View Article PDF

The recognition of mental health and addiction issues as pre-existing health conditions that place people at higher risk of serious outcomes or illness in the Ministry of Health’s vaccine rollout plan (ie, Group 3) is critical to prevent further physical health inequities for people with mental health and addiction issues.

People with mental health and addiction issues have two to three times the risk of dying before the age of 65 compared to the general population.[[1]] Two-thirds of this risk is caused by preventable and treatable physical illnesses. Policy-level changes, alongside practice changes, are crucial if this significantly reduced life expectancy is to be addressed.

Over the past five years there have been notable changes in Aotearoa New Zealand’s health policy towards formally recognising the physical health inequities experienced by people with mental health and addiction issues. These include Living Well with Diabetes, the five-year plan for people at high risk of or living with diabetes, which identifies people with mental health and addiction issues as a high-risk group and priority population for routine diabetes screening.[[2]] An evidence review around cardiovascular disease (CVD) risk and management in people with mental health and addiction issues informed new guidance for primary care CVD risk assessment and management.[[3]] This guidance prioritises people with mental health and addiction issues for CVD risk assessment and ongoing management from the age of 25.[[4]] The New Zealand Cancer Action Plan 2019–2029[[5]] has a focus on the need to improve the quality of cancer screening and treatment of people with addiction and mental health issues.

The whole of the healthcare system is consistently identified as a major factor to the physical health inequities experienced by people with mental health and addiction issues. This is particularly due to systemic issues that impact on access to, and quality of, physical healthcare.[[6]] At worst, this results in the denial of preventative services and routine care. Stigma and discrimination, particularly diagnostic overshadowing (the assumption that physical health symptoms are related to a mental health or addiction diagnosis) and clinicians seeing the person as their mental health or addiction diagnosis, means people are less likely to receive the expected standard of healthcare. This leads to delayed or missed physical health screening, care and treatment. Discrimination is experienced across the health system, including but not limited to diabetes care, routine cancer screening, blood pressure and cholesterol monitoring, surgical interventions for cardiovascular diseases and vaccinations.[[7]]

There is also the significant and often unrecognised intersection of ethnicity, mental health, addiction and physical health, with the largest inequities for Māori and Pasifika peoples living with mental health and addiction issues.[[8,9]] There is an important opportunity for the Government to meet its Te Tiriti o Waitangi commitments to active protection, as described in Whakamaua Māori Health Action Plan 2020–2025.[[10]]

Kia Kaha, Kia Māia, Kia Ora Aotearoa: Psychosocial and Mental Wellbeing Plan[[11]] identifies people with mental health and addiction issues as a priority group in relation to the psychosocial impacts of COVID-19,  and that they are more vulnerable to infection and negative outcomes from the virus. It is critical that there is formal recognition and that this recognition translates into vaccination policy and implementation, including workforce education and training.[[12]]

Understanding COVID-19 vulnerability

At the end of 2020, the backbone team of the Aotearoa New Zealand Equally Well collaborative convened a group of expert advisors to appraise the available evidence on COVID-19 vulnerability and people with mental health and addiction issues and, from this appraisal, to develop a position statement. The review of the evidence was conducted by Te Pou, a national workforce centre for mental health, addiction and disability in Aotearoa New Zealand.

In January 2021, the position statement and a summary of the evidence gathered were provided to the Ministry of Health’s policy team developing the COVID-19 vaccination sequencing framework. This information was also made available on the Te Pou website.[[13,14]]

This literature review was crucial for understanding both the extent of risk of infection for COVID-19 and poorer health outcomes for people with addiction and mental health issues. It was also important to look at whether any risks were only for people with existing physical health comorbidities (such as high body mass index [BMI], hypertension, cardiovascular disease or diabetes), or whether people with mental health and addiction issues have elevated risks from COVID-19 independent of coexisting issues. If the latter is true, it is crucial that vaccination prioritisation explicitly lists mental health and addiction issues as underlying health conditions that place people at greater risk. Other countries, including the UK, Ireland, Germany and Denmark, have identified and recognised a significantly greater risk in their respective vaccination prioritisation frameworks.[[15]]

Te Pou conducted the rapid literature scan in December 2020 and drew on systematic reviews, where available, and individual studies. The review sought to answer the following questions: For people with mental health and addiction issues:

  • is the risk of being infected with COVID-19 higher compared to other groups?
  • what is the independent risk of hospitalisation and death from COVID-19?

The review found a significant volume of high-quality research and evaluation that explores the relationship between COVID-19 infection and outcomes for people experiencing mental health and addiction issues. The research spans a wide range of countries and settings and consists of systematic literature reviews, quantitative survey data, qualitative narratives and retrospective cohort and case-control studies.[[14]] This included large studies in the US, the UK and Europe.

The review found that the risks of infection were particularly high for people meeting diagnostic criteria for a mental health or addiction issue in the past year (including first diagnosis); people experiencing multiple mental health or addiction issues;  and people accessing inpatient services. In terms of hospitalisation with COVID-19, the risk for people with experience of mental health and addiction issues is significantly higher compared to people not experiencing these issues, with the risk even higher for people who meet criteria for multiple diagnoses.[[16]] The risk of dying from COVID-19 may be up to twice as high for people with experience of mental health and addiction issues, and even higher for people with certain diagnoses and more complex needs. For example, people experiencing psychosis or schizophrenia may have a risk from 2.7 to 4.4 times higher than people without these experiences.[[16–18]]

Subsequently, even more compelling evidence has emerged. In February 2021, the Robert Koch Institute published an umbrella review of the evidence on the relative risks of hospitalisation and death for different underlying health conditions.[[19]] People with ‘severe mental illnesses’ (defined as meeting diagnostic criteria for schizophrenia, depression and bi-polar disorder) had the third highest risk of hospitalisation once infected with COVID-19 compared to all other underlying health conditions [OR 2.10 (95% CI 1.2–3.7)]. Only heart failure and organ transplantations had higher risk ratios. Similarly, the risk of death for people with severe mental illnesses was higher than all other underlying health conditions [OR 2.9 (95% CI 1.3–6.6)], except for lung disease, heart failure and cancer (not in remission).[[19]] The quality of the evidence was considered strong. In response to the findings of the Robert Koch Institute review, the German government have prioritised people with mental health and addiction issues within the same priority tier for vaccination as people in the general population aged 70–74. In March 2021, Toubasi and colleagues published a meta-analysis exploring the relationship between pre-diagnosis of mental health issues and COVID-19 outcomes. They found people with mental health diagnoses were more likely to become seriously ill or to die from COVID-19, an association that remained significant after adjusting for confounding variables. People with diagnoses of schizophrenia, schizotypal and delusional disorders had higher COVID-19 mortality compared to people with mood disorders. The authors recommend prioritising people with mental health and addiction issues for vaccination.[[20]]

Three key findings emerged from the Te Pou literature review:

  1. People with mental health and addiction issues are at higher risk of contracting COVID-19 than those without.
  2. Once infected, people with mental health and addiction issues have a higher risk of severe outcomes including hospitalisation and death.
  3. These risks, especially for people with ‘severe mental illness and addiction diagnoses’, are evident even once estimates are adjusted for other known risk factors for COVID-19 infection and severe outcomes. These factors include physical comorbidities, obesity and socioeconomic status.[[14]]

There is also emerging evidence from a UK study that people with mental health and addiction issues are much less likely to present for COVID-19 vaccination.[[21]] The authors hypothesise that this could reflect challenges in access. These experiences highlight the importance of specific information and targeted communication for people and whānau, as well as to the workforce, to support vaccination uptake and implementation.

As a result of the evidence review and their knowledge and experience of the physical health inequities experienced by people with mental health and addiction issues, the expert advisory group made the following recommendations in the position statement.

