COVID Vaccinations: Should People with Serious Mental Illness Move to the Front of the Line?

What’s happening – Prioritizing people with serious mental illness (SMI) for COVID-19 vaccines is a growing concern among mental health advocates, professional organizations, and governments worldwide. Also called severe mental illness, SMI refers to those with an illness that causes serious functional impairment such as schizophrenia, bipolar disorder, and major depressive disorder.

People with SMI have an increased risk of contracting COVID-19 and of having a severe case that could lead to hospitalization or death. They are also more likely to have physical ailments such as cardiovascular disease, diabetes, respiratory disease, obesity, inflammation, and be smokers. Socioeconomic risk factors for COVID-19 that are associated with SMI include limited access to care, jobs with poor working conditions, and living in institutions, crowded conditions, and homelessness, according to a newly published paper.

The details – Read the full paper by Mazereel et al in Lancet Psychiatry. In addition:

  • The American Psychiatric Association called on state health authorities to include people with SMI and substance use disorder (SUD) in Phase 1-C of vaccine distribution, saying that it’s common that people with SMI and SUD “don’t have access to health care, are of low socioeconomic status, or, based on history, harbor mistrust toward the medical establishment” and should be prioritized.
  • A report in Lancet provides an overview of several European countries that have prioritized vaccines for people with SMI.
  • A paper in World Psychiatry details the risk factors for people with SMI for COVID-19 and reviews the ethical principles that should guide the prioritization of this population in vaccination distribution programs.

Why it’s complicated – Achieving eligibility is one step toward vaccinations for people with SMI, and clinicians can help with another: facilitating vaccine acceptance and uptake. Specifically:

  • Mental health clinicians can help people with SMI overcome the individual- and system-level barriers to getting the COVID-19 vaccine as discussed in an article from JAMA Psychiatry.
  • The APA says psychological science will be important for promoting vaccines through communication, and the organization suggests that clinicians sharing their personal experiences with the vaccines could help build trust with patients.
  • WHO has issued recommendations to encourage vaccine acceptance.

The conversation

  • @_Roberts_Laura (Laura Roberts, MD, MA, chairman, Department of Psychiatry and Behavioral Sciences at Stanford) tweeted “With over 125k COVID-19 vaccine doses now administered at @StanfordMed, thankful for @StanfordPSY community’s great concern for vaccine equity among individuals facing increased health risks related to mental illness. We get better together.”
  • @MarisaCDias (Dr Marisa Dias, clinical research training fellow at the UK’s Medical Research Council), co-author of this study about SMI and COVID-19 vaccine strategies in Europe, tweeted “I’m now coming to realize this issue is much bigger than I thought. Writing and getting feedback on the topic of vaccine prioritization for people with severe mental illness has been an eye opener for me. #parity”
  • @EquallyWellUK, a group focused on providing resources for people with SMI, tweeted in mid-February “If you’re an adult living with a severe mental illness in England, you should now be eligible for a COVID-19 vaccination. We’ve just launched this #EquallyWellUK resource with key information.”

In practice – Additional reports that schizophrenia and psychiatric disorders may increase COVID mortality risk

Benzodiazepine Prescribing Is Down – But Why?

What’s happening – Benzodiazepine (BZD) prescribing to older adults declined from 2013-2017, with the biggest declines experienced by patients of the US Department of Veterans Affairs (VA) compared to those enrolled in Medicare and commercial insurance. Specifically, looking at the monthly percentage of adults 55 and older who received BZDs from April 2013–December 2017, researchers found that those receiving care from Medicare fell from 10.4% to 9.3%, compared to those commercially insured (6.6% to 6.5%), and those under VA care (5.7% to 3.0%).

Monthly BZD and opioid co-prescribing also declined more at the VA (from 2.2% to .6%) compared to Medicare (from 4.0% to 3.0%) and commercial insurance (from 2.3% to 2.0%). The authors wrote that age‐ and sex‐adjusted rates of prescribing decline were statistically significant for all systems. Prescribing declines may be attributed to the CDC’s 2016 Opioid Guidelines, the FDA’s 2016 boxed warning against co-prescribing, and the VA’s 2013 Opioid Safety Initiative and the 2013 Psychotropic Drug Safety Initiative, the authors wrote.

The details – Read the full study by Maust et al in the Journal of the American Geriatrics Society and a Q&A with him below in our weekly Psy-Q Challenge.

Why it’s complicated – Co-prescribing BZDs and opioids to older adults must be carefully considered because of the risk of fall-related injuries, traffic accidents, excessive sedation, impaired cognition, and overdose.

