Joint European policy on the COVID-19 risks for people with mental disorders: An umbrella review and evidence- and consensus-based recommendations for mental and public health

Examining self-described policy-relevant evidence base for policymaking: an evidence map of COVID-19 literature

Background

Evidence-based policymaking is a paradigm aimed at increasing the use of evidence by actors involved in policymaking processes. The COVID-19 pandemic highlighted a heavy reliance on emerging evidence for policymaking during emergencies.

Objective

This study describes the focus and types of evidence in journal articles self-described as relevant to policymaking using the COVID-19 pandemic as a case study, identifying gaps in evidence and highlighting author stated perceived biases specifically in evidence-based policy making.

Design

Evidence mapping.

Data sources

We systematically searched SCOPUS, PubMed and LexisNexis for literature identifying policy-relevant evidence available on the COVID-19 pandemic.

Eligibility criteria

The study included only peer-reviewed literature identified as 'article', 'book chapter', 'review' covering the period from January 2020 to December 2022. Inclusion criteria required that articles have an abstract, authorship attribution and are written in English.

Data extraction and synthesis

A minimum of two authors independently extracted and coded for every level and final outputs were compared for consistency.

Results

A total of 213 articles met the inclusion criteria and were reviewed in this study. Lead authorship affiliations were from 50 countries with 70% of the outputs from developed economies including USA (20.2%), UK (18.3%) and Australia (7.5%). The most common purpose of the articles was the presentation of research findings the authors considered of relevance to policy (60.1%), followed by work that examined the impact of policy (28.6%) or highlighted or supported a policy need (22.5%), while some papers had multiple stated purposes. The most common challenges in policymaking identified by the authors of the reviewed papers were process failures and poor evidence utilisation during policymaking.

Conclusions

The evidence map identified the need for an interdisciplinary policy approach involving relevant stakeholders and driven by quality research as a progressive step towards prevention of future public health crises/pandemics.

Anti-spike antibody responses to SARS-CoV-2 mRNA vaccines in people with schizophrenia and schizoaffective disorder

Importance

Individuals with schizophrenia are at higher risk for severe COVID-19 illness and severe breakthrough infection following vaccination. It is unclear whether immune response to vaccination differs in this population.

Objective

To assess whether anti-SARS-CoV-2 spike antibody titers after vaccination differ in people with a diagnosis of schizophrenia or schizoaffective disorder (SZ) compared to controls without a psychiatric disorder.

Design

This cohort study assessed antibody response following the first and second dose of mRNA vaccines at longitudinal timepoints, up to 7 weeks following the first dose of vaccine.

Setting

A multi-center study including psychiatric healthcare settings in the United States and Europe.

Participants

205 adults with no history of COVID-19 infection, including 106 individuals with SZ and 99 controls without a psychiatric disorder, who received their first dose of SARS-CoV-2 mRNA vaccine between December 20, 2020 and May 27, 2021.

Main outcomes and measures

Mean SARS-CoV-2 anti-Spike IgG antibody levels within 7 weeks after the first dose of vaccination.

Results

A total of 205 individuals (mean [SD] age, 44.7 [12.0] years; 90 [43.9%] male) were included, of which 106 (51.7%) were diagnosed with SZ. SZ was associated with lower mean log antibody levels (-0.15; 95% CI, -0.27 to -0.03, P = 0.016) after adjusting for age, sex, body mass index, smoking, days since vaccination, and vaccine manufacturer. In secondary analyses of dose-specific responses, SZ was associated with a lower mean log antibody level after the second dose of vaccine (-0.23; 95% CI -0.39 to -0.06, P = 0.006), but not the first dose of vaccine (0.00; 95% CI -0.18- 0.19, P = 0.96).

Conclusions and Relevance

In this cohort study of individuals with SZ and a control group without psychiatric disorders, SZ was associated with lower SARS-CoV-2 anti-spike antibody levels following 2 doses of SARS-CoV-2 mRNA vaccination. This highlights the need for further studies assessing vaccine immunogenicity in individuals with schizophrenia.

A retrospective review of COVID-19 testing and mitigation strategies at a psychiatric hospital and subsequent COVID-19 acquisition

BACKGROUND

Behavioral health settings present increased challenges in preventing the transmission of infectious agents. Characterizing the relative effectiveness of various strategies, including testing for asymptomatic carriage of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, will inform transmission reduction efforts in behavioral health settings.

