Diagnostic pathways and mortality across psychotic disorders: Evidence from Catalonia integrated health records

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INTRODUCTION: Although psychotic disorders are associated with significant morbidity and mortality, the diagnostic trajectories and mortality risks across the spectrum of these disorders remain poorly understood. This study aimed to characterize diagnostic pathways and compare mortality outcomes across psychotic disorders in Catalonia. METHODS: We conducted a retrospective cohort study using electronic health records of 357,007 adults accessing mental health services in Catalonia from 2015 through 2019. Diagnostic categories included schizophrenia, bipolar disorder, schizoaffective disorder, delusional disorder, other non-organic psychoses, unipolar psychotic depression, and other mental health diagnoses. Cox proportional hazards models assessed mortality risk, adjusting for sociodemographic factors and comorbidities. RESULTS: About one-third of the sample received their first psychotic disorder diagnosis in specialized care. All psychotic disorders showed elevated mortality risk vs other mental health conditions. Schizophrenia had the highest risk (HR, 2.63; 95%CI, 2.46-2.81, p<0.001 followed by schizoaffective (HR, 1.99; 95%CI, 1.77-2.24, p<0.001) and delusional disorders (HR, 1.92; 95%CI, 1.66-2.21, p<0.001). Low socioeconomic status (HR, 3.69; 95%CI, 3.48-3.92, p<0.001) and comorbidities (HR, 1.82 per comorbidity; 95%CI, 1.81-1.83, p<0.001) were significant predictors of mortality across diagnoses. Gradient boosting machine modeling identified comorbidities (56.07%) and diagnostic category (24.51%) as top predictors of mortality risk. CONCLUSIONS: This study demonstrates significantly elevated mortality risk across the spectrum of psychotic disorders in a Southern European context, with socioeconomic factors and medical comorbidities emerging as critical determinants. These findings underscore the need for integrated care approaches addressing both mental and physical health needs in psychotic disorders.

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