The success of the coronavirus vaccine rollout in the UK and internationally has allowed some return to normality for many people. However, one group that was – and continues to be – at risk of being overlooked in the context of COVID-19 is those with severe mental illness (SMI). In this blog, Dr Lamiece Hassan and Dr Joseph Firth outline the findings of new research into the continued risk coronavirus poses to those with SMI, and what policymakers and public health officials can do to protect this vulnerable group from the current (and future) pandemics.

• Even after the vaccine rollout, people with SMI remain up to three times more likely to die from COVID-19.
• There is strong overlap between SMI and other risk factors, such as physical illnesses; but these do not account for all the extra risk faced by those with SMI.
• National and local government must develop long-term strategies to understand the issues faced by people with SMI, including tackling tackle mental and physical health inequalities.

People with severe mental illnesses (SMI) – like schizophrenia, bipolar disorder and major depression – have been hit harder by the COVID-19 pandemic. In the first year of the pandemic, previous research (including our own studies), showed that people with SMI were more likely to catch COVID-19 and to suffer serious outcomes as a result. These studies helped to make the case why people with SMI needed extra support and priority access to vaccinations to protect them.

Fast forward a year or so, and vaccinations (and boosters) have become widely available, most social restrictions have been removed, and life is beginning to return to ‘normal’. But when it comes to people with SMI, a key question is; how concerned do we still need to be about protecting people from COVID-19?

Our recent research has aimed to answer this question, examining how people in Greater Manchester with SMI were affected by COVID-19 before, during and after vaccinations become available.

We looked at anonymised patient records from almost 1 million people with different mental illnesses, including their medical history, vaccinations and COVID-related outcomes like infections, hospitalisations and deaths. Our sample included people living with schizophrenia, bipolar disorder, and major depression, compared against records of patients with no history of mental illness. The sample was followed up from February 2020 until September 2021.

We found that after the vaccine roll-out began in December 2020, death rates due to COVID-19 declined across all groups of people, regardless of diagnosis. However, people with SMI were still more likely to die from COVID-19 compared to their matched counterparts without prior mental illness. Overall, this risk of death was about three times higher for people with schizophrenia and bipolar disorder, and 1.5 times higher for people with a history of major depression.

Underlying physical illnesses (like diabetes, cancer and heart disease) were more common among people with SMI than their matched counterparts. We also saw that vaccination rates by September 2021 varied among people with SMI: the rate of double vaccination was highest among people with major depression (74%) and lowest among people with schizophrenia (66%). When we took into account the impact of underlying physical illnesses and vaccination, this accounted for some, but not all, of the extra risk we saw among people with SMI. This means it is likely that other factors may be at play among people with SMI that we didn’t consider, or haven’t yet been identified.

This research – one of the largest studies of its kind in the world – was only possible because we had access to a large dataset of anonymised records from people in Greater Manchester, known as the GM Care Record. Wider moves to digitise and integrate patient records on a national scale, and to build secure analytics platforms suitable for research use, should make studies like this even easier in future.

Even so, it is challenging to conduct this kind of research. For one thing, we based our groupings of people on lifetime diagnoses (if they had ever/never had a specific diagnosis), which doesn’t take into account the severity or recency of illness. Furthermore, people may have had more than one diagnosis of SMI in their lifetime, masking some of the differences between groups. To unpick some of these complex issues, we worked with experts in statistics and people with lived experience of mental illness (and their carers) to help us interpret the results carefully.

What does this mean – and what can we do about it?

In summary, our research shows that people with SMI, and particularly those with schizophrenia and bipolar disorder, are still more likely to be at risk of dying from COVID-19, even after the vaccination roll out. Thankfully, deaths may be lower overall now, but the differences in relative risk are still arguably cause for concern. Strategies for preventing serious illness and death from future pandemics – including new COVID variants – should understand this risk and seek to mitigate it. This requires clear communication to and from public health bodies that those with SMI are a vulnerable group, alongside specific interventions to protect this group from infection.

We should be mindful that people with SMI also showed an increased risk of death due to causes other than COVID-19 through the study: so these risks of COVID-19 can be interpreted as added risks on top of those health inequalities that people usually face. Policymakers in national and local government, and in health and social care services, should take steps to understand the causes of these health inequalities, and how they might be mitigated to ensure this group is not at greater risk of serious illness and death. Policymakers must also be mindful of how poor mental health intersects with other factors associated with health disparities, such as lower income, age, and ethnicity.

Clearly, we need to understand reasons why people may or may not be vaccinated, and offer support and information. Indeed, we saw significant numbers of individuals who remained unvaccinated, which is concerning. Healthcare professionals should actively offer, discuss, and record attempts to promote vaccination in this group, where they are eligible. Efforts should be made to understand the reasons for vaccine hesitancy, particularly among people living with schizophrenia.

Finally, given the higher risks of physical health problems that people with severe mental illness suffer from, we need to resume regular physical health checks that may have taken less priority during the pandemic. Over the longer term, the impact of research like ours adds pressure on policymakers to address physical, as well as mental, health problems among people with severe mental illness to increase quality and years of life.

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