Abstract
We examined COVID-19 vaccination, incidence, and mortality rates among patients with mental health disorders in South Korea from 1 January 2020 to 31 December 2021. The study found that individuals with mental disorders had higher COVID-19 incidence and mortality than those without. Patients with mood disorders had higher vaccination rates and COVID-19 incidence and mortality than those without mental disorders. In contrast, patients with schizophrenia had lower vaccination rates, slightly lower COVID-19 incidence, and higher COVID-19 mortality. Patients with mental health disorders have been vulnerable to COVID-19, and more attention should be paid to their vaccination and health needs.
Keywords: COVID-19, Psychiatric disorders, Incidence, Mortality, Epidemiology, Mental health
1. Introduction
During the coronavirus disease 2019 (COVID-19) pandemic, health outcomes related to COVID-19 were worse in vulnerable populations than in the general population. Patients with mental disorders were vulnerable to COVID-19; racial and ethnic minorities and individuals of low socioeconomic status were also affected (Magesh et al., 2021, Tai et al., 2021). A nationwide study in the US reported that individuals with depression were more likely to be infected with COVID-19 (Wang et al., 2021). A systematic review and meta-analysis of mortality from COVID-19 in individuals with schizophrenia reported a 2.22 times higher risk of death due to COVID-19 than those without the disorder (Pardamean et al., 2022). Several studies have been conducted on the health outcomes of COVID-19 among individuals with mental health disorders in countries in Asia (Jeon et al., 2021, Lee et al., 2020). However, previous studies were conducted on limited cases and for limited periods because they were conducted during the early stages of the COVID-19 pandemic.
Further studies are needed to address the magnitude and extent of vulnerability to COVID-19 in patients with mental disorders and to provide scientific evidence to support and implement policies to protect patients with mental health disorders against infectious diseases such as COVID-19. In cooperation with the Korea Centers for Disease Control and Prevention, we studied the vulnerability of individuals with mental illnesses to COVID-19 during the pandemic using nationwide data on COVID-19 vaccination and health outcomes from 1 January 2020 to 31 December 2021. This study aimed to investigate the differences in COVID-19 vaccination, incidence, and mortality rates among individuals with mental disorders, including mood disorders and schizophrenia.
2. Methods
2.1. Study design
We used the Korea Disease Control and Prevention Agency-COVID-19-National Health Insurance Service cohort (K-COV-N cohort) from the National Health Insurance Service (NHIS), which covers most of the South Korean population. The cohort encompassed all medical use data for insurance reimbursement of NHIS patients, including COVID-19 vaccination history, diagnosis, and death registry data (date and cause of death). This study was exempt from review by the Institutional Review Board of Seoul National University Bundang Hospital (X-2207-768-901), as it used de-identified data provided by the NHIS according to the NHIS personal information protection guidelines.
2.2. Data collection
Participants without a history of medical utilisation with a psychiatric diagnostic code (F00–F99) of the International Classification of Diseases and Related Health Problems 10th revision (ICD-10), within three years before the study period, were defined as individuals without mental disorders. Patients with any mental disorder, mood disorders, and schizophrenia were defined as participants with a medical history with the following ICD-10 codes: any mental disorder (F00–F99), mood disorders (F32–34 and F38–39, excluding F32.3 and F33.3), and schizophrenia (F25, F30–31, F32.3, and F33.3) (Lee et al., 2020).
A vaccinated person was defined as someone who received a second dose of vaccination during the study period or a first dose of vaccination with the Janssen COVID-19 vaccine. COVID-19 incidence was defined as persons diagnosed with COVID-19 during the study period. COVID-19 mortality was defined as death due to COVID-19 during the follow-up period.
The demographic variables of the participants were derived from the NHIS database, including age (years), gender (male or female), residential district (metropolitan cities or other areas), and household income. The NHIS categorised the household income of participants in a range of one (lowest) to 20 (highest), and these were divided into five groups (Q1 = 1–4; Q2 = 5–8; Q3 = 9–12; Q4 = 13–16; and Q5 = 17–20). Comorbidities were defined as participants visited with the diagnostic codes in the five years before 1 January 2020, including hypertension, diabetes, or hypercholesterolaemia. Those with myocardial infarction, stroke, and cancer were also defined as participants with a history of claims in the past five years. The Charlson Comorbidity Index (CCI) was used to summarise the comorbidities statuses (Sundararajan et al., 2004).
