The COVID-19 Global Pandemic: Implications for People With Schizophrenia and Related Disorders

Nicole Kozloff; Benoit H. Mulsant; Vicky Stergiopoulos; Aristotle N. Voineskos


Schizophr Bull. 2020;46(4):752-757. 

In This Article

Factors That put People With Schizophrenia at Elevated Risk of Acquiring Covid-19 and of Experiencing Poor Outcomes

People with schizophrenia may be more susceptible to transmission of COVID-19 due to a number of factors: cognitive impairment, lower awareness of risk, and barriers to adequate infection control including congregate living.[10] As schizophrenia is characterized by impairments in insight and decision-making capacity,[11] it may be harder for people with schizophrenia to adopt and adhere to the protective measures recommended to prevent infection (eg, hand washing, social distancing or isolation, confinement).[12] Comorbid substance use disorders, highly prevalent in schizophrenia, may compound impairments in judgment and decision-making.[13] Furthermore, people with schizophrenia are overrepresented in vulnerable populations that are at increased risk for COVID-19 outbreaks, including prisoners and individuals experiencing homelessness.[14,15] For these groups, as well as people living in congregate housing such as rooming houses and mental health supportive housing, social distancing is near impossible.

Multiple factors increase the risk of poor outcomes from COVID-19 in people with schizophrenia. Smoking, which is prevalent in more than 60% of people with schizophrenia,[16] may increase the risk of disease progression and severe complications from COVID-19, including death, via its effects on lung health and immune responsiveness.[17] Early but robust data indicate that mortality from COVID-19 is particularly elevated in people with comorbid conditions, in particular cardiovascular disease, diabetes, and chronic respiratory disease,[18,19] all of which are more common in people with schizophrenia than the general population.[20–22] Antipsychotic medications commonly prescribed in schizophrenia, particularly clozapine, appear to be associated with risk of death from pneumonia related to impaired swallowing, sedation, and hypersalivation, which worsen during the immune response due to a feedback loop that increases clozapine concentrations;[23] while we are unaware of evidence specifically linking clozapine to deaths from coronaviruses, there is at least a hypothetical risk. Several other factors put people with schizophrenia at risk: they experience substantial disparities in access to health care, related in part to the effects of stigma on help-seeking[24,25] and discrimination when they access care: they are more likely to experience underdiagnosis of comorbid physical illnesses, less likely to receive screening and definitive interventions, and generally receive poorer-quality care.[26] The WHO recommends that "isolating, testing and treating every suspected case, and tracing every contact" is the best way of preventing widespread community transmission.[2] Barriers to uptake of protective measures and appropriate use of health care services among people with schizophrenia could have profound implications for containment of the pandemic. Furthermore, preexisting health disparities could be exacerbated in the context of limited resources. Failure to promote fair and equitable resource allocation could result in more severe complications for people with schizophrenia, including death.[27] Mechanisms and guidelines to uphold the rights to health for people with schizophrenia and promote equitable outcomes are urgently needed.