METHODS

A single-center retrospective study was conducted in an inpatient behavioral health hospital by reviewing COVID-19 mitigation and testing strategies with information collected from discharges between July 1, 2020 and February 28, 2021.

RESULTS

During the study period, there were 3,694 total discharges and 3,229 unique admitted patients, including 86 (2.7%) patients who had positive SARS-CoV-2 polymerase chain reaction test results. Preadmission testing from noncongregate care settings (38, 44.1%), and testing after an in-hospital exposure (27, 31.4%) were the most common indications for testing among patients with a positive test. Up to 29 (33.7%) potentially acquired the infection during their hospitalization. Asymptomatic screening tests identified approximately two-thirds (55, 64.0%) of potentially contagious patients.

CONCLUSION

Asymptomatic screening testing on admission and after exposure and universal masking were strong interventions to prevent SARS-CoV-2 transmission in this investigation Future studies of SARS-CoV-2 and other pathogens in behavioral health settings should endeavor to characterize the effectiveness of infection prevention interventions.

High unrecognized SARS-CoV-2 exposure of newly admitted and hospitalized psychiatric patients

BACKGROUND

Patients with pre-existing mental disorders are at higher risk for SARS-CoV-2 infection and adverse outcomes, and severe mental illness, including mood and psychosis spectrum disorders, is associated with increased mortality risk. Despite their increased risk profile, patients with severe mental illness have been understudied during the pandemic, with limited estimates of exposure in inpatient settings.

OBJECTIVE

The aim of this study was to describe the SARS-CoV-2 seroprevalence and antibody titers, and pro-inflammatory cytokine concentrations of newly admitted or hospitalized psychiatric inpatients without known history of COVID-19 infection, using robust quantitative multi-antigen assessments, and compare patients' exposure to that of hospital staff.

METHODS

This multi-centric, cross-sectional study compared SARS-CoV-2 seroprevalence and titers of 285 patients (University Psychiatric Centre Duffel [UPCD] N = 194; Assistance-Publique-Hopitaux de Paris [AP-HP] N = 91), and 192 hospital caregivers (UPCD N = 130; AP-HP N = 62) at two large psychiatric care facilities between January 1st and the May 30th 2021. Serum levels of SARS-CoV-2 antibodies against Spike proteins (full length), spike subunit 1 (S1), spike subunit 2 (S2), spike subunit 1 receptor binding domain (S1-RBD) and Nucleocapsid proteins were quantitatively determined using an advanced capillary Western Blot technique. To assess the robustness of the between-group seroprevalence differences, we performed sensitivity analyses with stringent cut-offs for seropositivity. We also assessed peripheral concentrations of IL-6, IL-8 and TNF-a using ELLA assays. Secondary analyses included comparisons of SARS-CoV-2 seroprevalence and titers between patient diagnostic subgroups, and between newly admitted (hospitalization ≤ 7 days) and hospitalized patients (hospitalization > 7 days) and correlations between serological and cytokines.

RESULTS

Patients had a significantly higher SARS-CoV-2 seroprevalence (67.85 % [95% CI 62.20-73.02]) than hospital caregivers (27.08% [95% CI 21.29-33.77]), and had significantly higher global SARS-CoV-2 titers (F = 29.40, df = 2, p < 0.0001). Moreover, patients had a 2.51-fold (95% CI 1.95-3.20) higher SARS-CoV-2 exposure risk compared to hospital caregivers (Fisher's exact test, P < 0.0001). No difference was found in SARS-CoV-2 seroprevalence and titers between patient subgroups. Patients could be differentiated most accurately from hospital caregivers by their higher Spike protein titers (OR 136.54 [95% CI 43.08-481.98], P < 0.0001), lower S1 (OR 0.06 [95% CI 0.02-0.15], P < 0.0001) titers and higher IL-6 (OR 3.41 [95% CI 1.73-7.24], P < 0.0001) and TNF-α (OR 34.29 [95% CI 5.00-258.87], P < 0.0001) and lower titers of IL-8 (OR 0.13 [95% CI 0.05-0.30], P < 0.0001). Seropositive patients had significantly higher SARS-COV-2 antibody titers compared to seropositive hospital caregivers (F = 19.53, df = 2, P < 0.0001), while titers were not different in seronegative individuals. Pro-inflammatory cytokine concentrations were not associated with serological status.

