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People with mental illness are at greater risk for developing COVID-19 than the general population, and vice versa — meaning reverberations from the pandemic are likely to be felt long after the virus has been brought to heel.

And whether infected or not, minorities, underserved communities, and others experiencing health disparities are at double the risk of long-term mental health impacts from COVID-19.

That’s the warning from National Institutes of Health researchers, speaking during the first in a three-part webinar series  hosted by the National Academies of Sciences Engineering and Medicine.

Mental Health and COVID-19

There are “bidirectional associations” between COVID-19 infection and psychiatric disorders, explained Joshua Gordon, MD, PhD, director of the National Institute of Mental Health.

One reason that people with psychiatric disorders are more at risk for COVID-19 than others could be that they are more likely to live in congregate settings, such as prisons. Or, maybe it’s because people with serious mental illness often have other comorbidities.

Conversely, those who contract COVID-19 and do not have a psychiatric disorder have an increased risk of developing one over the next few months, Gordon said.

Roughly 6% of all patients will have “a new onset of mental illness” following a COVID diagnosis, he said.

Several surveys “of varying scientific rigor” have shown increased rates of symptoms related to mental illness in the general population, said Gordon. Symptoms not diagnoses, he stressed.

He also noted that many of these surveys used convenience samples, though the most credible of these comes from the CDC.

Despite such limitations, “every single one” has shown increases in self-reported symptoms of anxiety, depression, and “starting or increased substance abuse, ” as well as trauma, stress-related symptoms, and suicidal ideation.

About 40% of adult respondents reported challenges with “one or more” of these symptoms, which is roughly twice previous rates, Gordon said.

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One potentially positive finding, while tentative, is that while suicidal ideation has increased, suicide deaths and suicide attempts haven’t yet, according to data from Greg Simon, MD, MPH, who leads the Mental Health Research Network.

The absolute number of visits for suicide attempts or self-injurious behavior appears to be “fairly steady” across 2019 and 2020 up to June, he said.

While this steady state could represent true stability in rates, it could also mean that, in the context of a lower number of overall emergency department visits, there may be more incidents but people are not seeking care.

In certain states where timely data is available, no increase in suicide deaths has occurred through the early 2020 summer, Gordon said.

As for the long-term risks of the pandemic, Gordon said most people exposed to trauma improve with time.

“A lot of people will have a lot of symptoms in the context of a disaster, but only a minority, a significant minority … will go on to have long-term or chronic experiences with mental illness as a consequence of involvement in those disasters,” Gordon said.

Those most at risk are those who have few social supports; who have a history of trauma or mental illness before the disaster; who were exposed most directly to morbidity or mortality; who had a severe acute psychiatric reaction to the disaster; or who experience ongoing stressors such as job-related or financial strains, he said.

Moreover, social inequalities and health disparities “both predict and exacerbate” the vulnerability to these long-term negative outcomes among marginalized populations.

This pandemic has had an outsized impact on minority and undeserved communities, Gordon said, which puts them “essentially doubly at risk” for long-term mental illness; not only because they are more likely to be impacted but because they are more likely to have pre-existing risk factors that raise their chances for a mental illness.

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COVID and Substance Abuse

Nora Volkow, MD, director of the National Institute of Drug Abuse, said researchers have gotten creative in identifying timely data on substance use and overdoses.

Data from Millennium Health and other testing laboratories early in the pandemic showed increases of 32% in individuals testing positive for fentanyl; 20% in methamphetamine positivity; 12% in heroin positivity; and 10% in cocaine positivity.

“We don’t know what has happened in the past 6 months. But even with that restrictive data set, you can see significant increases in the positivity rate of urine that are being sent to these laboratories,” she said.

That rise in positive drug tests was found across ages and genders, Volkow said.

One program called Overdose Detection Mapping Applications, which monitors areas of high drug consumption, found significant increases in the number of fatal and nonfatal overdoses, reaching as high as 42% in May 2020 versus the same month in 2019.

From April 2019 to April 2020, the CDC found a 13.2% increase in overdose mortality, according to the agency’s provisional data.

Like those with serious mental illness, people with substance use disorders are also at greater risk of contracting COVID-19.

This increased risk of illness is not only due to their social circumstances and living conditions, said Volkow, but also to drugs’ physiological effects on pulmonary, cardiac, metabolic, and immune function, all of which are targeted by COVID-19 as well.

As a result, people with substance use disorders who develop COVID are much more likely to be hospitalized and to die, compared with the general population, Volkow said.

She also highlighted the significantly higher rates of deaths among African Americans than whites, likely due to their higher rates of chronic medical conditions that lead to these poor outcomes.

That further underscores the role of health disparities and the multiple factors that worsen outcomes in disadvantaged groups, Volkow said, stressing the danger of stigma, which keeps people from getting treatment, exposes them to high-risk behaviors, and leads to worse outcomes.

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Volkow also warned against underestimating the “devastating” impacts of social isolation.

She cited studies showing that in “complex environments with multiple behavioral choices,” animals will not press a lever to receive drugs, whereas animals in social isolation will.

One 2018 experiment offered rats the choice between pressing a lever to get a drug and pressing a lever which enabled interaction with another rat, Volkow explained.

“When they have that choice, the animals … don’t take heroin. They choose the social interaction,” Volkow said.

When the researchers added another factor and shocked the rat for pressing the lever that offers the social reward, the rats began choosing the heroin lever instead. Volkow said the shocks’ parallel in humans represents stigma.

“If we want people to actually be able to achieve recovery, if we want to be able to prevent drug use, then we need to ensure that we are able as a society to provide social interactions that are rewarding and that are meaningful.”

By Shannon Firth, Health Policy and Washington Correspondent, MedPage Today
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