COVID-19-related psychological distress and engagement in preventative behaviors among individuals with severe mental illnesses

The COVID-19 pandemic has disproportionately affected vulnerable populations, including individuals with severe mental illnesses (SMIs) like psychosis and affective disorders. These individuals may be more susceptible to infection and experience a more severe clinical course due to factors such as increased vulnerability to stress, reduced healthcare access, higher rates of comorbidities (e.g., obesity, diabetes), and communal living situations. Concerns exist regarding their awareness of the pandemic and engagement in preventative behaviors. Previous research on H1N1 indicated reduced willingness to vaccinate and practice isolation among individuals with schizophrenia. This study, utilizing participants from three ongoing NIH-funded studies focusing on SMI, aimed to determine the prevalence of COVID-19 preventative behaviors among individuals with SMIs and identify demographic and psychological factors associated with these behaviors. Comparisons were made between individuals with schizophrenia spectrum illnesses and those with affective disorders, based on prior research suggesting differential stress responses to COVID-19.

Existing literature highlighted the increased vulnerability of individuals with SMIs to COVID-19 infection and severe outcomes. Studies showed higher susceptibility to infection and worse clinical courses in individuals with schizophrenia compared to those without the illness. Contributing factors include greater stress vulnerability, limited healthcare access, higher rates of high-risk comorbidities, and increased likelihood of residing in communal settings that facilitate transmission. Research from India indicated limited fear and awareness of COVID-19 among individuals with SMIs, with higher education, socioeconomic status, social support, and younger age correlating with increased knowledge. Prior work on the H1N1 pandemic showed reduced willingness to vaccinate and practice isolation among individuals with schizophrenia, raising concerns about their engagement in COVID-19 preventative behaviors.

This study involved 163 individuals with SMIs (94 with schizophrenia spectrum illnesses, 69 with affective disorders) and 27 psychiatrically healthy controls recruited from three ongoing studies across three sites. Participants completed a phone survey between April 3rd and June 4th, 2020. The survey assessed engagement in eight specific COVID-19 preventative behaviors performed at least once in the past month, along with standard assessments of depression, anxiety, perceived stress, loneliness, and coping. Responders and non-responders were compared to assess for self-selection bias. Chi-square tests compared group differences in preventative behavior endorsement, while independent samples t-tests compared psychological impacts between groups. Associations between demographic/clinical factors and preventative behaviors were examined using correlations. Logistic regression analyzed the effect of diagnostic category on preventative behaviors after controlling for potential confounds. Site differences were also examined.

The majority of the SMI sample reported engaging in multiple preventative behaviors. While healthy individuals were significantly more likely to work remotely, the SMI group reported similar or higher rates of other preventative behaviors, including self-distancing, avoiding public spaces, avoiding in-person visits, staying home, handwashing, using sanitizer, and cleaning/disinfecting surfaces. Individuals with affective disorders were more likely than those with schizophrenia spectrum illnesses to report working remotely, staying home, and wearing face masks, although only the difference in staying home remained significant after controlling for confounders. SMI individuals reported greater depression, anxiety, perceived stress, loneliness, and poorer coping than healthy controls, but no differences were found between the SMI diagnostic groups. Higher educational attainment was significantly associated with self-distancing and working remotely. COVID-related psychological distress had minimal relation to preventative behaviors, except anxiety was related to staying home, and loneliness and better coping were linked to avoiding in-person visits. Negative symptom severity was associated with reduced face mask use. Post-hoc analysis controlling for confounders showed that differences in staying home remained significant, with individuals with schizophrenia spectrum illnesses less likely to stay home than those with affective disorders. Significant site differences were observed for working remotely and wearing face masks.

These findings suggest that clinically stable outpatients with SMIs are largely aware of the COVID-19 pandemic and actively engage in preventative behaviors. The observed differences in working remotely likely reflect limitations in work flexibility rather than a lack of intention. While individuals with affective disorders showed a trend towards greater engagement in some preventative behaviors, particularly staying home, the clinical significance of this difference is uncertain. The minimal association between COVID-19 related psychological distress and preventative behavior engagement was unexpected, although the directionality of these relationships remains unclear. The lack of strong predictors of preventative behaviors highlights the complexity of this issue and suggests a need for further investigation.

This study provides encouraging evidence of COVID-19 awareness and proactive preventative behavior among stable outpatients with SMIs. While some differences exist between diagnostic groups, particularly concerning staying home, the overall engagement in preventative measures is comparable to healthy controls. The minimal relationship between psychological distress and preventative behaviors is noteworthy. Future studies should focus on larger, more diverse samples, including acutely ill individuals, to further elucidate the factors influencing preventative behavior engagement and the impact of COVID-19 on individuals with SMIs.

Limitations include the relatively small sample size of healthy controls, potential self-selection bias (responders had higher rates of female gender and education), and the focus on clinically stable outpatients, which limits generalizability to acutely ill individuals. The use of a retrospective, one-month recall period for preventative behaviors may have resulted in overestimation due to a potential ceiling effect. Future research should address these limitations by utilizing larger, more diverse samples, assessing behavior frequency, and employing anonymous survey methods.