  • That people with experience of mental health and addiction issues be included in the COVID-19 vaccine sequencing framework within the priority group ‘people aged under 65 with underlying health conditions and disabilities.’
  • The initial priority within this group should be adults (18 years and older) currently accessing secondary mental health and addiction services and people with long-term mental health and addiction issues in continuing primary care.
  • That a specific information and communication programme be developed for this population, designed with people with lived experience and cultural leaders, to support vaccination uptake and implementation.[[13]]

Prioritising the physical health of people with mental health and addiction issues

The findings of the literature review on COVID-19 vulnerability align with the established New Zealand and international evidence of the higher prevalence of a wide range of coexisting physical health issues for people with addiction and mental health issues.[[22–26]] The reasons for these associations have not yet been fully explained, but are thought to be based on causal mechanisms and shared determinants.[[27]] Causal mechanisms include a variety of biological, psychological, pharmacological and service delivery pathways, combined with racism and discrimination.[[9,28]] Shared determinants include socioeconomic and environmental factors, particularly childhood adversities and generic risk factors.[[27,29,30]]

Another recent New Zealand study makes an important contribution to knowledge in this area.[[25]] Four measures of ageing were examined across the prospective cohort of people at age 45. People with mental health and addiction issues were found to be ageing up to five years ahead of their actual age. This association between mental health and addiction issues and accelerated ageing remained after the study took account for childhood physical health, adversities, socioeconomic status, smoking and weight. Accelerated aging is an important measure as it provides a risk marker prior to the onset or diagnosis of physical illnesses, such as CVD or diabetes.

The evidence shows an independent association between infection and poor outcomes from COVID-19 for people across the range of mental health and addiction diagnoses. When this is combined with the evidence on accelerated ageing and well-established body of knowledge on coexisting physical health issues and premature mortality, the case is sadly compelling.

The evidence is clear. Mental health and addiction issues result in earlier onset of chronic physical conditions, and if vaccination prioritisation is based on physical health conditions alone, then it will exacerbate existing health inequities for people with experience of mental health and addiction issues. We need to change the kōrero. Health policy should identify people who experience mental health and addiction issues ipso facto as a priority group. An inclusive policy approach would enable people to take action at systems and practice levels to help achieve physical health equity for people experiencing mental health and addiction issues.

Supplementary note

Since this manuscript was first submitted, the Ministry of Health has taken up the recommendations of the advisory group. On 1 June 2021 the list of relevant underlying health conditions that increase the risk of worse outcomes from COVID-19 was updated. This list now includes people who “have been diagnosed with severe mental illness (which includes schizophrenia, major depressive disorder, bipolar or schizoaffective disorder, and adults currently accessing secondary and tertiary mental health and addiction services).” (Source: Ministry of Health, 2021 COVID-19 vaccine rollout groups,  covid19.govt.nz.)

Summary

Abstract

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the kōrero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy—including our COVID-19 pandemic response.

Aim

Method

Results

Conclusion

Author Information

Helen Lockett: Strategic Policy Advisor, the Wise Group, Hamilton; Honorary Senior Research Fellow, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington; Honorary Research Fellow, Department of Psychological Medicine, University of Auckland – Te Whare Wānanga o Tāmaki Makaurau, Auckland. Ashley Koning: Principal Advisor Addiction, Te Pou, Auckland. Cameron Lacey (Te Atiawa): Senior Lecturer, Māori Indigenous Health Institute (MIHI), University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch Susanna Every-Palmer: Head of Department, Department of Psychological Medicine, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Kate M Scott: Head of Department, Department of Psychological Medicine, University of Otago – Te Whare Wānanga o Otāgo, Dunedin. Ruth Cunningham: Senior Research Fellow, Director EleMent Research Group, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Tony Dowell: Professor of Primary Health Care and General Practice, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Linda Smith: Consumer Advisor, Canterbury District Health Board – Te Poari Hauora ō Waitaha, Christchurch. Alison Masters: Medical Director, Mental Health, Addictions & Intellectual Disability Service – Te-Upoko-me-te-Karu-o-Te-Ika, Wellington. Arran Culver: Chief Clinical Advisor, Ministry of Health – Manatū Hauora, Wellington. Stephen Chambers: Professor (Pathology), Department of Pathology and Biomedical Science, University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch.

Acknowledgements

The authors would like to acknowledge the Te Pou research team who conducted the literature review. In particular: Talya Postelnik, Dr Angela Jury, Maria Basabas. Along with Kirstie Saumure (Ministry of Health – Manatū Hauora) and Matthew Jenkins (University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke), who assisted with literature searches.

Correspondence

Dr Helen Lockett, PO Box 307, Waikato Mail Centre, Hamilton 3240, 0064 (0) 27 558 4658

Correspondence Email

helen.lockett@wisegroup.co.nz

Competing Interests

Nil.

1) Cunningham R, Sarfati D, Peterson D, et al. Premature mortality in adults using New Zealand psychiatric services. N Z Med J. 2014;127(1394):31-41.

2) Ministry of Health [Internet]. Living Well with Diabetes: A plan for people at high risk of or living with diabetes . Wellington: Ministry of Health; 2015 [cited 2021 Mar 4]. 39 p. Available from: https://www.health.govt.nz/system/files/documents/publications/living-well-with-diabetes-oct15.pdf

3) Lockett H, Bagnall C, Cunningham R, Arcus K. Cardiovascular disease risk and management in people who experience serious mental illness: An evidence review [Internet]. Hamilton: Te Pou; 2017 [cited 2021 Mar 11]. 7 p. Available from: https://www.tepou.co.nz/uploads/files/resources/CVD-risk-in-people-with-SMI.pdf

4) Ministry of Health [Internet]. Cardiovascular disease risk assessment and management for primary care . Wellington: Ministry of Health; 2018 [cited 2021 Mar 4]. 36 p. Available from: https://www.health.govt.nz/system/files/documents/publications/cardiovascular-disease-risk-assessment-management-primary-care-feb18-v4_0.pdf

5) Ministry of Health [Internet]. New Zealand Cancer Action Plan 2019-2029 - Te Mahere mō te Mate Pukupuku o Aotearoa 2019–2029. Wellington: Ministry of Health; 2019 [cited 2021 Mar 4]. 76 p. Available from: https://www.health.govt.nz/system/files/documents/publications/new-zealand-cancer-action-plan-revised-january-2020.pdf

6) Cunningham R, Sarfati D, Stanley J, et al. Cancer survival in the context of mental illness: a national cohort study. Gen Hosp Psychiatry. 2015;37(6):501-6. doi: 10.1016/j.genhosppsych.2015.06.003.

7) Livingston JD. Structural stigma in health-care contexts for people with mental health and substance use issues: A literature review. Ottowa: Mental Health Commission of Canada; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.mentalhealthcommission.ca/sites/default/files/2020-07/structural_stigma_in_healthcare_eng.pdf

8) Cunningham R, Rijnberg V, Gibbs S. Premature mortality among people using secondary mental health and addiction services in Aotearoa New Zealand: Scoping a key performance indicator [Internet]. Wellington: Mental Health and Addiction Key Performance Indicator Programme; 2020 [cited 2021 Mar 4]. Available from: https://new.mhakpi.health.nz/wp-content/uploads/2021/03/Final-Premature-mortality-among-secondary-MHA-service-users-in-NZ.pdf

9) Te Pou [Internet]. Achieving physical health equity for people with experience of mental health and addiction issues: Evidence update. Auckland: Te Pou; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.tepou.co.nz/resources/achieving-physical-health-equity-for-people-with-experience-of-mental-health-and-addiction-issues---evidence-update-july-2020

10) Ministry of Health [Internet]. Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health; 2020. 78 p. Available from: https://www.health.govt.nz/system/files/documents/publications/whakamaua-maori-health-action-plan-2020-2025-2.pdf

11) Ministry of Health [Internet]. Kia kaha, kia māia, kia ora Aotearoa: COVID-19 psychosocial and mental wellbeing plan. Wellington: Ministry of Health; 2020 [cited 2021 Mar 4]. 53 p. Available from: https://www.health.govt.nz/system/files/documents/publications/kia-kaha-kia-maia-kia-ora-aotearoa-covid-19-psychosocial-mental-wellbeing-plan-21dec2020-v2.pdf

12) Mazereel V, Van Assche K, Detraux J, De Hert M. COVID-19 vaccination for people with severe mental illness: why, what, and how? Lancet Psychiatry. 2021:S2215-0366(20)30564-2. doi: 10.1016/S2215-0366(20)30564-2.

