COMMENTARY

The Impact of COVID-19 on Patients With Schizophrenia

Lorenzo Norris, MD

Disclosures

April 16, 2021

This transcript has been edited for clarity.

Frank Chen, MD: I am Frank Chen. I'm a psychiatrist in the Houston area. I have been the chief medical officer of a hospital locally, called Houston Behavioral Healthcare Hospital, as well as my private practice, Houston Adult Psychiatry.

Lorenzo Norris, MD: This is Dr Lorenzo Norris, editor-in-chief of MDedge Psychiatry. Today, we're pleased to have Dr Chen with us. We're going to be talking about our patients that we treat who have schizophrenia and trying to think about how our patients with schizophrenia are dealing with the COVID-19 pandemic.

There have been some studies that have come out that have started to shed some more light in regard to the inherent risk that our patients with schizophrenia face from COVID-19. We're going to also think about how our schizophrenia patients with COVID-19 are coping with the pandemic. Please stay with us as Dr Chen guides us through this discussion, thinking about the clinical aspects of schizophrenia and COVID-19 as we face them every day.

Dr Chen, welcome to the Psychcast, sir.

Chen: Thanks for having me.

Norris: Dr Chen, I was really glad to have you here as a person being on the front lines, working with our patients with schizophrenia, and to talk a bit about schizophrenia and COVID-19.

I wanted to start with a recent article that came out of JAMA Psychiatry in regard to the association of psychiatric disorders with mortality among patients with COVID-19. That article had a number of interesting things, particularly as it related to patients with schizophrenia spectrum disorder. In particular, the article got at that idea that a diagnosis of schizophrenia spectrum disorder may be a risk factor for mortality in patients with COVID-19.

Dr Chen, I was wondering if you could just talk to us a little bit about your thoughts about that article and how we should start to look at it and interpret some of that data.

Chen: It's certainly concerning that our patients with schizophrenia seem to have the second highest risk group in terms of mortality from COVID-19, next to age. We want to examine that. As we all know, patients with schizophrenia have earlier mortality rates in part because they can't adequately care for themselves. They don't do some of the preventive medical care that we would be accustomed to, but also because they are on antipsychotic medications that may predispose them to metabolic factors, diabetes, and hypercholesterolemia that shorten their lifespan.

I want to explore the environmental factors that may be challenging to individuals with schizophrenia. Although most individuals with schizophrenia would naturally social distance if they can, quite a bit of our population reside in such places as group homes, where they are in very crowded situations. Our patients are also not very good at following directions, so masking may be a challenge for them.

I do think that if it were left up to them, they would hibernate in a room by themselves, but because of the challenges that they have from a social standpoint, they may be at risk of catching COVID-19 and subsequent mortality associated with COVID-19.

Norris: The authors of this study controlled for a number of things. There had already been some studies out there that had shown that increase in mortality broadly in mental disorders. This, I believe, was one of the first studies where, once they controlled for the various comorbid factors, such as age, weight, and things of that nature, the diagnosis of schizophrenia itself was associated with a higher risk.

I think you hit the nail right on the head that there are some other factors that have yet to be accounted for, whether it's in the environment, in terms of what our patients face. When we talk about the environment, you talk about masks and you talk about social distancing, of course. But I also think about access to care and the ability to follow-up.

This is not unlike what we would see in other medical populations. I think back to some of the work that I'd done in psycho-oncology and the cancer survivorship world, in that it wasn't so much lack of treatment — it was lack of access and ability to get people to the care that they need. With schizophrenia, particularly if we look at the cognitive dimension of it and the challenges at times with executive function, we can see where that would be certainly a challenge.

I would say that that this also brings up interesting questions about who should be vaccinated and at what time, certainly as we're doing the vaccine rollout — maybe we'll touch upon that a little bit later. For the audience, those who haven't read the JAMA Psychiatry article that came out on January 27, 2021, I encourage everyone to take a look at that.

Thinking about schizophrenia spectrum disorder and, again, this idea that perhaps the diagnosis of schizophrenia in and of itself is associated with increased mortality, we certainly know that many factors, whether it's access to care or the environment, can certainly leave these patients with increased vulnerability.

Can you walk us through how patients with schizophrenia might actually cope? We might have unexpected, more robust coping than we see in the general population. I'm curious about what you think about that.

Chen: Some of my patients who are not living in group homes — who are fairly well taken care of, and who are used to crisis in their lives and the thought that something fearful is occurring in the world — may have adapted to the news of the pandemic a little better than other people. It's not so much of a disruption to their lives because they are already used to this level of crisis, if you will.

If you have individuals who have their own rooms, for instance, they naturally would hibernate. They don't care about interactions if left to their own devices. In those situations, social distancing and isolation is not such a terrible thing. The individuals with schizophrenia who have access to the internet, or have caring family members who bring the internet to them, may actually get home visits as we explore telepsychiatry.

As you know, Dr Norris, the pandemic really yanks the training wheels off of telepsychiatry. We went from the use of telepsychiatry in the rural setting and maybe in the prison population to being something that's the norm. Just as with other patients that we typically see, we are making home visits with the individuals with schizophrenia. We get to see their environment.

I actually can pay a lot more attention to them because I can jump into their lives once a week as a result of the ease of telepsychiatry. Whereas in the past, it may have been very difficult getting them to an office. They may have transportation issues. With this new modality of care in medicine and in psychiatry, we're making home visits and we can see them much more frequently to make sure that they are adherent to treatment, make sure that they're taking care of themselves, and alert family members if we see concerning signs.

Norris: I might have to borrow that from you: "Yank the training wheels off of telepsychiatry."

Now, as you were talking about schizophrenia and our patients with schizophrenia, there are some really important things that struck me. One — and it links back with the earlier discussion — is family and support, which can make a huge difference. It makes me think about how outcomes can have so much to do with the family support, even more so than they do with the medications [sometimes].

I am not a schizophrenia expert. I would be very interested in what Dr Henry Nasrallah, editor-in-chief of Current Psychiatry and an eminent schizophrenia expert, would have to say about this. I would be curious, Dr Chen, [how this affects] some of our patients with the negative symptoms, in which case they might naturally socially isolate and withdraw.

Then the other thing, when we talk about quarantining and isolating, if you actually look at the news, look at any evidence base or whatnot, that wreaks havoc on the lives of everybody.

[But] with our patients with schizophrenia, depending on where they're at and how they've recovered, isolation or the need to quarantine or deal with the crisis could be a little bit more part of their daily life. I do find it interesting that in this particular situation — again, I'm focused on the idea of support and access — we can't overlook the ways in which they can show resilience in this pandemic.

I think it's an important point as we think about everything we're dealing with in terms of the death, the mortality, and the suffering.

You said you get to go into the homes of your patients. Can you elaborate just a little bit?

Chen: Sure. Let me make a couple of points about some of the things that you just brought up. Going back to the concept of telepsychiatry, I remember back in the early 2000s, I worked briefly in a correctional institute where we did telepsychiatry. We are talking about state-of-the-art technology then, with these huge machines that transmitted video signals from one treatment facility to another.

At some point, the internet became more involved and we now have things like FaceTime, but there are the regulations that our industry has faced in terms of the standards associated with privacy, and also payment-related issues that may have hindered the development of telepsychiatry.

I've used a telehealth platform for about 5 years in an upper middle-class neighborhood in Houston.

You would think that these high-functioning individuals who are very busy would adapt to telepsychiatry, but you know what? I think that they they're used to coming into the confines of the secure setting to discuss personal, emotional issues. Leaving it to many of these high-functioning individuals, they actually chose to come into the office rather than adapting to this technology that they're familiar with.

When Houston shut down and we had to transition to telepsychiatry, we had patients canceling on us, telling us, "We'd rather wait until this pandemic is over before we see you, because we just want to come in in person." This concept of telepsychiatry was actually much more pervasive out in the rural communities, and in a lot of these rural communities in Texas, you're used to seeing a treater via telepsychiatry.

It's interesting how the urban population had to kind of adapt to this modality of treatment, because I have to tell you, most of my patients really didn't want to do the appointment via the telepsychiatry platforms. That was a really interesting observation at the beginning of this pandemic.

As I said, the training wheels got yanked off of telemedicine and telepsychiatry and we all very quickly adapted to a certain new norm. I don't know if we're going to go back now, because most of my patients are actually asking for telemedicine sessions.

Norris: You bring up an interesting point in regard to how we adapt. One, when you said "high-functioning," I always have to be careful when I use that term. Even just myself, I'm high-functioning right now, but maybe if I don't get a cup of coffee in the morning and my sleep, I'm not that high-functioning. I think about that.

The next thing that I think about is, as it applies to all of us, the three main things that we're always thinking about in psychotherapy. Other authors have said it, but in terms of those themes, they are: What can you can control, who are you, and what can you trust? If we're used to having all of those things, particularly the control part where we have a set routine, that can cause a little bit of angst. We don't have to adapt in the way that we are accustomed to or we don't have the same resources, so that's tough.

The next thing that I think about as you're talking about this is, for all of us, psychological flexibility. How flexible are we in terms of changing our coping styles? Going back to our earlier point with schizophrenia, I think that depending on one's lifestyle, the ways in which people cope or how they live, might — and I'm sure we'll get many different comments about this — [make it] easier to adapt to crisis.

I was trained in New York, as an example, and I had the fortune of working with many patients who had dealt with [difficult situations], or who were homeless and knew how to survive very well without a number of things. I remember, in 2004 or whenever, that great power surge that dumped all the electricity out on the East Coast. I was a fish out of water. I was like, whoa, what's going on? Some of my patients who are used to actually adapting with very little resources, they were fine.

