Persons with mental disorders face an increased risk of COVID‐19‐related hospitalization and mortality. 1 , 2 , 3 This gives reasons to prioritize them for vaccination, 4 but their willingness to receive a COVID‐19 vaccine remains unclear. We investigated the association of attitudes towards COVID‐19 vaccination with mental disorders and symptom severity in persons with and without depressive, anxiety or obsessive–compulsive disorders (OCD).
Between 1 April 2020 and 11 June 2021, fourteen waves of online COVID‐19 questionnaires were distributed among participants (n = 2748) of three psychiatric case–control cohorts that started in early 2000: Netherlands Study of Depression and Anxiety, Netherlands Study of Depression in Older Persons, and Netherlands Obsessive Compulsive Disorder Association Study. Detailed information has been reported elsewhere. 5 The question ‘What is your current situation or view regarding vaccination against the COVID‐19 virus?’ was not included in the online COVID‐19 questionnaire until 23 February 2021 (the twelfth wave), when vaccines started to become available in the Netherlands. The current study consisted of 936 individuals (response rate 34.1%) with (n = 709) and without (n = 227) mental disorders who responded to the question of attitudes towards COVID‐19 vaccination at least once at the twelfth, thirteenth and fourteenth waves (mean age 58.7 [SD 12.4] years, 63.1% female).
We used participants' first response of attitudes towards COVID‐19 vaccination because their responses appeared to be consistent across the three waves of online questionnaires. They were categorized as willing to get vaccinated (including vaccinated persons) or unsure/unwilling to get vaccinated. We repeatedly collected information on whether participants themselves or household members had been diagnosed with COVID‐19, and whether close contacts died from COVID‐19 throughout the fourteen waves of online questionnaires. Participants who reported the experience at any wave were categorized as yes, otherwise no. We assessed symptom severity using four rating scales which have been validated in psychiatric cohorts: 16‐item Quick Inventory of Depressive Symptoms, 21‐item Beck Anxiety Inventory, 11‐item Penn State Worry Questionnaire and 6‐item de Jong Gierveld Loneliness scale, 5 at the same time as we collected information on attitudes towards COVID‐19 vaccination.
Mental disorders were diagnosed using DSM‐IV‐based clinical interview at pre‐pandemic waves, including major depressive disorder, dysthymia, panic disorder, generalized anxiety disorder, agoraphobia, social anxiety disorder and OCD. We counted the number of waves a participant attended and the number of waves at which a participant had a current (6‐month recency) disorder between 2006 and 2016. We divided the number of waves with a disorder by the number of waves attended yielding a ratio that represented the chronicity of disorders. Chronicity was categorized into no lifetime disorder (healthy controls), remitted disorder (participants who at baseline were diagnosed with a disorder that was persistently remitted during the remaining waves), low‐to‐medium chronicity (1%–50% of previous waves with disorders) and high chronicity (51%–100% of previous waves with disorders), conforming to prior analyses. 5
Considering the relatively large proportion of non‐responders in our study, we applied propensity score weighting 6 to address the potential problem of selective attrition bias. The propensity scores were estimated based on age, gender, education, source cohort and the chronicity of mental disorders. We performed logistic regression models to estimate the association of mental disorders, symptom severity, demographics and COVID‐19‐related factors with attitudes towards vaccination, weighted for the propensity scores.
Our study was approved by the Institutional Review Board of Vrije Universiteit Medical Center, Amsterdam, and adhered to the Declaration of Helsinki. All participants provided informed consent online.
Overall, 52.5% of participants were vaccinated and 35.1% reported a positive attitude towards COVID‐19 vaccination, while 8.1% and 4.3% expressed uncertainty and unwillingness for vaccination respectively. Older or more worried persons were more likely to be willing to get vaccinated, while female, persons with lower education, persons with more chronic mental disorders, those who were more lonely, and those who had been diagnosed with COVID‐19 were more unsure/unwilling to get vaccinated (Figure 1). Regarding specific psychiatric diagnoses, agoraphobia was associated with a lower willingness to get vaccinated, while OCD was associated with a higher willingness compared to persons with no lifetime mental disorder (Figure S1). Similar results were found when analysing unsure and unwilling as separate outcomes.
FIGURE 1.