13) COVID-19 vaccine expert advisory group [Internet]. Position statement from the mental health and addiction COVID-19 vaccine expert advisory group: January 2021. Auckland: Te Pou; 2021 [cited 2021 Mar 4]. 4 p. Available from: https://www.tepou.co.nz/resources/position-statement-from-the-mental-health-and-addiction-covid-19-vaccine-expert-advisory-group-january-2021

14) Te Pou [Internet]. The evidence on COVID-19 risk for people experiencing mental health and addiction issues. Auckland: Te Pou; 2021 [cited 2021 Mar 12]. 10 p. Available from: https://www.tepou.co.nz/resources/the-evidence-on-covid-19-risk-for-people-experiencing-mental-health-and-addiction-issues

15) De Picker LJ, Dias MC, Benros ME, et al. Severe mental illness and European COVID-19 vaccination strategies. Lancet Psychiatry. 2021:S2215-0366(21)00046-8. doi: 10.1016/S2215-0366(21)00046-8.

16) Yang H, Chen W, Hu Y, et al. Pre-pandemic psychiatric disorders and risk of COVID-19: a UK Biobank cohort analysis. Lancet Healthy Longev. 2020;1(2):e69-e79. doi: 10.1016/S2666-7568(20)30013-1.

17) Fond G, Pauly V, Orleans V, et al. Increased in-hospital mortality from COVID-19 in patients with schizophrenia. Encephale. 2020 Jul 30:S0013-7006(20)30188-3. doi: 10.1016/j.encep.2020.07.003.

18) Nemani K, Li C, Olfson M, Blessing EM, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. 2021:e204442. doi: 10.1001/jamapsychiatry.2020.4442.

19) Robert Koch Institut [Internet]. Epidemiologisches Bulletin: Beschluss der STIKO zur 2. Aktualisierung der COVID-19-Impfempfehlung und die dazugehörige wissenschaftliche Begründung. Berlin: Robert Koch Institut; 2021 [cited 2021 Mar 5]. 84 p. Available from: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2021/Ausgaben/05_21.pdf?__blob=publicationFile

20) Toubasi AA, AbuAnzeh RB, Tawileh HB, et al. A meta-analysis: the mortality and severity of COVID-19 among patients with mental disorders. Psychiatry Research. 2021 Mar 3:113856. doi: 10.1016/j.psychres.2021.113856.

21) The OpenSAFELY Collaborative, MacKenna B, Curtis HJ, et al. Trends, regional variation, and clinical characteristics of COVID-19 vaccine recipients: a retrospective cohort study in 23.4 million patients using OpenSAFELY. medRxiv. 2021. doi: 10.1101/2021.01.25.21250356.

22) Lockett H, Jury A, Tuason C, et al. Comorbidities between mental and physical health problems: An analysis of the New Zealand Health Survey data. New Zeal J Psychol. 2018;47(3):5-11.

23) Jury A, Koning A, Lai J, et al. Hazardous drinking and general practitioner visits in the past year. N Z Med J. 2020 Jul 17;133(1518):43-53.

24) Momen NC, Plana-Ripoll O, Agerbo E, et al. Association between mental disorders and subsequent medical conditions. N Engl J Med. 2020;382(18):1721-1731. doi: 10.1056/NEJMoa1915784.

25) Wertz J, Caspi A, Ambler A, et al. Association of history of psychopathology with accelerated aging at midlife. JAMA Psychiatry. 2021:e204626. doi: 10.1001/jamapsychiatry.2020.4626.

26) Richmond-Rakerd LS, D'Souza S, Milne BJ, et al. Longitudinal associations of mental disorders with physical diseases and mortality among 2.3 million New Zealand citizens. JAMA Netw Open. 2021;4(1):e2033448. doi: 10.1001/jamanetworkopen.2020.33448.

27) Scott KM, Lim C, Al-Hamzawi A, et al. Association of mental disorders with subsequent chronic physical conditions: World mental health surveys from 17 Countries. JAMA Psychiatry. 2016;73(2):150-8. doi: 10.1001/jamapsychiatry.2015.2688.

28) Cunningham R, Stanley J, Haitana T, et al. The physical health of Māori with bipolar disorder. Aust N Z J Psychiatry. 2020;54(11):1107-1114. doi: 10.1177/0004867420954290.

29) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with mental health conditions and/or addiction. Auckland: Te Pou o te Whakaaro Nui; 2017 [cited 2021 Mar 5]. 144 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-mental-health-conditions-and-or-addiction-evidence-update-december-2017

30) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with a serious mental illness and/or addiction: Evidence summary. Auckland: Te Pou o te Whakaaro Nui; 2014 [cited 2021 Mar 5]. 14 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-a-serious-mental-illness-and-or-addiction-an-evidence-review

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The recognition of mental health and addiction issues as pre-existing health conditions that place people at higher risk of serious outcomes or illness in the Ministry of Health’s vaccine rollout plan (ie, Group 3) is critical to prevent further physical health inequities for people with mental health and addiction issues.

People with mental health and addiction issues have two to three times the risk of dying before the age of 65 compared to the general population.[[1]] Two-thirds of this risk is caused by preventable and treatable physical illnesses. Policy-level changes, alongside practice changes, are crucial if this significantly reduced life expectancy is to be addressed.

Over the past five years there have been notable changes in Aotearoa New Zealand’s health policy towards formally recognising the physical health inequities experienced by people with mental health and addiction issues. These include Living Well with Diabetes, the five-year plan for people at high risk of or living with diabetes, which identifies people with mental health and addiction issues as a high-risk group and priority population for routine diabetes screening.[[2]] An evidence review around cardiovascular disease (CVD) risk and management in people with mental health and addiction issues informed new guidance for primary care CVD risk assessment and management.[[3]] This guidance prioritises people with mental health and addiction issues for CVD risk assessment and ongoing management from the age of 25.[[4]] The New Zealand Cancer Action Plan 2019–2029[[5]] has a focus on the need to improve the quality of cancer screening and treatment of people with addiction and mental health issues.

The whole of the healthcare system is consistently identified as a major factor to the physical health inequities experienced by people with mental health and addiction issues. This is particularly due to systemic issues that impact on access to, and quality of, physical healthcare.[[6]] At worst, this results in the denial of preventative services and routine care. Stigma and discrimination, particularly diagnostic overshadowing (the assumption that physical health symptoms are related to a mental health or addiction diagnosis) and clinicians seeing the person as their mental health or addiction diagnosis, means people are less likely to receive the expected standard of healthcare. This leads to delayed or missed physical health screening, care and treatment. Discrimination is experienced across the health system, including but not limited to diabetes care, routine cancer screening, blood pressure and cholesterol monitoring, surgical interventions for cardiovascular diseases and vaccinations.[[7]]

There is also the significant and often unrecognised intersection of ethnicity, mental health, addiction and physical health, with the largest inequities for Māori and Pasifika peoples living with mental health and addiction issues.[[8,9]] There is an important opportunity for the Government to meet its Te Tiriti o Waitangi commitments to active protection, as described in Whakamaua Māori Health Action Plan 2020–2025.[[10]]

Kia Kaha, Kia Māia, Kia Ora Aotearoa: Psychosocial and Mental Wellbeing Plan[[11]] identifies people with mental health and addiction issues as a priority group in relation to the psychosocial impacts of COVID-19,  and that they are more vulnerable to infection and negative outcomes from the virus. It is critical that there is formal recognition and that this recognition translates into vaccination policy and implementation, including workforce education and training.[[12]]

Understanding COVID-19 vulnerability

At the end of 2020, the backbone team of the Aotearoa New Zealand Equally Well collaborative convened a group of expert advisors to appraise the available evidence on COVID-19 vulnerability and people with mental health and addiction issues and, from this appraisal, to develop a position statement. The review of the evidence was conducted by Te Pou, a national workforce centre for mental health, addiction and disability in Aotearoa New Zealand.