Again, I think as you talk, Dr Chen, it really makes us start to think about all of our resilience, how we cope. I also think about psychological flexibility and how all of us start to tap into our own underlying resilience, regardless of whether you have schizophrenia, bipolar, demoralization, burnout, you name it.

I do want to come back to something, because you said you practiced in correctional facilities.

Chen: I spent a brief amount of time in the early part of my career in a correctional facility. Unfortunately, it's a correctional facility that serves as the state hospital for schizophrenic patients. I had the experience early in my career doing that for a period of time.

Norris: Not many psychiatrists, unfortunately, have experience in correctional facilities, myself included. I think that the audience would be very curious about any viewpoints that you would care to share with us.

Chen: I think that the unfortunate part about individuals with schizophrenia in correctional facilities is that, number one, they may be undermedicated. That leads to disaster oftentimes. The correctional facilities are very structured, and sometimes it is difficult for individuals with schizophrenia to follow very rigorous structure.

I worked at a day program for a period of time as well. You're constantly having to redirect these patients. The issue about having to redirect patients in a correctional facility is that they get redirected by correctional officers, who usually will end up enforcing some very punitive actions on these patients.

Certainly personally, I don't think that the correctional facility is the right venue for many of our patients with schizophrenia. I think that in this COVID-19 crisis, [patients with schizophrenia] might not be able to follow instructions in terms of masking. They're not able to follow instructions in terms of hygiene. That may work to their detriment in the correctional setting.

Going back to something that you pointed out earlier in terms of isolation, schizophrenia often makes it easy to [just hide in your room]. I grew up with a brother with schizophrenia. They can socially distance for days, and the pandemic doesn't seem like it's that big of a deal when the instructions are social distancing in isolation.

In terms of resilience, I think that this is a very unique situation for the individual with schizophrenia. This is one time where they can follow these natural directions, because these directions are instinctual to them. I think that certainly they may not have the resilience in other settings, because they can be very concrete in their thinking. I think that this is a unique situation where they may actually deal with a global crisis in ways that we are instructed to deal with it.

I do see many individuals who are rattled as a result of some of the chaos in the world. Things are shut down; their lives are not the same. Individuals who are really rigid and very structured have been thrown off as a result. I have patients who are used to going to the gym every day at 5:00 in the morning. All of a sudden, 3 months into the pandemic, they're wondering why they're feeling anxious and depressed. I have had patients who are used to going to Alcoholics Anonymous on a daily basis, and the loss of that structure was a detriment to them.

It seems like flexibility in your ability to adapt to situations certainly is called for in a pandemic like this, where we don't really have a set of rules. We have to react and stay afloat.

Norris: Dr Chen, you raised some extremely valid points. I thank you for sharing your own personal story with us, and one in medicine in your own family. As I think about this — and again, I'm going to say schizophrenia spectrum disorder for those clinicians and providers in the audience who work with schizophrenic patients — I'm not trying to paint a picture that one size fits all. Every patient is different.

As I hear Dr Chen talk, these are some of the things that I think about. I think that some or a certain proportion of our patients in certain ways may be able to follow directions better than we do as it pertains to quarantining. But some specific things, such as masking and things of that nature — particularly in environments where they don't have the access or support — may be more difficult.

The next thing that I think about is, again, access to support. Can we actually have environments that are going to empower our patients to best navigate this, because that's going to allow them to tap into their strengths? For example, whether or not we are leveraging family support, whether or not we are leveraging telehealth services — I've got Dr Henry Nasrallah in my ear — whether or not we are considering giving long-acting injectables to our patients so that they do not have to routinely go and get prescriptions?

If we're thinking about all of those things, we're really helping all of us start to think about and focus on the circle of control.

In the midst of this pandemic, we have to learn and grow from each other and always be mindful of what it is that we can control ourselves. We can learn from not only each other but also our patients.

Dr Chen, sir, I want to thank you for joining us on the Psychcast, and I want to leave you with the final words for our audience.

Chen: We're going through something that probably every one of us who's alive has never gone through. There isn't a playbook in terms of how we come out of this pandemic, but I think that we need to trust some of the experts on infectious disease and be able to feel that we have some control over aspects of your environment, so that we can all get through this without feeling that we're losing ourselves.

I know that this pandemic has certainly introduced telepsychiatry to the world. I hope that this is going to be a positive thing in terms of being able to engage with our patients more frequently with more care — being able to see them in an environment where we're essentially doing home visits, like the old days. I want everyone to know that we will come out of this as we all have. I want to share with the audience that we have, as a human population, come out of these pandemics in the past and things will get back to some normality. Stay safe, and stay alive.

Norris: Well said, Dr Chen. Thank you for joining us on the Psychcast.

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