CDC Adds Bipolar Disorder & Schizophrenia To High-Risk COVID-19 List

On October 14, 2021, the U.S. Centers for Disease Control and Prevention (CDC) added bipolar disorder and schizophrenia to the list of high-risk underlying medical conditions that are associated with higher risk of severe illness due to coronavirus disease 2019 (COVID-19). These conditions were added to the list based on the strength of evidence revealed by at least one meta-analysis or systematic review, or by review method defined in a scientific evidence brief.

The CDC’s decision to add bipolar disorder and schizophrenia was based on the findings in two studies structured as systematic reviews and meta-analysis. The studies are:

• “Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis” by Guillaume Fond, Katlyn Nemani, Damien Etchecopar-Etchart, Anderson Loundou, and colleagues. They reviewed 16 observational studies in seven countries that involved 19,086 individuals. The researchers found that mental health disorders were associated with increased COVID-19 mortality according to both pooled crude and adjusted odds ratios. Those with severe mental health disorders had the highest odds ratios. Specifically, the adjusted odds of death due to COVID-19 among those with mental health disorders were 38% higher than among people without mental health disorders. Among those with severe mental health disorders the adjusted odds of death were 67% higher.
• “Association Between Mood Disorders and Risk of COVID-19 Infection, Hospitalization, and Death: A Systematic Review and Meta-analysis” by Felicia Ceban, Danica Nogo, Isidro P Carvalho, Yena Lee, and colleagues. The review included 21 studies that involved more than 91 million individuals. The researchers found that individuals with preexisting mood disorders, compared with those without mood disorders, had significantly higher pooled odds ratios for COVID-19 hospitalization and death. For those with mood disorders, the odds of hospitalization were 31% higher and the odds of death were 51% higher.

The CDC groups high-risk underlying conditions for severe COVID-19 by level of evidence, with the highest at the top. Mental health conditions are listed eighth on a list of 12 conditions defined in a scientific evidence brief, indicating a lower level of risk than most other conditions on the list:

1. Cancer
2. Cerebrovascular disease
3. Chronic kidney disease (evidence for pregnant and non-pregnant people)
4. Chronic lung diseases limited to interstitial lung disease, pulmonary embolism, pulmonary hypertension, bronchopulmonary dysplasia, bronchiectasis, and chronic obstructive pulmonary disease (COPD)
5. Chronic liver diseases limited to cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease, and autoimmune hepatitis
6. Diabetes mellitus, type 1 and type 2 (evidence for pregnant and non-pregnant people)
7. Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
8. Mental health disorders limited to mood disorders (including depression) and schizophrenia spectrum disorders
9. Obesity (body mass index of at least 30 kg/m2 – evidence for pregnant and non-pregnant people)
10. Pregnancy and recent pregnancy
11. Smoking, current and former
12. Tuberculosis

The CDC recommends that health care professionals should take certain actions regarding individuals with conditions that are included on the list of high-risk underlying medical conditions that put adults of any age at higher risk for severe illness from the virus that causes COVID-19. These include:

• Giving the COVID-19 vaccination to these individuals, referring these individuals to an authorized vaccination site if unable to give the vaccination personally.
• Encourage individuals to keep appointments for routine care and adhere to treatment regimens.
• Consider use of telehealth in coordination with community-based organizations, family members, or other provider organizations, when appropriate (although some individuals may not have knowledge of or access to appropriate technology or internet service).
• Encourage individuals to continue practicing preventive measures, such as wearing a mask and physical distancing, to avoid infection with the virus that causes COVID-19. This becomes even more important with increasing age and number and severity of underlying conditions.
• Carefully consider potential additional risks of COVID-19 illness for individuals who are members of certain racial and ethnic minority groups, and how to facilitate access to culturally and linguistically appropriate resources. These individuals are often younger when they develop chronic medical conditions, might be at higher risk of having more than one underlying medical condition, and at higher risk for acquisition of COVID-19.

The list of high-risk underlying medical conditions is updated as additional information is found by the CDC. Conditions are added to the list of high-risk underlying medical conditions for severe COVID-19 by four levels of evidence:

• Comorbidities that are supported by at least one meta-analysis or systematic review or by review method defined in Scientific Evidence brief.
• Comorbidities that are supported by at least one observational study (e.g., cohort, case-control, or cross-sectional). These studies might include systematic review or meta-analysis that represents one condition in a larger group of conditions (for example, kidney transplant under the category of solid organ or blood stem cell transplantation).
• Comorbidities that are supported by mostly case series, case reports, or, if other study design, the sample size is small (and no systematic review or meta-analysis available was available to review). This is defined as having an association in one or more case series studies. If there are cohort or case-control studies, the sample size was small.
• Comorbidities that are supported by mixed evidence. This is defined as having an association in at least one meta-analysis or systematic review and additional studies or reviews that reached different conclusions about risk associated with a medical condition.

The full text of “Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis” was published July 27, 2021, by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2782457.

The full text of “Association Between Mood Disorders and Risk of COVID-19 Infection, Hospitalization, and Death: A Systematic Review and Meta-analysis” was published July 28, 2021, by JAMA Psychiatry. An abstract is available online at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2782453.

For more information, contact:

• U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, Georgia 30329; 800-232-4636; Email: media@cdc.gov; Website: https://www.cdc.gov/