2.3. Statistical analysis
Participant characteristics were described according to their mental disorder status (without mental disorders, any mental disorder, mood disorders, or schizophrenia). We constructed multivariate logistic regression models to compare COVID-19 vaccination, incidence, and mortality rates according to mental disorder status. Fully adjusted models were constructed using age, gender, income, region, number of persons per household, and CCI (0, 1–2, and 3) as covariates. Statistical analyses were performed using the R Software. Statistical significance was defined as a two-tailed P-value < 0.05.
3. Results
The data from 51,139,790 individuals were collected during the study period. Table 1 presents the baseline characteristics of the study participants and COVID-19 incidence, mortality, and vaccination status according to mental disorder status (See Table 1).
Table 1.
Baseline characteristics of participants and Coronavirus disease 2019 (COVID-19) vaccination, incidence, and mortality cases.
| Characteristic | Without mental disorders | Any mental disorder | Mood disorders | Schizophrenia |
|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | |
| Total | 39,610,986 (100.0) | 11,528,804 (100.0) | 4,688,981 (100.0) | 350,973 (100.0) |
| Gender | ||||
| Male | 21,025,817 (53.1) | 4,584,875 (39.8) | 1,812,203 (38.7) | 166,431 (47.4) |
| Female | 18,585,169 (46.9) | 6,943,929 (60.2) | 2,876,778 (61.4) | 184,542 (52.6) |
| Age (years) | ||||
| < 20 | 8,319,376 (21.0) | 526,790 (4.6) | 157,773 (3.4) | 11,399 (3.3) |
| 20–44 | 15,020,144 (37.9) | 2,639,558 (22.9) | 1,136,266 (24.2) | 109,135 (31.1) |
| 45–64 | 12,519,940 (31.6) | 4,313,140 (37.4) | 1,685,115 (35.9) | 151,466 (43.2) |
| 65–74 | 2,476,371 (6.3) | 1,937,416 (16.8) | 783,519 (16.7) | 36,004 (10.3) |
| ≥ 75 | 1,275,155 (3.2) | 2,111,900 (18.3) | 926,308 (19.8) | 42,969 (12.2) |
| Income | ||||
| 1st Quintile (highest) | 13,319,485 (33.6) | 3,814,300 (33.1) | 1,517,634 (32.4) | 70,336 (20.0) |
| 2nd Quintile | 10,122,093 (25.6) | 2,511,224 (21.8) | 977,258 (20.8) | 48,600 (13.9) |
| 3rd Quintile | 8,015,722 (20.2) | 2,138,975 (18.6) | 844,894 (18.0) | 47,093 (13.4) |
| 4th Quintile | 7,487,801 (18.9) | 2,246,674 (19.5) | 907,206 (19.4) | 64,021 (18.2) |
| 5th Quintile (lowest) | 665,885 (1.7) | 817,631 (7.1) | 441,989 (9.4) | 120,923 (34.5) |
| Region | ||||
| Metropolitan cities | 20,614,701 (52.0) | 5,153,804 (44.7) | 2,128,173 (45.4) | 163,336 (46.5) |
| Other areas | 18,996,285 (48.0) | 6,375,000 (55.3) | 2,560,808 (54.6) | 187,637 (53.5) |
| Comorbidities | ||||
| Hypertension | 5,422,378 (13.7) | 4,184,785 (36.3) | 1,746,024 (37.2) | 91,102 (26.0) |
| Diabetes mellitus | 2,919,605 (7.4) | 2,230,633 (19.4) | 979,937 (20.9) | 69,742 (19.9) |
| Dyslipidemia | 6,962,009 (17.6) | 4,864,846 (42.2) | 2,075,685 (44.3) | 118,169 (33.7) |
| Myocardial infarction | 110,712 (0.3) | 93,865 (0.8) | 41,582 (0.9) | 2,145 (0.6) |
| Stroke | 766,385 (1.9) | 1,175,182 (10.2) | 548,670 (11.7) | 28,315 (8.1) |
| Cancer | 1,143,245 (2.9) | 806,085 (7.0) | 357,660 (7.6) | 16,228 (4.6) |
| COVID-19 | ||||
| COVID-19 vaccination | 32,232,720 (81.4) | 10,240,354 (88.8) | 4,150,726 (88.5) | 290,952 (82.9) |
| COVID-19 incidence | 6,863,689 (17.3) | 1,871,232 (16.2) | 743,073 (15.9) | 47,848 (13.6) |
| COVID-19 mortality | 8682 (0.02) | 19,244 (0.2) | 9605 (0.2) | 1157 (0.3) |
Table 2 presents odds ratios for COVID-19 vaccination, incidence, and mortality. After adjusting for age, gender, income, region, persons per household, and comorbidities, the probability of vaccination was higher among any mental disorder and mood disorders groups. However, it was lower among patients with schizophrenia than among the general population. The risk of COVID-19 infection, compared to individuals without mental disorders, increased significantly among participants with mental and mood disorders but decreased significantly among those with schizophrenia. The risk of COVID-19 mortality was consistently higher in the mental disorders, mood disorders, and schizophrenia groups than in the general population.