In January 2021, the position statement and a summary of the evidence gathered were provided to the Ministry of Health’s policy team developing the COVID-19 vaccination sequencing framework. This information was also made available on the Te Pou website.[[13,14]]

This literature review was crucial for understanding both the extent of risk of infection for COVID-19 and poorer health outcomes for people with addiction and mental health issues. It was also important to look at whether any risks were only for people with existing physical health comorbidities (such as high body mass index [BMI], hypertension, cardiovascular disease or diabetes), or whether people with mental health and addiction issues have elevated risks from COVID-19 independent of coexisting issues. If the latter is true, it is crucial that vaccination prioritisation explicitly lists mental health and addiction issues as underlying health conditions that place people at greater risk. Other countries, including the UK, Ireland, Germany and Denmark, have identified and recognised a significantly greater risk in their respective vaccination prioritisation frameworks.[[15]]

Te Pou conducted the rapid literature scan in December 2020 and drew on systematic reviews, where available, and individual studies. The review sought to answer the following questions: For people with mental health and addiction issues:

  • is the risk of being infected with COVID-19 higher compared to other groups?
  • what is the independent risk of hospitalisation and death from COVID-19?

The review found a significant volume of high-quality research and evaluation that explores the relationship between COVID-19 infection and outcomes for people experiencing mental health and addiction issues. The research spans a wide range of countries and settings and consists of systematic literature reviews, quantitative survey data, qualitative narratives and retrospective cohort and case-control studies.[[14]] This included large studies in the US, the UK and Europe.

The review found that the risks of infection were particularly high for people meeting diagnostic criteria for a mental health or addiction issue in the past year (including first diagnosis); people experiencing multiple mental health or addiction issues;  and people accessing inpatient services. In terms of hospitalisation with COVID-19, the risk for people with experience of mental health and addiction issues is significantly higher compared to people not experiencing these issues, with the risk even higher for people who meet criteria for multiple diagnoses.[[16]] The risk of dying from COVID-19 may be up to twice as high for people with experience of mental health and addiction issues, and even higher for people with certain diagnoses and more complex needs. For example, people experiencing psychosis or schizophrenia may have a risk from 2.7 to 4.4 times higher than people without these experiences.[[16–18]]

Subsequently, even more compelling evidence has emerged. In February 2021, the Robert Koch Institute published an umbrella review of the evidence on the relative risks of hospitalisation and death for different underlying health conditions.[[19]] People with ‘severe mental illnesses’ (defined as meeting diagnostic criteria for schizophrenia, depression and bi-polar disorder) had the third highest risk of hospitalisation once infected with COVID-19 compared to all other underlying health conditions [OR 2.10 (95% CI 1.2–3.7)]. Only heart failure and organ transplantations had higher risk ratios. Similarly, the risk of death for people with severe mental illnesses was higher than all other underlying health conditions [OR 2.9 (95% CI 1.3–6.6)], except for lung disease, heart failure and cancer (not in remission).[[19]] The quality of the evidence was considered strong. In response to the findings of the Robert Koch Institute review, the German government have prioritised people with mental health and addiction issues within the same priority tier for vaccination as people in the general population aged 70–74. In March 2021, Toubasi and colleagues published a meta-analysis exploring the relationship between pre-diagnosis of mental health issues and COVID-19 outcomes. They found people with mental health diagnoses were more likely to become seriously ill or to die from COVID-19, an association that remained significant after adjusting for confounding variables. People with diagnoses of schizophrenia, schizotypal and delusional disorders had higher COVID-19 mortality compared to people with mood disorders. The authors recommend prioritising people with mental health and addiction issues for vaccination.[[20]]

Three key findings emerged from the Te Pou literature review:

  1. People with mental health and addiction issues are at higher risk of contracting COVID-19 than those without.
  2. Once infected, people with mental health and addiction issues have a higher risk of severe outcomes including hospitalisation and death.
  3. These risks, especially for people with ‘severe mental illness and addiction diagnoses’, are evident even once estimates are adjusted for other known risk factors for COVID-19 infection and severe outcomes. These factors include physical comorbidities, obesity and socioeconomic status.[[14]]

There is also emerging evidence from a UK study that people with mental health and addiction issues are much less likely to present for COVID-19 vaccination.[[21]] The authors hypothesise that this could reflect challenges in access. These experiences highlight the importance of specific information and targeted communication for people and whānau, as well as to the workforce, to support vaccination uptake and implementation.

As a result of the evidence review and their knowledge and experience of the physical health inequities experienced by people with mental health and addiction issues, the expert advisory group made the following recommendations in the position statement.

  • That people with experience of mental health and addiction issues be included in the COVID-19 vaccine sequencing framework within the priority group ‘people aged under 65 with underlying health conditions and disabilities.’
  • The initial priority within this group should be adults (18 years and older) currently accessing secondary mental health and addiction services and people with long-term mental health and addiction issues in continuing primary care.
  • That a specific information and communication programme be developed for this population, designed with people with lived experience and cultural leaders, to support vaccination uptake and implementation.[[13]]

Prioritising the physical health of people with mental health and addiction issues

The findings of the literature review on COVID-19 vulnerability align with the established New Zealand and international evidence of the higher prevalence of a wide range of coexisting physical health issues for people with addiction and mental health issues.[[22–26]] The reasons for these associations have not yet been fully explained, but are thought to be based on causal mechanisms and shared determinants.[[27]] Causal mechanisms include a variety of biological, psychological, pharmacological and service delivery pathways, combined with racism and discrimination.[[9,28]] Shared determinants include socioeconomic and environmental factors, particularly childhood adversities and generic risk factors.[[27,29,30]]

Another recent New Zealand study makes an important contribution to knowledge in this area.[[25]] Four measures of ageing were examined across the prospective cohort of people at age 45. People with mental health and addiction issues were found to be ageing up to five years ahead of their actual age. This association between mental health and addiction issues and accelerated ageing remained after the study took account for childhood physical health, adversities, socioeconomic status, smoking and weight. Accelerated aging is an important measure as it provides a risk marker prior to the onset or diagnosis of physical illnesses, such as CVD or diabetes.

The evidence shows an independent association between infection and poor outcomes from COVID-19 for people across the range of mental health and addiction diagnoses. When this is combined with the evidence on accelerated ageing and well-established body of knowledge on coexisting physical health issues and premature mortality, the case is sadly compelling.

The evidence is clear. Mental health and addiction issues result in earlier onset of chronic physical conditions, and if vaccination prioritisation is based on physical health conditions alone, then it will exacerbate existing health inequities for people with experience of mental health and addiction issues. We need to change the kōrero. Health policy should identify people who experience mental health and addiction issues ipso facto as a priority group. An inclusive policy approach would enable people to take action at systems and practice levels to help achieve physical health equity for people experiencing mental health and addiction issues.

Supplementary note

Since this manuscript was first submitted, the Ministry of Health has taken up the recommendations of the advisory group. On 1 June 2021 the list of relevant underlying health conditions that increase the risk of worse outcomes from COVID-19 was updated. This list now includes people who “have been diagnosed with severe mental illness (which includes schizophrenia, major depressive disorder, bipolar or schizoaffective disorder, and adults currently accessing secondary and tertiary mental health and addiction services).” (Source: Ministry of Health, 2021 COVID-19 vaccine rollout groups,  covid19.govt.nz.)

Summary

Abstract

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the kōrero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy—including our COVID-19 pandemic response.

