key: cord-0706204-yyoa59vi
authors: Fond, Guillaume; Masson, Marc; Richieri, Raphaelle; Korchia, Théo; Lançon, Christophe; Boyer, Laurent
title: You get psychotropic drugs, so you don’t need vaccination against Covid 19?
date: 2021-02-13
journal: Encephale
DOI: 10.1016/j.encep.2021.02.001
sha: c3c8524917d4a018ebb6d63d5273e5fe2e4d30f5
doc_id: 706204
cord_uid: yyoa59vi

nan

In the global race for a safe and effective COVID-19 vaccine, many challenges remain. Among them, the initial scarcity of doses requires ethical reflection on the prioritization of people to be vaccinated. In France, the French Health Administration, Haute Autorité de Santé (HAS), began a vaccination campaign in early 2021. On December 18, 2020, the HAS specified its opinion on the people to be vaccinated in response to an additional referral from the Direction Générale de la Santé [1] . In particular, it specifies that "it will be up to the doctor to evaluate the relevance of the vaccination on a case-by-case basis -and to propose it to people for whom the risks appear to be major". A recent study has suggested that antidepressant treatment may be protective from poor Covid-19 outcomes [2] . Should this mean that psychiatric patients are safe from Covid-19 and thus should not be vaccinated in priority?

Not all psychiatric patients are administered antidepressants and recent studies have shown that people with severe mental illness are at increased risk of morbidity and mortality from Covid-19. We published in 2020 the intra-hospital mortality data from the first wave of COVID -19 [3] : patients with schizophrenia had a mortality rate of 26% compared to 21% in individuals without mental illness, and this difference was particularly significant in the 65-80 age group [4] . We also noted differences in ICU admissions, with schizophrenia patients younger than 55 years of age being admitted to ICU more often than their controls without mental illness, suggesting that even younger patients with schizophrenia are at greater risk of Covid-related complications. We also found excess mortality in patients with bipolar disorder, as these results have not yet been published. They also confirm data that we have published on physical diseases other than Covid-19 [5] .

These data should be combined with international data showing very high risks of COVID -19 contamination in individuals with severe psychiatric disorders (with odds ratios ranging from 5.7 to 7.6 in a case-control study) [6] . Indeed, there is a strong link between severe mental illness and many environmental variables that are themselves risk factors for COVID-19 infection, such as low socio-economic status, working in hazardous environments, living in crowded or homeless conditions, institutionalization and lock-down. In addition, the stigma, discrimination, misbeliefs and negative attitudes associated with serious mental illness and systemic factors are barriers to recognizing and managing physical health in people with serious mental illness. Finally, people with serious mental illness find it more difficult to follow and apply the ever-changing rules that are being established in the fight against Covid-19.

The World Health Organization and other international organizations have an ethical framework for awarding the COVID-19 vaccine that adheres to three universal principles [7] .

A first principle is to minimize harm and maximize benefit: vaccination should reduce death and disease burden with a minimal side-effect profile.

The second principle advocates giving priority to populations whose health status makes them more vulnerable to Covid-19. Some groups are more exposed to the risk of being infected by COVID-19, of dying or of suffering lasting after-effects because of their age, profession, health status or socio-economic situation [7] . As such, people with co-morbidities such as cardiovascular disease, chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, obesity, immunodeficiency and cancer are particularly vulnerable to morbidity and mortality from COVID-19 and should logically be given priority.

These factors, as well as advanced age, have been identified as priority factors by the French National Authority for Health in its initial strategy [8] .

The third principle requires that individuals are considered and treated as having equal dignity and worth in the allocation and setting of priorities. In particular, people who experience barriers to vaccine access due to vulnerability or inequality should be given equal opportunities to be vaccinated compared to more privileged groups. With respect to the ethical principles outlined above, people with schizophrenia, major depression or bipolar disorder are characterized by both problems in accessing care and comorbidities such as cardiovascular disease, type 2 diabetes and respiratory tract diseases. Their mortality rate is two to three times higher than that of the general population independently of Covid-19, resulting in 10 to 20 years loss of life expectancy. The risk of obesity, which is a significant risk factor for mortality in patients with Covid-19, may be more than four times higher in people with schizophrenia and approximately one and a half times higher in people with major depressive disorder or bipolar disorder compared to the general population [9] .

In light of this knowledge and the prevalence of severe mental illness in the French population (6 million depressed people, 1. 6 million people with bipolar disorder and 500,000 people with schizophrenia), and taking into account the second and third ethical principles that should guide the allocation of vaccines, we consider it essential that people suffering from severe mental illness be given priority during the first phase of distribution of the COVID-19 vaccine, taking care to respect the autonomy and freedom of consent of patients as recalled in the latest opinion of the National Advisory Committee on Ethics [8] . It is our responsibility, as psychiatrists, in this global health crisis, to defend the needs of our patients with governments and public health policy institutes. In addition, public health agencies should develop and implement targeted programs to ensure that these patients and their health care providers are informed of these increased risks as well as the benefits of vaccination.

Conflicts of interest: no conflicts to disclose.

This work was funded by Assistance Publique -Hôpitaux Marseille (APHM) -Aix-Marseille University (AMU) and the PHRC National, Direction générale de l'offre de soins (DGOS), France.

Vaccination contre la Covid-19 : la HAS précise ses recommandations sur la priorisation des publics cibles

Association between antidepressant use and reduced risk of intubation or death in hospitalized patients with COVID-19: results from an observational study

Increased in-hospital mortality from COVID-19 in patients with schizophrenia

Disparities in Intensive Care Unit Admission and Mortality Among Patients With Schizophrenia and COVID-19: A National Cohort Study

End-of-life care among patients with schizophrenia and cancer: a population-based cohort study from the French national hospital database

Increased risk of COVID-19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States

Prioritizing COVID-19 vaccination for people with severe mental illness

HAS. Vaccins Covid-19 : quelle stratégie de priorisation à l'initiation de la campagne ? Haute Autorité de Santé 2020

The 10-year findings from the FondaMental Academic Center of Expertise for Schizophrenia (FACE-SZ): Review and recommendations for clinical practice