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    The impact that the COVID-19 pandemic has had around the world is undeniable and its effects on health care systems and the health of individuals is likely to be felt for many years to come. Issues surrounding the impact that COVID-19 has had on people with schizophrenia specifically were discussed during an educational symposium held at the 34th European College of Neuropsychopharmacology Congress.
    Presentations given during the symposium, entitled ‘The COVID-19 pandemic: implications for physical and mental health of people living with Schizophrenia’, provided an update of the impact of the COVID-19 pandemic on health status, treatment management, and access to care of people with schizophrenia.

    Pre-existing psychotic disorders and COVID-19

    Compared to people without a psychiatric condition, people with psychotic disorders such as schizophrenia were more likely to have been tested for SARS-CoV2 infection at the start of the pandemic,1 said Dr Amir Krivoy, Head of an Inpatient Rehab Psychiatric Ward at the Geha Mental Health Center in Petach-Tikva, Israel, who gave the opening lecture of the symposium.
    Not only that, but data have shown that people with schizophrenia who tested positive for SARS-CoV2 infection were also more likely to be hospitalized2 and to die3,4 as a result, compared to people without psychotic or other psychiatric disorders.5
    Then, Dr. Krivoy discussed the increased risk of poor outcomes in people with schizophrenia affected by COVID-19.
    In doing so, he highlighted a recent study performed in the United States that had looked at the hospitalization and death rates associated with serious SARS-CoV2 infection.2 The results showed that having a psychiatric diagnosis was associated with a 30% increased risk for death.2
    This increased death risk from COVID-19 was also corroborated by data from another US study3 and a French one as well.4 Dr. Krivoy showed that, in both studies, people with COVID-19 and mental health disorders had a higher rate of mortality compared to those without.3,4 In fact, in the French study not only did people with schizophrenia have a higher chance of dying in hospital, but they were also less likely to have been admitted to an intensive care unit. 4 This implies that people with schizophrenia did not receive as adequate care as other hospitalized patients, Dr. Krivoy suggested.4
    All in all, Dr. Krivoy highlighted that the chances of someone with schizophrenia being hospitalized due to COVID-19 were about five times higher than someone without schizophrenia, and their mortality risk was about 2.5 times higher.5
    Hospitalization and death risk already high in schizophrenia
    Moving on, Dr. Krivoy observed that people with schizophrenia are already a vulnerable patient population. So, he asked, what can be done to reduce the excess risk that may be caused by COVID-19?
    He shared some of his own unpublished data that had looked at the impact of the COVID-19 pandemic on people with mental health disorders. Using the Clalit Health Services electronic database, which includes the records of more than half a million participants, it was assessed whether psychotic disorders or antipsychotic treatment were risk factors for COVID-19 infection, hospitalization, and mortality. The results indicated that a lower incidence of COVID-19 infection was seen with the use of antipsychotic medications, but once infected, people with schizophrenia had a higher risk for hospitalization and death due to COVID-19 than those without.
    Concluding, Dr. Krivoy emphasized that people with psychotic disorders have a higher chance of being hospitalized regardless of whether they are infected with COVID-19 or not. Adding COVID-19 into the mix made their chances of being hospitalized much higher.6 Thus people with schizophrenia who test positive for SARS-Cov2- or who develop COVID-19 need to be managed with much more caution to ensure they achieve the best outcomes.

    Impact of pandemic on mental health services

    To try to put the impact of the COVID-19 pandemic on the care of people with schizophrenia into context, the next speaker and chair of the session, Professor Carmen Moreno, noted that spending on mental health services had always been low but this had reached critical levels during the pandemic.
    To illustrate her point, Prof. Moreno, a child and adult psychiatrist based at the Gregorio Marañón Hospital in Madrid, Spain, cited data by the World Health Organization. This showed how mental health services had been disrupted in 93% of 130 countries surveyed and that just 2% of national health care budgets were being spent on mental health services.6
    People with schizophrenia may have been particularly disadvantaged when it came to accessing mental health care during the pandemic, she suggested. Factors such as the stigma surrounding the condition, having a low income, residential instability, or unhealthy lifestyle could all have come into play to make their access to much-needed mental health services more difficult.7
    Changes to day-to-day practice
    Looking at how the pandemic had influenced routine psychiatric practice, Prof. Moreno discussed some of the immediate effects that had occurred in her region, which were probably similar to effects seen in other practices across the world. These included a dramatic drop in the number of psychiatric beds available, outpatient services, and rehabilitation units were closed, many of which are still not fully open yet. Throughout the pandemic, visits to psychiatric emergency departments were reduced by 75%, Prof Moreno said.8
    Furthermore, psychiatrists found they had additional demands on their time, such as taking care of the mental health needs of fellow hospital staff and the relatives of patients and helping people deal with the death process.8
    There is no doubt that the pandemic had changed mental health care and, in addition to continued infection control strategies, challenges such as access to care needed to be addressed, as does consideration that there may be new patients with mental health issues emerging because of the pandemic. 9 It is important for mental health care systems to become more flexible, Prof. Moreno said, to avoid an ever-increasing health care problem.9
    At the beginning of the pandemic, it was difficult to continue treating patients as usual and there was an unavoidable delay in providing optimal care to most patients, Prof. Moreno acknowledged. However, as the pandemic continued, some hospitals in her area became devoted to treating people with psychiatric illnesses who had COVID-19.
    Virtual consultations
    Another significant change during the pandemic was the greater reliance on telemedicine; interacting with each other virtually became a routine part of life and remains so today, Prof. Moreno observed. The question now is whether regular virtual consultations with schizophrenia patients should continue to be part of the day-to-day psychiatric practice.
    From a patient perspective, the answer might be yes. Data from more than 20 years ago showed that patients with schizophrenia preferred video conferencing to a live interview.10 Prof. Moreno suggested that this is understandable considering that some people may have avoidance behavior, and thus may prefer to stay at home.10
    More recent data11 have suggested that video conferencing may be favoured over live interactions for other reasons such as less time spent waiting for or traveling to an appointment.13 Video conferencing is associated with better patient attendance, adherence, and acceptance, said Prof. Moreno and may help bring lots of different people together more easily.11
    While telemedicine should not replace necessary face-to-face consultations, stressed Prof. Moreno, it does provide an opportunity to reach underserved populations. Using a combination of telemedicine and face-to-face interactions could potentially save all parties time and money. To do this more efficiently, patients’ digital skills and competencies should be improved, and clinicians should also be offered training on how to use telemedicine effectively.

