title: Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study.
abstract: BACKGROUND
  High mortality rates have been reported in people released from prison compared with the general population. However, few studies have investigated potential risk factors associated with these high rates, especially psychiatric determinants. We aimed to investigate the association between psychiatric disorders and mortality in people released from prison in Sweden.
  
  
  METHODS
  We studied all people who were imprisoned since Jan 1, 2000, and released before Dec 31, 2009, in Sweden for risks of all-cause and external-cause (accidents, suicide, homicide) mortality after prison release. We obtained data for substance use disorders and other psychiatric disorders, and criminological and sociodemographic factors from population-based registers. We calculated hazard ratios (HRs) by Cox regression, and then used them to calculate population attributable fractions for post-release mortality. To control for potential familial confounding, we compared individuals in the study with siblings who were also released from prison, but without psychiatric disorders. We tested whether any independent risk factors improved the prediction of mortality beyond age, sex, and criminal history.
  
  
  RESULTS
  We identified 47,326 individuals who were imprisoned. During a median follow-up time of 5·1 years (IQR 2·6-7·5), we recorded 2874 (6%) deaths after release from prison. The overall all-cause mortality rate was 1205 deaths per 100,000 person-years. Substance use disorders significantly increased the rate of all-cause mortality (alcohol use: adjusted HR 1·62, 95% CI 1·48-1·77; drug use: 1·67, 1·53-1·83), and the association was independent of sociodemographic, criminological, and familial factors. We identified no strong evidence that other psychiatric disorders increased mortality after we controlled for potential confounders. In people released from prison, 925 (34%) of all-cause deaths in men and 85 (50%) in women were potentially attributable to substance use disorders. Substance use disorders were also an independent determinant of external-cause mortality, with population attributable fraction estimates at 42% in men and 70% in women. Substance use disorders significantly improved the prediction of external-cause mortality, in addition to sociodemographic and criminological factors.
  
  
  CONCLUSIONS
  Interventions to address substance use disorders could substantially decrease the burden of excess mortality in people released from prison, but might need to be provided beyond the immediate period after release.
  
  
  BACKGROUND
  Wellcome Trust, Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.
authors.affiliation: Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Zheng
authors.initials: Z
authors.lastname: Chang
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Paul
authors.initials: P
authors.lastname: Lichtenstein
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Henrik
authors.initials: H
authors.lastname: Larsson
authors.affiliation: Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK. Electronic address: seena.fazel@psych.ox.ac.uk.
authors.forename: Seena
authors.initials: S
authors.lastname: Fazel
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005610:Freedom; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology*; D009026:Mortality / Q000639:trends*; D011329:Prisoners / Q000523:psychology* / Q000706:statistics & numerical data; D019966:Substance-Related Disorders / Q000453:epidemiology*; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult