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| EDITORIAL |
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| Year : 2021 | Volume
: 26
| Issue : 1 | Page : 1-4 |
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The interaction of COVID-19 pandemic and schizophrenia
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Web Publication | 30-Jul-2021 |
Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_133_21
How to cite this article:
Grover S. The interaction of COVID-19 pandemic and schizophrenia. J Mental Health Hum Behav 2021;26:1-4 |
| Introduction | |  |
Schizophrenia is a severe mental disorder, which usually runs a chronic course. In addition, schizophrenia is also associated with adverse outcomes like higher rates of suicide when compared to the general population,[1] and it is associated with higher premature cardiovascular mortality[2] when compared to the general population. Many patients continue to have residual symptoms in the long run. The management of schizophrenia involves the long-term use of antipsychotics and various psychosocial interventions.[3] Patients with schizophrenia must remain in touch with their treating psychiatrist in the long run. However, it is well known that a significant proportion of patients with schizophrenia are poorly adherent to the medications.[4]
The COVID-19 pandemic has emerged as a worldwide crisis for patients with various chronic illnesses, including schizophrenia. The pandemic led to lockdown in most of the countries across the globe, closure or curtailment of outpatient and inpatient services, closure of daycare and rehabilitation services, limited access to electroconvulsive therapy, and other brain stimulation treatments in India too.[5],[6] A recent study showed that a diagnosis of schizophrenia spectrum disorder was associated with a significantly higher risk of mortality due to COVID-19 infection.[7] All these indicate that the pandemic will have a significant negative impact on the outcome of patients with schizophrenia. Another recent study showed that patients with schizophrenia are less likely to test positive for COVID-19, but if they test positive, then they are two times more likely to get admitted to the hospital for the COVID-19 infection and three times more likely to die, compared to controls, even after controlling for sociodemographic and clinical factors.[8]
However, everything does not appear to be adverse for patients with mental illnesses like schizophrenia. This editorial discusses the possible negative and positive impact of the pandemic on the various aspects of schizophrenia.
| Impact of Closure of Outpatient Services and Limited Inpatient Services | | |
The pandemic has lead to the closure or reduction in the capacity of inpatient units across the world. At some places, the psychiatric wards have been converted to COVID wards.[9] Similarly, the pandemic has led to the closure of outpatient services.[5],[6] The lack of services has led to a lack of access to treatment and free medications. Further, the lockdown has led to a lack of medication availability, even though the patients want to purchase the same.[10] The pandemic has also led to lower income, job loss, and more worries about income.[11] There is an increase in expenses due to inflation.[12] This has further contributed to the lack of ability to purchase the medication on the part of the patients. The pandemic has also led to the shutting down of rehabilitation and daycare services and restricted access to electroconvulsive therapy services and brain stimulation treatment. The reduction in the number of inpatient beds has led to frequent visits to emergency services. The pandemic has also led to a decrease in the investigation facilities or access to investigation facilities. This has led different recommendations for monitoring hemogram in patients on clozapine.[13] The closure or lack of access to laboratory facilities also means that the pandemic leads to difficulty in monitoring the metabolic parameters in patients on antipsychotics. Taken together, these may mean either stoppage of antipsychotics in patients already receiving the same, delay in starting of clozapine in patients with treatment-resistant schizophrenia due to lack of monitoring facilities, and delay in the management of treatment-emergent metabolic abnormalities.
However, it is also being noted that many patients with schizophrenia, who were on antipsychotics for long, are now doing well, even after stopping antipsychotics independently. This suggests that the pandemic may allow us to re-evaluate the long-term use of antipsychotics in patients with schizophrenia. Another positive aspect of less (or more) frequent contact of patients with the clinicians could mean the use of antipsychotics in adequate doses for a longer duration before a change in antipsychotics is ordered. The tendency to change in antipsychotics would be reduced due to consideration of difficulty in procuring newer antipsychotics. This may help in understanding the effectiveness of various antipsychotics in better ways. Further, due to a lack of monitoring of metabolic parameters, the pandemic may also force clinicians to try first-generation antipsychotics more frequently, rather than relying mainly on the second-generation antipsychotic medication. The pandemic has also restricted the availability and possible use of tobacco products, alcohol, and other substances. It can be said that this can have a positive impact on patients with schizophrenia in the form of better symptom control.