CONCLUSION

Our work demonstrated a very high unrecognized exposure to SARS-CoV-2 among newly admitted and hospitalized psychiatric inpatients, which is cause for concern in the context of highly robust evidence of adverse outcomes following COVID-19 in psychiatric patients. Attention should be directed toward monitoring and mitigating exposure to infectious agents within psychiatric hospitals.

COVID-19 vaccine uptake in mental healthcare users: Czech nationwide register study

BACKGROUND

The excessive covid-related mortality of psychiatric patients was reduced by vaccination. The vaccine uptake in patients diagnosed with different mental health disorders is, however, not fully described.

AIMS

A nationwide, record-based retrospective cross-sectional study examines the effect of substance use, psychotic, affective, anxiety, and personality disorders on COVID-19 vaccination rates in August and December 2021. Further, it quantifies the effect of receiving mental healthcare on vaccine uptake.

METHODS

The COVID-19 vaccine rates of mental healthcare users in August and December 2021 were examined using logistic regression models adjusted for sex and age on a sample of 7,235,690 adult inhabitants of the Czech Republic. The probability of vaccine uptake in the week following mental healthcare appointment or hospitalization on any day in the fall 2021 was compared to the general probability of getting vaccinated during that week.

RESULTS

The vaccination rate in August 2021 was related to history of hospitalization due to substance use (OR = 0.71), personality (OR = 0.87), psychotic (OR = 0.92), and anxiety (OR = 1.15) disorders, while mood disorders had no effect (OR = 1.00). Compared to general population, mental healthcare users were undervaccinated in August but not in December 2021. Vaccine uptake was low in those with history of psychiatric hospitalizations but higher in those utilizing inpatient or outpatient mental healthcare recently, predominantly for affective disorders. Increased vaccine uptake was observed following utilization of mental healthcare as well as in those with repeated psychiatric hospitalizations.

CONCLUSIONS

The vaccination rates of mental healthcare users relative to general population largely differ across nosological categories and during the vaccination campaign. Psychiatrists were successful in promoting vaccination against COVID-19.

COVID-19 mortality among selective serotonin reuptake inhibitor users-results from a nationwide cohort

OBJECTIVE

To examine differences in mortality and/or severe acute respiratory syndrome between selective serotonin reuptake inhibitor- (SSRI) users and non-SSRI users up to 60 days after a positive SARS-CoV-2 real-time reverse transcription PCR test.

METHODS

Retrospective cohort study including all Danish residents above the age of eighteen with a positive SARS-CoV-2 PCR test from 26 February, 2020 to 5 October, 2021. The follow-up period was 60 days. The primary outcome was all-cause mortality, and the secondary outcome was severe acute respiratory syndrome. Exposure of interest was SSRI use. Differences between SSRI users and non-users were examined with Cox regression.

RESULTS

Altogether, 286,447 SARS-CoV-2 positive individuals were identified, and 7113 met the criteria for SSRI use. SSRI users had a mean age of 50.4 years, and 34% were males. Non-SSRI users had a mean age of 41.4 years, and 50% were males. Similar vaccination frequency was observed among the two groups. Sertraline was the most commonly used SSRI, followed by citalopram and escitalopram. We found 255 deaths among SSRI users (3.6%) and 2872 deaths among non-SSRI users (1.0%). SSRI use was significantly associated with increased mortality, with a hazard ratio of 1.32 (95% confidence interval, 1.16 -1.50; p 0.015), even when adjusting for age, sex, vaccination status, and comorbidities.

DISCUSSION

We found significantly higher mortality when comparing SSRI users to non-SSRI users within 60 days after a positive SARS-CoV-2 PCR test. Even when considering possible residual confounding, a positive effect of SSRI intake seems highly unlikely. Our study therefore speaks against the hypothesis of repurposing SSRI drugs for COVID-19 treatment.