Aim

Method

Results

Conclusion

Author Information

Helen Lockett: Strategic Policy Advisor, the Wise Group, Hamilton; Honorary Senior Research Fellow, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington; Honorary Research Fellow, Department of Psychological Medicine, University of Auckland – Te Whare Wānanga o Tāmaki Makaurau, Auckland. Ashley Koning: Principal Advisor Addiction, Te Pou, Auckland. Cameron Lacey (Te Atiawa): Senior Lecturer, Māori Indigenous Health Institute (MIHI), University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch Susanna Every-Palmer: Head of Department, Department of Psychological Medicine, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Kate M Scott: Head of Department, Department of Psychological Medicine, University of Otago – Te Whare Wānanga o Otāgo, Dunedin. Ruth Cunningham: Senior Research Fellow, Director EleMent Research Group, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Tony Dowell: Professor of Primary Health Care and General Practice, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Linda Smith: Consumer Advisor, Canterbury District Health Board – Te Poari Hauora ō Waitaha, Christchurch. Alison Masters: Medical Director, Mental Health, Addictions & Intellectual Disability Service – Te-Upoko-me-te-Karu-o-Te-Ika, Wellington. Arran Culver: Chief Clinical Advisor, Ministry of Health – Manatū Hauora, Wellington. Stephen Chambers: Professor (Pathology), Department of Pathology and Biomedical Science, University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch.

Acknowledgements

The authors would like to acknowledge the Te Pou research team who conducted the literature review. In particular: Talya Postelnik, Dr Angela Jury, Maria Basabas. Along with Kirstie Saumure (Ministry of Health – Manatū Hauora) and Matthew Jenkins (University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke), who assisted with literature searches.

Correspondence

Dr Helen Lockett, PO Box 307, Waikato Mail Centre, Hamilton 3240, 0064 (0) 27 558 4658

Correspondence Email

helen.lockett@wisegroup.co.nz

Competing Interests

Nil.

1) Cunningham R, Sarfati D, Peterson D, et al. Premature mortality in adults using New Zealand psychiatric services. N Z Med J. 2014;127(1394):31-41.

2) Ministry of Health [Internet]. Living Well with Diabetes: A plan for people at high risk of or living with diabetes . Wellington: Ministry of Health; 2015 [cited 2021 Mar 4]. 39 p. Available from: https://www.health.govt.nz/system/files/documents/publications/living-well-with-diabetes-oct15.pdf

3) Lockett H, Bagnall C, Cunningham R, Arcus K. Cardiovascular disease risk and management in people who experience serious mental illness: An evidence review [Internet]. Hamilton: Te Pou; 2017 [cited 2021 Mar 11]. 7 p. Available from: https://www.tepou.co.nz/uploads/files/resources/CVD-risk-in-people-with-SMI.pdf

4) Ministry of Health [Internet]. Cardiovascular disease risk assessment and management for primary care . Wellington: Ministry of Health; 2018 [cited 2021 Mar 4]. 36 p. Available from: https://www.health.govt.nz/system/files/documents/publications/cardiovascular-disease-risk-assessment-management-primary-care-feb18-v4_0.pdf

5) Ministry of Health [Internet]. New Zealand Cancer Action Plan 2019-2029 - Te Mahere mō te Mate Pukupuku o Aotearoa 2019–2029. Wellington: Ministry of Health; 2019 [cited 2021 Mar 4]. 76 p. Available from: https://www.health.govt.nz/system/files/documents/publications/new-zealand-cancer-action-plan-revised-january-2020.pdf

6) Cunningham R, Sarfati D, Stanley J, et al. Cancer survival in the context of mental illness: a national cohort study. Gen Hosp Psychiatry. 2015;37(6):501-6. doi: 10.1016/j.genhosppsych.2015.06.003.

7) Livingston JD. Structural stigma in health-care contexts for people with mental health and substance use issues: A literature review. Ottowa: Mental Health Commission of Canada; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.mentalhealthcommission.ca/sites/default/files/2020-07/structural_stigma_in_healthcare_eng.pdf

8) Cunningham R, Rijnberg V, Gibbs S. Premature mortality among people using secondary mental health and addiction services in Aotearoa New Zealand: Scoping a key performance indicator [Internet]. Wellington: Mental Health and Addiction Key Performance Indicator Programme; 2020 [cited 2021 Mar 4]. Available from: https://new.mhakpi.health.nz/wp-content/uploads/2021/03/Final-Premature-mortality-among-secondary-MHA-service-users-in-NZ.pdf

9) Te Pou [Internet]. Achieving physical health equity for people with experience of mental health and addiction issues: Evidence update. Auckland: Te Pou; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.tepou.co.nz/resources/achieving-physical-health-equity-for-people-with-experience-of-mental-health-and-addiction-issues---evidence-update-july-2020

10) Ministry of Health [Internet]. Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health; 2020. 78 p. Available from: https://www.health.govt.nz/system/files/documents/publications/whakamaua-maori-health-action-plan-2020-2025-2.pdf

11) Ministry of Health [Internet]. Kia kaha, kia māia, kia ora Aotearoa: COVID-19 psychosocial and mental wellbeing plan. Wellington: Ministry of Health; 2020 [cited 2021 Mar 4]. 53 p. Available from: https://www.health.govt.nz/system/files/documents/publications/kia-kaha-kia-maia-kia-ora-aotearoa-covid-19-psychosocial-mental-wellbeing-plan-21dec2020-v2.pdf

12) Mazereel V, Van Assche K, Detraux J, De Hert M. COVID-19 vaccination for people with severe mental illness: why, what, and how? Lancet Psychiatry. 2021:S2215-0366(20)30564-2. doi: 10.1016/S2215-0366(20)30564-2.

13) COVID-19 vaccine expert advisory group [Internet]. Position statement from the mental health and addiction COVID-19 vaccine expert advisory group: January 2021. Auckland: Te Pou; 2021 [cited 2021 Mar 4]. 4 p. Available from: https://www.tepou.co.nz/resources/position-statement-from-the-mental-health-and-addiction-covid-19-vaccine-expert-advisory-group-january-2021

14) Te Pou [Internet]. The evidence on COVID-19 risk for people experiencing mental health and addiction issues. Auckland: Te Pou; 2021 [cited 2021 Mar 12]. 10 p. Available from: https://www.tepou.co.nz/resources/the-evidence-on-covid-19-risk-for-people-experiencing-mental-health-and-addiction-issues

15) De Picker LJ, Dias MC, Benros ME, et al. Severe mental illness and European COVID-19 vaccination strategies. Lancet Psychiatry. 2021:S2215-0366(21)00046-8. doi: 10.1016/S2215-0366(21)00046-8.

16) Yang H, Chen W, Hu Y, et al. Pre-pandemic psychiatric disorders and risk of COVID-19: a UK Biobank cohort analysis. Lancet Healthy Longev. 2020;1(2):e69-e79. doi: 10.1016/S2666-7568(20)30013-1.

17) Fond G, Pauly V, Orleans V, et al. Increased in-hospital mortality from COVID-19 in patients with schizophrenia. Encephale. 2020 Jul 30:S0013-7006(20)30188-3. doi: 10.1016/j.encep.2020.07.003.

18) Nemani K, Li C, Olfson M, Blessing EM, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. 2021:e204442. doi: 10.1001/jamapsychiatry.2020.4442.

19) Robert Koch Institut [Internet]. Epidemiologisches Bulletin: Beschluss der STIKO zur 2. Aktualisierung der COVID-19-Impfempfehlung und die dazugehörige wissenschaftliche Begründung. Berlin: Robert Koch Institut; 2021 [cited 2021 Mar 5]. 84 p. Available from: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2021/Ausgaben/05_21.pdf?__blob=publicationFile

20) Toubasi AA, AbuAnzeh RB, Tawileh HB, et al. A meta-analysis: the mortality and severity of COVID-19 among patients with mental disorders. Psychiatry Research. 2021 Mar 3:113856. doi: 10.1016/j.psychres.2021.113856.