An essential outcome of the COVID-19 pandemic has been expanding telepsychiatry services across the globe, including India.[5],[6] Patients and caregivers are now able to contact the clinicians by sitting at their homes. This has led to a significant reduction in the need to travel, treatment cost, time spent in seeking medical help, more closure monitoring of the patients, possible evaluation of the patient in their natural environment, access to all possible caregivers rather than the limited number of caregivers who could travel to the hospital, and closure monitoring of the patients. A study showed that simple telephonic monitoring of patients on clozapine is feasible.[10] The mental health gap (mhGAP) in India for patients with psychotic illnesses is 75%.[14] However, it must be remembered that there is a high disparity in developing countries, and many people do not have access to a smartphone, which may preclude access to telepsychiatry services. Further, there are restrictions to what can be prescribed while issuing prescriptions through telepsychiatry services. The telepsychiatry may preclude the use of certain medications and hence discourage some of the clinicians from practicing the same. Another major limitation of the telepsychiatry services in the context of the pandemic is that though the telepsychiatry services have been able to fulfill the consultation needs, the need of free medications for the patients remains largely unfulfilled. Telepsychiatry services are not able to cater to the need of patients who have comorbid physical illnesses requiring clinical attention as physical examination is not possible, and the clinical needs of the patients who are actively suicidal are not fulfilled.
Further, some clinicians feel that telepsychiatry cannot substitute the in-person contact between the patient and the clinicians. Overall, it can be said that in future, there would be more expansion of the telepsychiatry services, and this could lead to a reduction in the mhGAP for schizophrenia and the emergence of newer hybrid treatment models. These treatment models may also give rise to the concepts of admission and rehabilitation at home, where the patients with schizophrenia can be monitored at home on a daily basis by a remotely located psychiatrist.
| Risk and Severity of COVID-19 Infection | | |
Some of the available evidence suggests that patients with mental illnesses are at high risk of COVID-19 infection. This is attributed to poor self-care and the inability to comply with the COVID-19-related behavior like the use of masks, frequent hand hygiene measures, and maintaining the desired social distancing. Additional factors which put the patients with schizophrenia at higher risk of COVID-19 infection include cognitive deficits, lower awareness about the risk, and poor insight.[15] Further, it is suggested that patients with schizophrenia are at increased risk of adverse outcomes of COVID-19 infection, including increased mortality, due to higher smoking rates and higher risk of pneumonia in patients receiving second-generation antipsychotics.[15] Other factors known to increase the risk of adverse outcomes among patients with schizophrenia include significant disparity in access to health care and stigma and discrimination when faced with COVID-19 infection.[15] Available data also suggest that patients on certain antipsychotics, such as those on clozapine, are at higher risk of COVID-19 infection than those receiving other antipsychotic medications.[16] The higher risk in patients receiving clozapine is additionally attributed to side effects like hypersalivation.[16]
However, some authors have proposed that the use of antipsychotics like chlorpromazine may be associated with a lower chance of developing COVID-19 infection, as chlorpromazine blocks the entry of the severe acute respiratory syndrome virus in the brain. It has been shown that the COVID-19 virus enters the human brain by its interaction with the angiotensin-converting enzyme (ACE) 2 receptors in the brain. Chlorpromazine has been reported to have immune-modulatory and antiviral properties and blocks ACE receptors in the brain.[17] Other reports suggest that the use of haloperidol may be associated with a lower chance of developing cytochrome storms.[18] This proposal is based on the available data from previous studies, which reported decreased mortality in patients on mechanical ventilation and it is hypothesized that this could be due to the lowering effect of haloperidol on cytokine levels.[18] Many second-generation antipsychotics (aripiprazole, risperidone, olanzapine, quetiapine, and clozapine) have been shown to have anti-inflammatory properties in various animal models. Clinical studies have also supported the anti-inflammatory properties of olanzapine, risperidone, and quetiapine.[19] These findings suggest that patients on various antipsychotics may be at lower risk of COVID-19 complications.
Taking all the above factors into account, except for one study that showed a higher incidence of COVID-19 infection in patients on clozapine, compared to other antipsychotics, there are no published data to prove that a higher proportion of patients with schizophrenia have suffered from COVID-19 infection. Similarly, there are no data to suggest that the use of antipsychotics has been protective in terms of the severity of COVID-19 disease. Hence, there is a need to evaluate these facts in the future. An improvement in understanding these facts may help to decide about the selection of antipsychotics in patients with psychotic illnesses. However, one recent large sample size study from the United States suggests that people who have developed COVID-19 infection have a higher risk of developing psychotic illnesses later on.[20] Understanding the anti-inflammatory response of antipsychotics may also help select antipsychotics in persons' developing psychotic illnesses in the post-COVID phase. Although farfetched, the possible beneficial role of antipsychotics like chlorpromazine and haloperidol may lead to a comeback for the first-generation antipsychotics in the management of schizophrenia.
