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Risk of COVID-19 Infection, Mortality in Patients with Bipolar Disorder, SMI Varies Depending on Medications Prescribed
In the final installment of this Q&A, Katlyn Nemani, MD, New York School of Medicine, examines the practical applications and further areas of research surrounding her study that found the use of second-generation antipsychotic medications was associated with a decreased risk of COVID-19 infection in patients with bipolar disorder and other serious mental health disorders. The retrospective cohort study was published in JAMA Network Open.
In part 1, Dr Nemani discussed the study’s design, significant findings, and surprising outcomes including the increased risk of infection observed in association with valproic acid use.
In a previous Q&A, Dr Nemani discusses her study that found a schizophrenia spectrum diagnosis was associated with increased mortality risk in patients with COVID-19.
Question: Are there any practical applications of your findings for clinicians treating patients with bipolar disorder, specifically?
Answer: Clinicians should continue to follow current clinical guidelines. We did observe increased infection in association with valproic acid, a mood stabilizer that is commonly used for the treatment of bipolar disorder. However, it is unclear whether this association is related to the drug itself, an interaction with other medications, or an unmeasured variable which may differ in patients prescribed valproic acid. Valproic acid is often used to treat mood lability and mania; failure to treat these symptoms may negatively affect adherence to infection prevention measures such as mask wearing and social distancing.
Second-generation antipsychotics, which are often used as adjunctive therapy in the treatment of bipolar disorder, are not associated with increased risk of infection or adverse outcomes; some may even be associated with protection against infection. Close clinical surveillance and monitoring for potential drug interactions is warranted for all patients with SMI to reduce the risk of adverse events.
Q: Are there any practical applications for clinicians treating patients with other serious mental health disorders (schizophrenia, schizoaffective disorder, or depression with psychotic features)?
A: Findings from this study suggest that clozapine does not increase risk of Covid-19 infection and may even reduce risk of mortality among infected patients. This was a reassuring finding suggesting that clinicians can continue to safely prescribe clozapine in the setting of the pandemic. Based on prior research, clozapine drug levels should be closely monitored and a dose reduction may be needed in the setting of infection to prevent toxicity.
Q: How might these results differ among patients with less severe psychiatric disease than the population in the study?
A: It is unclear at this time. There are a variety of factors that differ between patients in this study and patients in a wider clinical setting which may influence risk including type of psychopathology, length of treatment, use of polypharmacy, and clinical surveillance. We observed decreased mortality in patients prescribed antidepressant medications; this is consistent with prior studies of patients without SMI that found reduced risk of adverse outcomes associated with antidepressant use. However, several of the medications examined in the study are not routinely used to treat patients with less severe psychiatric illness. Additional research is needed to determine the generalizability of our findings.
Q: Are you conducting any more research in this area, and are there any other studies you feel are needed?
A: Future studies, including those with prospective cohort designs, are needed to confirm our findings. The potential effects of polypharmacy, medication dose, and duration of medication use should be explored. Vaccination status and type of variant will also need to be taken into consideration. My current research involves assessing the immune response to vaccination in people with SMI to determine whether this differs by psychiatric diagnosis or exposure to psychiatric medications. In the future it will be important to determine whether these findings are unique to SARS-Cov-2 or whether they might be seen in the setting of other infections.
Reference
Dr Katlyn Nemani is a clinical research psychiatrist at the Nathan Kline Institute and Research Assistant Professor of Psychiatry at the New York University School of Medicine. After earning her medical degree at Tufts University, Medford, Massachusetts, she completed combined residency training in neurology and psychiatry at NYU. Her research is focused on understanding the bidirectional relationship between systemic disease and psychopathology, particularly the interaction between the nervous system and immune system in people with psychosis.
