The Centers for Disease Control and Prevention (CDC) has identified factors that put patients at a higher risk of severe COVID-19 infection, which include advanced age, obesity, cardiovascular disease, diabetes, chronic kidney disease, lung disease, and immunocompromising conditions. The CDC also acknowledges that mood disorders, including depression and schizophrenia, contribute to the progression to severe COVID-19.1 Antiviral therapies, such as nirmatrelvir and ritonavir combination, remdesivir, and molnupiravir, and monoclonal antibody (mAb) therapies, have been used to prevent hospitalization and mortality from COVID-19 infection for individuals with mild-to-moderate COVID-19 who are at high risk of progressing to severe infection.2 Although antiviral and mAb therapies likely have mitigated many infections, poor prognoses are prevalent. It is important to identify all patients at risk of progressing to severe COVID-19 infection.
Although the CDC considers depression and schizophrenia to be risk factors for severe COVID-19 infection, the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois, does not, making these patients ineligible for antiviral or mAb therapies unless they have another risk factor. As a result, these patients could be at risk of severe COVID-19 infection, but might not be treated appropriately. Psychiatric diagnoses are common among veterans, with 19.7% experiencing a mental illness in 2020.3 It is imperative to determine whether depression or schizophrenia play a role in the progression of COVID-19 to expand access to individuals who are eligible for antiviral or mAb therapies.
Because COVID-19 is a novel virus, there are few studies of psychiatric disorders and COVID-19 prognosis. A 2020 case control study determined that those with a recent mental illness diagnosis were at higher risk of COVID-19 infection with worse outcomes compared with those without psychiatric diagnoses. This effect was most prevalent among individuals with depression and schizophrenia.4 However, these individuals also were found to have additional comorbidities that could have contributed to poorer outcomes. A meta-analysis determined that psychiatric disorders were associated with increased COVID-19-related mortality.5 A 2022 cohort study that included vaccinated US Department of Veterans Affairs (VA) patients determined that having a psychiatric diagnosis was associated with increased incidence of breakthrough infections.6 Individuals with psychiatric conditions are thought to be at higher risk of severe COVID-19 outcomes because of poor access to care and higher incidence of untreated underlying health conditions.7 Lifestyle factors also could play a role. Because there is minimal data on COVID-19 prognosis and mental illness, further research is warranted to determine whether psychiatric diagnoses could contribute to more severe COVID-19 infections.
Methods
This was a retrospective cohort chart review study at FHCC that compared COVID-19 outcomes in individuals with depression or schizophrenia with those without these diagnoses. FHCC patients with the International Classification of Diseases code for COVID-19 (U07.1) from fiscal years 2020 to 2022 were included. We then selected patients with a depression or schizophrenia diagnosis noted in the electronic health record (EHR). These 2 patient lists were consolidated to identify every individual with a COVID-19 diagnosis and a diagnosis of depression or schizophrenia.
Patients were included if they were aged ≥ 18 years with a positive COVID-19 infection confirmed via polymerase chain reaction or blood test. Patients also had to have mild-to-moderate COVID-19 with ≥ 1 symptom such as fever, cough, sore throat, malaise, headache, muscle pain, loss of taste and smell, or shortness of breath. Patients were excluded if they had an asymptomatic infection, presented with severe COVID-19 infection, or were an FHCC employee. Severe COVID-19 was defined as having oxygen saturation < 94%, a respiratory rate > 30 breaths per minute, or supplemental oxygen requirement.
Patient EHRs were reviewed and analyzed using the VA Computerized Patient Record System and Joint Legacy Viewer. Collected data included age, medical history, use of antiviral or mAb therapy, and admission or death within 30 days of a positive COVID-19 test. The primary outcome of this study was severe COVID-19 outcomes defined as hospitalization, admission to the intensive care unit, intubation or mechanical ventilation, or death within 30 days of infection. The primary outcome was analyzed with a student t test; P < .05 was considered statistically significant.