| Treatment of COVID-19 and its Impact on the Outcome of Schizophrenia | | |
The treatments which have been evaluated for the management of COVID-19 have changed over time. Multiple medications have been repurposed for the same, with none of these being found to unequivocally effective, except for steroids. Available data suggest that the use of steroids can beneficial in patients with severe COVID-19 infection.[21] However, the use of steroids in patients with schizophrenia can lead to a relapse of symptoms. Further, the use of steroids in persons vulnerable to developing psychosis (first-degree relatives) may lead to unmasking psychosis. The use of steroids in patients with COVID-19 has also led to the unmasking of diabetes mellitus, especially in persons who are obese.[22] Considering this, it can be said that patients with schizophrenia, who are already on second-generation antipsychotics, will form a vulnerable group for the development of diabetes mellitus. Hence, it is quite possible that as the pandemic recedes, we may end up seeing more and more patients with schizophrenia having comorbid diabetes mellitus.
| COVID-19 Infection and Schizophrenia | | |
The COVID-19 infection leads to hypoxic brain injury, neurodegenerative changes, and cognitive deficits.[23] Patients with schizophrenia and mental illnesses have more cognitive deficits compared to healthy controls.[24] If the patients with schizophrenia develop severe COVID-19 infection and develop adverse brain outcomes, it may negatively impact the already impaired cognitive functions. The effects of COVID-19 on neurocognitive functions in patients with schizophrenia will receive significant attention shortly.
| COVID-19 Norms and Schizophrenia | | |
Data from South Korea suggest that there was an outbreak of COVID-19 infection in one of the psychiatric wards involving 100 of 102 patients, which resulted in the death of seven patients.[25] It was seen that the outbreak occurred due to lack of ventilation due to sealing of the windows to prevent suicide and restrictions on the use of sanitizers due to apprehension of some of the patients consuming the same.[26] The COVID-19 norms of social distancing and the use of a mask for patients with schizophrenia can lead to a feeling of abandonment. Further, the COVID norms may give rise to the emergence or re-emergence of obsessive–compulsive symptoms in patients who are already vulnerable to develop the same because of the ongoing antipsychotics.
Further, as seen in the general population,[27] patients with schizophrenia may also experience a higher stress level due to the ongoing pandemic and experience relapse. The restriction in the movement due to lockdown can reduce physical activity and weight gain. In addition, it can be said that, due to lockdown and closure of routine outpatient services, there could be a delay in help-seeking. This may lead to an increase in the duration of untreated psychosis and may have an impact on the long-term outcome of psychosis in patients with the new-onset illness. However, it can also be said that following COVID-19 norms may possibly lead to improvement in self-care among patients with schizophrenia. Further, the use of masks, awareness about the higher risk, and awareness about the higher risk among those with comorbid illnesses can reduce smoking. It can also be hypothesized that prolonged use of masks may reduce food intake and prevent weight gain.
| COVID-19 and Psychopathology | | |
As has already been mentioned, emerging data suggest a higher risk of developing psychosis among the COVID-19 survivors.[20] There are also reports of psychotic disorders in which psychopathology has been colored by the pandemic.[28] These findings suggest that in due course of time, the clinicians should always inquire about the history of COVID-19 infection among patients presenting with first-episode psychosis. Similarly, the clinicians should focus on psychopathology, that may be colured by the different aspects of the pandemic.
| COVID-19, Home Confinement, and Caregivers | | |
The COVID-19 has led to the confinement of patients with schizophrenia at home. In addition, the closure of offices and work from home has given the patients and caregivers more opportunities to interact. This can have both positive and negative impacts on the course and outcome of schizophrenia. For the caregivers, this may mean a higher caregiver burden and facing a higher level of aggression from the patient. In addition, spending more time with each other may also mean higher mutual exchange of expressed emotions between the patient and the caregivers. This can lead to a relapse of symptoms. However, all the family members at home may also mean higher caregiver involvement, higher sharing of the caregiving responsibilities rather than one person shouldering all the duties, higher social support, and emotional involvement with the patient. The availability of higher free time for the caregivers can also mean that they may more often get involved in cognitive remediation, cognitive rehabilitation, and engage with the patients in social skill training. All these may have a positive impact on the course and outcome of schizophrenia.
| Conclusion | | |
The pandemic is having a significant impact on the life of every human being. However, the effect of the pandemic on patients with schizophrenia is yet to be fully understood. Little research has emerged on this area. There is a need to research the impact of the COVID-19 pandemic on patients with schizophrenia in terms of various aspects of treatment, course, and outcome. The current level of understanding suggests that the COVID-19 pandemic is going to have a significant negative impact on patients with schizophrenia.
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