Schizophrenia is associated with risk factors for poor outcomes with SARS-CoV-2/coronavirus disease 2019 (COVID-19) infection, including diabetes, hypertension, and chronic obstructive pulmonary disease (COPD).1 A recent Korean study found that schizophrenia was associated with an increased risk of severe COVID-19 infection.1 Whether health outcomes and care differ between patients with COVID-19 with (versus without) comorbid schizophrenia remains unclear. Fond and colleagues2 compared in-hospital mortality and intensive care unit (ICU) admissions between patients with schizophrenia and those without a diagnosis of severe mental illness in a French population-based cohort study.
Study authors used the Programme de Medicalisation des Systemes d’Information (PMSI database), the French national hospital database. They included all hospitalized patients aged 15 years or older between February 1 and June 9, 2020, with identified COVID-19 and respiratory symptoms and a length of hospital stay longer than 24 hours. Patients with other severe mental illnesses, including bipolar disorder or recurrent major depression, were excluded. There was no loss to follow-up during the study period. Cases were defined as patients with a diagnosis of schizophrenia (ICD-10 codes F20*, F22*, or F25*) in either the acute care or psychiatric PMSI database. Controls were patients without a diagnosis of severe mental illness in the acute care PMSI database and were not listed in the psychiatric PMSI database. The primary outcome measure was in-hospital mortality and the secondary outcome was ICU admission. Outcomes were analyzed using multivariable logistic regression models, controlling for potential confounding factors.
A total of 50,750 patients were included in the analysis, including 823 patients with schizophrenia. The median age was 71 years. Patients with schizophrenia were more likely to be female, younger smokers, institutionalized, have dementia, hospitalized in a university (versus public or private) hospital, and have a longer length of hospital stay. Patients with schizophrenia were less likely to have invasive mechanical ventilation (10.7% vs 13.4%) and renal replacement therapy (2.1% vs 3.6%) than controls.
Patients with schizophrenia had increased in-hospital mortality compared with controls (25.6% vs 21.7%), with a 1.3-fold increased odds of death in multivariable analysis (adjusted odds ratio [OR] = 1.30, 95% confidence interval [CI] 1.08-1.56). There was a significant interaction between schizophrenia and age, with significantly increased mortality in patients with schizophrenia aged 65 to 80 years (adjusted OR = 1.62).
Patients with schizophrenia were less frequently admitted to the ICU compared with controls (23.7% vs 28.4%), which was confirmed by multivariable analysis (adjusted odds ratio [OR] = 0.75, 95% CI 0.62-0.91). There was also a significant interaction between schizophrenia and age, with more ICU admissions in patients aged < 55 years (adjusted OR = 1.58), and fewer ICU admissions in patients aged 65 to 80 years (adjusted OR = 0.53) and > 80 (adjusted OR = 0.51).
The authors concluded that this is the largest series of patients with schizophrenia and COVID-19 to date. They found evidence for the existence of disparities in health and health care between patients with versus without schizophrenia, including increased in-hospital mortality and decreased ICU admission. Study limitations include the absence of data on the time between onset of infection and hospitalization, psychotropic medication, and the use of anti-COVID-19 treatments. Nevertheless, findings suggest the importance of health care strategies before, during, and after hospitalization for reducing health disparities in this vulnerable population
The bottom line
Younger patients with schizophrenia who smoke, are obese, and have COPD are at heightened risk for poor outcomes with COVID-19 infection and should be targeted for early intervention.
Dr Miller is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric TimesTM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.
1. Ji W, Huh K, Kang M, et al. Effect of underlying comorbidities on the infection and severity of COVID-19 in Korea: A Nationwide Case–Control Study. J Korean Med Sci. 2020;35:e237.
2. Fond G, Pauly V, Leone M, et al. Disparities in intensive care unit admission and mortality among patients with schizophrenia and COVID-19: a national cohort study. Schizophr Bull. 2020;22;sbaa158. Epub ahead of print.
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