21) The OpenSAFELY Collaborative, MacKenna B, Curtis HJ, et al. Trends, regional variation, and clinical characteristics of COVID-19 vaccine recipients: a retrospective cohort study in 23.4 million patients using OpenSAFELY. medRxiv. 2021. doi: 10.1101/2021.01.25.21250356.

22) Lockett H, Jury A, Tuason C, et al. Comorbidities between mental and physical health problems: An analysis of the New Zealand Health Survey data. New Zeal J Psychol. 2018;47(3):5-11.

23) Jury A, Koning A, Lai J, et al. Hazardous drinking and general practitioner visits in the past year. N Z Med J. 2020 Jul 17;133(1518):43-53.

24) Momen NC, Plana-Ripoll O, Agerbo E, et al. Association between mental disorders and subsequent medical conditions. N Engl J Med. 2020;382(18):1721-1731. doi: 10.1056/NEJMoa1915784.

25) Wertz J, Caspi A, Ambler A, et al. Association of history of psychopathology with accelerated aging at midlife. JAMA Psychiatry. 2021:e204626. doi: 10.1001/jamapsychiatry.2020.4626.

26) Richmond-Rakerd LS, D'Souza S, Milne BJ, et al. Longitudinal associations of mental disorders with physical diseases and mortality among 2.3 million New Zealand citizens. JAMA Netw Open. 2021;4(1):e2033448. doi: 10.1001/jamanetworkopen.2020.33448.

27) Scott KM, Lim C, Al-Hamzawi A, et al. Association of mental disorders with subsequent chronic physical conditions: World mental health surveys from 17 Countries. JAMA Psychiatry. 2016;73(2):150-8. doi: 10.1001/jamapsychiatry.2015.2688.

28) Cunningham R, Stanley J, Haitana T, et al. The physical health of Māori with bipolar disorder. Aust N Z J Psychiatry. 2020;54(11):1107-1114. doi: 10.1177/0004867420954290.

29) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with mental health conditions and/or addiction. Auckland: Te Pou o te Whakaaro Nui; 2017 [cited 2021 Mar 5]. 144 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-mental-health-conditions-and-or-addiction-evidence-update-december-2017

30) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with a serious mental illness and/or addiction: Evidence summary. Auckland: Te Pou o te Whakaaro Nui; 2014 [cited 2021 Mar 5]. 14 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-a-serious-mental-illness-and-or-addiction-an-evidence-review

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The recognition of mental health and addiction issues as pre-existing health conditions that place people at higher risk of serious outcomes or illness in the Ministry of Health’s vaccine rollout plan (ie, Group 3) is critical to prevent further physical health inequities for people with mental health and addiction issues.

People with mental health and addiction issues have two to three times the risk of dying before the age of 65 compared to the general population.[[1]] Two-thirds of this risk is caused by preventable and treatable physical illnesses. Policy-level changes, alongside practice changes, are crucial if this significantly reduced life expectancy is to be addressed.

Over the past five years there have been notable changes in Aotearoa New Zealand’s health policy towards formally recognising the physical health inequities experienced by people with mental health and addiction issues. These include Living Well with Diabetes, the five-year plan for people at high risk of or living with diabetes, which identifies people with mental health and addiction issues as a high-risk group and priority population for routine diabetes screening.[[2]] An evidence review around cardiovascular disease (CVD) risk and management in people with mental health and addiction issues informed new guidance for primary care CVD risk assessment and management.[[3]] This guidance prioritises people with mental health and addiction issues for CVD risk assessment and ongoing management from the age of 25.[[4]] The New Zealand Cancer Action Plan 2019–2029[[5]] has a focus on the need to improve the quality of cancer screening and treatment of people with addiction and mental health issues.

The whole of the healthcare system is consistently identified as a major factor to the physical health inequities experienced by people with mental health and addiction issues. This is particularly due to systemic issues that impact on access to, and quality of, physical healthcare.[[6]] At worst, this results in the denial of preventative services and routine care. Stigma and discrimination, particularly diagnostic overshadowing (the assumption that physical health symptoms are related to a mental health or addiction diagnosis) and clinicians seeing the person as their mental health or addiction diagnosis, means people are less likely to receive the expected standard of healthcare. This leads to delayed or missed physical health screening, care and treatment. Discrimination is experienced across the health system, including but not limited to diabetes care, routine cancer screening, blood pressure and cholesterol monitoring, surgical interventions for cardiovascular diseases and vaccinations.[[7]]

There is also the significant and often unrecognised intersection of ethnicity, mental health, addiction and physical health, with the largest inequities for Māori and Pasifika peoples living with mental health and addiction issues.[[8,9]] There is an important opportunity for the Government to meet its Te Tiriti o Waitangi commitments to active protection, as described in Whakamaua Māori Health Action Plan 2020–2025.[[10]]

Kia Kaha, Kia Māia, Kia Ora Aotearoa: Psychosocial and Mental Wellbeing Plan[[11]] identifies people with mental health and addiction issues as a priority group in relation to the psychosocial impacts of COVID-19,  and that they are more vulnerable to infection and negative outcomes from the virus. It is critical that there is formal recognition and that this recognition translates into vaccination policy and implementation, including workforce education and training.[[12]]

Understanding COVID-19 vulnerability

At the end of 2020, the backbone team of the Aotearoa New Zealand Equally Well collaborative convened a group of expert advisors to appraise the available evidence on COVID-19 vulnerability and people with mental health and addiction issues and, from this appraisal, to develop a position statement. The review of the evidence was conducted by Te Pou, a national workforce centre for mental health, addiction and disability in Aotearoa New Zealand.

In January 2021, the position statement and a summary of the evidence gathered were provided to the Ministry of Health’s policy team developing the COVID-19 vaccination sequencing framework. This information was also made available on the Te Pou website.[[13,14]]

This literature review was crucial for understanding both the extent of risk of infection for COVID-19 and poorer health outcomes for people with addiction and mental health issues. It was also important to look at whether any risks were only for people with existing physical health comorbidities (such as high body mass index [BMI], hypertension, cardiovascular disease or diabetes), or whether people with mental health and addiction issues have elevated risks from COVID-19 independent of coexisting issues. If the latter is true, it is crucial that vaccination prioritisation explicitly lists mental health and addiction issues as underlying health conditions that place people at greater risk. Other countries, including the UK, Ireland, Germany and Denmark, have identified and recognised a significantly greater risk in their respective vaccination prioritisation frameworks.[[15]]

Te Pou conducted the rapid literature scan in December 2020 and drew on systematic reviews, where available, and individual studies. The review sought to answer the following questions: For people with mental health and addiction issues:

  • is the risk of being infected with COVID-19 higher compared to other groups?
  • what is the independent risk of hospitalisation and death from COVID-19?

The review found a significant volume of high-quality research and evaluation that explores the relationship between COVID-19 infection and outcomes for people experiencing mental health and addiction issues. The research spans a wide range of countries and settings and consists of systematic literature reviews, quantitative survey data, qualitative narratives and retrospective cohort and case-control studies.[[14]] This included large studies in the US, the UK and Europe.

