Sudden unexpected death in schizophrenia: autopsy findings in psychiatric inpatients

Schizophrenia is associated with premature mortality and a high rate of sudden, unexpected deaths. Autopsy data are scant, and in studies using death certificates or root cause assessments, a majority of sudden deaths remained unexplained. In the community, post-mortem data indicate that the most common cause of sudden "natural" death is coronary artery disease. In this study, we used autopsy findings to determine the cause of sudden death in a consecutive cohort of 7189 schizophrenia patients admitted to a free-standing, psychiatric teaching hospital from 1989 to 2013. Medical record review identified 57 patients (0.79%) who died suddenly and unexpectedly during hospitalization. Autopsies were performed in 51 (89.5%) patients (55.9±9.4years, male=56.9%). Autopsy-based causes of sudden death were most commonly cardiovascular disorders (62.8%). Specific causes included myocardial infarction (52.9%), pneumonia (11.8%), airway obstruction (7.8%), myocarditis (5.9%), and dilated cardiomyopathy, hemopericardium, pulmonary embolus, hemorrhagic stroke and brain tumor (2.0% each). The sudden death remained unexplained in 6 (11.8%) patients, 3 of whom had evidence of coronary arteriosclerosis on autopsy. Patients with and without myocardial infarction were similar regarding age, gender, smoking, body mass index and psychotropic treatment (p values≥0.10). In conclusion, sudden cardiac death occurs at a 0.8% rate in a psychiatric hospital, well above general population rates. Autopsy findings indicate that sudden death in schizophrenia is caused by structural cardiovascular, respiratory and neurological abnormalities, with most cases due to acute myocardial infarction. Early recognition and treatment of coronary artery disease must become a clinical priority for all adults with schizophrenia.