Disparities in Intensive Care Unit Admission and Mortality Among Patients With Schizophrenia and COVID-19

A National Cohort Study

Guillaume Fond; Vanessa Pauly; Marc Leone; Pierre-Michel Llorca; Veronica Orleans; Anderson Loundou; Christophe Lancon; Pascal Auquier; Karine Baumstarck; Laurent Boyer

Disclosures

Schizophr Bull. 2021;47(3):624-634. 

In This Article

Abstract and Introduction

Abstract

Patients with schizophrenia (SCZ) represent a vulnerable population who have been understudied in COVID-19 research. We aimed to establish whether health outcomes and care differed between patients with SCZ and patients without a diagnosis of severe mental illness. We conducted a population-based cohort study of all patients with identified COVID-19 and respiratory symptoms who were hospitalized in France between February and June 2020. Cases were patients who had a diagnosis of SCZ. Controls were patients who did not have a diagnosis of severe mental illness. The outcomes were in-hospital mortality and intensive care unit (ICU) admission. A total of 50 750 patients were included, of whom 823 were SCZ patients (1.6%). The SCZ patients had an increased in-hospital mortality (25.6% vs 21.7%; adjusted OR 1.30 [95% CI, 1.08–1.56], P = .0093) and a decreased ICU admission rate (23.7% vs 28.4%; adjusted OR, 0.75 [95% CI, 0.62–0.91], P = .0062) compared with controls. Significant interactions between SCZ and age for mortality and ICU admission were observed (P = .0006 and P < .0001). SCZ patients between 65 and 80 years had a significantly higher risk of death than controls of the same age (+7.89%). SCZ patients younger than 55 years had more ICU admissions (+13.93%) and SCZ patients between 65 and 80 years and older than 80 years had less ICU admissions than controls of the same age (−15.44% and −5.93%, respectively). Our findings report the existence of disparities in health and health care between SCZ patients and patients without a diagnosis of severe mental illness. These disparities differed according to the age and clinical profile of SCZ patients, suggesting the importance of personalized COVID-19 clinical management and health care strategies before, during, and after hospitalization for reducing health disparities in this vulnerable population.

Introduction

By July 2020, approximately 30 000 French individuals had died from the SARS-CoV-2/coronavirus disease 2019 (COVID-19) infection, placing France in the absolute fifth place in the world behind the United States (130 000), Brazil (60 000), the United Kingdom (43 000), and Italy (34 000). The speed of the pandemic expansion and the risk of saturation of intensive care units (ICUs) led the French government to pronounce confinement for 2 months between mid-March and mid-May 2020. During this period, several regions were particularly affected by saturation of ICUs, such as the Paris Ile-de-France area and the northeast. This saturation may have led some services to "sort" patients, choosing those who were admitted to ICUs while being aware that patients admitted with respiratory failure could not be released from their respirators for several weeks. Learning the lessons of this first wave is crucial in anticipating another potential health crisis.

Schizophrenia (SCZ) patients are a population at particular risk of poor outcomes in COVID-19 infection. A recent Korean study has found SCZ to be associated with an increased risk of severe COVID-19 infection.[1] SCZ individuals have multiple comorbidities that have been identified as risk factors for severe COVID-19:[1] diabetes, hypertension, chronic obstructive respiratory disease, and end-stage renal disease. Previous studies have also shown reduced access to critical care for SCZ patients.[2,3] More information is thus needed to determine whether COVID-19 patients with SCZ have the same health outcomes and care delivered as patients without a diagnosis of severe mental illness.

We aimed to establish whether health outcomes and care differed between patients with SCZ and patients without a diagnosis of severe mental illness. The primary objective was to compare in-hospital mortality between SCZ patients and patients without a diagnosis of severe mental illness after adjustment for main confounding factors (ie, sociodemographic data, clinical data at baseline, stay data, management data, hospital data, and geographical areas of hospitalization). The secondary objective was to compare ICU admissions between SCZ patients and patients without a diagnosis of severe mental illness.

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