People with severe mental illness have a substantially reduced life expectancy, from 15–20 years less than those without schizophrenia, bipolar, or major depressive disorders. This grim statistic is, unfortunately, one of the few things that all in the mental health field can agree on—the evidence is too overwhelming to argue otherwise. The primary reasons for this disgraceful disparity are also well established: our governments and societies are not designed to support people with severe mental illness, leaving them vulnerable to a host of physical health comorbidities associated with unstable housing, unemployment, lack of education, and poor access to quality health care. Unsurprisingly, studies have also shown a strong association between COVID-19 mortality and severe mental illness. As risk factors for dying from COVID-19 go, the evidence clearly shows that a history of severe mental illness ranks near the top. Given these facts, it is astonishing that some governments are now doubting whether people with severe mental illness should be prioritised for COVID-19 vaccination.
A review of European Union vaccine priority plans revealed that only a small handful of 20 countries specifically prioritise those with severe mental illness, with a few additional countries using inclusion categories such as inpatient units, which would presumably cover some people with severe mental illness. New York State, which was ground zero for the COVID-19 epidemic in the USA and the first to administer approved vaccines, also prioritised people in inpatient psychiatric centres during the earliest phase of vaccinations. But most people with severe mental illness are in outpatient or community settings—and far too many live without shelter or any official care—which means that the majority of them are not being prioritised for vaccination.
The situation is even worse in other countries. In India, the Union Ministry of Health recently decided that specifically prioritising people with severe mental illness for COVID-19 vaccines was not needed since, as of May 1, 2021, all individuals older than 18 years are eligible to receive the vaccine. However, this logic cynically ignores the challenging realities of COVID-19 and vaccines in India, where demand far outweighs availability and where competition for access—between those who can afford to pay and those who will require state resources—is likely to fuel wide inequalities in vaccination rates, leaving many with severe mental illness to fend for themselves and be treated “as children of a lesser god”, according to Dr Soumitra Pathare, Director of the Centre for Mental Health Law & Policy, Pune, India. Another clear example of discrimination is the United Arab Emirates (UAE), whose government earlier this year actively excluded those with severe mental illness from receiving COVID-19 vaccines, a move shocking in its callousness and contempt for scientific evidence.
The Lancet Psychiatry would like to highlight, however, that injustice is not inevitable. Some of the aforementioned European Union countries did not initially see the need to prioritise until new evidence from mental health researchers convinced them otherwise. In the UAE, mental health clinicians and academics spoke out against the government's initial policy, and the exclusion of those with severe mental illness was reversed. These are small but important victories, and they demonstrate the need for our community to unite and continue focusing our efforts on evidence and advocacy to improve vaccination rates for those with severe mental illness.
But, still, more is needed. Discrimination against people with severe mental illness is an entrenched phenomenon and simply pushing for more prioritisation is unlikely to result in a substantial shift in vaccinations. For example, although the UK used an evidence-based approach that included severe mental illness as a factor when determining prioritisation, these patients are still not being vaccinated at the same rate as others. A broader effort to actively reach out to people with severe mental illness and to provide them with access to vaccines as well as to additional physical and mental health services, will be necessary and requires substantial immediate investment in staff and resources to make this a reality. From the early months of the pandemic, The Lancet Psychiatry urged the mental health community to focus on the most vulnerable populations, including those with severe mental illness, as they were likely to be at high risk to both COVID-19 and the negative effects of lockdown measures. We would like to remind our readers of this message, and urge policy makers and clinicians everywhere to make sure vaccination campaigns prioritise those with severe mental illness, not just on paper but in practice.
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