Patients with psychosis spectrum disorders hospitalized during the COVID-19 pandemic unravel overlooked SARS-CoV-2 past infection clustering with HERV-W ENV expression and chronic inflammation

Epidemiology has repeatedly associated certain infections with a risk of further developing psychiatric diseases. Such infections can activate retro-transposable genetic elements (HERV) known to trigger immune receptors and impair synaptic plasticity of neuroreceptors. Since the HERV-W ENV protein was recently shown to co-cluster with pro-inflammatory cytokines in a subgroup of patients with schizophrenia or bipolar disorder, we questioned the influence of the COVID-19 pandemic on patients with psychosis spectrum disorders (PSD). Present results revealed that (i) SARS-CoV-2 serology shows high prevalence and titers of antibodies in PSD, (ii) HERV-W ENV is detected in seropositive individuals only and (iii) SARS-CoV-2 and HERV-W ENV positivity co-clustered with high serum levels of pro-inflammatory cytokines in psychotic patients. These results thus suggest that SARS-CoV-2 infection in many patients with psychotic disorders now admitted in the psychiatry department did not cause severe COVID-19. They also confirm the previously reported association of elevated serum pro-inflammatory cytokines and HERV-W ENV in a subgroup of psychotic patients. In the context of the COVID-19 pandemic, this cluster is only found in SARS-CoV-2 seropositive PSD cases, suggesting a dominant influence of this virus on HERV-W ENV and cytokine expression, and/or patients' greater susceptibility to SARS-CoV-2 infection. Further investigation on an interplay between this viral infection and the clinical evolution of such PSD patients is needed. However, this repeatedly defined subgroup of psychotic patients with a pro-inflammatory phenotype and HERV expression calls for a differential therapeutic approach in psychoses, therefore for further precision medicine development.

Post-COVID condition: dispensation of drugs and diagnostic tests as proxies of healthcare impact

With the goal to increase knowledge on the healthcare impact of the post-COVID-19 condition we exploited the administrative claims database of Lombardy, the largest Italian region and the first after China to be heavily hit by the SARS-CoV-2 pandemic in February-May 2020. We chose to employ the dispensation of drugs and diagnostic tests as proxies of the impact of the post-COVID condition in 46,574 cases who recovered from COVID-19 and were negative at PCR testing within June 20, 2020. Data were obtained throughout the 18-month post-negativization period until December 2021 and results on the use of drugs and diagnostic tests were compared with those accrued in the same cases during the pre-COVID period in July-December 2019. After an increase in the first semester after SARS-CoV-2 negativization (July-December 2020), trends in the dispensation of drugs according to the broad ATC classes and of diagnostic tests decreased or remained substantially stable. However, dispensation of drugs for acid related disorders (A02), diabetes (A10), heparins (B01AB), direct oral anticoagulants (B01AP), antipsychotics (N05A), antidepressants (N06A) and for obstructive airways diseases (R03) was still higher than in the pre-COVID period. These findings, based upon drug and diagnostic test dispensation as proxies of the healthcare impact of the post-COVID condition, show that in a substantial proportion of recovered cases the post-COVID condition is active and clinically relevant 18 months after the acute disease. The findings also provide indirect evidence of the body organs and systems more compromised in the post-COVID period.

A closer look at yoga nidra- early randomized sleep lab investigations

OBJECTIVES

We aimed to examine trial feasibility plus physiological and psychological effects of a guided meditation practice, Yoga Nidra, in adults with self-reported insomnia.

METHODS

Twenty-two adults with self-reported insomnia were recruited to attend two visits at our research center. At Visit 1 (V1), participants were asked to lie quietly for ninety minutes. The primary outcome was change in electroencephalography (EEG). Heart rate variability (HRV), respiratory rate and self-reported mood and anxiety were also measured. At Visit 2 (V2), the same protocol was followed, except half of participants were randomized to practice Yoga Nidra for the first 30-min.

RESULTS

There were no between-group changes (V1-V2) in alpha EEG power at O1 (Intervention: 13 ± 70%; Control: -20 ± 40%), HRV or sleep onset latency in response to Yoga Nidra. Respiratory rate, however, showed statistically significant difference between groups (Yoga Nidra -1.4 breaths per minute (bpm) change during and - 2.1 bpm afterwards vs. Control +0.2 bpm during and + 0.4 bpm after; p = .03 for both during and after). The intervention displayed good acceptability (well-tolerated) and credibility (perceived benefit ratings) with implementation success (target sample size reached; 5% dropout rate).

