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People With Schizophrenia Are Uniquely Vulnerable to COVID

Schizophrenia is a most burdensome disease.

Key points

  • When compared to well-matched, non-diagnosed peers, people with schizophrenia had higher rates of bad outcomes during the COVID-19 pandemic.
  • When compared to other psychiatric diagnoses, rates of poor outcome after COVID-19 infection are higher in people with schizophrenia.
  • Improved communication about the benefits of vaccination and treatment for people with schizophrenia has crucial public health importance..

Just as COVID-19 placed into stark relief substantial gaps in medical access and clinical outcomes between people from high and low socioeconomic groups, and diverse ethnic and racial communities, so too has it emphasized differences between the general population and those with schizophrenia.

Even prior to the pandemic, the World Health Organization considered schizophrenia among the top 20 of the most burdensome diseases around the globe. In addition to daily symptoms that interfere with a person’s ability to think clearly, manage emotions, make decisions and relate to others, schizophrenia is associated with profound reductions in life expectancy – as much as 15 years less than their non-mentally-ill peers.

Hallucinations and irrational beliefs don’t cause people to die, but limitations around work and social activities imposed by these symptoms do. People with schizophrenia have difficulties completing their education and holding gainful employment and they suffer disproportionately from poverty’s associated physical depredations: heart disease, hypertension, diabetes, obesity, and smoking-related lung disease.

Now compound this crisis with the COVID-19 pandemic.

A recent longitudinal study of over 25,000 people with schizophrenia during a year of the pandemic in Israel showed that over the year these patients had a nearly five-time increase in the risk of hospitalization from COVID-19 and a 2.5 times likelihood of dying from the disease as compared with their age and gender-matched peers, even when accounting for group differences in education and accompanying medical comorbidities such as diabetes and obesity, which were—not surprisingly— considerably higher in the schizophrenia group.

Findings from patients already hospitalized for COVID-19 infection are similarly concerning for those with a diagnosis of schizophrenia.

A recent study on the outcomes of people with schizophrenia hospitalized for at least a day with COVID-19 and respiratory symptoms collected data across the entire French hospital system during a five-month period at the start of the pandemic. The study showed significant elevations in mortality for schizophrenia patients between the ages of 65 and 80. The study also showed an elevation in ICU admission in younger patients with schizophrenia.

Closer to home, research from the NYU health system suggests that people with schizophrenia are uniquely vulnerable to the very worst outcomes of COVID-19 even when compared with other mental disorders. In that study, a research team used existing medical records to identify 7348 patients with a positive COVID-19 PCR test and a history of psychiatric illness. Patients with a history of schizophrenia, depression or bipolar illness, or an anxiety disorder were followed for 45 days after their test.

Remarkably, only a previous diagnosis of schizophrenia was associated with increased mortality as a function of a COVID-19 infection in the study. In fact, people with schizophrenia had a nearly three times increased likelihood of death during the 45-day study period relative to their non-psychiatrically diagnosed peers with COVID-19 infections. These differences in mortality also remained when the elevated mortality risks associated with common medical comorbidities in schizophrenia were corrected for. In fact, the effect of schizophrenia on the likelihood of death was larger than every other factor evaluated in the study with the exception of age. History of heart failure, kidney disease, COPD, and heart attack all played a smaller role in the likelihood of fatality from COVID-19 than a diagnosis of schizophrenia.

In light of these alarming findings in early October of 2021, the CDC appropriately added schizophrenia (along with depression) to its list of medical conditions as conferring a greater risk of hospitalization and death from COVID-19 infection.

While the information on vaccination rates among people with schizophrenia remains sparse, there is a concerning suspicion they may lag rates in the general population. Surveys of service use in schizophrenia suggest woefully low treatment participation rates in the U.S. even before the pandemic with treatment availability and cost as particularly potent barriers.

Peer support in the form of “social clubs” and other in-person and online support networks can reduce social isolation and enhance recovery in people with schizophrenia and other severe mental illnesses. Training specific members of these peer support groups to serve as “vaccine information ambassadors” providing information on vaccine safety and ways to access shots could play a significant role.

Numerous studies have shown that family education plays a significant role in reducing both symptoms and hospital readmission in people with schizophrenia, particularly early in the illness. Adding education around vaccines to these family training curricula could also help. And lastly, ensuring that psychiatric medication prescribers, in many cases the only health care professional a person with schizophrenia reliably meets with, include education around vaccines as a key element of their medication management meetings.

Vaccines remain among the few current reliable ways to address the increased vulnerability of people with schizophrenia to the novel coronavirus. But the good news is that data from the Israeli study indicates that for those patients who got the vaccines the differences in rates of hospitalizations and deaths between people with schizophrenia and the general population were substantially reduced.

While COVID-19 has represented a pandemic of catastrophic proportions for all of us, it is of the utmost importance that our most vulnerable, and those often least able to self-advocate due to social stigma, poverty, and disconnection from social services and family, not be forgotten.

References

Batan, D., Cride, K., Cohen, A., Weinstein, O. (2021). COVID-19 hospitalisation, mortality, vaccination, and
postvaccination trends among people with schizophrenia in
Israel: a longitudinal cohort study. Lancet: Psychiatry, 8, 901-908.

Fond., G, Pauly., V, Leone., M, Llorca., PM, Orleans., V, Loundou., A, Lancon., C, Auquier, P., Baumstarck, K., Boyer, L.. (2021). Disparities in intensive care unit admission and mortality among patients With schizophrenia and COVID-19: A national cohort study. Scz Bull, 47, 624-634.

Nemani, K., Li, C, Olfson, M., Blessing, EM., Razavian, N., Chen, J., Petkova, E., Goff, DC. (2021). Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry, 78(4):380-386.

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