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Psychiatry Practice Research Review

Released: September 29, 2021

COVID-19 Hospitalization, Mortality, Vaccination, and Postvaccination Trends Among People With Schizophrenia in Israel: Longitudinal Cohort Study

Bitan DT, et al. Lancet Psychiatry. 2021;8:901-908.

Background
Individuals with schizophrenia have an increased risk of severe COVID-19 outcomes; nonetheless, no previous study has provided a yearlong account of this risk or assessed postvaccination trends in this population. This study assessed temporal trends in COVID-19 hospitalization and mortality among people with schizophrenia during the first year of the pandemic, the predictors for COVID-19 vaccination, postvaccination infection, admission to hospital, and mortality.

Methods
In this longitudinal cohort study, patients with schizophrenia (n = 25,539) and controls (n = 25,539) were assessed for COVID-19 outcomes before and after vaccination, up to April 30, 2021. Statistical analyses were performed to assess longitudinal trends. The study used the databases of Clalit Health Services, the largest healthcare organization in Israel.

Results
The sample included 51,078 participants, of whom 31,141 (61%) were male and 19,937 (39%) were female participants, with a mean age of 51.94 years. Most of the sample was from the general Jewish population (75.9%), followed by the Arab (19.1%) and ultraorthodox Jewish (5.1%) populations. Overall, of 51,078 individuals, 356 (0.7%) people had been hospitalized, 133 (0.3%) had died, and 27,400 (53.6%) had been vaccinated. People with schizophrenia showed a statistically significantly higher risk for COVID-19 hospitalization and mortality. They also showed a statistically significantly sharper decline in survival as time progressed. The control group showed a statistically sharper incline in probability to vaccinate. A medical comorbidity of diabetes, hypertension, obesity, or ischemic heart disease played a statistically significant role in predicting vaccination rates in the schizophrenia group but not in the control group. Hospitalization and mortality disparities remained higher among people with schizophrenia who had not been vaccinated in comparison to controls (incidence rate difference: 6.2 and 3.2, respectively) but substantially declined in fully vaccinated groups (incidence rate difference: 1.1 and -0.9, respectively).

Conclusions
People with schizophrenia have higher hospitalization and mortality risk, but they have lower rates of vaccination than in the general population. Disparities in COVID-19 severe outcomes can be substantially reduced by national vaccination plans aimed at actively reaching out to people with schizophrenia.

Clinical Commentary
The COVID-19 pandemic continues to challenge the medical field and poses unique obstacles for psychiatrists. It is crucial to identify vulnerable populations predisposed to negative outcomes. Patients with severe and persistent mental illness remain a challenge for getting vaccinated due to reduced access to medical care reflected in the low uptake of immunizations among this group. Studies suggest that people with severe mental illness have a 2- to 3-times higher mortality rate than do the general population and are more likely to be obese or have physical diseases, such as cardiovascular diseases, type 2 diabetes, and respiratory tract diseases, all risk factors for worse COVID-19–related outcomes. This study includes a control group and has a large sample size, and comparisons were conducted between patients with schizophrenia and controls as well as between vaccinated vs nonvaccinated cohorts. The limitations of this study were that patients were identified by diagnosis code, included a narrow homogenous group of patients with schizophrenia, and did not include patients with new-onset schizophrenia. This study was conducted in Israel, which was one of the first countries to reach a high COVID-19 vaccination rate as the vaccines became available.

Clinical Insights

  • This study replicates the findings of previous studies. Patients with schizophrenia who contract COVID-19 have increased risk of hospitalization and mortality. As the hospitalization is prolonged, the risk of mortality increases.
  • Vaccination works as noted by this study. Vaccinated patients with schizophrenia had better post–COVID-19 outcomes.
  • Patients with schizophrenia have lower digital literacy, inadequate broadband access, and impaired insight, all of which affect their ability to set up vaccination appointments.
  • These patients may be misinformed about the COVID-19 vaccination, which may be incorporated into their delusions. Negative symptoms may result in a lack of motivation to get the COVID-19 vaccine.
  • A focused vaccination effort is needed such as is being done for the medically ill, older patients, and immunocompromised individuals. Patients with severe mental illnesses, such as schizophrenia, should be added to this priority list.

Summary
In my professional opinion and based on this large study, patients with schizophrenia have a higher risk of COVID-19 mortality especially those who are not vaccinated. Medical conditions, like diabetes, dyslipidemia, obesity, and cardiovascular disease, which are common in this population, increase their risk of negative outcomes. Among patients with schizophrenia, paranoia may need to be addressed with to reduce vaccine hesitancy and increase immunization rates. Hence, psychiatrists and mental health professionals are uniquely qualified to lead advocacy in this area.

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