Deaths from COVID-19 among those with mental health disabilities were nine times higher than the general population

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The greater number of deaths amongst those with mental health conditions and intellectual disabilities has been amplified during the COVID-19 pandemic, a study based on more than 160,000 patients has revealed.

Before the pandemic the rates of mortality in those with severe mental health conditions were already higher than the general population. New research published in The Lancet Regional Health – Europe shows that between March and June 2020, during the first wave of COVID-19, mortality further increased in people with mental health conditions and intellectual disabilities compared with the general population.

The study was published in the run up to World Mental Health Day on 10 October 2021 which this year has the theme ‘Mental Health in an Unequal World’.

Deaths from COVID-19 among those with learning disabilities were nine times higher than the general population during the first lockdown period, according to the study, and for those with eating disorders almost five times higher.

For those with personality disorders and those with dementia, deaths from COVID-19 were about four times higher than the general population and more than three times higher in people with schizophrenia.

The research was part-funded by the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) and used the Clinical Record Interactive Search (CRIS) system to analyze anonymised data from clinical e-records of patients from South London.

Lead author Dr. Jayati Das-Munshi, Reader in Social and Psychiatric Epidemiology at King’s College London and Honorary Consultant Psychiatrist with South London and Maudsley NHS Foundation Trust, said: “The results from our study paint a stark picture of how the existing vulnerability of those with mental health conditions and intellectual disabilities have worsened during the COVID-19 pandemic.

The higher death rates compared to the general population were associated with more deaths from COVID-19 infection itself, as well as deaths from other causes.

“People living with severe mental health conditions and intellectual disabilities should be considered a vulnerable group at risk of COVID-19 mortality, as well as deaths from other causes, throughout the pandemic. We suggest a need to prioritize vaccination and optimize physical health care and suicide risk reduction, before, during and after peaks of COVID-19 infection in people living with mental health conditions.”

Through the NIHR Maudsley BRC’s Clinical Records Interactive System (CRIS) researchers analyzed anonymised data from 167,122 patients at South London and Maudsley NHS Foundation Trust on deaths between 2019 and 2020.

They assessed mortality ratios across nine mental health conditions and intellectual disabilities and by ethnicity. These were standardized by age and gender and were also compared with five-year average weekly deaths (from 2015 to 2019) from England and Wales. These were then standardized against population data from London, to assess whether estimates were accounted for by local area-level effects.

Senior author Rob Stewart, Professor of Psychiatric Epidemiology & Clinical Informatics at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, said: “These findings and their implications illustrate the importance of being able to learn from the information contained in health records. We have worked with the Maudsley’s CRIS platform for nearly 15 years now and a key focus has been to highlight inequalities in mortality and general health. Because CRIS information is updated on a weekly basis, this has allowed us to track the progress of the COVID-19 pandemic and its impact on mental health services.”

Deaths in those with mental health conditions and intellectual disabilities fell from July 2020 to September 2020 as COVID-19 cases fell and lockdowns eased, however remained double that of the general population which was similar to the figures before the pandemic.

Similar mortality trends were observed across minority ethnic groups within the sample, with South Asian and Black Caribbean people with severe mental health conditions and intellectual disabilities being 2.5 times more likely to die in the pandemic period compared to the year prior to the pandemic.

Elevated mortality risks were also evident for White British and Black African people with severe mental health conditions and intellectual disabilities.


The increased incidence of COVID-19 among individuals with mental disorders has been reported in at least 2 nationwide cohort studies in the US,8,9 with depression and schizophrenia associated with the highest infection risk in one sample.8

This association may be attributable to socioeconomic and environmental factors that contribute to exposure (eg, crowded housing, institutional settings, and lack of personal protective equipment).

Because outcomes may differ by diagnosis, it is important to determine which infected patients are at increased risk of adverse outcomes. In a US cohort study of 1685 hospitalized patients with COVID-19, those with any psychiatric disorder had an increased risk of death, but specific diagnoses were not examined.10

A Korean study found similar rates of adverse clinical events between patients with COVID-19 who had any mental illness and matched controls, but a higher risk of adverse clinical outcomes in individuals with severe mental illness.11 To our knowledge, the risk of mortality by psychiatric diagnosis has yet to be evaluated.