The review found that the risks of infection were particularly high for people meeting diagnostic criteria for a mental health or addiction issue in the past year (including first diagnosis); people experiencing multiple mental health or addiction issues;  and people accessing inpatient services. In terms of hospitalisation with COVID-19, the risk for people with experience of mental health and addiction issues is significantly higher compared to people not experiencing these issues, with the risk even higher for people who meet criteria for multiple diagnoses.[[16]] The risk of dying from COVID-19 may be up to twice as high for people with experience of mental health and addiction issues, and even higher for people with certain diagnoses and more complex needs. For example, people experiencing psychosis or schizophrenia may have a risk from 2.7 to 4.4 times higher than people without these experiences.[[16–18]]

Subsequently, even more compelling evidence has emerged. In February 2021, the Robert Koch Institute published an umbrella review of the evidence on the relative risks of hospitalisation and death for different underlying health conditions.[[19]] People with ‘severe mental illnesses’ (defined as meeting diagnostic criteria for schizophrenia, depression and bi-polar disorder) had the third highest risk of hospitalisation once infected with COVID-19 compared to all other underlying health conditions [OR 2.10 (95% CI 1.2–3.7)]. Only heart failure and organ transplantations had higher risk ratios. Similarly, the risk of death for people with severe mental illnesses was higher than all other underlying health conditions [OR 2.9 (95% CI 1.3–6.6)], except for lung disease, heart failure and cancer (not in remission).[[19]] The quality of the evidence was considered strong. In response to the findings of the Robert Koch Institute review, the German government have prioritised people with mental health and addiction issues within the same priority tier for vaccination as people in the general population aged 70–74. In March 2021, Toubasi and colleagues published a meta-analysis exploring the relationship between pre-diagnosis of mental health issues and COVID-19 outcomes. They found people with mental health diagnoses were more likely to become seriously ill or to die from COVID-19, an association that remained significant after adjusting for confounding variables. People with diagnoses of schizophrenia, schizotypal and delusional disorders had higher COVID-19 mortality compared to people with mood disorders. The authors recommend prioritising people with mental health and addiction issues for vaccination.[[20]]

Three key findings emerged from the Te Pou literature review:

  1. People with mental health and addiction issues are at higher risk of contracting COVID-19 than those without.
  2. Once infected, people with mental health and addiction issues have a higher risk of severe outcomes including hospitalisation and death.
  3. These risks, especially for people with ‘severe mental illness and addiction diagnoses’, are evident even once estimates are adjusted for other known risk factors for COVID-19 infection and severe outcomes. These factors include physical comorbidities, obesity and socioeconomic status.[[14]]

There is also emerging evidence from a UK study that people with mental health and addiction issues are much less likely to present for COVID-19 vaccination.[[21]] The authors hypothesise that this could reflect challenges in access. These experiences highlight the importance of specific information and targeted communication for people and whānau, as well as to the workforce, to support vaccination uptake and implementation.

As a result of the evidence review and their knowledge and experience of the physical health inequities experienced by people with mental health and addiction issues, the expert advisory group made the following recommendations in the position statement.

  • That people with experience of mental health and addiction issues be included in the COVID-19 vaccine sequencing framework within the priority group ‘people aged under 65 with underlying health conditions and disabilities.’
  • The initial priority within this group should be adults (18 years and older) currently accessing secondary mental health and addiction services and people with long-term mental health and addiction issues in continuing primary care.
  • That a specific information and communication programme be developed for this population, designed with people with lived experience and cultural leaders, to support vaccination uptake and implementation.[[13]]

Prioritising the physical health of people with mental health and addiction issues

The findings of the literature review on COVID-19 vulnerability align with the established New Zealand and international evidence of the higher prevalence of a wide range of coexisting physical health issues for people with addiction and mental health issues.[[22–26]] The reasons for these associations have not yet been fully explained, but are thought to be based on causal mechanisms and shared determinants.[[27]] Causal mechanisms include a variety of biological, psychological, pharmacological and service delivery pathways, combined with racism and discrimination.[[9,28]] Shared determinants include socioeconomic and environmental factors, particularly childhood adversities and generic risk factors.[[27,29,30]]

Another recent New Zealand study makes an important contribution to knowledge in this area.[[25]] Four measures of ageing were examined across the prospective cohort of people at age 45. People with mental health and addiction issues were found to be ageing up to five years ahead of their actual age. This association between mental health and addiction issues and accelerated ageing remained after the study took account for childhood physical health, adversities, socioeconomic status, smoking and weight. Accelerated aging is an important measure as it provides a risk marker prior to the onset or diagnosis of physical illnesses, such as CVD or diabetes.

The evidence shows an independent association between infection and poor outcomes from COVID-19 for people across the range of mental health and addiction diagnoses. When this is combined with the evidence on accelerated ageing and well-established body of knowledge on coexisting physical health issues and premature mortality, the case is sadly compelling.

The evidence is clear. Mental health and addiction issues result in earlier onset of chronic physical conditions, and if vaccination prioritisation is based on physical health conditions alone, then it will exacerbate existing health inequities for people with experience of mental health and addiction issues. We need to change the kōrero. Health policy should identify people who experience mental health and addiction issues ipso facto as a priority group. An inclusive policy approach would enable people to take action at systems and practice levels to help achieve physical health equity for people experiencing mental health and addiction issues.

Supplementary note

Since this manuscript was first submitted, the Ministry of Health has taken up the recommendations of the advisory group. On 1 June 2021 the list of relevant underlying health conditions that increase the risk of worse outcomes from COVID-19 was updated. This list now includes people who “have been diagnosed with severe mental illness (which includes schizophrenia, major depressive disorder, bipolar or schizoaffective disorder, and adults currently accessing secondary and tertiary mental health and addiction services).” (Source: Ministry of Health, 2021 COVID-19 vaccine rollout groups,  covid19.govt.nz.)

Summary

Abstract

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the kōrero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy—including our COVID-19 pandemic response.

Aim

Method

Results

Conclusion

Author Information

Helen Lockett: Strategic Policy Advisor, the Wise Group, Hamilton; Honorary Senior Research Fellow, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington; Honorary Research Fellow, Department of Psychological Medicine, University of Auckland – Te Whare Wānanga o Tāmaki Makaurau, Auckland. Ashley Koning: Principal Advisor Addiction, Te Pou, Auckland. Cameron Lacey (Te Atiawa): Senior Lecturer, Māori Indigenous Health Institute (MIHI), University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch Susanna Every-Palmer: Head of Department, Department of Psychological Medicine, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Kate M Scott: Head of Department, Department of Psychological Medicine, University of Otago – Te Whare Wānanga o Otāgo, Dunedin. Ruth Cunningham: Senior Research Fellow, Director EleMent Research Group, Department of Public Health, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Tony Dowell: Professor of Primary Health Care and General Practice, University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke, Wellington. Linda Smith: Consumer Advisor, Canterbury District Health Board – Te Poari Hauora ō Waitaha, Christchurch. Alison Masters: Medical Director, Mental Health, Addictions & Intellectual Disability Service – Te-Upoko-me-te-Karu-o-Te-Ika, Wellington. Arran Culver: Chief Clinical Advisor, Ministry of Health – Manatū Hauora, Wellington. Stephen Chambers: Professor (Pathology), Department of Pathology and Biomedical Science, University of Otago, Christchurch – Te Whare Wānanga o Otāgo ki Ōtautahi, Christchurch.

Acknowledgements

The authors would like to acknowledge the Te Pou research team who conducted the literature review. In particular: Talya Postelnik, Dr Angela Jury, Maria Basabas. Along with Kirstie Saumure (Ministry of Health – Manatū Hauora) and Matthew Jenkins (University of Otago, Wellington – Te Whare Wānanga o Otāgo ki Poneke), who assisted with literature searches.

Correspondence

Dr Helen Lockett, PO Box 307, Waikato Mail Centre, Hamilton 3240, 0064 (0) 27 558 4658

Correspondence Email

helen.lockett@wisegroup.co.nz

Competing Interests

Nil.

1) Cunningham R, Sarfati D, Peterson D, et al. Premature mortality in adults using New Zealand psychiatric services. N Z Med J. 2014;127(1394):31-41.

