By: Fayaz Ahmad Paul
Starting in January 2020, coronavirus rapidly became global pandemic and the World Health Organization and many governments promulgated social distancing, isolation and a number of guidelines to slow the spread of the virus even after a vaccine were arrived at. These public health efforts are targeting the entire populations but these strategies may be less effective for certain marginalized groups, notably those with schizophrenia and related disorders. The features of these disorders, such as delusions, hallucinations, disorganized behavior, cognitive impairment, and poor insight, and socio-demographic characteristics, including living in congregate housing and homelessness, may put these individuals at higher risk of becoming infected with Covid19.
People living with schizophrenia are at greater risk for adverse outcomes, including death, as these people typically have poorer physical health, greater socioeconomic disadvantage, are more socially disconnected, and experience pervasive stigma and discrimination. Due to a number of factors including cognitive impairment, lower awareness of risk and barriers to adequate infection control including congregate living make them more susceptible to the virus. As schizophrenia is characterized by impairments in insight and decision-making capacity, it may be harder for people with schizophrenia to adopt and adhere to the protective measures recommended to prevent infection (for example, hand washing, social distancing or isolation, confinement).
Further, co-morbid substance use disorders, highly prevalent in schizophrenia, may compound impairments in judgment and decision-making. Multiple factors increase the risk of poor Covid-19 in people with schizophrenia including smoking, which is prevalent in more than 60% of people with schizophrenia and it may increase the risk of disease progression and severe complications including death, via its effects on lung health and immune responsiveness. Several other factors put people with schizophrenia at risk as they experience substantial disparities in access to health care, related in part to the effects of stigma on help-seeking and discrimination when they access care they are more likely to experience under-diagnosis of co-morbid physical illnesses, less likely to receive screening and definitive interventions, and generally receive poorer-quality care. The World Health Organization recommends that “isolating, testing and treating every suspected case, and tracing every contact” is the best way of preventing widespread community transmission.
The stress related to the Covid-19 and corresponding public health measures worsens mental health in the general population; one would expect that their impact might be even higher in people living with schizophrenia. In addition, Covid-19 infection itself may exacerbate symptoms in people with schizophrenia, as corona-virus may be associated with psychotic symptoms through an immune-related mechanism. Furthermore, symptoms associated with corona-virus and their treatments have been associated with distress related to symptom severity and isolation, as well as psychosis secondary to steroids and other interventions. Social distancing, whereby governments have discouraged and imposed restrictions to reduce physical proximity, has been widely adopted in order to decrease community transmission of Covid-19.
Social distancing practices could have a particularly negative impact on individuals with schizophrenia; typically, individuals with schizophrenia on average have smaller and poorer quality social networks than the general population. Thus, they may be more able to comply with, and tolerate, social distancing directives. However, social support has been associated with higher scores on recovery measures in schizophrenia, and broad community supports, including casual contacts at pharmacies, grocery stores, and other important shops, have also been associated with improved recovery and community integration scores in schizophrenia. These casual contacts will be disrupted by social distancing, putting patients at risk among people with schizophrenia, social isolation may increase the risk for suicide, and stress has been associated with aggressive behavior.
Social distancing may also disproportionately impact the ability of people with schizophrenia to maintain their basic needs, given their high reliance on income support and other community services that become more difficult to access. Thus, developing approaches to maintain social connection to instrumental supports in the face of social distancing may be especially crucial for people with schizophrenia. Video conferencing apps are widely used to maintain face-to-face connection during the outbreak. Similarly, programs and government agencies that provide essential services to the community should strive to find ways to maintain their efforts to ensure continued and safe delivery of services to vulnerable populations.
The Covid-19 pandemic has created challenges for the health professionals and programs that provide services to patients with schizophrenia. Continuity of care is critical for these patients to prevent decompensation and its consequences, including emergency department visits and hospital admissions resulting in further strain on the health care system, mental and physical deterioration, and even deaths. The immediate impact of Covid-19 could be even greater in outpatient settings, where the majority of mental health care is delivered. Evidence-based models of care for schizophrenia, including assertive community treatment and intensive case management, emphasize in-person contacts in the community and in patients’ homes. While outreach visits increase the risk of transmission to both patients and providers, abrupt changes to how mental health services are delivered could increase the risk of service disengagement, medication non-adherence, and distress, all leading to decompensation and relapse.
Author is Research Scholar in the Department of Psychiatry. Paulfayazpaul@gmail.com
