Disparities in Intensive Care Unit Admission and Mortality Among Patients With Schizophrenia and COVID-19: A National Cohort Study

Abstract

Patients with schizophrenia (SCZ) represent a vulnerable population who have been understudied in COVID-19 research. We aimed to establish whether health outcomes and care differed between patients with SCZ and patients without a diagnosis of severe mental illness. We conducted a population-based cohort study of all patients with identified COVID-19 and respiratory symptoms who were hospitalized in France between February and June 2020. Cases were patients who had a diagnosis of SCZ. Controls were patients who did not have a diagnosis of severe mental illness. The outcomes were in-hospital mortality and intensive care unit (ICU) admission. A total of 50 750 patients were included, of whom 823 were SCZ patients (1.6%). The SCZ patients had an increased in-hospital mortality (25.6% vs 21.7%; adjusted OR 1.30 [95% CI, 1.08–1.56], P = .0093) and a decreased ICU admission rate (23.7% vs 28.4%; adjusted OR, 0.75 [95% CI, 0.62–0.91], P = .0062) compared with controls. Significant interactions between SCZ and age for mortality and ICU admission were observed (P = .0006 and P < .0001). SCZ patients between 65 and 80 years had a significantly higher risk of death than controls of the same age (+7.89%). SCZ patients younger than 55 years had more ICU admissions (+13.93%) and SCZ patients between 65 and 80 years and older than 80 years had less ICU admissions than controls of the same age (−15.44% and −5.93%, respectively). Our findings report the existence of disparities in health and health care between SCZ patients and patients without a diagnosis of severe mental illness. These disparities differed according to the age and clinical profile of SCZ patients, suggesting the importance of personalized COVID-19 clinical management and health care strategies before, during, and after hospitalization for reducing health disparities in this vulnerable population.

COVID-19 in People With Schizophrenia: Potential Mechanisms Linking Schizophrenia to Poor Prognosis

“…The prevalence of COVID-19 in people with comorbid schizophrenia is not dissimilar between the genders (49 and 51% for males and females, respectively), while women had higher death rates and less ICU admissions than men (13). This is discrepant to the general population, where male gender is a risk factor for ICU admission and mortality (31).…”

“…Schizophrenia appears to be associated with poorer prognosis in patients with COVID-19. A French population-based cohort study has reported a higher odds of mortality among in-patients with schizophrenia compared with controls [AOR 1.30 [95% CI, 1.08-1.56], P = 0.0093) (13). Another case-control study reported that patients with SMD including schizophrenia are 1.3 times more likely to experience severe outcomes (mortality, It is noteworthy that all the study estimates described above were adjusted for potential confounders, including age, gender and chronic medical comorbidities such as CVD, DM, COPD, cancer etc.…”

“…The risk of SARS-CoV-2 infection and associated mortality increases with age, with males more at risk of higher mortality rates than females (30). The average age of patients with schizophrenia hospitalised for COVID-19 is younger than the general population (13). Moreover, a recent study has reported that younger patients with comorbid schizophrenia (<55 years) and COVID-19 had an increased risk of intensive care unit (ICU) admissions (13).…”

“…The average age of patients with schizophrenia hospitalised for COVID-19 is younger than the general population (13). Moreover, a recent study has reported that younger patients with comorbid schizophrenia (<55 years) and COVID-19 had an increased risk of intensive care unit (ICU) admissions (13). In addition, age may also interact with schizophrenia liability for increased risk of SARS-CoV-2 infection.…”

“…Importantly, the increased risk of COVID-19 in patients with SMD remained after adjusted analysis, suggesting that the underlying SMD itself could directly contribute to the increased risk of COVID-19 infections (15). In hospitalised COVID-19 patients with schizophrenia, the prevalence of CVD was (23%), cerebrovascular disease (8%), COPD (15%), diabetes (25%), dementia (25%), cancer (6%), and renal disease (12%) compared to those without schizophrenia (29,6,13,28,9, and 14%, respectively) (13). The prevalence for CVD was higher among younger patients (<55 years) who also had more ICU admissions (13).…”