Patients With Mental Illness a Priority for COVID Vaccine, Experts Say

Megan Brooks

November 11, 2020

With this week's announcement that Pfizer's vaccine candidate against SARS-CoV-2 was 90% effective in preventing COVID-19, the world is one step closer to an effective vaccine.

Nevertheless, with a limited supply of initial doses, the question becomes, who should get it first? Individuals with severe mental illness should be a priority group to receive a COVID-19 vaccine, assert the authors of a perspective article published November 1 in World Psychiatry.

Patients with underlying physical conditions, such as cardiovascular disease, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, obesity, immunodeficiency, and cancer, are particularly vulnerable to developing more severe illness and dying from COVID-19.

In these populations, the risk of a more severe course of infection or early death is significant enough for the US National Academies of Sciences, Engineering, and Medicine to make these patients priority recipients of a vaccine against COVID-19.

Marc De Hert, MD, PhD, professor of psychiatry at KU Leuven in Leuven, Belgium, and coauthors argue that those with severe mental illness also fit into this group.

Even without factoring COVID-19 into the calculation, those with severe mental illness have a two- to threefold higher mortality rate than the general population, resulting in reduction in life expectancy of 10 to 20 years, they note. This is largely due to physical diseases including cardiovascular disease, type 2 diabetes, and respiratory ailments.

Individuals with severe mental illness also have higher rates of obesity than the general population and obesity is a risk factor for dying from COVID-19. 

High-Risk Population

Like their peers with physical illnesses, recent studies suggest that those with severe mental illness are also at increased risk of morbidity and mortality from COVID-19.

For example, a recent US case-control study with over 61 million adults showed that those recently diagnosed with a mental health disorder had a significantly increased risk for COVID-19 infection, an effect strongest for depression and schizophrenia. 

Other recent studies have confirmed these data, including one linking a psychiatric diagnosis in patients hospitalized with COVID-19 to a significantly increased risk for death, as reported by Medscape Medical News

De Hert and colleagues put these findings into perspective with this example: in 2017, there were an estimated 11.2 million adults in the US with severe mental illness. Taking into account the 8.5% death rate in COVID-19 patients recently diagnosed with a severe mental illness, this means that about 1 million patients with severe mental illness in the US would die if all were infected with the virus.

In light of this knowledge, and taking into account published ethical principles that should guide vaccine allocation, De Hert and colleagues say it is "paramount" that persons with severe mental illness be prioritized to guarantee that they receive a COVID-19 vaccine during the first phase of its distribution.

"It is our responsibility as psychiatrists in this global health crisis to advocate for the needs of our patients with governments and public health policy bodies," they write. 

The authors also encourage public health agencies to develop and implement targeted programs to ensure that patients with severe mental illness and their healthcare providers "are made aware of these increased risks as well as the benefits of vaccination."

An Argument for Fairness

Commenting for Medscape Medical News, Paul S. Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York City, also believes those with severe mental illness should be a priority group for a COVID vaccine.

"When we're prioritizing groups for a COVID-19 vaccine, let's not forget that people with serious mental illness have much lower life expectancies, more obesity, and more undiagnosed chronic conditions. They should be a priority group," Appelbaum told Medscape Medical News.

"The argument for including people with severe mental illnesses among the vulnerable populations who should be prioritized for receipt of a COVID-19 vaccine is an argument for fairness in constructing that group," he added.

"Like people with other chronic conditions associated with poor outcomes after SARS-CoV-2 infection, people with severe mental illnesses are more likely to be hospitalized and more likely to die. Although they are often systematically ignored when decisions are made about allocation of resources, there is some hope that, with enough public attention to this issue, they can be included this time," Appelbaum said.

De Hert and Applebaum have disclosed no relevant financial relationships.

World Psychiatry. Published online November 1, 2020. Perspective

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