Living with schizophrenia in a pandemic

As researchers around the world race to unravel the two-way enigma of severe mental illnesses and COVID-19, countries should prioritise vaccination for the millions affected by the double malady, says Debanjan Banerjee*.

doi:10.1038/nindia.2021.78 Published online 24 May 2021

MRI brain scan of a 58 year old man with paranoid schizophrenia.
Malati has missed her psychiatric appointments regularly since the second wave of COVID-19 struck India in March 2021. Last week, a distress call by her daughter alerted her psychiatrist. “She has been extremely restless, hasn’t eaten for a week suspecting someone has poisoned her food.”

Malati suffers from chronic schizophrenia, a severe psychotic disorder that she has been able to manage well with medicines for the last three years. She gets a monthly quota of medicines free from a public hospital in Bangalore, India, against a ‘Below Poverty Line’ (BPL) card. Long lockdowns have made her hospital visits erratic worsening her symptoms. Her family is now worried she may get COVID-19 for her reluctance to wear a mask.

For millions of people living with mental illnesses, the complex two-way relationship between existing disease and COVID-19 infection is real.

A study involving over 62,000 people with COVID-19 in the US found increased incidence of psychiatric diagnosis between 14 to 90 days of contracting the coronavirus1. The risk is greatest for anxiety disorders, insomnia, dementia and psychosis. Studying people six months after the COVID-19 infection, researchers also report increased risk of psychiatric illnesses, anxiety disorders, psychosis and dementia2.

An unequal pandemic

The pandemic has disproportionately affected people with mental disorders, especially severe mental illnesses (SMI) like schizophrenia that impair perception, thought and judgement. Some SMI patients suffer from delusion, auditory hallucination, suspiciousness, decreased motivation and disturbed sleep. Though they also show depressive tendencies, more than two-thirds respond to treatment.

People with mental illnesses may neglect their clinical condition and not adhere to COVID appropriate behaviour3. Travel restrictions and lockdowns further alienate them from accessing medical care. Besides, social chaos and fear, prolonged uncertainty, a deluge of misinformation and insomnia could lead to emotional dysregulation, aggression and relapses in disorders like schizophrenia. The rate of relapse following drug-default is as high as 30% and this adds a huge burden to the quality of life of the affected people and their families. Societal disruption and isolation are also associated with negative psychiatric outcomes4.

The National Mental Health Survey (NMHS), conducted during 2015-16 with more than 34,000 people across 12 Indian states5, found 1.9% suffering from SMI some time or the other in their life and 0.4% with schizophrenia and related disorders. Three out of 1000 Indians suffer from schizophrenia with men showing a younger age of onset6. Schizophrenia related disorders also have a significant burden of socio-economic status, poverty, health inequality, social stigma, discrimination, chronic cognitive deficits and homelessness7.

Complex intersections

Tarun was diagnosed with paranoid schizophrenia a year back and was doing well with antipsychotics. After a missed clinical appointment, his psychiatrist found out during a tele-consultation that Tarun was in his 13th day of COVID-19 infection. Though his respiratory parameters were better, he was in a delirium and quite agitated.

Delirium is a known neuropsychiatric sequalae of SARS-CoV-2, the other common ones being ischaemic strokes, hypercoagulable states, venous thrombosis, seizures and prolonged cognitive deficits. People with pre-existing SMI are at increased risk from almost all biopsychosocial factors1, 2. A month after recovery from COVID, Tarun developed a severe psychotic relapse and needed psychiatric inpatient care.

While a causal association is difficult to establish at the moment, there are known correlations between schizophrenia and COVID-19 infection8. Studying more than 15,000 COVID-19 patients in the US, researchers have found that the illness was higher in people with a recent diagnosis of schizophrenia, who also had higher hospitalisation and death rates. In South Korea and France, people affected with schizophrenia were found to have higher infection rates, morbidity, mortality, ICU care, respiratory complications and impaired quality of life when affected with SARS-CoV-2. A study in Spain with 625 patients found that people with psychosis experienced higher rates of anxiety, depression and sleep disturbance during lockdowns. In India, a survey showed that symptoms worsened in 30% of people SMI and one in five stopped taking medicines. Increase in distress, paranoia, delusions and hallucinations in schizophrenia patients was also common following social isolation and chronic stress.

The evidence on whether COVID-19 could trigger mental illness is still weak, documented only in some case reports and series. In most such cases, middle aged to older persons with moderate to severe COVID-19 infection showed brief and treatable acute onset paranoid delusions, auditory hallucinations, insomnia, wandering and agitation. This was strongly associated with COVID-19 inflammatory markers. In some others, an overdose of information and misinformation during the pandemic caused increased stress and anxiety leading to relapse of symptoms in schizophrenia8,9.

