Research suggests that people with schizophrenia are at increased risk of contracting and dying of SARS-CoV-2, the virus that causes COVID-19.

The relationship between COVID-19 and mental health is complex. The pandemic has led to an unprecedented rise in the prevalence of anxiety and depression. It has also become increasingly clear that COVID-19 can affect, and be affected by, mental health.

Researchers found that people with schizophrenia seem to be at particularly high risk. Those who received a diagnosis within the past year were more than seven times more likely to contract COVID-19 than people without a mental health disorder.

According to the results of another recent study published in JAMA Psychiatry, schizophrenia was also one of the most significant risk factors for dying from COVID-19, second only to age.

To better understand these results, Medical News Today spoke with Katlyn Nemani, MD, a psychiatrist at New York University (NYU) Grossman School of Medicine and the lead author on the study.

The study examined the medical records of over 7,300 adults who tested positive for SARS-CoV-2 and received treatment at the NYU Langone Health System, including:

  • 75 people with a history of schizophrenia
  • 564 people with a history of a mood disorder, including major depression and bipolar disorder
  • 360 people with a history of an anxiety disorder

The researchers compared the number of deaths in each group within 45 days of a positive SARS-CoV-2 test. They found that people with schizophrenia were 2.7 times more likely to die from COVID-19 than those without a history of a mental health disorder.

People with an anxiety or mood disorder were not at an increased risk of dying.

Other research has identified an increased risk of severe COVID-19 and death in people with schizophrenia, including studies conducted in Israel and South Korea.

Dr. Nemani explained that there are several factors that might put people with schizophrenia at increased risk of COVID-19 and complications, including:

  • living in crowded settings, such as group homes
  • lack of protective equipment, such as masks
  • poor access to healthcare
  • a higher prevalence of underlying medical conditions, such as heart disease and diabetes

“However, these factors were unlikely to account for the increased risk of [death] associated with schizophrenia in our study,” Dr. Nemani explained. After adjusting for these factors, people with schizophrenia were still 2.7 times more likely to die from COVID-19 than people without schizophrenia.

She suggested that people with schizophrenia may be more likely to experience severe COVID-19 because of underlying immune system dysfunction.

“Evidence from animal and human studies point toward a central role of inflammation in schizophrenia, in which certain risk genes and environmental stressors may alter the immune response and contribute to a chronic pro-inflammatory state,” Dr. Nemani said.

A pro-inflammatory state occurs due to increased immune system activity. When the immune system remains overactive for too long, it can lead to widespread tissue damage that can cause health problems.

Some experts have proposed that an over-activation of the immune system, known as a cytokine storm, is a possible cause of severe COVID-19.

Increased underlying immune activity in people with schizophrenia may therefore increase the risk of a cytokine storm. This can lead to severe COVID-19, and ultimately, death.

Henry Nasrallah, MD, a professor of psychiatry at the University of Cincinnati College of Medicine in Ohio, agreed that immune dysregulation in people with schizophrenia might explain the higher risk of death associated with COVID-19.

As he explained, immune system dysfunction can cause complications that make it harder for the body to fight off an infection, such as oxidative stress and impaired energy production.

The study by Dr. Nemani and colleagues accounted for many factors that may increase the risk of developing severe COVID-19. However, Dr. Nasrallah emphasized that people with schizophrenia are likely to have other underlying health and behavioral concerns that may increase the risk of severe disease and death, including:

  • sleep apnea
  • poor nutrition
  • substance use
  • neurodegeneration

In addition to immune dysregulation, Dr. Nemani added that medications used to treat schizophrenia might increase the risk of more severe COVID-19 and death.

“We are currently conducting studies to examine both possibilities,” she said.

There is currently no evidence that antipsychotics have associations with a higher risk of death in people with COVID-19 and schizophrenia. Dr. Nemani emphasized that it is important for people to stay in contact with their healthcare team to receive the most up-to-date treatment guidance.

Implications for other psychiatric disorders

Immune dysregulation is not unique to schizophrenia.

“We know that the brain and immune system communicate with each other through a common language that includes neurotransmitters and hormones,” Dr. Nemani explained. “It seems plausible that alterations to these pathways in the setting of a variety of psychiatric disorders could alter the immune response to COVID-19.”

Their study found that people with a history of mood or anxiety disorders did not have an increased risk of death. However, Dr. Nemani noted that more complications might occur in real life.

Other mental health conditions tend to follow a pattern, where symptoms get worse and then improve. This could help explain why people with other disorders did not seem to be at increased risk of COVID-19. “This may be different from the risk associated with schizophrenia, which is generally considered to be a chronic illness,” she said.

Dr. Nemani emphasized that people with schizophrenia and their loved ones should follow guidelines to reduce their risk of contracting COVID-19 by:

  • wearing a mask
  • avoiding crowded indoor settings
  • seeking vaccination when possible

“It is important that people with schizophrenia maintain a connection with their mental health team and follow treatment recommendations during the pandemic,” Dr. Nemani added.

Some experts have argued that people with severe mental health disorders, such as schizophrenia, should receive priority vaccinations for COVID-19, given their increased risk of severe disease.

However, as of early 2021, the Centers for Disease Control and Prevention (CDC) do not include mental health disorders in their most recent list of conditions that constitute high-risk underlying medical conditions.

Schizophrenia is a complicated disease characterized by several behavioral and health factors that may increase the risk of severe COVID-19 and death.

Although scientists are still investigating the exact processes underlying this relationship, chronic activation of the immune system in people with schizophrenia may cause health problems that make it harder to fight off the virus and increase the severity of the disease.

People with schizophrenia should take steps to reduce their risk of COVID-19 when possible, including wearing a mask, avoiding crowds, and having the vaccination when available.

Dr. Nemani added that while all of these steps are very important, it is also important to protect your mental health as well. “Physical distancing is important to prevent infection, but maintaining connection is important,” she said.