Our data indicate increasing mortality among people with schizophrenia. Standardised mortality ratios increased over time for all causes of death, but the appreciable increases in deaths from natural and cardiovascular causes suggest that the somatic health of these patients deteriorated, perhaps because their illness causes them to adopt an unhealthy lifestyle and to be less inclined to seek health care.4
High mortality from suicide in schizophrenia patients was also reported in a registry linked study from Denmark.3
Mortality from unspecified violence in our study may include cases of suicide.
The changing criteria for hospital admission during the study period meant that proportionately more patients with severe illness were admitted; this represents a potential confounding factor. However, the number of patients admitted to hospital with schizophrenia increased over this time, arguing against the occurrence of selection bias. Diagnostic specificity is another concern, but validation based on medical records of clinical schizophrenia diagnoses in Stockholm County estimated that 80%-85% of these met the operational diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders,
third edition, revised.5
During the study period there were important changes in psychiatric care offered to patients with schizophrenia: outpatient treatment replaced long term inpatient care. In Stockholm between 1976 and 1994, the number of hospital bed days associated with schizophrenia fell by 64%, and this reduction in beds is the most probable explanation for the rising mortality. The same conclusion was drawn in a Danish study reporting increasing mortality from suicide.3
Our findings emphasise the importance of monitoring trends in mortality for patients with schizophrenia as well as for other patient groups as indicators of outcome and quality of psychiatric and medical care.