Table 2.
Odds ratios for coronavirus disease 2019 (COVID-19) complete vaccination, incidence, and mortality according to mental disorder.
| Odds ratios (95% confidence intervals) |
|||
|---|---|---|---|
| Group | Total | Male | Female |
| COVID-19 Vaccination | |||
| Without mental disorders |
1 (reference) | 1 (reference) | 1 (reference) |
| Any mental disorder | 1.157 (1.154–1.160) | 1.056 (1.053–1.060) | 1.246 (1.242–1.250) |
| Mood disorders | 1.060 (1.057–1.064) | 0.958 (0.953–0.963) | 1.139 (1.134–1.144) |
| Schizophrenia | 0.584 (0.579–0.590) | 0.590 (0.582–0.598) | 0.584 (0.576–0.591) |
| COVID-19 Incidence | |||
| Without mental disorders |
1 (reference) | 1 (reference) | 1 (reference) |
| Any mental disorder | 1.062 (1.060–1.064) | 1.070 (1.066–1.073) | 1.049 (1.046–1.051) |
| Mood disorders | 1.032 (1.029–1.035) | 1.034 (1.029–1.038) | 1.029 (1.026–1.033) |
| Schizophrenia | 0.921 (0.912–0.931) | 0.979 (0.964–0.994) | 0.885 (0.874–0.897) |
| COVID-19 Mortality | |||
| Without mental disorders |
1 (reference) | 1 (reference) | 1 (reference) |
| Any mental disorder | 1.710 (1.663–1.758) | 1.652 (1.509–1.715) | 1.773 (1.701–1.848) |
| Mood disorders | 1.947 (1.885–2.012) | 1.861 (1.778–1.948) | 2.017 (1.924–2.115) |
| Schizophrenia | 4.091 (3.829–4.370) | 3.600 (3.259–3.977) | 4.425 (4.047–4.839) |
Bold text indicates a statistically significant difference with a P-value < 0.05
The covariates in the fully adjusted model were as follows: age, gender, income, region, number of persons per household, and Charlson comorbidity index (0, 1–2, and 3).
4. Discussion
We discovered that mental disorders significantly increased COVID-19 incidence and mortality risk. Thus, the results of this study are consistent with those of previous studies (Ceban et al., 2021, Sartorious, 2013, Taquet et al., 2021, Wang et al., 2021). Among Asian countries, it has been suggested that the COVID-19 pandemic could increase the risk of mental health crisis, and strategic plans and resource allocation are needed to address the risk (Efstathiou et al., 2022, Mallik and Radwan, 2021, Shoib et al., 2021). Considering that the number of patients with mental disorders could increase during the pandemic, and they are more vulnerable to the general population, it implies that more attention and action to protect this vulnerable group are necessary.
A slightly higher OR for COVID-19 incidence and a moderately higher OR for COVID-19 mortality were observed among patients with mood disorders than those without mental disorders. There could be some explanations for the much higher mortality rate than the general population, even considering the slightly higher incidence of COVID-19. First, common behavioural risk factors among patients with mood disorders (Strine et al., 2008), such as smoking and obesity are significant risk factors for COVID-19 mortality (Dessie and Zewotir, 2021). Second, vaccine efficacy may be weakened in patients with mood disorders (Kiecolt-Glaser et al., 1996, Li et al., 2007, Madison et al., 2021) Third, disturbances in the immune system of individuals with mood disorders could lead to COVID-19 mortality (Howren et al., 2009).
