COVID 19 vaccination of persons with schizophrenia in India - Need for imperative action!

COVID 19 [Coronavirus disease], an unprecedented global pandemic, has led to the most significant strain on healthcare resources and has adversely impacted mental healthcare delivery. Schizophrenia is a chronic severe mental illness associated with increased morbidity and mortality (Jablensky, 2000). Persons with schizophrenia are at increased risk for COVID 19 illness given the biological vulnerability, impaired judgment, decreased foresight, disorganized symptoms, homelessness, potential socioeconomic difficulties, comorbid physical illnesses [such as nicotine use, metabolic syndrome], and treatment-related factors such as clozapine use associated risk of pneumonia (Kozloff et al., 2020; Nemani et al., 2021). Additionally, COVID 19, is associated with more incident rates of psychosis and relapse in individuals with pre-existing psychosis (Brown et al., 2020). These are possibly mediated through direct [viral exposure, immune mediated mechanisms and treatment with corticosteroids] and indirect [stress mediated] mechanisms (Hamada and Fan, 2020).

A recent study reported that schizophrenia spectrum disorders are second only to age as a risk factor and are associated with 2.7 times increased mortality due to COVID 19 after adjusting for confounders (Nemani et al., 2021). Although there is enough literature on attitudes towards vaccination in persons with medical illnesses, there is a dearth of evidence regarding vaccine hesitancy and studies on the attitudes of persons with schizophrenia towards vaccination.

The Government of India has rolled out the world's largest vaccination drive for Indian citizens (Bagcchi, 2021). In the first leg of vaccination, healthcare workers were prioritized, and in the second leg that has opened since March 1, 2021, medically ill persons over 45 years and all citizens over 60 years have been prioritized for the vaccination.

There is a need to prioritize the needs for vaccination in persons with severe mental illnesses in line with the ethical guiding principles of vaccine rollout that are as follows (Mazereel et al., 2021)

The benefit should exceed the risk

There should be equal concern for all prioritized persons

There should be efforts towards mitigation of inequalities to disadvantaged groups.

What is the role of mental health professionals in meeting this need?

Psychiatrists can help address this urgent need by improving the systems approach with multipronged strategies such as

Staying up to date with latest guidelines: Psychiatrists should be up to date with latest position papers and guidelines issued by international and national psychiatry bodies (Stewart and Appelbaum, 2020)

Liaison with administration: Formulate local consensus guidelines regarding vaccination of persons with mental illnesses and sensitization of healthcare administration in meeting the unmet need for vaccination. This policy document should emphasize the increased risk of death in persons with schizophrenia in line with Denmark, the UK, the Netherlands, and Germany (Siva, 2021).

Advanced directives and assessment of capacity: The psychiatrist must prepare for the arduous task of assessing capacity, advocating advanced directives to include patient's wishes about vaccination after adequate education.

Vaccine advocacy and awareness: Psychiatrists should raise awareness about COVID in persons who have schizophrenia and their caregivers and counter vaccine-related misinformation and negative attitudes.

Secondary prevention: Reducing the risk of COVID 19 related deaths by adaptive lifestyle modifications and prompt treatment of comorbidities that increase the risk of COVID 19 related complications, including smoking cessation, prevention, and treatment of the metabolic syndrome.

Healthcare facilities: Emphasize on healthcare workers vaccination and COVID 19 appropriate behavior in shelters and healthcare facilities caring for persons with schizophrenia. This should be followed by equipping the healthcare personnel with the vaccine know-how to ensure effective delivery of services.

Vaccine rollout: Engaging community psychiatry services actively in planning, organizing, and execution of vaccine rollout strategies for persons with schizophrenia

Consultation-Liaison: Sensitize the treating physicians and engage in better consultation-liaison to ensure effective triaging of persons with mental illness as having a higher risk of death secondary to COVID in line with higher risk with medical illnesses.

Improved aftercare to ensure the completion of the vaccination schedule and continued care of mental health needs.

Conclusion

The world especially in other developing and underdeveloped nations look towards India's vaccine rollout strategy as a template for replication. Psychiatrists in India should be the champions of advocacy to ensure prioritization of vaccination in persons with schizophrenia.

CRediT authorship contribution statement

Dr. Satish Suhas prepared the manuscript.

Declaration of competing interest

Dr. Satish Suhas reports no conflict of interest.