The death certificate allows underlying conditions leading to the cause of death, as well as other significant conditions unrelated to the immediate cause of death, to be listed. Perusal of statistics of the causes of death is instructive. The list of drugs in the Office for National Statistics’ Statistical Bulletin on deaths related to drug poisoning in England and Wales includes illicit and prescription drugs. Tricyclic antidepressants, dosulepin, selective serotonin reuptake inhibitors, benzodiazepines and hypnotics are detailed as well as individual illegal substances. ¹

Ischaemic heart disease is the number one killer of both males and females. An Expert Working Group of the National Heart Foundation in Australia concluded that there is strong evidence of a causal association between depression, social isolation and lack of quality social support and the causes and prognosis of coronary heart disease. The evidence for a causal association with stressors at work, anxiety and panic disorders, hostility and type A behaviour patterns was not strong. ^{Reference Bunker, Colquhoun, Esler, Hickie, Hunt and Jelinek2} Psychological factors have been shown to play a role in cardiovascular disease through the impact on smoking, hypertension, obesity and alcohol intake. ^{Reference Hamer, Molloy and Stamatakis3} There are modifiable and non-modifiable risk factors related to the premature mortality in schizophrenia. These are well reviewed. ^{Reference Wildgust and Beary4} Substance misuse and eating disorders are the highest risks for premature death. The risk of death from unnatural causes is high in schizophrenia and depression. Deaths from ‘natural’ causes are also increased in organic mental disorders, DSM-III-R mental retardation and epilepsy. ^{Reference Harris and Barraclough5} ‘All mental disorders have an increased risk of premature death.’ ^{Reference Harris and Barraclough5} Is this reflected in national mortality statistics?

In ICD-10, F00 to F99 are the statistical codes for mental illnesses. ⁶ There are about 500 000 deaths annually in England and Wales. If 0.9% of the population has schizophrenia, the number of deaths recorded reflecting this statistic is a great understatement at about 200 per year in 2005. ⁷ Depression is clearly underreported even with its known role in cardiac diseases; the number with affective disorders F30 to F39 is 141 in the same table. Clearly, to focus appropriate resources on health needs, there is a need for improvement in the accuracy of death certification.