As evidence mounts that patients with severe mental illness are at increased risk of severe COVID-19, some countries are reassessing their vaccine priority strategies. Nayanah Siva reports.
“The evidence is really very clear. We have well over six studies now published with data from US, the UK, Denmark, and Sweden all showing the same thing”, Livia De Picker, University Psychiatric Hospital Campus Duffel, Antwerp, Belgium, told The Lancet. “Patients with severe mental illness, which is patients with psychotic disorder, bipolar disorder, or severe depression, are at a significantly increased risk of being hospitalised or dying from COVID.”
Currently, however, only four countries have updated their vaccination strategies to proritise patients with severe mental illness. In December, 2020, both Denmark and the UK updated their vaccination guidance. The Netherlands followed in January, 2021, and 2 weeks ago Germany did the same.
Evidence shows that the severity of outcomes due to COVID-19 in this patient group is similar to that of those with cardiac, pulmonary, or autoimmune issues. “Their [patients with severe mental illness] odds are double that of people without severe mental illness, which is the same range as the highest risk groups”, said De Picker.
People with severe mental illness may be more likely to have living circumstances, diet, or comorbidities, such as diabetes or cardiovascular disease, that contribute to an increased risk of severe outcomes from COVID-19. We also need to think about there being an association with severe mental illness and immune system dysfunction, explained Carmine Pariante, professor of psychiatry, King's College London, London, UK.
Prioritising vaccination is based on risk factors for having a severe outcome, and so when the evidence shows that people with severe mental illness are at high risk they should be among the prioritised groups, explained Michael E Benros, Biological and Precision Psychiatry, Copenhagen Research Centre for Mental Health, Copenhagen, Denmark. “In a Danish nationwide study, psychotic disorders were associated with an increased 30-day mortality when having COVID-19 by 3·3 times compared with other COVID-19 patients. In the same study, having psychotic disorders was associated with a 2·5 times increased risk of being hospitalised due to COVID-19”. Benros also points to another study in JAMA showing that schizophrenia was a risk factor for mortality in patients with COVID-19.
The evidence is new and still emerging and experts do not think countries are necessarily being neglectful. But there is a concern about this group because they are often neglected in policy making. “It is our hope that raising awareness to this disconnect between evidence and policy will lead to more countries to follow suit”, said Marisa Casanova Dias, vice president, European Union of Medical Specialists (UEMS), Section of Psychiatry.
Groups in Belgium are advocating for patients with severe mental illness to be considered in their vaccine strategy. “We don’t want people with severe mental illness to jump over other categories with high risk. The main issue is as always, [patients with severe mental illness] tend to be forgotten”, said Marc De Hert, KU Leuven, Leuven, Belgium. “Our argument is one of equity...people with severe mental illness must enter the line of people with high risk compared with the general population of the same age”, added De Hert.
Despite patients with severe mental illness being included in the priority vaccination group in the UK, a study of over 23 million National Health Service patients has found that those with severe mental illness were less likely to be vaccinated. “We were very concerned to see that among the over-70s, who are currently being prioritised for vaccination in the UK, people with severe mental illness, such as schizophrenia and bipolar affective disorder, are less likely to have received vaccination”, said Ben Goldacre, director of The DataLab, University of Oxford, Oxford, UK, and one of the authors of the study. “At the moment it is impossible to tell from the data whether this...is due to increased rates of vaccine hesitance among people with severe mental illness, or somehow related to the logistics of service delivery”, he added.
Organisations in many countries continue to campaign for this patient group to be prioritised. “At the end of January, the Polish Psychiatric Association shared a position calling for the removal of existing barriers and priority vaccination in a group of people with serious mental illnesses, but it seems it takes much more shared action between different stakeholders to make this voice heard”, said Anna Szczegielniak, Department of Psychiatric Rehabilitation, Medical University of Silesia, Katowice, Poland.
“Different countries are at different stages of developing and putting in practice their plans”, said Casanova Dias. “Now is the time to act. Europe's main psychiatry and patient organisations call for concerted action to ensure that vulnerable mental health patients are prioritised in vaccination strategies.”