While stigma, unhealthy lifestyle (reduced physical activity, obesity, changed dietary patterns, disruption in day-night rhythms) and health inequality increases COVID-19 related mortality, the associated medical comorbidities in schizophrenia and lack of COVID appropriate behaviour may further increase the risk of infection8. This “double jeopardy” is worsened by preoccupation with self, low level of concern for infection, reduced information processing and other cognitive deficits, which make it difficult to communicate the health risks to them. It is possible, however, that this very self-absorbed nature may shield them from pandemic-related stress.

The role of viral and immune-mediated mechanisms in triggering psychotic disorders like schizophrenia has long been discussed. In fact, influenza infections form one of the prominent prenatal risk factors for schizophrenia. Whether SARS-CoV-2 can be added to this list is a research question for the future.

Treatment and vaccination concerns

Malati’s family is doubly stressed since she is yet to be vaccinated. Apart from a pre-existing mental illness and the lockdown, misinformation and vaccine hesitancy have made her miss the jab. Tarun, on the other hand, had a tough time juggling eight medicines (12 tablets) a day when hospitalised with COVID-19.

People with schizophrenia have a nearly 2.7 times higher mortality rate with COVID-199 than those who don’t have the SMI, and therefore need to be prioritised in national vaccination programmes. Mental health professionals should serve as “vaccine advocates” for all people with SMI considering their unique biopsychosocial vulnerabilities. Such professionals must stay updated about vaccination guidelines, liaise with primary healthcare, attempt to improve the knowledge-attitude-practice (KAP) of the families, raise awareness about vaccination drives to counter hesitancy and debunk fake news to counter anti-vax campaigns.

Psychiatrists and psychologists are in unique positions to understand the psychological dynamics behind the spread of misinformation. Further population-based research is needed to improve health-risk behaviours of the affected people10.

Of special mention is treatment of people already on antipsychotic drugs for schizophrenia being simultaneously treated for COVID-19. Safe and effective prescription of psychotropic medicine is of paramount importance11. However, medication like remdesivir, ivermectin and prednisolone commonly used in COVID-19 may affect the blood levels of common antipsychotics such as haloperidol, olanzapine, risperidone, aripiprazole and clozapine, and vice versa11. Corticosteroids commonly used in COVID-19 have a high risk of worsening schizophrenia and any other forms of psychosis12. The risk of cardiovascular and neurological side-effects is high with multiple drugs (polypharmacy). The impact of psychotropic drugs on vaccination-related antibody formation also needs to be researched further.

Special care needs to be adopted for older adults prone to severe COVID-19 infections. As a norm, too many drugs must be avoided and non-pharmacological care must be given, as far as possible.

Integrated care

Despite a sea of research around COVID-19 and SMIs in the last year, studies are limited by methodology, biases of online surveys and low-quality evidence such as case reports, series, opinions and clinical consensus. Robust cohort-based studies have just started and may elucidate this bi-directional enigma in the years to come. Nevertheless, SMI such as schizophrenia and related psychotic disorders can add to significant morbidity and social dysfunction both for the affected people and their families.

The Indian Mental Healthcare Act (2017) brought a rights-based dignified approach to psychiatric care. Improving health access, encouraging social welfare benefits, ensuring adequate awareness about COVID-19 infection and involving media for community-based awareness programs are imperative to reduce stigma associated with this SMI, especially during the pandemic.

With an overwhelmed healthcare infrastructure and limited mental health specialists, India’s rising burden of these disorders can affect resources at all levels. India’s recently released telepsychiatry guidelines provide a legal framework and standards for virtual mental health consultations. This can go a long way in disease surveillance, monitoring, and continued care13. Vulnerable populations with the illness such as the older persons, homeless mentally ill, socio-economically impoverished and those with treatment resistance need special attention.

Coming amidst India’s severe second wave of COVID-19, the World Schizophrenia Day (24 May 2021) offers an opportunity to advocate for holistic and comprehensive care for people affected with this severe mental disorder. Besides reaffirming commitment to better management of people with schizophrenia, this year an additional pledge that countries must make is to promote COVID appropriate behavior and prioritise vaccination for people with severe mental illness.

(*Debanjan Banerjee is a psychiatrist at the National Institute of Mental Health and Neurosciences, Bangalore, India. Names of the patients and case details have been altered to protect confidentiality.)


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