People with psychiatric illness who become severely ill with COVID-19 face increased in-hospital mortality compared to their peers with no psychiatric diagnoses, new research shows.

“It is always important that people struggling with these illnesses get the help that they need. Now, as we appreciate the increased COVID-19 mortality risk, the importance of seeing that people with psychiatric disorders get the help that they need is even greater,” John Krystal, MD, McNeil Professor and Chair of Psychiatry at Yale School of Medicine in New Haven, Connecticut, and senior author of the new study, told Psycom Pro.

Examining COVID-Related Mortality and Psychiatric Diagnosis

Previous research has suggested that psychiatric disorders can increase mortality from cardiovascular and infectious disease, Dr. Krystal and his team note in their report, published in JAMA Network Open as a Research Letter.1  

To investigate the effect of a psychiatric diagnosis on COVID-19 outcomes, they analyzed data from the Yale New Haven Health System on 1,685 patients hospitalized with COVID-19 between February 15 and April 25, 2020, and followed for mortality until May 27, 2020. Patients’ mean age was 65.2 years, and 52.6% were men. Twenty-eight percent had previously received a psychiatric diagnosis; these individuals were more likely to be female, to be white, and to have more medical comorbidities.

Overall mortality was 18.9%, over a median follow-up of 9 days. Two-week mortality was 35.7% for patients with a psychiatric diagnosis and 14.7% for those with no diagnosis, while 4-week mortality rates were 44.8% and 31.5%, respectively. The unadjusted hazard ratio for in-hospital mortality due to COVID-19 was 2.3 for people with a psychiatric diagnosis, and 1.5 after adjustment for demographic factors, comorbidities, and hospital location.

“It is unclear why psychiatric illness predisposes to COVID-19-related mortality,” the authors wrote. “Psychiatric symptoms may arise as a marker of systemic pathophysiologic processes, such as inflammation, that may, in turn, predispose to mortality. Similarly, psychiatric disorders may augment systemic inflammation and compromise the function of the immune system, while psychotropic medications may also be associated with mortality risk.”

Although the team conducted a sub-analysis of COVID-19 outcomes based on different psychiatric diagnoses, “the numbers were too small to have a conclusive result to share more widely,” said Luming Li, MD, assistant professor and medical director of clinical operations at Yale New Haven and the study’s lead author.

Among the study limitations acknowledged by the authors: the sample did not include people who died outside the hospital or who were not hospitalized, and they did not account for psychiatric treatment status or include information on COVID-19 treatment.

The Stress – Inflammation Cycle

“People with psychiatric disorder have been an invisible community during the COVID-19 pandemic, yet we know that this group has experienced particularly high levels of stress,” Dr. Krystal said. Long-standing major depressive disorder (MDD) reduces life expectancy by 5 to 10 years, he noted as an example, while schizophrenia can shorten life expectancy by 10 to 20 years.

“There are limited data about this, but those data that exist suggest that people with pre-existing mental illnesses have experienced higher levels of stress than the general public,” he explained. “For some people, this stress may undermine their commitment to treatments for psychiatric illnesses and other medical problems. Further, since stress, generally, is associated with increased smoking and alcohol use, this group also may be at increased risk for problems.”

We know that stress can contribute to inflammation and having a psychiatric disorder itself is also associated with increased inflammation, Dr. Krystal noted. “On a long-term basis, this form of inflammation can worsen diseases affecting most organs of the body.” Add to this the novel coronavirus infection – which triggers a strong inflammatory response in the body – and there could be a perfect storm of negative factors. “It is possible that stress- and depression-related inflammation could contribute to excessive inflammation, previously shown to damage body organs during COVID-19 infection.”

Access to Ongoing Care and PPE

Dr. Li shared some additional reasons why people with psychiatric illness may be more vulnerable to contracting COVID and dying from the disease. For instance, “individuals with psychiatric conditions often face greater challenges with social determinants of health, including homelessness and living in congregate care settings, which can impact contact in the community of COVID-19,”  he said. In addition, their “access to PPE and public health recommendations may be limited given their clinical condition or lack of resources in the community.”

Mental health providers should advise their patients on how to use personal protective equipment correctly and how to take precautions in their own communities, Dr. Li advised. If a patient is hospitalized, she added, the treating provider should be informed about any mental health diagnoses.

In addition, the general advice given to people living with mental disorders still applies during the pandemic. For instance, said Dr. Krystal, people under care for chronic mental illness should be advised to continue their psychiatric treatments and to enhance their ability to care for themselves. In addition, it is important that they continue to get needed medications for comorbid medical problems, such as high blood pressure, high cholesterol levels, heart disease, asthma, and diabetes.

Lastly, as noted, the stresses associated COVID-19 are leading some people to smoke more and/or to consume more alcohol – which can threaten the long-term health of people with mental disorders and other medical problems. Clinicians should refer and/or collaborate with addiction experts when necessary.


Last Updated: May 27, 2021