  • The VA reported in July 2020 that it had reduced prescription opioid use by 64% in the past 8 years and that the number of patients co-prescribed opioids and BZDs was reduced by 87% since 2012. The VA’s Opioid Safety Initiative Toolkit includes resources for clinicians and patients.
  • Geriatric psychiatrist Marc E. Agronin, MD, discusses factors to consider when prescribing BZDs to older patients.
  • A recent article explores the positive association between BZD use and dementia in older adults while acknowledging the lack of causality. Another article features three doctors (including Dr. Maust) who discuss BZDs and dementia risk.
  • The nonprofit Alliance for Benzodiazepine Best Practices recently published a book about the harms of BZDs, called “The Benzodiazepines Crisis,” and warned that the drugs are not safe for long-term use.

The conversation

  • @dtmaust (lead author on the BZD study Donovan Maust, MD, MS) tweeted a thread about the highlights of the study, saying “We have work in progress outlining some of the BZD-reducing strategies used across VA that community organizations might consider if they want to address this issue.”
  • @LizGoldbergMD (an ER physician and associate professor at Brown Medicine) replied to Dr. Maust’s thread with “Wonderful to hear. Also notable that @GeriDocVaughan has done work on EQUiPPED in VAs to reduce prescribing of potentially inappropriate medication at emergency department discharge, including BZP.” See Dr. Vaughan’s latest study here.

In practiceProper dosing, monitoring, and tapering of benzodiazepines and opioids. Plus, BZD label changes and related trivia.

Psy-Q: This Week's Challenge

Among which group has benzodiazepine prescribing declined the most: those enrolled in Medicare, commercial insurance, or the VA. Donovan Maust, MD, answers.

Get the Answer

The Conversation Continues Regarding Psychiatry’s Ties to Structural Racism

What’s happening – The American Psychiatric Association issued a statement on Martin Luther King, Jr, Day apologizing to black, indigenous, and people of color (BIPOC) for its role in supporting structural racism in psychiatry during its 176-year history. The apology said that the organization is “committed to identifying, understanding, and rectifying our past injustices” and pledges to develop anti-racist policies, but some people – including practicing psychiatrists – aren’t buying it.

The apology comes on the heels of the association’s formation of a Presidential Task Force to Address Structural Racism Throughout Psychiatry, which aims to develop and report achievable actions to eliminate structural racism to its board of trustees through May 2021. The American Psychological Association (APA) issued a statement as well, last fall, pledging to dismantle systemic racism in its organization and psychology.

The details – Read the American Psychiatric Association’s apology and historical addendum.  Read the APA’s statement.

Why it’s complicated – Discussions of structural racism in psychiatry are not new but they have increased in frequency since last summer when Black Lives Matter protests throughout the US brought the topic of systemic racism to the forefront of public awareness and discussion.

The perspectives

  • Psychiatrist Racquel Reid published her response to the apology on Medium. Psycom Pro shared the post, echoed by Editorial Advisor and Psychiatrist Danielle Hairston.
  • A Psychiatric Times article asks whether the APA’s apology will “advance or hinder the conversation” and offers ways to advance discussions on racism in psychiatry.
  • This article explores the need for discussions on structural racism to be a part of psychiatric training.
  • In July 2020, Dr. Ruth S. Shim discussed her experiences of structural racism and why she decided to leave the APA in this article from STAT News.
  • For historical insights into structural racism in psychiatry, see this article from NAMI and this book review from Nature on Mab Segrest’s book about the Milledgeville State Hospital in Georgia.
  • Guidelines and best practices for diversity leadership in psychiatry are discussed in the American Journal of Psychiatry.

The conversation

  • @LetUsBeBlount (Shatiea Blount, LICSW, LCSW-C) tweeted in response to the American Psychiatric Association’s apology “This is an important step for the @APAPsychiatric. Racism in the mental health field is rampant and Black culture continues to be pathologized and misunderstood by clinicians. I pray this is not just symbolism, but a real step toward atonement, restitution, and reconciliation.”
  • @CMangurian (Christina Mangurian, MD, MAS) retweeted Dr. Shim’s article, saying, “Important read by my fellow UC psychiatry faculty member @ucdavis, the incredible Dr. Ruth Shim. Voices like hers—and others—are critical as we reflect upon our own institutions and how we can dismantle structural racism.”
  • @egaly (Jonathan Jackson, PhD) also retweeted Dr. Shim’s article, saying “I have had my most frustrating conversations about structural racism with folks in psychiatry. There’s no willingness to acknowledge harms or complicity or even…racism(?) within the discipline. This opinion piece in @statnews draws back the curtain.”

In practice – See also how depression and hypertension assessments are treated differently in African American women and why comorbidity screening is crucial. More feedback on this important topic welcome. Email the editor.

Last Updated: Apr 20, 2021