Sir, - In The Irish Times of November 17th, Vincent Browne drew attention to a statement contained in the Report of the Inspector of Mental Hospitals for 1998 which noted the increasing number of sudden deaths in psychiatric hospitals, some of which were attributed to drug-related effects. From this statement Mr Browne drew some rather alarming conclusions. In the circumstances, and in order to allay any anxiety that public comment on this matter may have caused to psychiatric patients or to their relatives or friends, I feel it is important that my remarks be clarified.
It has been known for a very long time that persons suffering from psychiatric illness have a higher mortality and poorer life expectation than the general population. This raised mortality is due to a variety of causes of death, some the consequence of health-damaging lifestyles associated with psychiatric disorder, such as cigarette smoking, alcohol or drug abuse, family dietary habits and self-induced or community-determined social exclusion.
These factors result in greater mortality from cardiovascular diseases, cancers and other less common causes of death. To these have to be added sudden deaths such as suicide and deaths believed to be drug-related, both of which have increased in this country in recent years. These latter two causes of death are by statute reported to the Inspector of Mental Hospitals when they occur in psychiatric hospitals and in psychiatric units in general hospitals.
Sudden deaths among patients suffering from psychiatric illness have increased from 23 in 1983 to 36 in 1998. Of those deemed on clinical grounds and by coroners to have been due to suicide, the numbers have gone from 15 in 1983 to 20 in 1998. The majority of suicides, on average three-quarters, occur in patients who, although technically "on the books" of hospitals or units, are on authorised or unauthorised leave from hospital, with only a minority occurring on the premises. The increase in suicide in hospitalised psychiatric patients in the last two decades reflects, almost exactly, a similar increase in the general population.
Drug-related deaths, as determined by coroners, increased from two in 1983 to eight in 1998. This group of deaths consists of two broad components. The first relates to those occurring in older, long-stay patients who either choke or develop aspiration pneumonia because of faulty swallowing practices - a phenomenon encountered in elderly psychiatric patients long before the modern drug era. In 1997 during an inquest on such a death, a Dublin coroner expressed the view that deaths of this nature were occurring in patients on relatively high doses of psychiatric drugs. Accordingly in May of that year, I circulated a letter to all psychiatric services pointing out the coroner's concern, urging vigilance in the matter and stressing the necessity of ensuring that nursing staff were fully trained in resuscitation techniques to deal with emergencies of this type. These matters were again referred to in the Guidelines on Good Practice and Quality Assurance in Mental Services which I produced and which were distributed by the Department of Health and Children to all mental health service providers in 1998. Deaths in this category fell from two in 1983 to one in 1998.
The second type of drug-related death is characterised by sudden collapse and death in younger patients taking psychiatric drugs in recommended dosages. There is no satisfactory scientific explanation for these deaths, which occur unpredictably. This condition is a well-recognised, but fortunately rare side-effect of psychotropic drug administration. The number of such deaths has been rising, up from one in 1983 to seven in 1998 and it was primarily this category of sudden deaths to which I referred in my report.
I believed it prudent, in the light of these considerations, to draw attention in my 1998 report to the importance of reviewing prescriptions of medications regularly. I intend to keep this issue under review and, through my regular inspections of psychiatric in-patient facilities, to ensure, as far as possible, that good practices are adhered to in the care and treatment of people suffering from psychiatric illness. - Yours, etc.,
Dr Dermot Walsh, Inspector of Mental Hospitals, Department of Health and Children, Hawkins House, Dublin 2.