05. Association Between Mood Disorders and Risk of COVID-19 Infection, Hospitalization, and Death

Text version

Obesity, lung disease, hypertension, and diabetes all are risk factors for hospitalization and death from COVID-19 infection. Here is another: A pre-existing mood disorder.

Hi! Jim Phelps here for the Psychopharmacology Institute. Perhaps this comes as no surprise to you considering the physical debility that goes with being depressed, and of course there’s that much harder to measure effect of the psychological state of depression. Let’s look into both here.

According to a new meta-analysis in JAMA Psychiatry, a pre-existing mood disorder clearly increases the risk of hospitalization and death. This is now a very firm association, as shown in this meta-analysis of 21 studies, 8 case control, 12 cohort, and 1 exposure crossover, from all over the world. Relative to people without a pre-existing mood disorder, the odds ratio for hospitalization was 1.3 times higher. In other words, people with a mood disorder are 30% more likely to end up in the hospital if infected with COVID compared with those without a mood problem. The odds ratio for death was even higher at 1.5, which meant that those with a mood disorder were 50% more likely to die from COVID if infected.

Let’s see what the authors lined up to explain this connection. For ease of recall, we could lump the multiple pathways into 3 baskets: First, social factors; second, concomitant physical conditions and the risk behaviors in people with depression that lead to those conditions; and third, inflammation.

Basket 1: Social factors. The authors used the phrase “economic insecurity.” Imagine all the complexity that lies behind that pair of words. As my daughter schooled me, young people nowadays refer to this as intersectionality, which is the interplay of income disparities, systemic racism, gender inequality, environmental degradation, and increasing risks from climate change. Economic insecurity is only the beginning. The authors point out many individuals with mood disorders reside in congregate facilities, such as psychiatric inpatient units, homeless shelters, community housing, and prisons, where the risk of COVID-19 transmission is increased because of the inability to effectively socially distance or quarantine themselves.

Basket 2: Established risk factors for COVID-19 infection. These are significantly more prevalent among individuals with mood disorders and include other illnesses, such as lung and heart disease, obesity, and adverse health behaviors. The authors cite sleep dysregulation and habitual inactivity.

And finally, basket 3: Inflammation. This is a little tricky. Some mood disorders, but not all, are associated with increased inflammatory factors, such as increased C-reactive protein, interleukin-6, and tumor necrosis factor. But how this interacts with increased cytokine activity associated with COVID-19 is not well established. Yet, as you’ve likely heard, antidepressants have been found to provide protective effects against COVID-19 complications, possibly via direct anti-inflammatory or antireplication effects, at least according to preclinical work. Antipsychotics and lithium have also been found to have anti-inflammatory effects in some preclinical studies.

In conclusion, had you any doubt, a pre-existing mood disorder increases the likelihood of poor outcomes among people infected with COVID-19, namely hospitalization and death. This may suggest that vaccination is even more of a good idea for this group, which then suggests that psychiatrists who are in contact with this population have a role to play in managing the pandemic by checking the vaccination status of our patients and using motivational interviewing to encourage the as-yet unvaccinated toward getting vaccinated.

If you’d like to see more on this, Figure 2 in the article, which is linked here, will show you in a glance the study findings and their meta-analytic origin.

Abstract

Importance: Preexisting noncommunicable diseases (eg, diabetes) increase the risk of COVID-19 infection, hospitalization, and death. Mood disorders are associated with impaired immune function and social determinants that increase the risk of COVID-19. Determining whether preexisting mood disorders represent a risk of COVID-19 would inform public health priorities.

Objective: To assess whether preexisting mood disorders are associated with a higher risk of COVID-19 susceptibility, hospitalization, severe complications, and death.

Data sources: Systematic searches were conducted for studies reporting data on COVID-19 outcomes in populations with and without mood disorders on PubMed/MEDLINE, The Cochrane Library, PsycInfo, Embase, Web of Science, Google/Google Scholar, LitCovid, and select reference lists. The search timeline was from database inception to February 1, 2021.

Study selection: Primary research articles that reported quantitative COVID-19 outcome data in persons with mood disorders vs persons without mood disorders of any age, sex, and nationality were selected. Of 1950 articles identified through this search strategy, 21 studies were included in the analysis.

Data extraction and synthesis: The modified Newcastle-Ottawa Scale was used to assess methodological quality and risk of bias of component studies. Reported adjusted odds ratios (ORs) were pooled with unadjusted ORs calculated from summary data to generate 4 random-effects summary ORs, each corresponding to a primary outcome.

Main outcomes and measures: The 4 a priori primary outcomes were COVID-19 susceptibility, COVID-19 hospitalization, COVID-19 severe events, and COVID-19 death. The hypothesis was formulated before study search. Outcome measures between individuals with and without mood disorders were compared.

Results: This review included 21 studies that involved more than 91 million individuals. Significantly higher odds of COVID-19 hospitalization (OR, 1.31; 95% CI, 1.12-1.53; P = .001; n = 26 554 397) and death (OR, 1.51; 95% CI, 1.34-1.69; P < .001; n = 25 808 660) were found in persons with preexisting mood disorders compared with those without mood disorders. There was no association between mood disorders and COVID-19 susceptibility (OR, 1.27; 95% CI, 0.73-2.19; n = 65 514 469) or severe events (OR, 0.94; 95% CI, 0.87-1.03; n = 83 240). Visual inspection of the composite funnel plot for asymmetry indicated the presence of publication bias; however, the Egger regression intercept test result was not statistically significant.

Conclusions and relevance: The results of this systematic review and meta-analysis examining the association between preexisting mood disorders and COVID-19 outcomes suggest that individuals with preexisting mood disorders are at higher risk of COVID-19 hospitalization and death and should be categorized as an at-risk group on the basis of a preexisting condition.

Reference

Ceban, F., Nogo, D., Carvalho, I. P., Lee, Y., Nasri, F., Xiong, J., … & McIntyre, R. S. (2021). Association between mood disorders and risk of COVID-19 infection, hospitalization, and death: A systematic review and meta-analysis. JAMA Psychiatry, 78(10), 1079-1091.