Association of Psychiatric Disorders With Mortality Among Patients With COVID-19 | Anxiety Disorders | JAMA Psychiatry | JAMA Network
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    4 Comments for this article
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    Let's give people with schizophrenia help
    Neil Sachs, MD, MPH | West County Adult Behavioral Health Clinic, Contra Costa County
    The authors of the study favor some unknown immune dysregulation as a factor in why the rates of death from Covid were higher in the schizophrenia group. This seems like a possible but not primary conclusion.

    Sure, the researchers controlled for various factors related to various health measures; and, sure, there may indeed be something unusual going on in the immune system--or any other system for that matter.

    But the conclusion and intervention that seems to make the most sense in helping people with schizophrenia to avoid death from Covid--and all the other modifiable risk factors
    from which they die--would be increased wrap-around social services. We have, as society, willfully neglected this obvious and cost-effective approach to some of our most vulnerable.

    Neil Sachs, MD, MPH
    Psychiatrist
    CONFLICT OF INTEREST: None Reported
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    Obesity and medications may influence COVID-19 outcomes in schizophrenia
    Zeryab Meyer | Institute of Psychiatry, Psychology & Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF
    Nemani et al(1) find the odds of a patient with schizophrenia dying or being discharged to hospice due to COVID-19 to be 2.67 times higher than for non-psychiatric patients. Although variables relevant to COVID-19 outcome were controlled for in the regression analysis underpinning this conclusion (including age, co-morbidities, gender, and smoking status), one crucially relevant variable was not adjusted for nor discussed: body mass index (BMI).

    Obesity, independent of diabetes, has been correlated with increased mortality in COVID-19 patients,(2) so much so that the United States Center for Disease Control and Prevention list a BMI ≥ 30 kg/m2 as a
    definite risk factor for severe COVID-19 infection.

    Relevantly, the association of schizophrenia with physical health issues is long documented, with obesity an important concern.(3) The increased odds of mortality observed here, therefore, may have been due to an effect of high BMI on COVID-19 outcome, as opposed to a direct effect of schizophrenia.

    Additionally, the absence of data on medication history was a significant limitation. Although briefly acknowledged by the authors, the subject warranted a more thorough discussion. Anti-psychotic drugs are ubiquitous across the schizophrenia population. Some of these medications carry immunological and thromboembolic effects(4) and many are known for their propensity to cause weight gain; hence, they may influence COVID-19 mortality. Further, without medication history, we have no knowledge of whether those who survived did so because they received more intensive pharmacological therapies for COVID-19, or because patients with schizophrenia are more likely to refuse potentially life-saving COVID-19 interventions; historically, schizophrenia patients have shown high rates of non-compliance with medical treatments,(5) an example coming from our own psychiatric services when a patient with schizophrenia suffering from COVID-19 refused oxygen, dexamethasone and heparin.

    Overall, we believe this to be a noteworthy initial report on the topic of COVID-19 outcomes in patients with psychiatric conditions. However, these analyses do omit relevant confounders, and any resulting interpretations regarding the effects of schizophrenia on COVID-19 mortality should take this caution into consideration.

    Mr Zeryab Meyer, 5th Year Medical Student.
    Dr Diego Quattrone, M.D., Ph.D.
    Professor Sir Robin M Murray Dsc., FRS.

