Background

Evidence on mortality in severe mental illness (SMI) comes primarily from clinical samples in high-income countries.

Aims

To describe mortality in people with SMI among a population cohort from a low-income country.

Method

We followed-up 919 adults (from 68 378 screened) with SMI over 10 years. Standardised mortality ratios (SMR) and years of life lost (YLL) as a result of premature mortality were calculated.

Results

In total 121 patients (13.2%) died. The overall SMR was twice that of the general population; higher for men and people with schizophrenia. Patients died about three decades prematurely, mainly from infectious causes (49.6%). Suicide, accidents and homicide were also common causes of death.

Conclusions

Mortality is an important adverse outcome of SMI irrespective of setting. Addressing common natural and unnatural causes of mortality are urgent priorities. Premature death and mortality related to self-harm should be considered in the estimation of the global burden of disease for SMI.

Premature mortality is a well-established adverse outcome of severe mental illness (SMI), most notably for schizophrenia, bipolar disorder and depressive disorder.1 Nonetheless, investigating mortality patterns remains important for: (a) for monitoring the profile of changing risk factors over time;2 (b) for evaluating the impact of sociocultural and geographic settings on mortality; (c) for reviewing the contribution of SMI to the global burden of disease; (d) for advocating for the inclusion of SMI in the global health agenda; and (e) to establish the mortality profile in population samples, which has not been demonstrated adequately to date. Moreover, the contribution of SMI to the global burden of disease has increased in the most recent analyses3,4 but is still likely to be underestimated substantially. For example, although mental disorders, particularly SMI, are the strongest predictors of mortality from self-harm,5 self-harm is calculated separately in the global burden of disease estimations.6 In addition, the indirect yet substantial contributions of mental disorders to mortality related to physical conditions are underrecognised in calculations of the global burden of disease.6,7 This underestimation has the potential to perpetuate the low prioritisation of mental disorders and the underinvestment in research and services related to SMI, particularly in low-income country settings, where policy-makers have to prioritise disorders with the highest burden and best outcome returns for their investment. Furthermore, our knowledge about mortality associated with SMI derives from clinical samples recruited in the context of service receipt or hospital admission, mostly from high-income countries, although over 80% of the world’s population lives in low- and middle-income countries with limited access to treatment. The little knowledge we have about the mortality of people with SMI from low- and middle-income countries comes from anecdotal accounts8 and the pioneering studies of the World Health Organization, which are now over three decades old.9–11 For example the International Pilot Study of Schizophrenia was initiated over 45 years ago, in 1966.11 Many changes have occurred in our understanding of mental disorders since: more refined methods of illness classification, case identification and monitoring have evolved; new methods for ascertainment of causes of mortality applicable in low-income settings have enabled researchers to define causes of death in more precise ways. Additionally, virtually no data exist on the mortality outcomes in bipolar disorder and severe depressive disorders in low-income country settings, which are also important contributors to premature mortality alongside schizophrenia. There is, therefore, a pressing need for up-to-date, methodologically rigorous, population-based studies from low-income countries. The aim of this report is to present the mortality outcomes of people with SMI from the Butajira-Ethiopia study on SMI, a recently completed large-scale, population-based cohort study.