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Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014

  • Joseph F. Hayes (a1), Louise Marston (a2), Kate Walters (a2), Michael B. King (a3) and David P. J. Osborn (a3)...



Bipolar disorder and schizophrenia are associated with increased mortality relative to the general population. There is an international emphasis on decreasing this excess mortality.


To determine whether the mortality gap between individuals with bipolar disorder and schizophrenia and the general population has decreased.


A nationally representative cohort study using primary care electronic health records from 2000 to 2014, comparing all patients diagnosed with bipolar disorder or schizophrenia and the general population. The primary outcome was all-cause mortality.


Individuals with bipolar disorder and schizophrenia had elevated mortality (adjusted hazard ratio (HR) = 1.79, 95% CI 1.67–1.88 and 2.08, 95% CI 1.98–2.19 respectively). Adjusted HRs for bipolar disorder increased by 0.14/year (95% CI 0.10–0.19) from 2006 to 2014. The adjusted HRs for schizophrenia increased gradually from 2004 to 2010 (0.11/year, 95% CI 0.04–0.17) and rapidly after 2010 (0.34/year, 95% CI 0.18–0.49).


The mortality gap between individuals with bipolar disorder and schizophrenia, and the general population is widening.

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This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Corresponding author

Joseph F. Hayes, Division of Psychiatry, UCL, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Email:


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See editorial, pp. 130–131, this issue.