Patients with schizophrenia had a significantly lower vaccination rate. In Israel, the vaccination rate among patients with schizophrenia was approximately 80 % of that of the general population (Bitan, 2021). Patients with schizophrenia could have limited health literacy, so health professionals’ recommendation for vaccination is necessary (Kim et al., 2019, Lorenz et al., 2013). The vaccination policy of the South Korean government has mainly covered psychiatric patients admitted to or institutionalised in hospitals. However, many patients with schizophrenia in the community have not been cared for properly as the community healthcare system has weakened and cannot provide face-to-face services during the COVID-19 pandemic.
Among patients with schizophrenia in South Korea, a significantly lower COVID-19 incidence and a considerably higher COVID-19 mortality were observed than in individuals without mental disorders. This finding is inconsistent with previous research reporting that patients with schizophrenia have a lower risk of COVID-19 incidence (Wang et al., 2021). However, the increased risk of COVID-19 mortality among patients with schizophrenia noted in the present study is consistent with the findings of previous studies (Lee et al., 2020, Nemani et al., 2021). Patients with schizophrenia may be more vulnerable to COVID-19 through several mechanisms. First, their low vaccination rate could be related to high COVID-19 mortality. Second, patients with schizophrenia have a higher prevalence of smoking, obesity, diabetes mellitus, and cardiovascular disease than the general population, which is closely related to the severity of COVID-19 (Dickerson et al., 2018, Pardamean et al., 2022, Patanavanich and Glantz, 2020, Shinn and Viron, 2020). Finally, the medical needs of patients with COVID-19 and schizophrenia were unmet in South Korea; admission into general hospitals, despite their poor health status, was difficult. As the World Health Organization suggested, mental health should be integrated into the general health system (World Health Organization, 2005). However, most hospitals in South Korea to which psychiatric patients can be admitted are psychiatric hospitals or institutional care facilities; however, the available psychiatric resources in general hospitals are insufficient to handle psychiatric patients with severe respiratory symptoms.
4.1. Conclusion
Individuals with mental disorders in South Korea are more vulnerable than the general population to the COVID-19 pandemic. In particular, patients with mood disorders exhibited significantly higher COVID-19 incidence and mortality rates than those without mental disorders, despite the high COVID-19 vaccination rate in South Korea, implying that COVID-19 prevention strategies should be strengthened and tailored for patients with mood disorders to provide sufficient medical resources, including hospitals and beds, to treat severe COVID-19 cases. Patients with schizophrenia exhibited a considerably lower vaccination rate than the general population and a four-fold higher COVID-19 mortality rate than those without mental disorders. Based on these findings, health policies and strategies against infectious diseases should be implemented to target vulnerable populations.
CRediT authorship contribution statement
Dong-Wook Lee: Writing – original draft, Visualization, Conceptualization. Ye-Seul Bae: Writing – review & editing. Jae-Ryun Lee: Investigation, Data curation. Ji Hoon Son: Writing – review & editing. Hye-Jin Lee: Writing – review & editing, Project administration. Jin-Yong Lee: Project administration, Supervison.
Financial Disclosure
We received no external funding for this study.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Acknowledgements
This study was conducted as part of the public-private joint research on COVID-19 co-hosted by the KDCA and the NHIS. This study used the database of the KDCA and the NHIS for policy and academic research. The research number of this study is KDCA-NHIS-2022-1-528.
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The KDCA is the Korea Disease Control and Prevention Agency, the Republic of Korea.
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The NHIS is the National Health Insurance Service, the Republic of Korea.
Declaration of interest
The authors have no conflicts of interest to declare.
Patient and other consents
Due to retrospective and anonymiㄴed nature, the need for consent was waived.
Data statement
The data supporting this study’s findings are available from The National Health Insurance Service. Restrictions apply to the availability of these data, which were used under license for this study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this study’s findings are available from The National Health Insurance Service. Restrictions apply to the availability of these data, which were used under license for this study.