Predictors of attitudes towards COVID‐19 vaccination. Odds ratios were weighted using propensity scores. Unadjusted weighted odds ratios were from models where predictors were entered separately; adjusted weighted odds ratios were from a model where all predictors were entered simultaneously. Symptom severity was based on standardized scores. QIDS, Quick Inventory of Depressive Symptoms; BAI, Beck Anxiety Inventory; PSWQ, Penn State Worry Questionnaire; DJGLS, de Jong Gierveld Loneliness scale
In Dutch psychiatric case–control cohorts of middle aged and older persons, we identified several characteristics, including younger age, female, lower education and a history of COVID‐19 infection, that were predictive of a lower willingness to get vaccinated. These findings are consistent with a previous study of general population. 7
We found that persons with more chronic mental disorders were less willing to get vaccinated. In contrast, self‐reported mental health conditions were unrelated to attitudes towards COVID‐19 vaccination in the British general population. 7 Furthermore, in China, persons with depression or anxiety disorders were more willing to pay for the COVID‐19 vaccine. 8 In our study, persons with OCD were more willing to get vaccinated, which may be due to the contamination subset of OCD with obsession over contracting or spreading germs. Contrastingly, those with agoraphobia were less willing to get vaccinated.
Prior research reported that concerns about the unforeseen future effects of vaccines, and general mistrust in the benefits and safety of vaccines were predictive of a negative attitude towards COVID‐19 vaccination. 7 Our finding of worry symptoms being predictive of a greater willingness to get vaccinated supports the notion that worrying during the COVID‐19 pandemic overshadows the concerns about the potential harms of vaccination.
Strengths of our study include the well‐phenotyped psychiatric status based on several diagnostic interviews before the pandemic and the use of multiple validated symptom severity scales which enable a broad assessment of emotional states during the pandemic. Limitations include selectivity of the responders; compared to non‐responders, responders were less likely to have high chronicity of mental disorders, resulting in underrepresentation of the most vulnerable groups in our sample. This may have biased our results towards an underestimation of the association between high chronicity of mental disorder and negative vaccination attitudes, which, however, may have been addressed by propensity score weighting. Furthermore, we were not able to distinguish the impact of specific concerns about COVID‐19 vaccine from that of general worrying during the pandemic on the willingness to get vaccinated due to the lack of information.
In conclusion, our study identified factors including demographics, mental disorders, symptom severity and COVID‐19 infection that were predictive of attitudes towards COVID‐19 vaccination. Specifically, persons with more chronic mental disorders seemed to be less willing to get vaccinated. We invite clinicians to take into account these factors when giving advice to psychiatric patients on COVID‐19 vaccination.
CONFLICT OF INTEREST
Prof. Penninx reports grants from Janssen Research and Boehringer Ingelheim, outside of the submitted work. All other authors declare no competing interests.
PEER REVIEW
The peer review history for this article is available at https://publons.com/publon/10.1111/acps.13399.
Supporting information
Fig S1
ACKNOWLEDGEMENTS
COVID‐19 online data collection and analyses were partly funded by a ‘fast track grant’ from the Dutch Research Council (grant no 440.20.009) and by the RESPOND project which has received funding from the European Union’s Horizon 2020 research and innovation programme Societal Challenges under grant agreement No 101016127. The infrastructure for the NESDA study is funded through the Geestkracht programme of the Netherlands Organisation for Health Research and Development (grant no 10‐000‐1002) and financial contributions by participating universities and mental health‐care organizations (VU University Medical Center, Geestelijke Gezondheidszorg (GGZ) inGeest, Leiden University Medical Center, Leiden University, GGZ Rivierduinen, University Medical Center Groningen, University of Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Rob Giel Onderzoekscentrum). The infrastructure for the NESDO study is funded through the Fonds NutsOhra (project 0701‐065), Stichting tot Steun VCVGZ, NARSAD The Brain and Behaviour Research Fund (grant id 41080), and by participating universities and mental health‐care organizations (VU University Medical Center, Leiden University Medical Center, University Medical Center Groningen, University Medical Center St Radboud, GGZ inGeest, GGNet, GGZ Nijmegen, GGZ Rivierduinen, Lentis, and Parnassia). The infrastructure for the NOCDA study is funded by participating universities and mental health‐care organizations (Academic Department VU Medical Center, GGZ inGeest, Innova Research Centre, Mental Health Care Institute GGZ Centraal, Marina de Wolf Anxiety Research Centre, Center for Anxiety Disorders Overwaal, Dimence, GGZ Overijssel, Department of Psychiatry at Leiden University Medical Center, Vincent van Gogh Institute Mental Health Care Centre, Academic Anxiety Center, PsyQ Maastricht University, Division Mental Health and Neuroscience, and Stichting Steun VCVGZ).
Pan K, Kok AAL, Penninx BWJH, Giltay EJ. Attitudes towards COVID‐19 vaccination: A comparison between persons with different chronicity of pre‐pandemic depressive, anxiety or obsessive–compulsive disorders Acta Psychiatr Scand.2022;145:412–415. doi: 10.1111/acps.13399
Brenda W. J. H. Penninx and Erik J. Giltay joint senior authors.
Funding information
The supporters had no role in the design, analysis, interpretation or publication of this study.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Fig S1
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.