    Management of clozapine treatment in the pandemic

    In the final lecture of the symposium, the use of clozapine during the COVID-19 pandemic was discussed by Dr Siobhan Gee, the principal pharmacist for psychiatric liaison at South London and the Maudsley NHS Foundation Trust in London, UK. She focussed on three important aspects of clozapine treatment: the potential for it to cause neutropenia, its progression to agranulocytosis, and monitoring plasma levels of the drug. 
    Dr. Gee began by recounting her early experience of the pandemic and how fellow doctors had reached out to her for advice on how to manage their patients who were taking clozapine. Emerging data on the new coronavirus was causing concern as it reduced white cell counts in those taking the drug.
    It is a well-known fact that clozapine has the potential to cause neutropenia in a small number of patients, Dr. Gee said, and there is the potential for this to progress to severe and life-threatening agranulocytosis in a minority of patients.12
    To address the concerns over clozapine’s use and possible blood dyscrasias in patients with SARS-CoV2, her hospital had developed some local guidance.13 This recommended that clozapine should be continued as usual, but that more frequent monitoring should be done to look for any changes in the white blood cells, especially neutrophils.
    Dr. Gee acknowledged that the pandemic had a big impact on the frequency of blood testing, with a decreased capacity. There was also reduced communication with patients who perhaps needed testing.
    She reassured her audience that while a reduction in white cell counts had been observed in people taking clozapine early in the pandemic, it was mainly the lymphocyte and not neutrophil counts that were influenced.14
    Moreover, Dr. Gee observed that the neutropenia seen in patients with COVID-19 who were taking clozapine was usually mild and transient and thus there was no need to stop the drug unless the neutrophil count fell below 1.0 × 109/L.12 This is particularly important when treating this vulnerable group of patients, she concluded, as stopping treatment may cause patients to relapse.12


    1. van der Meer D, Pinzón-Espinosa J, Lin BD, et al.Associations between psychiatric disorders, COVID-19 testing probability and COVID-19 testing results: findings from a population-based study.BJ Psych Open. 2020;6(5):e87.
    2. Li L, Li F, Fortunati F, et al. Association of a prior psychiatric diagnosis with mortality among hospitalized patients with coronavirus disease 2019 (COVID-19) infection. JAMA Netw Open. 2020;3(9):e2023282.
    3. Wang Q, Xu R, Volkow ND. Increased risk of COVID-19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States. World Psychiatry. 2021;20(1): 124–30.
    4. Fond G, Pauly V, Leone M, et al. Disparities in intensive care unit admission and mortality among patients with schizophrenia and COVID-19: a national cohort study. Schizophr Bull. 2021;47(3):624–34.
    5. Tzur Bitan D, Krieger I, Kridin K, et al. COVID-19 prevalence and mortality among schizophrenia patients: a large-scale retrospective cohort study Schizophr Bull. 2021;47(5): 1211–17.
    6. World Health Organization (WHO). The impact of COVID-19 on mental, neurological and substance use services. WHO survey Geneva: WHO, 2021. ISBN: 978-92-4-001245-5.
    7. Kahl KG, Correll CU. Management of patients with severe mental illness during the coronavirus disease 2019 pandemic. JAMA Psychiatry. 2020;77(9):977–8.
    8. Arango C. Lessons learned from the coronavirus health crisis in Madrid, Spain: how covid-19 has changed our lives in the last 2 weeks. Biol Psychiatry. 2020;88(7):e33–4.
    9. Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):813–24.
    10. Zarate CA Jr, Weinstock L, Cukor P, et al. Applicability of telemedicine for assessing patients with schizophrenia: acceptance and reliability. J Clin Psychiatry. 2021;58(1):22–5.
    11. Santesteban-Echarri O, Piskulic R, Nyman R, et al. Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. J Telemed Telecare. 2020;26(1-2):14–20. 
    12. Gee S, Taylor D.COVID-19 infection causes a reduction in neutrophil counts in patients taking clozapine. J Psychiatry Neurosci. 2021;46(2):E232–7.
    13. South London and the Maudsley NHS Foundation Trust. Clozapine and blood dyscrasias in patients with coronavirus (COVID-19) 2020.
    14. Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–20.

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