Mental Health Disorders Tied to Higher COVID-19 Mortality

Mental health disorders were associated with an increased risk of COVID-19-related mortality, according to a systematic review and meta-analysis of 16 studies from seven countries.

Results from these population-based cohort studies — from the U.S., South Korea, Israel, and four European countries — found that patients with mental health disorders were at an elevated risk of COVID-19 mortality as compared with those without mental health disorders, reported Guillaume Fond, MD, PhD, of Aix-Marseille University in France, and colleagues.

As they showed in their study in JAMA Psychiatry, this was the case when looking at both crude and adjusted odds ratios (ORs, P<0.05 for both):

• Crude: OR 1.75 (95% CI 1.40-2.20)
• Adjusted: OR 1.38 (95% CI 1.15-1.65)

Patients who had the most severe mental health disorders — schizophrenia spectrum disorders and/or bipolar disorder — had the highest likelihood for COVID-19-related mortality (crude OR 2.26, 95% CI 1.18-4.31; adjusted OR 1.67, 95% CI 1.02-2.73), Fond and co-authors found.

They noted that although they were able to determine the associations between severe mental health disorders and risk of COVID-19 mortality, it wasn’t possible to identify significant differences between specific mental health disorders.

This was because all the studies (except one) that included patients with non-severe mental health disorders — defined by the research team as mood disorders, anxiety disorders, personality disorders, eating disorders, and alcohol and substance misuses — combined those patients with others who had severe mental health problems. It was only possible to distinguish between severe mental health disorders for six of the 16 studies included in the meta-analysis; some studies involved just patients with schizophrenia, while others combined those with bipolar disorders. In all, there were seven studies from the U.S.; three from South Korea; two from France; and one study from Denmark, Israel, Spain, and the U.K. each.

The definitions of the patient groups with mental health disorders also varied across countries; for example, the South Korean studies, two of the U.S.-based studies, and the U.K. study blended mental health disorders with substance-use disorders, without distinguishing between them. Two other U.S. studies included only patients with substance use disorders, and the Danish study examined substance use disorders separately from mental health disorders.

The meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and systematic bibliographic searches were carried out using Cochrane Methodology. The studies — which covered December 2019 to July 2020 and included data from 19,086 patients — were accessed through Medline, Web of Science, and Google Scholar, and the literature was assessed for biases using the Newcastle-Ottawa Quality Assessment Scale.

Fond and colleagues explained that they had aimed to determine whether patients with mental health disorders were at increased risk of admission to intensive care units (ICUs) as a result of COVID-19, in comparison with patients without mental health disorders. However, only four of the studies in the meta-analysis included data about ICU admissions, so the sample was deemed insufficient for meta-analysis. And among the four studies available, the results were heterogeneous and contradictory from country to country.

Other limitations, the team said, included that most of the studies in the analysis were conducted throughout the pandemic’s first peak of COVID-19 cases, during which testing was limited in some countries, likely leading to discrepancies in mortality rates by country.

The team wrote that although there is still much to be learned about ICU admissions and COVID-19 mortality for patients with certain mental health problems, “patients with mental health disorders should have been targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies.”

“Social factors (e.g., socioeconomic status, family or household composition, and environmental factors) were also reported to be associated with increased COVID-19 mortality and are known to be highly influential in patients with mental health disorders,” Fond and team wrote. “These factors need to be explored in depth in future works on mental health disorders and COVID-19, and they need to be considered for health policies.”