Mental disorders, COVID-19-related life-saving measures and mortality in France: A nationwide cohort study

Abstract

Background

Meta-analyses have shown that preexisting mental disorders may increase serious Coronavirus Disease 2019 (COVID-19) outcomes, especially mortality. However, most studies were conducted during the first months of the pandemic, were inconclusive for several categories of mental disorders, and not fully controlled for potential confounders. Our study objectives were to assess independent associations between various categories of mental disorders and COVID-19-related mortality in a nationwide sample of COVID-19 inpatients discharged over 18 months and the potential role of salvage therapy triage to explain these associations.

Methods and findings

We analysed a nationwide retrospective cohort of all adult inpatients discharged with symptomatic COVID-19 between February 24, 2020 and August 28, 2021 in mainland France. The primary exposure was preexisting mental disorders assessed from all discharge information recorded over the last 9 years (dementia, depression, anxiety disorders, schizophrenia, alcohol use disorders, opioid use disorders, Down syndrome, other learning disabilities, and other disorder requiring psychiatric ward admission). The main outcomes were all-cause mortality and access to salvage therapy (intensive-care unit admission or life-saving respiratory support) assessed at 120 days after recorded COVID-19 diagnosis at hospital. Independent associations were analysed in multivariate logistic models.

Of 465,750 inpatients with symptomatic COVID-19, 153,870 (33.0%) were recorded with a history of mental disorders. Almost all categories of mental disorders were independently associated with higher mortality risks (except opioid use disorders) and lower salvage therapy rates (except opioid use disorders and Down syndrome). After taking into account the mortality risk predicted at baseline from patient vulnerability (including older age and severe somatic comorbidities), excess mortality risks due to caseload surges in hospitals were +5.0% (95% confidence interval (CI), 4.7 to 5.2) in patients without mental disorders (for a predicted risk of 13.3% [95% CI, 13.2 to 13.4] at baseline) and significantly higher in patients with mental disorders (+9.3% [95% CI, 8.9 to 9.8] for a predicted risk of 21.2% [95% CI, 21.0 to 21.4] at baseline). In contrast, salvage therapy rates during caseload surges in hospitals were significantly higher than expected in patients without mental disorders (+4.2% [95% CI, 3.8 to 4.5]) and lower in patients with mental disorders (−4.1% [95% CI, −4.4; −3.7]) for predicted rates similar at baseline (18.8% [95% CI, 18.7-18.9] and 18.0% [95% CI, 17.9-18.2], respectively).

The main limitations of our study point to the assessment of COVID-19-related mortality at 120 days and potential coding bias of medical information recorded in hospital claims data, although the main study findings were consistently reproduced in multiple sensitivity analyses.

Conclusions

COVID-19 patients with mental disorders had lower odds of accessing salvage therapy, suggesting that life-saving measures at French hospitals were disproportionately denied to patients with mental disorders in this exceptional context.

Abstract

Michaël Schwarzinger and colleagues examine the associations between mental disorders and mortality among all inpatients discharged with symptomatic COVID-19 in mainland France.

Author summary

Why was this study done?

• Systematic reviews and meta-analyses of previous studies suggest that mental disorders are associated with higher mortality risk in Coronavirus Disease 2019 (COVID-19) patients, but evidence remains limited to the first months of the pandemic, the community setting, and two categories of mental disorders (mood disorders and schizophrenia).

• There is no obvious explanation for the relationship, although the potential role of COVID-19 caseload surges in hospitals that impacted triage decisions for life-saving measures has not been fully explored.

What did the researchers do and find?

• We examined the associations between various categories of mental disorders and mortality among all inpatients discharged with symptomatic COVID-19 in mainland France, controlling not only for sociodemographic variables and multiple somatic conditions, but also for pandemic periods over 18 months.

• Of 465,750 inpatients discharged with symptomatic COVID-19, one third were recorded with pre-existing mental disorders over the last 9 years, and of 103,890 COVID-19 related deaths, almost half were recorded in patients with pre-existing mental disorders.

• We found independent associations of almost all categories of mental disorders with higher mortality risks and lower salvage therapy rates in COVID-19 inpatients.

• We found that patients with pre-existing mental disorders were disproportionately affected by COVID-19 caseload surges in hospitals with higher-than-expected excess mortality risks and gaps in salvage therapy rates compared to patients without pre-existing mental disorders.

What do these findings mean?

• The higher mortality risk for COVID-19 patients with mental disorders raises major ethical issues as it seems this patient group was disproportionately denied life-saving measures at hospital.

• The stability of the study findings should be examined in other jurisdictions.