Declaration of interest




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1 Laursen, TM. Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophr Res 2011; 131: 101–4.
2 Laursen, TM, Wahlbeck, K, Hallgren, J, Westman, J, Osby, 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: ee.
3 Chang, C-K, Hayes, RD, Perera, G, Broadbent, MT, Fernandes, AC, Lee, WE, et al. Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 2011; 6: ee.
4 Hoang, U, Stewart, R, Goldacre, MJ. Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999–2006. BMJ 2011; 343: dd.
5 Hoang, U, Goldacre, MJ, Stewart, R. Avoidable mortality in people with schizophrenia or bipolar disorder in England. Acta Psychiatr Scand 2013; 127: 195201.
6 Tiihonen, J, Lönnqvist, J, Wahlbeck, K, Klaukka, T, Niskanen, L, Tanskanen, A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009; 374: 620–7.
7 Saha, S, Chant, D, McGrath, J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64: 1123–31.
8 Bushe, CJ, Taylor, M, Haukka, J. Review: Mortality in schizophrenia: a measurable clinical endpoint. J Psychopharmacol 2010; 24 (4 suppl): 1725.
9 Wahlbeck, K, Westman, J, Nordentoft, M, Gissler, M, Laursen, TM. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. Br J Psychiatry 2011; 199: 453–8.
10 Martin Roland, D. Linking physicians' pay to the quality of care – a major experiment in the United Kingdom. N Engl J Med 2004; 351: 1448–54.
11 Doran, T, Kontopantelis, E, Valderas, JM, Campbell, S, Roland, M, Salisbury, C, et al. Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ 2011; 342: dd.
12 Edwards, J, McGorry, PD. Implementing Early Intervention in Psychosis: A Guide to Establishing Psychosis Services. Taylor & Francis, 2002.
13 Schizophrenia Commission. The Abandoned Illness: A Report from the Schizophrenia Commission. Rethink Mental Illness, 2012.
14 Department of Health. No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages. Department of Health, 2011.
15 Department of Health. Closing the Gap: Priorities for Essential Change in Mental Health. Department of Health, 2014.
16 Colton, CW, Manderscheid, RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight States. Prev Chronic Dis 2006; 3: AA.
17 Swinson, N, Ashim, B, Windfuhr, K, Kapur, N, Appleby, L, Shaw, J. National confidential inquiry into suicide and homicide by people with mental illness: new directions. Psychiatrist 2007; 31: 161–3.
18 Druss, BG, Rohrbaugh, RM, Levinson, CM, Rosenheck, RA. Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry 2001; 58: 861–8.
19 Koyanagi, C, Carty, L. Get it Together: How to Integrate Physical and Mental Health Care for People with Serious Mental Disorders. Bazelon Center for Mental Health Law, 2004.
20 Callaghan, RC, Khizar, A. The incidence of cardiovascular morbidity among patients with bipolar disorder: a population-based longitudinal study in Ontario, Canada. J Affect Disord 2010; 122: 118–23.
21 Canadian Psychiatric Association. Clinical practice guidelines: treatment of schizophrenia. Can J Psychiatry 2005; 50: 7S.
22 Galletly, CA, Foley, DL, Waterreus, A, Watts, GF, Castle, DJ, McGrath, JJ, et al. Cardiometabolic risk factors in people with psychotic disorders: the second Australian national survey of psychosis. Aust NZ J Psychiatry 2012: 46: 753–61.
23 The Royal Australian and New Zealand College of Psychiatrists. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Aust NZ J Psychiatry 2016; 50: 410–72.
24 Pirkis, J, Harris, M, Hall, W, Ftanou, M. Evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule Initiative. Centre for Health Policy, Programs and Economics, 2011.
25 Fleischhacker, WW, Cetkovich-Bakmas, M, De Hert, M, Hennekens, CH, Lambert, M, Leucht, S, et al. Comorbid somatic illnesses in patients with severe mental disorders: clinical, policy, and research challenges. J Clin Psychiatry 2008; 69: 514.
26 De Hert, M, Dekker, J, Wood, D, Kahl, K, Holt, R, Möller, H-J. Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). Eur Psychiatry 2009; 24: 412–24.
27 Roshanaei-Moghaddam, B, Katon, W. Premature mortality from general medical illnesses among persons with bipolar disorder: a review. Psychiatr Serv 2009; 60: 147–56.
28 Weiner, M, Warren, L, Fiedorowicz, JG. Cardiovascular morbidity and mortality in bipolar disorder. Ann Clin Psychiatry 2011; 23: 40–7.
29 Osborn, DP, Levy, G, Nazareth, I, Petersen, I, Islam, A, King, MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007; 64: 242–9.
30 McCreadie, RG. Diet, smoking and cardiovascular risk in people with schizophrenia. Br J Psychiatry 2003; 183: 534–9.
31 Cormac, I. Promoting healthy lifestyles in psychiatric services. In Physical Health in Mental Health. Final Report of a Scoping Group. (Occasional Paper OP 67): 62–7. Royal College of Psychiatrists, 2009.
32 Miller, LJ. Management of atypical antipsychotic drug-induced weight gain: focus on metformin. Pharmacotherapy 2009; 29: 725–35.
33 Hayes, J, Miles, J, Walters, K, King, M, Osborn, D. A systematic review and meta-analysis of premature mortality in bipolar affective disorder. Acta Psychiatr Scand 2015; 131: 417–25.
34 Brown, S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997; 171: 502–8.
35 Owens, D, Horrocks, J, House, A. Fatal and non-fatal repetition of self-harm. Br J Psychiatry 2002; 181: 193–9.
36 Singhal, A, Ross, J, Seminog, O, Hawton, K, Goldacre, MJ. Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage. J R Soc Med 2014; 107: 194204.
37 Lis, Y, Mann, RD. The VAMP Research multi-purpose database in the UK. J Clin Epidemiol 1995; 48: 431–43.
38 Blak, BT, Thompson, M, Dattani, H, Bourke, A. Generalisability of The Health Improvement Network (THIN) database: demographics, chronic disease prevalence and mortality rates. Inform Prim Care 2011; 19: 251–5.
