Psychiatric Illnesses and COVID-19-Associated Mortality

A number of studies have investigated the association between psychiatric disorders and death from COVID-19. Benedetta Vai and colleagues combined data from a large number of these studies to determine which specific psychiatric disorders and types of psychiatric medications are associated with increased mortality. They recently published their findings in Lancet Psychiatry.

The investigators searched several databases for articles published between January 1, 2020, and March 5, 2021, that reported COVID-19 outcomes for patients with pre-existing psychiatric disorders in comparison to patients without psychiatric illness. From these articles, they selected a subset of studies that fulfilled specific criteria. They found 23 articles fulfilling their criteria and combined the data utilizing meta-analytic techniques.

The final analysis included almost 1.5 million patients with COVID-19. About 44,000 of these had a pre-existing psychiatric illness. Patients with the following groups of disorders were included in the analysis: schizophrenia and psychotic disorders, bipolar and depressive disorders, anxiety and stress-related disorders, substance use disorders, and intellectual disability and developmental disorders. The investigators also examined the relationship between COVID-19 mortality and the use of antipsychotic, antidepressant, and anxiolytic medications.

What did their analysis demonstrate? They found that there was a doubling of the odds of dying from COVID-19 for individuals with pre-existing mental disorders. The only disorders that were not associated with increased mortality were anxiety and stress-related disorders. This relationship between psychiatric illness and increased COVID-19 mortality was most robust for pre-existing psychotic disorders and mood disorders. Substance use disorders, more than the other groups of psychiatric disorders, were associated with the highest odds of needing hospitalization.

Both antipsychotic drugs and antianxiety medications were associated with increased COVID-19-related mortality. Antidepressants were not. The investigators noted that they could not determine how much of the risk from psychotropic medications was actually due to the increased risk associated with the underlying illness being treated with those medications. Interestingly, there was a relationship between anxiolytic medications and mortality even though there was no association between anxiety disorders and mortality. However, anxiolytics are used for multiple psychiatric illnesses and can have a direct effect on respiration that may account for increased morbidity in those with COVID-19.

Why are psychotic and mood disorders associated with increased mortality in patients with COVID-19? There are likely several reasons. Poorer self-care often occurs in individuals suffering from these disorders. Furthermore, some people with these illnesses may not receive adequate medical care for underlying medical conditions that may increase the risk of death from COVID-19. In addition, persons with psychotic or mood disorders may have abnormal inflammatory responses.

Health care providers should be aware that patients with mental disorders, particularly psychotic or mood disorders, are at increased risk of dying from COVID-19. Increased efforts at mitigation strategies to prevent COVID-19 are urgently needed for the entire population and especially for high-risk groups.

This column was written by Eugene Rubin, M.D., Ph.D., and Charles Zorumski, M.D.