The present study evaluated the association between psychiatric disorders and mortality among adults with COVID-19. Psychiatric disorders were grouped into schizophrenia spectrum disorders, mood disorders, and anxiety disorders.

Based on previous studies of all-cause mortality,12 we hypothesized that the risk of mortality would be increased in all 3 psychiatric diagnostic groups and would be highest for patients with schizophrenia spectrum disorders, intermediate for mood disorders, and lowest in patients with anxiety disorders compared with patients without psychiatric diagnoses.

Discussion

In this retrospective cohort study of 7348 patients with confirmed COVID-19, a schizophrenia spectrum diagnosis was associated with increased odds for 45-day mortality after controlling for age, sex, race, and known medical risk factors.

Without adjustment, the odds for mortality in adults with mood disorders was increased compared with the reference group but was no longer statistically significant after adjustment for demographic characteristics and medical comorbidities. There was not a significant association between an anxiety disorder diagnosis and mortality.

Although previous observational studies in the US have reported an increased incidence of COVID-19 among patients with psychiatric disorders8,9 and increased mortality risk in broadly defined cohorts of patients with any mental disorder,8,10 to our knowledge, this is the first study to report the risk of mortality by psychiatric diagnostic group.

The results of this analysis suggest that the risk of severe or fatal illness may differ by diagnosis. In a population that may be more susceptible to infection, determining which patients may be at highest risk for adverse outcomes is necessary to guide clinical decision-making, including the need for enhanced monitoring and targeted interventions.

The results should be interpreted with several caveats. During the study period, the pandemic was at its peak in New York City. Testing was largely restricted to symptomatic and high-risk people, as reflected in the high rate of positive test results (27.7%).

The study population was limited to patients who had access to treatment within the NYU health care system and received testing and evaluation. Mortality risk was increased in those with recent documentation of a mood disorder after demographic adjustment, suggesting that stage of illness (acute vs stable) may contribute to differential risk in patients with episodic psychiatric disorders.

The most notable finding from this study is the high risk of mortality associated with schizophrenia spectrum diagnoses, ranking second behind age in strength of an association among all demographic and medical risk factors examined in this sample. Individuals with schizophrenia spectrum disorders had 2.7 times the odds of dying after adjustment for known risk factors.

A higher risk with schizophrenia spectrum diagnoses was expected based on previous studies of all-cause mortality, but the magnitude of the increase after adjusting for comorbid medical risk factors was unexpected. It is possible that unmeasured medical comorbidities contributed to this finding, although the risk remained significantly increased after adjustment for multiple established risk factors.

Delays in treatment seeking or reduced access to care may have contributed to worse outcomes. However, the lower rate of positive test results in the schizophrenia spectrum group compared with the reference group argues against selection bias as an explanation for the higher odds of mortality observed.

Beyond systemic barriers to care and delayed treatment, adults with schizophrenia spectrum diagnoses may be more susceptible to COVID-19 mortality due to biological factors related to their psychiatric illness or treatment. The results of this analysis are consistent with those of a nationwide study from South Korea in which government-mandated testing and enhanced monitoring were provided to all citizens.

The investigators reported a similar risk of infection but higher risk of severe clinical outcomes in patients with psychotic disorders.11 Although the mechanism underlying this association is not clear, immune dysregulation in the setting of genetic or acquired risk factors is a possibility.

Variation in the major histocompatibility complex is one of the most highly replicated findings in genome-wide association studies of schizophrenia susceptibility,14-17 and previous research has shown deficits in cellular immunity resulting in dysfunctional T cell–mediated immune responses in patients with schizophrenia.18,19

Genetic variability across major histocompatibility complex class I genes may contribute to differences in immune response to COVID-19,20 and inappropriate T-cell responses have been implicated in the pathophysiologic characteristics of severe infection.21-23 Perturbations in inflammatory cytokine signaling have been reported in association with schizophrenia,24-26 which may increase COVID-19 severity and mortality.27

reference link : https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2775179


More information: All-cause and cause-specific mortality in people with mental disorders and intellectual disabilities, before and during the COVID-19 pandemic: cohort study, The Lancet Regional Health—Europe, DOI: 10.1016/j.lanepe.2021.100228

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