The effects of treatment on mortality in affective illness

All studies of mortality in patients with a diagnosis of affective illness agree that the death rate is increased. The excess mortality appears primarily to result from suicide; any excess mortality from physical illness, most notably cardiovascular disease, now appears unlikely to be a simple consequence of affective illness. Historical comparisons suggest that acute treatment of affective disorder reduces the immediate risk of death. It is much more difficult to assess the impact of treatment upon the subsequent rates of suicide. This is true of all aspects of the acute and short-term continuation of treatment for an episode of illness, from the need for hospital admission to the choice of drug treatment. Adequate treatment of refractory depression and the possibility that some actions of drugs may increase the risks of suicide are emergent therapeutic issues that are still providing more questions than answers. Prophylaxis should also reduce the risk of suicide. However, although standardized mortality rates, reflecting relative risk, are very high, only ∼2% of patients with affective disorder will commit suicide in a follow-up interval of 2 years. Comparison of mortality data for patients on lithium registers with that from lithium clinics shows important reductions in specialized clinics. Indeed, mortality from suicide may actually be lower than expected. It raises the question of whether long- term hospital follow-up by personnel with a specialist interest in drug treatment of major mental illness is safer than a potentially more erratic provision of care in the community. The future issues in the prevention of suicide include whether to treat patients by admission to a hospital in-patient unit or not, whether to treat for at least a year with adequate doses of tricyclic drugs or a selective 5-hydroxytryptamine (5-HT, serotonin) re-uptake inhibitor, and whether to maintain patients with a second episode of affective illness or a prolonged first illness indefinitely with lithium or antidepressants.