COVID-19 Risks for People with Serious Mental Illness

To date, nearly one million Americans  have lost their lives to COVID-19. As we learn more about COVID-19 illness and recovery and the effectiveness of vaccination, public health experts are turning their attention from the general public to those most at risk from infection. Older adults and those with pre-existing medical conditions are more likely to experience severe COVID-19 if infected, raising the risk of hospitalization and death. And even though vaccination dramatically reduces this risk, it does not eliminate it. It is therefore crucial that people who are at highest risk seek medical attention right away after testing positive for COVID-19. Research shows that, if given early enough, antiviral treatments can help reduce illness and death among people diagnosed with COVID-19.

Many of the factors that increase the chances of severe COVID-19 are likely well known to the general public. Risk factors such as high blood pressure, diabetes, heart disease, chronic obstructive pulmonary disease (COPD), and smoking are all frequently cited by public health experts and featured in articles in the popular press. But one major risk factor is less known: serious mental illness (SMI). Study after study has documented that people with SMI are not only more likely to get COVID-19 compared to the general population, they are also more likely to suffer from severe COVID-19, require hospitalization, and die.

We saw some evidence of the risks associated with SMI as early as the fall of 2020. A team led by my colleague, Nora Volkow, M.D., Director of the National Institute on Drug Abuse, used electronic health records to examine  COVID-19 outcomes among adults with diagnosed mental illnesses. The study showed that Americans with a recent diagnosis of depression or schizophrenia had a seven-fold increased likelihood of COVID-19 infection. These individuals died at nearly twice the rate of those without a mental disorder. The risks were even greater for African Americans with SMI.

These findings have since been confirmed and extended in several additional studies from the U.S. and other countries. One Canadian study  examined the increased risk associated with SMI and a range of other risk factors. Studying health care records from almost 170,000 people, the researchers found that SMI raised the risk of death from COVID-19 by more than 40%, a bigger increase than that associated with such well-known risk factors as heart disease, high blood pressure, or COPD.

Similarly, a study of the UK Biobank , a research cohort of more than 440,000 people in the United Kingdom, showed that people with SMI were hospitalized with COVID-19 twice as often as those without SMI, and that SMI was associated with higher rates of illness and death compared to heart disease, COPD, diabetes, and other better-known health risk factors.

Why do people with serious mental illnesses such as schizophrenia, depression, and bipolar disorder have higher rates of COVID-19 and why are they more likely to die from the disease?

One contributing factor may be increased rates of co-occurring health risks among people with SMI. Relative to the general population, people with SMI have higher rates of smoking, high blood pressure, heart disease, obesity, and other COVID-19 risk factors. And yet, research shows that people with SMI still are at increased risk even after accounting for these co-occurring risk factors.

Another possibility is that the medications that people with SMI take to help manage their symptoms could contribute to COVID-19 severity. However, a study examining antidepressant medications  does not support this theory. In fact, people with depression taking antidepressants appeared to be at slightly lower risk of dying from COVID-19 than people with depression who were not taking antidepressants.

Finally, although vaccines are a highly effective tool to mitigate COVID-19 risk, research shows  that vaccinated people with SMI remain at increased risk of coronavirus infection compared to vaccinated people without SMI.

It is important for people with SMI and their families to know that SMI is an independent risk factor for severe illness or death from COVID-19. The good news is there are things people can do to decrease this risk! We know that vaccination dramatically reduces the likelihood of severe illness. And people with SMI who get COVID-19 should know that there are antiviral medications that can reduce the risk of hospitalization, so it is important to reach out as soon as possible after a positive test and to ask your health care provider about these life-saving drugs.

The Centers for Disease Control website has more information on risk factors  and available treatments .

So stay safe, get vaccinated, and stay informed about your options if you should get COVID-19.

References

Ge, E., Li, Y., Wu, S., Candido, E., & Wei, X. (2021). Association of pre-existing comorbidities with mortality and disease severity among 167,500 individuals with COVID-19 in Canada: A population-based cohort study. PLOS ONE, 16 (10), e0258154. https://doi.org/10.1371/journal.pone.0258154 

Hassan, L., Peek, N., Lovell, K., Carvalho, A. F., Solmi, M., Stubbs, B., & Firth, J. (2022). Disparities in COVID-19 infection, hospitalisation and death in people with schizophrenia, bipolar disorder, and major depressive disorder: A cohort study of the UK Biobank. Molecular Psychiatry, 27(2), 1248–1255. https://doi.org/10.1038/s41380-021-01344-2 

Nishimi, K., Neylan, T. C., Bertenthal, D., Seal, K. H., & O'Donovan, A. (2022). Association of psychiatric disorders with incidence of SARS-CoV-2 breakthrough infection among vaccinated adults. JAMA Network Open, 5, e227287. https://doi.org/10.1001/jamanetworkopen.2022.7287 

Oskotsky, T., Marić, I., Tang, A., Oskotsky, B., Wong, R. J., Aghaeepour, N., Sirota, M., Stevenson, D. K. (2021). Mortality risk among patients with COVID-19 prescribed selective serotonin reuptake inhibitor antidepressants. JAMA Network Open, 4, e2133090. https://doi.org/10.1001/jamanetworkopen.2021.33090 

Wang, Q., Xu, R., & Volkow, N.D. (2020). Increased risk of COVID‐19 infection and mortality in people with mental disorders: Analysis from electronic health records in the United States. World Psychiatry, 20, 124-130. https://doi.org/10.1002/wps.20806