Underlying Mental Illness and Risk of Severe Outcomes Associated With COVID-19
Background: According to the Centers for Disease Control and Prevention, depression and schizophrenia, among other conditions, put individuals at high risk for severe COVID-19 infection. Patients at high risk often are eligible for outpatient therapies, such as antiviral and monoclonal antibody therapies, to prevent severe infection. However, depression and schizophrenia are not considered risk factors for severe COVID-19 infection at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, making patients with these conditions ineligible for outpatient therapy unless they have another high-risk condition.
Methods: This retrospective cohort study assessed outcomes among patients with mild-to-moderate COVID-19 to determine whether depression and/or schizophrenia impacted the risk of severe disease or negative outcomes. The primary outcome was severe COVID-19 outcomes defined as hospitalization, admission to the intensive care unit, intubation or mechanical ventilation, or death within 30 days of infection.
Results: Patients with depression or schizophrenia had more hospitalizations and deaths, but this difference was not statistically significant (P = .36). Death within 30 days of COVID-19 infection only occurred in patients with depression or schizophrenia.
Conclusions: Although there were more hospitalizations and deaths from COVID-19 within 30 days of infection among patients with depression and schizophrenia compared with individuals without these disorders, this finding was not statistically significant.
Results
More than 5000 individuals had a COVID-19 diagnosis during the study period. Among these patients, 4530 had no depression or schizophrenia diagnosis; 1021 individuals had COVID-19 and a preexisting diagnosis of depression or schizophrenia. Among these 1021 patients, 279 charts were reviewed due to time constraints; 128 patients met exclusion criteria and 151 patients were included in the study. Of the 151 patients with COVID-19, 78 had no depression or schizophrenia and 73 patients with COVID-19 had a preexisting depression or schizophrenia diagnosis (Figure).
The 2 groups were similar at baseline. The most common risk factors for severe COVID-19 included age > 60 years, obesity, and cardiovascular disease. However, more than half of the individuals analyzed had no risk factors (Table 1). Some patients with risk factors received antiviral or mAb therapy to prevent severe COVID-19 infection; combination nirmatrelvir and ritonavir was the most common agent (Table 2). Of the 73 individuals with a psychiatric diagnosis, 67 had depression (91.8%), and 6 had schizophrenia (8.2%).
Hospitalization or death within 30 days of COVID-19 infection between patients with depression or schizophrenia and patients without these psychiatric diagnoses was not statistically significant (P = .36). Sixteen individuals were hospitalized, 8 in each group. Three individuals died within 30 days; death only occurred in patients who had depression or schizophrenia (Table 3).
Discussion
This study found that hospitalization or death within 30 days of COVID-19 infection occurred more frequently among individuals with depression or schizophrenia compared with those without these psychiatric comorbidities. However, this difference was not statistically significant.
This study had several limitations. It was a retrospective, chart review study, which relied on accurate documentation. In addition, we reviewed COVID-19 cases from fiscal years 2020 to 2022 and as a result, several viral variants were analyzed. This made it difficult to draw conclusions, especially because the omicron variant is thought to be less deadly, which may have skewed the data. Vaccinations and COVID-19 treatments became available in late 2020, which likely affected the progression to severe disease. Our study did not assess vaccination status, therefore it is unclear whether COVID-19 vaccination played a role in mitigating infection. When the pandemic began, many individuals were afraid to come to the hospital and did not receive care until they progressed to severe COVID-19, which would have excluded them from the study. Many individuals had additional comorbidities that likely impacted their COVID-19 outcomes. It is not possible to conclude if the depression or schizophrenia diagnoses were responsible for hospitalization or death within 30 days of infection or if it was because of other known risk factors. Future research is needed to address these limitations.
Conclusions
More COVID-19 hospitalizations and deaths occurred within 30 days of infection among those with depression and schizophrenia compared with individuals without these comorbidities. However, this effect was not statistically significant. Many limitations could have contributed to this finding, which should be addressed in future studies. Because the sample size was small, further research with a larger patient population is warranted to explore the association between psychiatric comorbidities such as depression and schizophrenia and COVID-19 disease progression. Future studies also could include assessment of vaccination status and exclude individuals with other high-risk comorbidities for severe COVID-19 outcomes. These studies could determine if depression and schizophrenia are correlated with worse COVID-19 outcomes and ensure that all high-risk patients are identified and treated appropriately to prevent morbidity and mortality.
Acknowledgements
Thank you to the research committee at the Captain James A. Lovell Federal Health Care Center who assisted in the completion of this project, including Shaiza Khan, PharmD, BCPS; Yinka Alaka, PharmD; and Hong-Yen Vi, PharmD, BCPS, BCCCP.
