Mental Illness Tied to Increased Mortality in COVID-19

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A psychiatric diagnosis for patients hospitalized with COVID-19 is linked to a significantly increased risk for death, new research shows.

Investigators found that patients who were hospitalized with COVID-19 and who had been diagnosed with a psychiatric disorder had a 1.5-fold increased risk for a COVID-related death in comparison with COVID-19 patients who had not received a psychiatric diagnosis.

“Pay attention and potentially address/treat a prior psychiatric diagnosis if a patient is hospitalized for COVID-19, as this risk factor can impact the patient’s outcome — death — while in the hospital,” lead investigator Luming Li, MD, assistant professor of psychiatry and associate medical director of quality improvement, Yale New Haven Psychiatric Hospital, New Haven, Connecticut, told Medscape Medical News.

The study was published September 30 in JAMA Network Open.

Negative Impact

“We were interested to learn more about the impact of psychiatric diagnoses on COVID-19 mortality, as prior large cohort studies included neurological and other medical conditions but did not assess for a priori psychiatric diagnoses,” said Li.

“We know from the literature that prior psychiatric diagnoses can have a negative impact on the outcomes of medical conditions, and therefore we tested our hypothesis on a cohort of patients who were hospitalized with COVID-19,” she added.

To investigate, the researchers analyzed data on 1685 patients hospitalized with COVID-19 between February 15 and April 25, 2020, and whose cases were followed to May 27, 2020. The patients (mean [SD] age, 65.2 [18.4] years; 52.6% men) were drawn from the Yale New Haven Health System.

The median follow-up period was 8 days (interquartile range, 4 – 16 days) .

Of these patients, 28% had received a psychiatric diagnosis prior to hospitalization. The patients with psychiatric disorders were significantly older and were more likely to be women, White, non-Hispanic, and to have medical comorbidities (ie, cancer, cerebrovascular disease, congestive heart failure, diabetes, kidney disease, liver disease, myocardial infarction, and/or HIV).

Psychiatric diagnoses were defined in accordance with ICD codes that included mental and behavioral health, Alzheimer’s disease, and self-injury.

Vulnerability to Stress

The following table shows mortality rates of psychiatric vs nonpsychiatric hospitalzed COVID-19 patients (P < .001).

2 weeks 35.7% vs 14.7%
3 weeks 40.9% vs 22.2%
4 weeks 44.8% vs 31.5%

In the unadjusted model, the risk for COVID-19–related hospital death was greater for those who had received any psychiatric diagnosis compared to those had not (hazard ratio [HR], 2.3; 95% CI, 1.8 – 2.9; P < .001).

In the adjusted model that controlled for demographic characteristics, other medical comorbidities, and hospital location, the mortality risk somewhat decreased but still remained significantly higher (HR, 1.5; 95% CI, 1.1 – 1.9; P = .003).

Li noted a number of factors that might account for the higher mortality rate among psychiatric patients who had COVID-19 in comparison with COVD-19 patients who did not have a psychiatric disorder. These included “potential inflammatory and stress responses that the body experiences related to prior psychiatric conditions,” she said.

Having been previously diagnosed with a psychiatric disorder may also “reflect existing neurochemical differences, compared to those who do not have a prior psychiatric diagnosis, [and] these differences may make the population with the prior psychiatric diagnosis more vulnerable to respond to an acute stressor such as COVID-19,” she said.

Quality Care

Commenting on the findings for Medscape Medical News, Harold Pincus, MD, professor and vice chair of the Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York City, said it “adds to the fairly well-known and well-established phenomenon that people with mental illnesses have a high risk of all sorts of morbidity and mortality for non–mental health conditions.”

The researchers “adjusted for various expected [mortality] risks that would be independent of the presence of COVID-19,” so “there was something else going on associated with mortality,” said Pincus, who is also co-director of the Irving Institute for Clinical and Translation Research. He was not involved with the study.

Beyond the possibility of “some basic immunologic process affected by the presence of a mental disorder,” it is possible that the vulnerability is “related to access to quality care for the comorbid general condition that is not being effectively treated,” he said.

“The take-home message is that people with mental disorders are at higher risk for death, and we need to make sure that, irrespective of COVID-19, they get adequate preventive and chronic-disease care, which would be the most effective way to intervene and protect the impact of a serious disease like COVID-19,” he noted. This would include being appropriately vaccinated and receiving preventive healthcare to reduce smoking and encourage weight loss.

No source of funding for the study was provided. Li reported receiving grants from a Health and Aging Policy Fellowship during the conduct of the study. The other authors’ disclosures are listed in the original article. Pincus reports no relevant financial relationships.

JAMA Netw Open. Published online September 30, 2020. Full text

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