Updated: May 22, 2020
In January 2020, coronavirus disease-19 (COVID-19) rapidly and suddenly grew to a global pandemic causing an unprecedented death count that continues to rise. The World Health Organization and many governments have enforced social distancing and isolation guidelines to flatten the viral infection curve and slow the spread of the virus (WHO, 2020). Although these public health efforts are targeting entire populations, these strategies are less effective in certain marginalized groups, including those with schizophrenia and related disorders. Schizophrenia is a long-term mental disorder that involves the breakdown between thought, emotion, and behavior leading to a withdrawal from reality. Features of these disorders that may put these individuals at higher risk of becoming infected with COVID-19 include delusions, hallucinations, disorganized behavior, cognitive impairment, and poor insight (Morgan et al., 2017). Sociodemographic characteristics, including a high proportion of individuals living in congregate housing or being homeless (Olfsan et al., 2015) put those with schizophrenia at a high risk for poor mental and physical health during the pandemic. Furthermore, individuals with schizophrenia have been found to have more adverse outcomes, including premature death, compared to the general population even prior to the pandemic. This has been linked to poor health maintenance, greater socioeconomic disadvantage and the stigma surrounding schizophrenia (Saha et al., 2007). This paper will examine factors in why individuals with schizophrenia are at increased risk of COVID-19 infection and poor outcomes, mental health consequences, and what situations we can apply these findings to. Protective measures and appropriate use of healthcare services among people with schizophrenia and other mental disorders could have profound implications for containment of the pandemic.
Why are Schizophrenic Individuals at Elevated Risk of Acquiring COVID-19
The neurological disruptions of schizophrenia often translates into a poor quality of living which is linked to higher rates of COVID-19 infection and serious symptoms. Cognitive impairment, lower awareness of risk, and barriers to adequate infection control including congregate living may make individuals with schizophrenia more susceptible to transmission of COVID-19 (Yao et al., 2020). Since schizophrenia is characterized by impairments in insight and decision-making capacity, it may be harder for people with schizophrenia to adopt the protective measures recommended to prevent infection (Maguire et al., 2019). Hand washing, social distancing, and wearing masks is something that is much more difficult for those with schizophrenia to comprehend or adhere to. Their tendency to make disillusioned and risky decisions are also the reason many are homeless or in prisons, which are hot spots of COVID-19 infection (Kinner et al., 2020). For incarcerated or homeless individuals, mental health support and social distancing is near impossible during a pandemic. The stress created from these low quality living conditions compounded with decreased services during stay-at-home orders, widespread fear of COVID-19, and restricted access to information create a whirlwind of bad psychological and physical consequences.
Comorbid substance abuse disorders are highly prevalent in schizophrenic patients which increases the frequency of impaired judgments and decision-making for a large portion of schizophrenic individuals (Hunt et al., 2018). For example, smoking is prevalent in more than 60% of people with schizophrenia. This behavior may increase the risk of disease progression and severe complications from COVID-19 including death due decreased lung and immune responsiveness. Early data found that mortality from COVID-19 is particularly increased in patients with comorbid diseases such as cardiovascular disease, diabetes, and chronic respiratory disease which are more common in the schizophrenic population compared to the general populations (Wu et al., 2020). Antipsychotic medications such as clozapine, commonly prescribed in schizophrenia, appear to increase risk of death from pneumonia related to impaired swallowing, sedation, and hypersalivation (De Leon et al., 2020). On the other hand, with rapidly changing policies such as curb-side delivery of medication can be difficult for those with schizophrenia to adapt to without a caretaker. Without their regularly scheduled medicine, their positive symptoms may increase or reappear making them relapse into disillusioned thoughts or even life-threatening hallucinations.
Furthermore, preexisting health disparities could be exacerbated in the context of limited resources. Resources tend to go to more privileged demographics before going to disadvantaged ones. Demand for ventilators, blood transfusions, and COVID-19 tests rose to the point where states and countries were attempting to out-bid each other to get them. Failure to promote fair and equitable resource allocation could result in more severe complications for people with schizophrenia amongst other marginalized populations (Emanuel et al., 2020). The combination of preexisting conditions, risky behavior, and disadvantaged living areas that many patients with schizophrenia have serious physical consequences. The mental health of these individuals also need to be examined to understand the extent at which they are at risk of bad outcomes during the pandemic and understanding the implications of these discrepancies.
Mental Health Impact of COVID-19 on Schizophrenia
Previous outbreaks such as the 2003 Severe Acute Respiratory Syndrome (SARS) pandemic have had persistent mental health effects (Mak et al., 2009). The SARS pandemic was accompanied by significantly elevated rates of psychiatric disorder symptoms and psychological distress. Early on, public health experts already put out the mental health warnings of COVID-19 to the general public with extra precautions for patients with preexisting disorders (Yao et al., 2020). Since stress levels related to a global pandemic relates to worsening mental health in the general population, the impact for those living with schizophrenia may have a compounded effect. Moreover, COVID-19 infection itself may exacerbate symptoms in people with schizophrenia, as coronaviruses may be associated with psychotic symptoms via an immune-related mechanism (Severance et al., 2011). Steroid treatment is often needed when patients are in critical care and psychosis is a common side effect. If a patient has schizophrenia, this psychosis can become even more pronounced and psychologically damaging. So not only are they battling the virus, they have to deal with the high mental health consequences due to their disorder.
More than half of the general public surveyed in China reported that the outbreak had a moderate or severe psychological impact on them due to fears of contracting COVID-19 (Wang et al., 2020). Social distancing practices have a particularly negative impact on individuals with schizophrenia who already have smaller and more poor quality social networks than the general population (Degnan et al., 2018). Since strong social bonds are essential for our health and physical outcome, social support can lead to better recovery and coping mechanisms in the midst of a pandemic. Among individuals with schizophrenia, social isolation may increase the risk for suicide and the extreme stress of the pandemic has been associated with aggressive behavior (Volavka & Citrome, 2011). Thus, social distancing may disproportionately impact the ability of those with schizophrenia to maintain their basic needs, given their high reliance on external support. Their impaired mental state in conjunction with the unprecedented COVID-19 situation make them more of a danger to themselves and others.
Schizophrenic individuals present a unique intersection of many demographics. It is a psychological disease with many comorbid health issues. Homelessness, incarceration, congregate housing, risky behaviors are all in a high proportion of those diagnosed with schizophrenia. During the COVID-19 pandemic, the very orders that are attempting to keep the population safe are exacerbating the mental and physical health issues of individuals in these vulnerable populations. Developing solutions and approaches to maintain social connection while social distancing is especially crucial for these individuals. Understanding the struggles these populations face can allow caretakers, clinicians and even the government to find solutions to help treatment adherence, communication of COVID-19 precautions, and psychological support. Even beyond the schizophrenic population, those who face similar issues in society can also benefit.
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