CONCLUSIONS

This preliminary clinical trial provides early evidence that Yoga Nidra is a well-tolerated, feasible intervention for adults reporting insomnia. Decreased respiratory rate in response to Yoga Nidra needs to be confirmed in more definitive studies.

TRIAL REGISTRATION INFORMATION

This trial was registered on ClinicalTrials.gov as "A Closer Look at Yoga Nidra: Sleep Lab Analyses" (NCT#03685227).

Impact of mental disorders on clinical outcomes of physical diseases: an umbrella review assessing population attributable fraction and generalized impact fraction

Empirical evidence indicates a significant bidirectional association between mental disorders and physical diseases, but the prospective impact of men-tal disorders on clinical outcomes of physical diseases has not been comprehensively outlined. In this PRISMA- and COSMOS-E-compliant umbrella review, we searched PubMed, PsycINFO, Embase, and Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, up to March 15, 2022, to identify systematic reviews with meta-analysis that examined the prospective association between any mental disorder and clinical outcomes of physical diseases. Primary outcomes were disease-specific mortality and all-cause mortality. Secondary outcomes were disease-specific incidence, functioning and/or disability, symptom severity, quality of life, recurrence or progression, major cardiac events, and treatment-related outcomes. Additional inclusion criteria were further applied to primary studies. Random effect models were employed, along with I2 statistic, 95% prediction intervals, small-study effects test, excess significance bias test, and risk of bias (ROBIS) assessment. Associations were classified into five credibility classes of evidence (I to IV and non-significant) according to established criteria, complemented by sensitivity and subgroup analyses to examine the robustness of the main analysis. Statistical analysis was performed using a new package for conducting umbrella reviews (https://metaumbrella.org). Population attributable fraction (PAF) and generalized impact fraction (GIF) were then calculated for class I-III associations. Forty-seven systematic reviews with meta-analysis, encompassing 251 non-overlapping primary studies and reporting 74 associations, were included (68% were at low risk of bias at the ROBIS assessment). Altogether, 43 primary outcomes (disease-specific mortality: n=17; all-cause mortality: n=26) and 31 secondary outcomes were investigated. Although 72% of associations were statistically significant (p<0.05), only two showed convincing (class I) evidence: that between depressive disorders and all-cause mortality in patients with heart failure (hazard ratio, HR=1.44, 95% CI: 1.26-1.65), and that between schizophrenia and cardiovascular mortality in patients with cardiovascular diseases (risk ratio, RR=1.54, 95% CI: 1.36-1.75). Six associations showed highly suggestive (class II) evidence: those between depressive disorders and all-cause mortality in patients with diabetes mellitus (HR=2.84, 95% CI: 2.00-4.03) and with kidney failure (HR=1.41, 95% CI: 1.31-1.51); that between depressive disorders and major cardiac events in patients with myocardial infarction (odds ratio, OR=1.52, 95% CI: 1.36-1.70); that between depressive disorders and dementia in patients with diabetes mellitus (HR=2.11, 95% CI: 1.77-2.52); that between alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C (RR=3.15, 95% CI: 2.87-3.46); and that between schizophrenia and cancer mortality in patients with cancer (standardized mean ratio, SMR=1.74, 95% CI: 1.41-2.15). Sensitivity/subgroup analyses confirmed these results. The largest PAFs were 30.56% (95% CI: 27.67-33.49) for alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C, 26.81% (95% CI: 16.61-37.67) for depressive disorders and all-cause mortality in patients with diabetes mellitus, 13.68% (95% CI: 9.87-17.58) for depressive disorders and major cardiac events in patients with myocardial infarction, 11.99% (95% CI: 8.29-15.84) for schizophrenia and cardiovascular mortality in patients with cardiovascular diseases, and 11.59% (95% CI: 9.09-14.14) for depressive disorders and all-cause mortality in patients with kidney failure. The GIFs confirmed the preventive capacity of these associations. This umbrella review demonstrates that mental disorders increase the risk of a poor clinical outcome in several physical diseases. Prevention targeting mental disorders - particularly alcohol use disorders, depressive disorders, and schizophrenia - can reduce the incidence of adverse clinical outcomes in people with physical diseases. These findings can inform clinical practice and trans-speciality preventive approaches cutting across psychiatric and somatic medicine.