Schizophrenia is the second-biggest predictor of death from COVID-19, exceeded only by old age, but this mental health risk factor is underrecognized.
Complex biopsychosocial factors underlie the association between schizophrenia and COVID-19, and could include employment loss, decreased access to healthcare, lack of support, or impact on immunity.
From a societal perspective, patients with schizophrenia need better programs to boost employment and income; clinicians can address patients’ lack of insight about COVID-19 by educating them about the disease and engaging in virtual healthcare visits.
Experts have conceptualized COVID-19 on various fronts. Risk factors such as older age, heart disease, and diabetes are well-documented. Identifying such risk factors, which have been tied to poor outcomes, guides decision-making. This also helps improve protective measures, as well as resource allocation.
One overlooked area, however, is the contribution of psychiatric illness to COVID-19 burden.
According to an article recently published in JAMA Psychiatry, the higher incidence of COVID-19 in individuals with mental illness has been reinforced by two nationwide cohort studies.
Specifically, depression and schizophrenia are tied to the highest infection risk.
In one study, NYU Grossman School of Medicine investigators compiled a cohort of 7348 adults with lab-confirmed COVID-19 in the New York health system. After compensation for demographic and medical risk factors, a schizophrenia spectrum diagnosis predicted death, whereas mood and anxiety disorders did not.
The investigators discovered that, after the factor of older age (75 years or more), which increases the odds of death 35.7 times, schizophrenia was the second-largest risk factor for death and increased these odds 2.7 times.
“Our findings illustrate that people with schizophrenia are extremely vulnerable to the effects of COVID-19,” stated lead author Katlyn Neman, MD, in a press release. “With this newfound understanding, healthcare providers can better prioritize vaccine distribution, testing, and medical care for this group.”
As for reasons underlying a greater risk of death in COVID-19 patients, even though this association held after controlling for comorbid illness, unmeasured coexistent disease could still have been a factor. Delays in treatment or decreased access to care could‘ve played more prominent roles.
“Beyond systemic barriers to care and delayed treatment, adults with schizophrenia spectrum diagnoses may be more susceptible to COVID-19 mortality due to biological factors related to their psychiatric illness or treatment,” the JAMA Psychiatry authors wrote. “Although the mechanism underlying this association is not clear, immune dysregulation in the setting of genetic or acquired risk factors is a possibility.”
In a study published in Healthcare, Spanish researchers assessed which COVID-19-related factors increased risk of decompensation for severe mental disorders in a cohort of 270 mentally ill patients.
The biggest risk factors (in decreasing magnitude) were unemployment, lack of psychotherapy, and lack of occupational therapy.
Other factors cited as risks for decompensation include social isolation, fear of infection, death of family members, social distancing, and disruption of health and community services.
What can be done?
In a piece published in Current Opinions in Psychiatry, authors highlighted the low levels of information patients with schizophrenia display regarding COVID-19 infection. They recommended that clinicians “inform and educate their patients on the risks related to SARS-CoV-2 infection and COVID-19 and on the precautions that they should adopt to avoid contagion.
Particular attention should be devoted to maintaining the continuity of care, especially in frail patients. Telemedicine might represent a valid support, but face-to-face visits in some cases remain essential.”
The authors explained that the hypothesis that viruses somehow mediate psychosis is controversial. In fact, viral involvement of the central nervous system is uncommon in COVID-19.
According to the Healthcare study authors, to prevent decompensation for those with severe mental illness, clinicians should institute virtual care and promote technology literacy, as this population may lack such understanding.
To improve employment status and income measures, support programs should be instituted, including vocational guidance, training activities, preparation for job interviews, job searches, and work-environment coping skills.
“For people diagnosed with SMDs [severe mental disorders] and without the possibility of developing an adequate work environment, the system of financial aid for greater autonomy and independence should be more flexible,” the authors stated. “This would have a decisive impact on this population’s mental health. Further research showing the impact of these factors on mental health is important.”
What does this mean for you?
The reality that schizophrenia is the second-leading risk factor for death in the context of COVID-19 should concern all physicians. Individuals with schizophrenia often lack knowledge and insight about COVID-19 contagion, so physicians should take special care to educate them. Continuity of care, aided by in-person or virtual healthcare visits, is important in maintaining stability and healthcare access for these individuals.