The general population has been operating under the fallacy that we are all being proportionately affected by the pandemic. However, a cohort study, recently published in JAMA Psychiatry, has alerted the scientific community of a new, unprecedented risk factor for the deterioration of COVID-19 diagnosis. The research indicated that people on the schizophrenia spectrum, as opposed to neurotypical people, were 2.7 times more likely to die within 45 days after testing positive for SARS-CoV-2, the causative agent of COVID-19. Schizophrenia is a chronic, severe mental illness (SMI) characterised by delusions, hallucinations, disorganised speech patterns, and catatonic behaviour. The schizophrenia spectrum comprises a variety of similar disorders including schizoaffective disorder and schizotypal personality disorder. Patients diagnosed with other mood disorders, such as anxiety disorder or depression, did not have an increased risk of mortality. This raises questions as to why this spectrum of mental illness is disproportionately affected, compared to other mood disorders and mental illnesses.
Recent research by the National Health Service (2020) suggests that the utilisation of clozapine is likely to increase the susceptibility of the patients to coronavirus, and other respiratory infections such as pneumonia. Clozapine is an atypical, antipsychotic drug, commonly prescribed to patients with treatment-resistant schizophrenia. Owing to its unique efficacy, the patients taking this drug are unable to switch to options with lower risk profiles. Moreover, the prospect of changing medication causes patients to be more vulnerable as they stay at risk for interruption of treatment, leading to possible psychotic relapses without clozapine regulating their hormones.
The drug, clozapine, is classified as a major tranquilliser and works by blocking receptors for neurotransmitters to reduce dopaminergic transmission and to antagonise serotonin type 2 receptors to induce sedation by which there is an increase in the number of dopamine and serotonin molecules in the patients’ central nervous system. These molecules are mood regulators and are often referred to as “happy hormones”. When present in low or excess quantities, these hormones can cause disorders including anxiety, depression, and schizophrenia. As there is an imbalance of these hormones, the drug works to regulate it. However, adverse side-effects of the medication include rapid loss of white blood cells (neutrocytes, agranulocytes and leukocytes) in the form of neutropenia, agranulocytosis, and the more recently reported cases of induced leukocytosis. Although this drastic fall in white blood cell count is categorised as a rare side effect, a study conducted in Finland reported that 50% of the patients that developed agranulocytosis after exposure to clozapine and soon died of a secondary infection. Patients on this medication are usually asked to have their blood tested periodically to monitor their WBC count. Severe neutropenia has also been found in cases of COVID-19 among those who were not exposed to clozapine.
Another important factor to take into consideration for schizophrenia in the context of COVID-19 is that people with schizophrenia have a greater likelihood to congregate in living facilities rather than individual residential settings. Approximately 20% of individuals with schizophrenia live in assisted living. Contextual data also leads us to infer that patients facing prolonged periods of social isolation are more prone to suffering a psychotic relapse and are undergoing severe emotional distress. The restrictions of living in a pandemic and the resultant fear can worsen the symptoms of severe mental illnesses like schizophrenia. Recent evidence also suggests that isolation can induce biochemical and behavioural schizophrenia-like changes in mice. Social isolation has been observed to render amotivation and physical inactivity in people with schizophrenia, which can further increase the already high rates of obesity and hyperlipidemia. Combined with a lack of proper housing facilities, poor households, or community living, a higher mortality rate among the general population is expected. However, these are common living conditions for people with schizophrenia. An initial study from China indicated that of the 79.9% of the outbreaks that happened indoors, almost all were in apartment settings indicating that those living with others are more likely to contract the virus than those living independently.
In addition to their situational conditions, people with schizophrenia have behavioural tendencies that can make them more vulnerable in the pandemic. For instance, they are 3 times more likely than the general population to smoke, and 60% of them are active smokers, putting them at a greater risk for pulmonary diseases. There have been links to a mutation on the CHRNA5 gene which has been found to increase risks for both smoking and schizophrenia. Smoking is known to induce epigenetic modifications in the bronchial epithelium and cause mucous metaplasia. Due to this, the amount of mucous in our lungs is said to increase, and thus trap virus particles. Moreover, there is also growing evidence that former smokers appear to be at an increased risk of hospitalization and have worse outcomes once infected with COVID-19. Health care providers and the World Health Organisation are strongly advising smoking cessation, especially during COVID-19. Smoking has also been shown to worsen various other comorbidities such as cardiovascular diseases, diabetes, and hypertension.
As for the psychosocial impact, people with schizophrenia have a difficulty in maintaining relationships, and the isolation caused by the pandemic can worsen feelings of loneliness and detachment from reality. As they need constant support from their family and peers, the pandemic stands to have an adverse effect on their mental health. They have also been shown to have difficulty with discipline and may find it hard to grasp COVID rules and follow the recommended regulations to keep them safe during the pandemic.
In conclusion, people on the schizophrenia spectrum are unfairly affected by the pandemic and must be focused on in terms of healthcare, vaccine supply, and preventative treatment. Appropriate social distancing measures must be put in place in places of residence with one or more people with schizophrenia, while still taking into consideration the mental and social engagement required to reduce psychological strain and keep them stimulated.
Aria Dabholkar
