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Is there any literature that assesses psychiatric disorders (e.g., schizophrenia, mood disorders, anxiety disorders) as risk factors for COVID-19 (either severity or mortality)?

Comment by InpharmD Researcher

A recent study shows adults with a schizophrenia spectrum disorder diagnosis may be associated with an increased risk for COVID-19 mortality, while mood and anxiety disorders are not associated with a risk of mortality.
Background

Concerns have been expressed regarding the risk of COVID-19 severity and mortality in persons with pre-existing mental disorders. A large database study of adults across the United States found patients with a recent diagnosis of a mental disorder had a significantly increased risk for COVID‐19 infection, which was strongest for depression (adjusted odds ratio [aOR] 7.64; 95% confidence interval [CI] 7.45‐7.83; p<0.001) and schizophrenia (aOR 7.34; 95% CI 6.65‐8.10; p<0.001). Patients with both a recent diagnosis of a mental disorder and COVID‐19 infection had an increased mortality rate compared with COVID-19 patients with no mental disorders (8.5% vs 4.7%; p<0.001). Hospitalization for COVID-19 was also higher among patients with a recent mental disorder diagnosis (27.4% vs 18.6%; p<0.001). [1]

A number of case reports and case-control studies also suggest patients with schizophrenia disorders may have other adverse outcomes due to the COVID-19 pandemic. In addition to poorer COVID-19 outcomes, case reports describe psychosis relapse in patients with schizophrenia spectrum disorders and/or new-onset psychosis in patients without any previous history. These patients have several risk factors, such as: lower health literacy, negative health-related behaviors, unstable housing and communal settings, presence of coexisting conditions, delays in seeking treatment, less access to care, and receiving lower quality of care. There are many, multifactorial health-related, emotional, social, and economic factors that put people with psychiatric disorders at risk for COVID-19 infections, complications, and mortality. [2-3]

References:

[1] Wang Q, Xu R, Volkow ND. Increased risk of COVID ‐19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States. World Psychiatry. 2021;20(1):124-130.
[2] Zhand N, Joober R. Implications of the COVID-19 pandemic for patients with schizophrenia spectrum disorders: narrative review. BJPsych Open. 2021;7(1):e35.
[3] Shinn AK, Viron M. Perspectives on the COVID-19 Pandemic and Individuals With Serious Mental Illness. The Journal of Clinical Psychiatry. 2020;81(3).

Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

Is there any literature that assesses psychiatric disorders (e.g., schizophrenia, mood disorders, anxiety disorders) as risk factors for COVID-19 (either severity or mortality)?

Please see Table 1 for your response.


 

Association of Psychiatric Disorders With Mortality Among Patients With COVID-19

Design

Retrospective, observational, cohort study

N=7,348

Objective

To assess whether a diagnosis of a schizophrenia spectrum disorder, mood disorder, or anxiety disorder is associated with mortality in patients with COVID-19

Study Groups

Schizophrenia spectrum (n=75)

Mood disorders (n=564)

Anxiety disorders (n=360)

Control (n=6,349)

Inclusion Criteria

Aged ≥18 years, confirmed SARS-CoV-2 test, data available in the health system

Exclusion Criteria

Patients without available medical records before testing

Methods

This was a retrospective, observational study from a health system in New York. Patients with a positive SARS-CoV-2 test were stratified based on ICD-10 diagnoses for schizophrenia spectrum disorders, mood disorders, and anxiety disorders. Due to certain nonspecific diagnosis codes, medical reviews were performed for all schizophrenia diagnoses.

These patients were compared to a control group without psychiatric diagnoses. The control group excluded patients with other psychiatric disorders (e.g., OCD, somatoform disorders, dissociative disorders, etc.); however, organic mental disorders, substance use disorders, mental retardation, and psychological development disorders were included in the reference group.

Odds ratios were conducted unadjusted, adjusted based on demographics (age, race, and sex), and adjusted for medical risk factors plus demographics.

Duration

Positive test: March 3 to May 31, 2020

Follow-up: 45-days after positive test or up to July 15, 2020

Outcome Measures

Mortality 45-days after positive SARS-CoV-2 test

Baseline Characteristics

 

Schizophrenia spectrum (n=75)

Mood disorders (n=564)

Anxiety disorders (n=360)

Control (n=6,349)

Age, years

59.7 ± 15.0 62.3 ± 18.7 54.9 ± 19.3 53.6 ± 18.4

Female

44% 60.1% 60.3% 52%

White

62.7% 57.8% 61.1% 38.2%

Comorbidities

Hypertension

Heart failure

MI

Diabetes

COPD

 

77.3%

24%

42.7%

37.3%

52%

 

68.8%

21.5%

37.2%

41.1%

47.9%

 

52.8%

12.2%

24.7%

25.3%

37.5%

 

42.5%

5.3%

13.2%

24.3%

20.8%

MI=myocardial infarction; COPD=chronic obstructive pulmonary disease

Results

 

Schizophrenia spectrum (n=75)

Mood disorders (n=564)

Anxiety disorders (n=360)

Control (n=6,349)

45-day mortality

aOR (95% CI)

20 (26.7%)

aOR 2.67 (1.48-4.80)

104 (18.4%)

aOR 1.14 (0.87-1.49)

39 (10.8%)

aOR 0.96 (0.65-1.40)

701 (11%)

Reference

aOR=adjusted odds ratio; CI=confidence interval

Adverse Events

Not studied

Study Author Conclusions

In this cohort study of adults with SARS-CoV-2–positive test results in a large New York medical system, adults with a schizophrenia spectrum disorder diagnosis were associated with an increased risk for mortality, but those with mood and anxiety disorders were not associated with a risk of mortality.

InpharmD Researcher Critique

This study has several limitations. The study period during a time when the pandemic was peaking in New York, with testing restricted to symptomatic and high-risk persons. The was also prior to the results of RECOVERY-dexamethasone were published and during a time when inappropriate therapies were being used (i.e., hydroxychloroquine, lopinavir/ritonavir) by inpatients and outpatients.

The data set was unbalanced did not match psychiatric patients with controls. As such, the patients with schizophrenia disorders had a higher prevalence of risk factors for severe COVID-19 (e.g., COPD, hypertension, diabetes). This degree of confounding could have lead to the results seen in this study, regardless of underlying schizophrenia.

This study may also be at risk of selection bias. Patients with psychiatric disorders may be less likely to seek medical attention; however, all patients included in this study had previous treatment and established access to healthcare.

The severity of COVID-19, the incidence of hospitalization, or if the patients were asymptomatic were not reported. This study also failed to report the status of psychological disorders (i.e., if they are managed or trying new therapies).



References:

Nemani K, Li C, Olfson M, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry. Published online January 27, 2021. doi:10.1001/jamapsychiatry.2020.4442