2) Ministry of Health [Internet]. Living Well with Diabetes: A plan for people at high risk of or living with diabetes . Wellington: Ministry of Health; 2015 [cited 2021 Mar 4]. 39 p. Available from: https://www.health.govt.nz/system/files/documents/publications/living-well-with-diabetes-oct15.pdf

3) Lockett H, Bagnall C, Cunningham R, Arcus K. Cardiovascular disease risk and management in people who experience serious mental illness: An evidence review [Internet]. Hamilton: Te Pou; 2017 [cited 2021 Mar 11]. 7 p. Available from: https://www.tepou.co.nz/uploads/files/resources/CVD-risk-in-people-with-SMI.pdf

4) Ministry of Health [Internet]. Cardiovascular disease risk assessment and management for primary care . Wellington: Ministry of Health; 2018 [cited 2021 Mar 4]. 36 p. Available from: https://www.health.govt.nz/system/files/documents/publications/cardiovascular-disease-risk-assessment-management-primary-care-feb18-v4_0.pdf

5) Ministry of Health [Internet]. New Zealand Cancer Action Plan 2019-2029 - Te Mahere mō te Mate Pukupuku o Aotearoa 2019–2029. Wellington: Ministry of Health; 2019 [cited 2021 Mar 4]. 76 p. Available from: https://www.health.govt.nz/system/files/documents/publications/new-zealand-cancer-action-plan-revised-january-2020.pdf

6) Cunningham R, Sarfati D, Stanley J, et al. Cancer survival in the context of mental illness: a national cohort study. Gen Hosp Psychiatry. 2015;37(6):501-6. doi: 10.1016/j.genhosppsych.2015.06.003.

7) Livingston JD. Structural stigma in health-care contexts for people with mental health and substance use issues: A literature review. Ottowa: Mental Health Commission of Canada; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.mentalhealthcommission.ca/sites/default/files/2020-07/structural_stigma_in_healthcare_eng.pdf

8) Cunningham R, Rijnberg V, Gibbs S. Premature mortality among people using secondary mental health and addiction services in Aotearoa New Zealand: Scoping a key performance indicator [Internet]. Wellington: Mental Health and Addiction Key Performance Indicator Programme; 2020 [cited 2021 Mar 4]. Available from: https://new.mhakpi.health.nz/wp-content/uploads/2021/03/Final-Premature-mortality-among-secondary-MHA-service-users-in-NZ.pdf

9) Te Pou [Internet]. Achieving physical health equity for people with experience of mental health and addiction issues: Evidence update. Auckland: Te Pou; 2020 [cited 2021 Mar 4]. 36 p. Available from: https://www.tepou.co.nz/resources/achieving-physical-health-equity-for-people-with-experience-of-mental-health-and-addiction-issues---evidence-update-july-2020

10) Ministry of Health [Internet]. Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health; 2020. 78 p. Available from: https://www.health.govt.nz/system/files/documents/publications/whakamaua-maori-health-action-plan-2020-2025-2.pdf

11) Ministry of Health [Internet]. Kia kaha, kia māia, kia ora Aotearoa: COVID-19 psychosocial and mental wellbeing plan. Wellington: Ministry of Health; 2020 [cited 2021 Mar 4]. 53 p. Available from: https://www.health.govt.nz/system/files/documents/publications/kia-kaha-kia-maia-kia-ora-aotearoa-covid-19-psychosocial-mental-wellbeing-plan-21dec2020-v2.pdf

12) Mazereel V, Van Assche K, Detraux J, De Hert M. COVID-19 vaccination for people with severe mental illness: why, what, and how? Lancet Psychiatry. 2021:S2215-0366(20)30564-2. doi: 10.1016/S2215-0366(20)30564-2.

13) COVID-19 vaccine expert advisory group [Internet]. Position statement from the mental health and addiction COVID-19 vaccine expert advisory group: January 2021. Auckland: Te Pou; 2021 [cited 2021 Mar 4]. 4 p. Available from: https://www.tepou.co.nz/resources/position-statement-from-the-mental-health-and-addiction-covid-19-vaccine-expert-advisory-group-january-2021

14) Te Pou [Internet]. The evidence on COVID-19 risk for people experiencing mental health and addiction issues. Auckland: Te Pou; 2021 [cited 2021 Mar 12]. 10 p. Available from: https://www.tepou.co.nz/resources/the-evidence-on-covid-19-risk-for-people-experiencing-mental-health-and-addiction-issues

15) De Picker LJ, Dias MC, Benros ME, et al. Severe mental illness and European COVID-19 vaccination strategies. Lancet Psychiatry. 2021:S2215-0366(21)00046-8. doi: 10.1016/S2215-0366(21)00046-8.

16) Yang H, Chen W, Hu Y, et al. Pre-pandemic psychiatric disorders and risk of COVID-19: a UK Biobank cohort analysis. Lancet Healthy Longev. 2020;1(2):e69-e79. doi: 10.1016/S2666-7568(20)30013-1.

17) Fond G, Pauly V, Orleans V, et al. Increased in-hospital mortality from COVID-19 in patients with schizophrenia. Encephale. 2020 Jul 30:S0013-7006(20)30188-3. doi: 10.1016/j.encep.2020.07.003.

18) Nemani K, Li C, Olfson M, Blessing EM, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. 2021:e204442. doi: 10.1001/jamapsychiatry.2020.4442.

19) Robert Koch Institut [Internet]. Epidemiologisches Bulletin: Beschluss der STIKO zur 2. Aktualisierung der COVID-19-Impfempfehlung und die dazugehörige wissenschaftliche Begründung. Berlin: Robert Koch Institut; 2021 [cited 2021 Mar 5]. 84 p. Available from: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2021/Ausgaben/05_21.pdf?__blob=publicationFile

20) Toubasi AA, AbuAnzeh RB, Tawileh HB, et al. A meta-analysis: the mortality and severity of COVID-19 among patients with mental disorders. Psychiatry Research. 2021 Mar 3:113856. doi: 10.1016/j.psychres.2021.113856.

21) The OpenSAFELY Collaborative, MacKenna B, Curtis HJ, et al. Trends, regional variation, and clinical characteristics of COVID-19 vaccine recipients: a retrospective cohort study in 23.4 million patients using OpenSAFELY. medRxiv. 2021. doi: 10.1101/2021.01.25.21250356.

22) Lockett H, Jury A, Tuason C, et al. Comorbidities between mental and physical health problems: An analysis of the New Zealand Health Survey data. New Zeal J Psychol. 2018;47(3):5-11.

23) Jury A, Koning A, Lai J, et al. Hazardous drinking and general practitioner visits in the past year. N Z Med J. 2020 Jul 17;133(1518):43-53.

24) Momen NC, Plana-Ripoll O, Agerbo E, et al. Association between mental disorders and subsequent medical conditions. N Engl J Med. 2020;382(18):1721-1731. doi: 10.1056/NEJMoa1915784.

25) Wertz J, Caspi A, Ambler A, et al. Association of history of psychopathology with accelerated aging at midlife. JAMA Psychiatry. 2021:e204626. doi: 10.1001/jamapsychiatry.2020.4626.

26) Richmond-Rakerd LS, D'Souza S, Milne BJ, et al. Longitudinal associations of mental disorders with physical diseases and mortality among 2.3 million New Zealand citizens. JAMA Netw Open. 2021;4(1):e2033448. doi: 10.1001/jamanetworkopen.2020.33448.

27) Scott KM, Lim C, Al-Hamzawi A, et al. Association of mental disorders with subsequent chronic physical conditions: World mental health surveys from 17 Countries. JAMA Psychiatry. 2016;73(2):150-8. doi: 10.1001/jamapsychiatry.2015.2688.

28) Cunningham R, Stanley J, Haitana T, et al. The physical health of Māori with bipolar disorder. Aust N Z J Psychiatry. 2020;54(11):1107-1114. doi: 10.1177/0004867420954290.

29) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with mental health conditions and/or addiction. Auckland: Te Pou o te Whakaaro Nui; 2017 [cited 2021 Mar 5]. 144 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-mental-health-conditions-and-or-addiction-evidence-update-december-2017

30) Te Pou o te Whakaaro Nui [Internet]. The physical health of people with a serious mental illness and/or addiction: Evidence summary. Auckland: Te Pou o te Whakaaro Nui; 2014 [cited 2021 Mar 5]. 14 p. Available from: https://www.tepou.co.nz/resources/the-physical-health-of-people-with-a-serious-mental-illness-and-or-addiction-an-evidence-review

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.

LOGINSUBSCRIBE