39 Maguire, A, Blak, BT, Thompson, M. The importance of defining periods of complete mortality reporting for research using automated data from primary care. Pharmacoepidemiol Drug Saf 2009; 18: 7683.
40 Horsfall, L, Walters, K, Petersen, I. Identifying periods of acceptable computer usage in primary care research databases. Pharmacoepidemiol Drug Saf 2013; 22: 64–9.
41 Langley, TE, Szatkowski, L, Gibson, J, Huang, Y, McNeill, A, Coleman, T, et al. Validation of The Health Improvement Network (THIN) primary care database for monitoring prescriptions for smoking cessation medications. Pharmacoepidemiol Drug Saf 2010; 19: 586–90.
42 Lewis, JD, Schinnar, R, Bilker, WB, Wang, X, Strom, BL. Validation studies of the health improvement network (THIN) database for pharmacoepidemiology research. Pharmacoepidemiol Drug Saf 2007; 16: 393401.
43 Chisholm, J. The Read clinical classification. BMJ 1990; 300: 1092.
44 Nazareth, I, King, M, Haines, A, Rangel, L, Myers, S. Accuracy of diagnosis of psychosis on general practice computer system. BMJ 1993; 307: 32–4.
45 Hardoon, S, Hayes, JF, Blackburn, R, Petersen, I, Walters, K, Nazareth, I, et al. Recording of severe mental illness in United Kingdom primary care, 2000–2010. PLoS One 2013; 8: ee.
46 Ruigómez, A, Martín-Merino, E, Rodríguez, LAG. Validation of ischemic cerebrovascular diagnoses in the health improvement network (THIN). Pharmacoepidemiol Drug Saf 2010; 19: 579–85.
47 Hammad, TA, McAdams, MA, Feight, A, lyasu, S, Dal Pan, GJ. Determining the predictive value of Read/OXMIS codes to identify incident acute myocardial infarction in the General Practice Research Database. Pharmacoepidemiol Drug Saf 2008; 17: 1197–201.
48 Ogdie, A, Yu, Y, Haynes, K, Love, TJ, Maliha, S, Jiang, Y, et al. Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. Ann Rheum Dis 2015; 74: 326–32.
49 Haw, C, Casey, D, Holmes, J, Hawton, K. Suicidal intent and method of self-harm: a large-scale study of self-harm patients presenting to a general hospital. Suicide Life Threat Behav 2015; 45: 732–46.
50 Arana, A, Wentworth, CE, Ayuso-Mateos, JL, Arellano, FM. Suicide-related events in patients treated with antiepileptic drugs. N Engl J Med 2010; 363: 542–51.
51 Hayes, JF, Pitman, A, Marston, L, Walters, K, Geddes, JR, King, M, et al. Selfharm, unintentional injury, and suicide in bipolar disorder during maintenance mood stabilizer treatment: a UK population-based electronic health records study. JAMA Psychiatry 2016; 73: 630–7
52 Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002; 27: 299309.
53 Kim, H-J, Fay, MP, Feuer, EJ, Midthune, DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med 2000; 19: 335–51.
54 Zhang, NR, Siegmund, DO. A modified Bayes information criterion with applications to the analysis of comparative genomic hybridization data. Biometrics 2007; 63: 2232.
55 Schoenfeld, D. Partial residuals for the proportional hazards regression model. Biometrika 1982; 69: 239–41.
56 Townsend, P. Deprivation. J Soc Policy 1987; 16: 125–46.
57 Ford, ES, Mokdad, AH, Giles, WH, Mensah, GA. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: findings from the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation 2003; 107: 2185–9.
58 National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National High Blood Pressure Education Program, 2004.
59 Lawrence, D, Kisely, S. Review: Inequalities in healthcare provision for people with severe mental illness. J Psychopharmacol 2010; 24 (4 suppl): 61–8.
60 Weinmann, S, Read, J, Aderhold, V. Influence of antipsychotics on mortality in schizophrenia: systematic review. Schizophr Res 2009; 113: 111.
61 Hayes, J, Prah, P, Nazareth, I, King, M, Walters, K, Petersen, I, et al. Prescribing trends in bipolar disorder: cohort study in the United Kingdom THIN primary care database 1995–2009. PLoS One 2011; 6: ee.
62 Fakhoury, W, Priebe, S. Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psychiatry 2007; 6: 313–6.
63 Green, B, Griffiths, E. Hospital admission and community treatment of mental disorders in England from 1998 to 2012. Gen Hosp Psychiatry 2014; 36: 442–8.
64 Cooper, B. Economic recession and mental health: an overview. Neuropsychiatr 2011; 25: 113–7.
65 Riumallo-Herl, C, Basu, S, Stuckler, D, Courtin, E, Avendano, M. Job loss, wealth and depression during the Great Recession in the USA and Europe Int J Epidemiol 2014: 43: 1508–17.
66 Liu, NH, Daumit, GL, Dua, T, Aquila, R, Charlson, F, Cuijpers, P, et al. Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry 2017; 16: 3040.
67 Office for National Statistics. Mortality Statistics: Deaths Registered in England and Wales (Series DR). ONS, 2016 (–deaths-registered-in-england-and-wales–series-dr-/index.html).
68 Brown, S, Kim, M, Mitchell, C, Inskip, H. Twenty-five year mortality of a community cohort with schizophrenia. Br J Psychiatry 2010; 196: 116–21.
69 Townsend, N, Bhatnagar, P, Wilkins, E, Wickramasinghe, K, Rayner, M. Cardiovascular Disease Statistics 2015. British Heart Foundation, 2014.
70 Vandenbroucke, J, Pearce, N. Point: incident exposures, prevalent exposures, and causal inference: does limiting studies to persons who are followed from first exposure onward damage epidemiology? Am J Epidemiol 2015; 182: 826–33.
71 Ösby, U, Correia, N, Brandt, L, Ekbom, A, Sparén, P. Time trends in schizophrenia mortality in Stockholm county, Sweden: cohort study. BMJ 2000; 321: 483–4.
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Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014

  • Joseph F. Hayes (a1), Louise Marston (a2), Kate Walters (a2), Michael B. King (a3) and David P. J. Osborn (a3)...


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Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014

  • Joseph F. Hayes (a1), Louise Marston (a2), Kate Walters (a2), Michael B. King (a3) and David P. J. Osborn (a3)...
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