    References

    1. Nemani K, Li C, Olfson M, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry. 2021.
    2. Docherty AB, Harrison EM, Green CA, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. Bmj. 2020;369:m1985.
    3. Annamalai A, Kosir U, Tek C. Prevalence of obesity and diabetes in patients with schizophrenia. World J Diabetes. 2017;8(8):390-396.
    4. Ostuzzi G, Papola D, Gastaldon C, et al. Safety of psychotropic medications in people with COVID-19: evidence review and practical recommendations. BMC Medicine. 2020;18(1):215.
    5. Piette JD, Heisler M, Ganoczy D, McCarthy JF, Valenstein M. Differential Medication Adherence Among Patients With Schizophrenia and Comorbid Diabetes and Hypertension. Psychiatric Services. 2007;58(2):207-212.
    CONFLICT OF INTEREST: None Reported
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    Obesity, metabolic syndrome and the use of antipsychotics should be included in any analyses in mortality by COVID in schizophrenia spectrum
    Fabio Souza, MD, PhD. | Federal University of Ceará
    The paper by Nemani et al. focused on patients with schizophrenia spectrum disorders (SSD) and COVID mortality. They report an important finding: the association between SSD and mortality by COVID 19. In their research many variables were found to be highly related to death by COVID, such as smoking status, hypertension, heart failure, diabetes, COPD, cancer, chronic kidney disease, myocardial infarction and age. It was found that the diagnosis of SSD was the second most important variable associated with death by COVID losing only to age. However, the paper has major flaws: It did not analyze obesity, metabolic syndrome (metS) and the use of antipsychotics in the population.1
    It was not wise to leave obesity aside. Obesity augments significantly the mortality by COVID.3 Why the paper examines the consequences of obesity (diabetes and heart condition) but it did not analyze the underlying disease which is obesity?
    People with a diagnosis of schizophrenia have a 2–3 times increased standard mortality ratio, for all causes of death. Compared to the general population, the risk of developing cardiovascular illness is doubled They have high obesity rates which may have been aggravated in COVID pandemic due sedentarism, lack of social contact and overeating.3
    Second generation antipsychotic (SGA) are of proven efficacy in controlling positive and negative symptoms, but they have a downside, they induce an expressive weight gain that is associated with premature death.3
    Long term use of antipsychotics (AP) is associated with increased mortality risk. It has been shown that long term use of AP was associated with more weight gain compared with short term use. Body Mass Index (BMI) increases after first exposure to AP from more than 1 BMI point after 4–8 weeks, to almost 4 BMI points after 24–48 weeks. Increasing number of reports have shown that SGAs are strongly associated with accelerated weight gain, insulin resistance, diabetes, dyslipidemia, and increased the cardiovascular risk.3 Therefore, duration of AP use is thought to constitute an important factor contributing to weight gain and should have been included in the paper by Nemani et al.1
    The metS is a major risk factor for mortality in schizophrenia as demonstrated by Vancampfort’s meta-analysis4 that found schizophrenia patients have a significantly higher risk of abdominal obesity (OR=4.43), low HDL-C (OR=2.35), hypertriglyceridemia (OR=2.73), and MetS (OR=2.35).5 None of these aspects were evaluated in the paper by Nemani et al.1
    In the logistic regression analysis, the authors did not include these important variables. It is not possible to exclude the influence of these variables in the mortality by COVID in patients diagnosed with schizophrenia spectrum disorders.
    References
    1. Nemani K, Li C, Olfson M, Blessing EM, et al. Association of Psychiatric Disorders With Mortality Among Patients With COVID-19. JAMA Psychiatry. 2021 Jan 27:e204442.
    2. Petrakis D, Margină D, Tsarouhas K, et al. Obesity a risk factor for increased COVID 19 prevalence, severity and lethality (Review). Mol Med Rep. 2020 Jul;22(1):9-19.
    3. Bak M, Fransen A, Janssen J, et al. Almost all antipsychotics result in weight gain: a meta-analysis. PLoS One. 2014 Apr 24;9(4): e94112.
    4. Vancampfort D, Wampers M, Mitchell AJ, et al. A meta-analysis of cardio-metabolic abnormalities in drug naïve, first-episode and multi- episode patients with schizophrenia versus general population controls. World Psychiatry. 2013;12(3):240-250.
    Fabio GM Souza
    Luísa Bisol
    Pedro Victor Cabral
    Gerardo Autran
    CONFLICT OF INTEREST: None Reported
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    Excess SARS-CoV-2 Mortality of Patients With Schizophrenia Spectrum Disorder due to the Dis-Order of the Core Self
    Daniel Brenner, MD, MPH | Psychiatric Services of Aargau, Switzerland
    The 2.7-fold excess Covid-19 mortality of people affected by a schizophrenia spectrum disorder is most likely not only explained by a possibly impaired immunological response or the not completely controlled risk for somatic diseases but by the core Gestalt of schizophrenia as Josef Parnas has pointed out (World Psychiatry 2012;11:67-9). The dis-order of the core self (World Psychiatry 2018;17:220-1) also impairs the caring of oneself contributing to the excess SARS-CoV-2 mortality of patients with schizophrenia spectrum disorder in comparison to other psychiatric disorders.

