In a new article in The Lancet Psychiatry, researchers suggest that people diagnosed with “severe mental illness” should be among the first in line to receive a vaccine against the coronavirus (COVID-19). The researchers, led by Marc De Hert at KU Leuven, Belgium, write that this population has an increased risk of worse COVID outcomes, including an increased risk of death.
Research recently published in JAMA Psychiatry found that people diagnosed with schizophrenia were almost three times more likely (than the “healthy” control group) to die of COVID-related causes. The researchers were at a loss to explain why. That same study found that people diagnosed with “mood disorders or anxiety disorders” were not more likely to experience worse outcomes from COVID.
Thus, the schizophrenia diagnosis is most associated with a high risk of mortality from COVID. The current study focuses on promoting vaccination for this group and explaining possible reasons for the worse outcomes. De Hert writes:
“We have argued that people with severe mental illness should be given priority because they are a disadvantaged group based on both medical and socioeconomic risk factors for [COVID] infection, morbidity, and mortality.”
One of the primary reasons here is the high rate of comorbidities—people with “severe mental illness” are more likely to also suffer from obesity, diabetes, respiratory disease, and cardiovascular disease, according to De Hert.
These problems are known effects of psychiatric drugs, particularly antipsychotics, and most people diagnosed with schizophrenia are likely to take such drugs. This is one factor that may account for the decreased life expectancy that accompanies a psychiatric diagnosis.
Research in the British Journal of Psychiatry has found that the “mortality gap”—the likelihood that someone with a psychiatric diagnosis will die earlier than someone without—has worsened steadily since the dawn of the antipsychotic era. Researchers in the Archives of General Psychiatry argued that the use of antipsychotics might “further adversely influence mortality rates in the decades to come.”
According to De Hert, the immune system in people with “severe mental illness” may be compromised. He cites a few reasons for this. First, childhood adversity—which is highly associated with “severe mental illness”—is also associated with “dysregulated immunological function.” Additionally, chronic stress may have the same effect; so could sleep problems.
De Hert writes that previous research has found that people experiencing chronic stress or who had a psychiatric diagnosis also have an impaired reaction to vaccines—citing the flu vaccine, the varicella-zoster vaccine, and the hepatitis B vaccine—and are thus more likely to contract these diseases even after vaccination.
De Hert goes on to note that psychiatric drugs may also influence the immune system, leaving patients vulnerable to worsening COVID infections—and it may further impede the effectiveness of the COVID vaccine. Some drugs are specifically associated with an increased risk of infections; in particular, De Hert cites clozapine’s effects:
“Clozapine use is associated with neutropenia, which can confer susceptibility to infection. A secondary antibody deficiency has been observed in patients with long-term clozapine use, putting these patients at risk of immunodeficiency.”
Antipsychotic, antidepressant and “mood-stabilizing” drugs such as lithium may have an anti-inflammatory effect, but De Hert states that this may interfere with vaccine response. In particular, all of these drugs can impair normal cytokine function, which has unclear effects but may be responsible for the reduced effectiveness of vaccines.
“Future studies should evaluate vaccine efficacy, safety, and interactions with psychotropic medication specifically in people with severe mental illness so they can be properly informed of the benefits and risks of vaccination,” De Hert writes.
Despite the potential reduced efficacy of the COVID vaccine, De Hert suggests it is still imperative that people diagnosed with “severe mental illness” receive it. After all, with the increased likelihood of COVID-related complications and death, even slightly reduced protection is better than no protection.
“Because people with severe mental illness are at high risk for SARS-CoV-2 infection and COVID-19-related morbidity and mortality, they must be offered early access to safe and efficacious vaccines.”
De Hert urges that people with “severe mental illness” be prioritized, provided with accurate information about the vaccine and about COVID and that their providers engage in a discussion if the patient is hesitant about receiving the vaccine. However, he suggests that mandatory or involuntary vaccination may only increase people’s fear and reluctance to receive medical care.
“Clinicians should provide their patients with adequate information and counter misinformation, address negative attitudes in a respectful way, and discuss the advantages and possible risks of vaccination. In the end, it should be left to the individual to weigh the benefits and the risks, and to give informed consent for vaccination.”
Mazereel V, Van Assche K, Detraux J, & De Hert M. (2021). COVID-19 vaccination for people with severe mental illness: why, what, and how? The Lancet Psychiatry. Available online 3 February 2021. https://doi.org/10.1016/S2215-0366(20)30564-2 (Link)