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Schizophrenia Identified as Major Risk Factor for COVID-19 Death

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Key Takeaways

  • People with schizophrenia are almost three times more likely to die from COVID-19 than those who don't have the disorder, according to a new study.
  • Experts don't know exactly what's behind the association, so further research is required.
  • Socio-environmental stressors and biological vulnerability are two possible reasons for the higher risk of death or serious illness from COVID-19 for schizophrenia patients.

A new study, published January 27 in the journal JAMA Psychiatry, found that people with schizophrenia are almost three times more likely to die from COVID-19 than those without the illness. In fact, schizophrenia is second only to age when it comes to coronavirus risk factors.

The researchers, from the New York University Grossman School of Medicine, say this risk can’t be attributed to other factors, such as diabetes, smoking, or higher rates of heart disease.

Gayani DeSilva, MD

[Having schizophrenia] is essentially being out of touch with reality, having hallucinations, delusions, paranoia, thought disorders such as disorganized thinking, speaking in odd ways, and behaving in odd ways.

— Gayani DeSilva, MD

The Study in Detail 

The team analyzed 7,348 patient records of men and women treated for COVID-19 in NYU Langone hospitals in New York City and Long Island between March 3 and May 31, 2020. They identified 14% who were diagnosed with schizophrenia, mood disorders, or anxiety. Next, they calculated patient death rates within 45 days of testing positive for the virus.

Their investigation showed that people with schizophrenia had 2.7 times increased odds of dying from COVID-19 (being age 75 or over increased the odds of death 37.5 times). After schizophrenia, male sex, heart disease, and race were the greatest risk factors.

There are several potential explanations for the schizophrenia risk factor, says the lead author of the study, Katlyn Nemani, MD, a research assistant professor in the department of psychiatry at NYU Langone Health.

"Within the context of our study, two potential explanations include an abnormal immune response to infection associated with schizophrenia, or risk associated with medications used to treat the disorder," she says. The team currently is conducting further studies to examine both possibilities.

Katlyn Nemani, MD

Increased risk of severe COVID-19 infection and death has been reported in patients with schizophrenia in large nationwide cohorts in France and South Korea, and further research is needed to see if this finding is replicated in other healthcare settings.

— Katlyn Nemani, MD

Interestingly, the study showed that people with other mental health problems, such as mood or anxiety disorders, were not at increased risk of death from COVID-19 infection.

One of the main limitations of the study was the relatively limited number of patients with schizophrenia in the cohort (75 out of 7,348 patients). Dr. Nemani says this was expected based on the nationwide prevalence of this mental disorder.

"Increased risk of severe COVID-19 infection and death has been reported in patients with schizophrenia in large nationwide cohorts in France and South Korea, and further research is needed to see if this finding is replicated in other healthcare settings," Dr. Nemani says.

Another limitation of the study was that the sample was limited to patients with access to testing and treatment within the NYU Healthcare system. So the risk of adverse outcomes may be further increased among patients with reduced access to medical care.

What Is Schizophrenia?

Schizophrenia is a chronic mental disorder marked by persistent psychosis. "This is essentially being out of touch with reality, having hallucinations, delusions, paranoia, thought disorders such as disorganized thinking, speaking in odd ways, and behaving in odd ways," says psychiatrist and author Gayani DeSilva, MD.

The illness can range in severity—some people experience mild difficulties with psychosis, while others endure severe disruptions to daily life. "People with schizophrenia typically have a difficult time maintaining employment and relationships, and symptoms get worse over time," Dr. DeSilva says.  

Schizophrenia is typically treated with antipsychotic medications. But Dr. DeSilva stresses that rehabilitative strategies to address activities of daily living and relationships are just as important to improve quality of life.

What’s the Relationship Between Schizophrenia and COVID-19?

The researchers expected patients with psychiatric illness to be at higher risk for mortality in the setting of COVID-19, given their higher rates of medical conditions—particularly cardiovascular disease.

Even so, the high risk of mortality associated with schizophrenia spectrum disorders in the setting of COVID-19 came as a surprise to the researchers. "The magnitude of this finding after adjusting for other medical risk factors was unexpected," Dr. Nemani says.

"Severe infections often precede the diagnosis of schizophrenia—so it seems unlikely that medications used to treat the disorder fully explain the risk," Dr. DeSilva says. "Both socio-environmental stressors and biological vulnerability may contribute to immune alterations that make people less efficient at fighting off viruses and more prone to an uncontrolled inflammatory response."

Katlyn Nemani, MD

[Schizoprenia] patients often face structural barriers to accessing medical care, including testing and vaccines. Prioritizing testing and vaccination for this group would help mitigate health inequities and save lives.

— Katlyn Nemani, MD

Dr. DeSilva adds that people with schizophrenia can have difficulty judging reality and struggle with delusions. They may not trust or be able to follow public health mandates. "They may believe in conspiracy theories, or avoid getting vaccinated or seeking care for acute symptoms. They may avoid wearing masks, and congregate in close quarters with like-minded people," she adds. "Many people with schizophrenia are homeless, which also increases their risk of getting COVID-19."

Dr. Nemani hopes that the study—along with the existing body of evidence suggesting that people with serious mental illness, including schizophrenia, are at increased risk of worse outcomes following COVID-19 infection—will encourage the CDC to make people with schizophrenia a priority group for COVID-19 testing and vaccination.

"These patients often face structural barriers to accessing medical care, including testing and vaccines," she says. "Prioritizing testing and vaccination for this group would help mitigate health inequities and save lives."

What This Means For You

If you or your loved one has schizophrenia, speak to your primary care doctor for the best advice on how to protect against COVID-19. It's particularly important to keep doctor appointments, take medication as directed, and take steps to reduce stress.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.

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  1. Nemani K, Li C, Olfson M, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. 2021;78(4):380. doi:10.1001/jamapsychiatry.2020.4442