    PS to the Editor: Please replace my comment of March 28, 2021 with is updated version
    - many thanks in advance!
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    January 27, 2021

    Association of Psychiatric Disorders With Mortality Among Patients With COVID-19

    Author Affiliations
    • 1Department of Psychiatry, New York University Langone Medical Center, New York, New York
    • 2Nathan Kline Institute for Psychiatric Research, Orangeburg, New York
    • 3Department of Population Health, New York University Langone Medical Center, New York, New York
    • 4Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
    JAMA Psychiatry. 2021;78(4):380-386. doi:10.1001/jamapsychiatry.2020.4442
    Key Points

    Question  Is a diagnosis of schizophrenia spectrum, mood, or anxiety disorders associated with increased risk of mortality in patients with coronavirus disease 2019 (COVID-19)?

    Findings  In this cohort study of 7348 adults with laboratory-confirmed COVID-19 in a New York health system, a schizophrenia spectrum diagnosis was associated with an increased risk of death after adjusting for demographic and medical risk factors. Mood and anxiety disorders were not associated with increased risk of mortality.

    Meaning  A diagnosis of a schizophrenia spectrum disorder may be a risk factor for mortality in patients with COVID-19.

    Abstract

    Importance  To date, the association of psychiatric diagnoses with mortality in patients infected with coronavirus disease 2019 (COVID-19) has not been evaluated.

    Objective  To assess whether a diagnosis of a schizophrenia spectrum disorder, mood disorder, or anxiety disorder is associated with mortality in patients with COVID-19.

    Design, Setting, and Participants  This retrospective cohort study assessed 7348 consecutive adult patients for 45 days following laboratory-confirmed COVID-19 between March 3 and May 31, 2020, in a large academic medical system in New York. The final date of follow-up was July 15, 2020. Patients without available medical records before testing were excluded.

    Exposures  Patients were categorized based on the following International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnoses before their testing date: (1) schizophrenia spectrum disorders, (2) mood disorders, and (3) anxiety disorders. Patients with these diagnoses were compared with a reference group without psychiatric disorders.

    Main Outcomes and Measures  Mortality, defined as death or discharge to hospice within 45 days following a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result.

    Results  Of the 26 540 patients tested, 7348 tested positive for SARS-CoV-2 (mean [SD] age, 54 [18.6] years; 3891 [53.0%] women). Of eligible patients with positive test results, 75 patients (1.0%) had a history of a schizophrenia spectrum illness, 564 (7.7%) had a history of a mood disorder, and 360 (4.9%) had a history of an anxiety disorder. After adjusting for demographic and medical risk factors, a premorbid diagnosis of a schizophrenia spectrum disorder was significantly associated with mortality (odds ratio [OR], 2.67; 95% CI, 1.48-4.80). Diagnoses of mood disorders (OR, 1.14; 95% CI, 0.87-1.49) and anxiety disorders (OR, 0.96; 95% CI, 0.65-1.41) were not associated with mortality after adjustment. In comparison with other risk factors, a diagnosis of schizophrenia ranked behind only age in strength of an association with mortality.

    Conclusions and Relevance  In this cohort study of adults with SARS-CoV-2–positive test results in a large New York medical system, adults with a schizophrenia spectrum disorder diagnosis were associated with an increased risk for mortality, but those with mood and anxiety disorders were not associated with a risk of mortality. These results suggest that schizophrenia spectrum disorders may be a risk factor for mortality in patients with COVID-19.

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