident in people who
hae been psychiatric inpatients. Most psychiatric diagnoses were associated with increased
mortality from all three causes, the highest risks of homicide and accident being in drug use
and alcoholism, and the highest risk of suicide being in drug use. 8oweer, perhaps our most
important finding is the high risk of death by homicide among people with mental disorders,
including seere mental illnesses such as schi6ophrenia and affectie psychoses. 2hese
findings on homicide hae not been highlighted in preious reports of mortality in psychiatric
patients.
',,
Inpatient facilities in Denmark are all in public hospitals. 0ur findings are, therefore, based on
figures from a whole population, and calculations of risk by two different methods did not
affect oerall conclusions. 8oweer, certain criticisms can be made. :ll indiiduals had been
inpatients, suggesting seere illness. Dstimates of risk, especially suicide risk, in a sample
that included community patients might hae been lower than the figures presented here.
;urthermore, the diagnoses were based on Eudgments made by doctors and were not
standardised. In some diagnosis or se1 groups, especially in deaths by homicide, the
estimated mortality ratios are based on only a few cases. :dditionally, although the risk of
homicide is raised, the actual risk remains substantially lower than the risk of suicide or death
by accident. ;inally, we do not know whether our findings can be e1trapolated to other
countries, which hae different systems of mental"health care and for determining cause of
death.
: high mortality from homicide in drug use and alcoholism might be predicted, since these
groups would be e1pected to lie in, and contribute to, a iolent subculture. #hy, howeer,
should people with affectie psychoses and men with schi6ophrenia be at increased homicide
riskF Seeral factors might contribute. ;irst, such people might be more likely to lie in places
where homicide rates are generally high, such as inner cities. Second, they might hae
behaioural characteristics, such as alcohol or drug misuse, that increase their risk. 2hird,
they might prooke the hostility of others through the symptoms of illness, such as irritability
or paranoia. ;ourth, they might, as a result of illness, be less aware of their own safety needs.
;ifth, they might be killed by other mentally ill people with whom they are in contact""mentally
ill people who kill, most often kill family members.
5
;inally, they might be more likely to be
ictims of motieless killings because of their appearance. #hateer the cause, the public
and the media, who hae historically been concerned about the risk that the mentally ill
present to others, should be made aware of the ulnerability of these patients to the iolence
of others.
8oweer, most unnatural deaths in mental disorders are by suicide. 0ur results suggest, by
contrast with preious findings,
+
that high rates of suicide in people with mental disorders
e1tend to all diagnostic groups, including learning disability and dementia, though this finding
could reflect the fact that all patients were ill enough at one stage to be admitted to hospital.
2here is also a high risk of death from accidental causes in all mental disorders. 0ur results
particularly emphasise the risk of unnatural death in people with alcoholism who are drug
users. Serices for these groups should routinely assess suicide risk and alert their patients to
the risks they could face. 0erall, our findings confirm the need to emphasise suicide in any
strategy to reduce mortality among the mentally ill, but they also show the need for such
strategies to coer all unnatural deaths.
'ontri*utors
G 8iroeh, C :ppleby, and P 9 Mortensen designed the study and wrote the report. G 8iroeh
did the e1perimental work, superised by C :ppleby and P 9 Mortensen, and analysed the
results. P 9 Mortensen did the record linkage and helped analyse results. H Dunn superised
the analysis and contributed to the final ersion of the report.
-c%no.led("ents
#e thank :nne IingJrd 0lesen for adice on analysis, and Hurli Pertu for help with record
linkage and preparation of the dataset.
2he work was funded by the Danish Medical Research *ouncil.
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