People With Mental Illness Should Be Given Priority for COVID-19 Vaccination, APA Says

Numerous studies have been published during the COVID-19 pandemic, highlighting that people with serious mental illness (SMI) and substance use disorders (SUDs) have an increased risk for complications, hospitalization, and death from COVID-19. Whether those individuals are prioritized to receive the COVID-19 vaccine, however, varies across the country.

In a news release, APA urged public health authorities to include people with mental illness in the equivalent of the Centers for Disease Control and Prevention’s Phase 1c, which includes people with high-risk medical conditions who should receive priority access to the vaccine, as well as those who are aged 65 to 74 years and essential workers.

“APA and its member psychiatrists have worked throughout this pandemic, many on the frontlines,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the news release. “We will continue to promote policies that keep our patients safe.”

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Historically, people with SMI and SUDs “have had limited access to preventative care and vaccinations, foreshadowing inequitable distribution of COVID-19 vaccines,” stated an APA guidance document titled “The Role of the Psychiatrist in the Equitable Distribution of the COVID-19 Vaccine.” The document was created by APA’s Committee on Psychiatric Dimensions of Disaster, Committee on Integrated Care, Council on Communications, Council on Minority Mental Health and Health Disparities, and Council on Healthcare Systems and Financing.

“This is a vulnerable group, and it would be wise to vaccinate them for their own and others’ safety and health, especially as they are more likely to live in congregate settings,” said Lisa Dixon, M.D., M.P.H., editor of Psychiatric Services and the Edna L. Edison Professor of Psychiatry and director of the Division of Behavioral Health Services and Policy Research in the Department of Psychiatry at Columbia University Medical Center. “We know that this is a population that often experiences inequities in access to health care, which makes it only more important that they are vaccinated as soon as possible.”

Two national studies co-written by Nora Volkow, M.D., director of the National Institute on Drug Abuse, found that people with SMI and SUDs are more likely to experience a severe illness course if they develop COVID-19 (Psychiatric News and here). In February, a study in JAMA Psychiatry found that COVID-19 especially increases the risk of mortality in patients with schizophrenia (Psychiatric News).

“It’s all too common that people with serious mental illness and/or substance use disorders don’t have access to health care; are of low socioeconomic status; or, based on history, harbor mistrust toward the medical establishment,” said APA President Jeffrey Geller, M.D., M.P.H., in the news release. “States should treat psychiatric illnesses like other high-risk conditions and prioritize this population’s access to the vaccine.”

Vaccine Prioritization Varies By State

The Centers for Disease Control and Prevention (CDC) keeps a list of medical conditions that may increase an individual’s risk of severe illness due to COVID-19. While it does not include serious mental illnesses like schizophrenia, it does include current or former cigarette smokers. The CDC’s website notes that the list is “a living document” that is subject to change. It was most recently updated on March 15, 2021, and includes people with Down syndrome. According to a Kaiser Family Foundation (KFF) policy document, some states are using the CDC’s list to guide their own policies, but each state can choose which populations are considered eligible for priority access due to their high-risk illnesses.

Many patients with mental illness “fall into high-priority groups due to medical comorbidity or social risk factors such as homelessness,” the APA guidance document pointed out. According to the KFF policy document, some states include people with disabilities in their definitions of high-risk medical conditions, including those with intellectual and developmental disabilities. Other states “allow for provider discretion in determining conditions,” the policy document stated.

In California, psychiatrists in several APA district branches have been involved in advocacy efforts to ensure prioritization for people with SMI. “Our goal was to have severe mental illness—especially schizophrenia—listed explicitly along with other prioritized conditions,” said Eric Rafla-Yuan, M.D., the San Diego Psychiatric Society’s legislative representative and a voluntary assistant clinical professor in the Department of Psychiatry at the University of California, San Diego.

The advocacy resulted in the state government’s inclusion of individuals with developmental or other severe, high-risk disabilities on its vaccine prioritization list. Then on March 11, the list was further updated to explicitly state that people with SMI and severe SUDs are eligible. “There is dramatic confusion around who can receive the vaccine, when they can get it, and how they can get it, so being as explicit as possible is helpful for everyone,” Rafla-Yuan said. He and his fellow advocates are now working to ensure physicians are informed that their patients with an SMI diagnosis meet the criteria for vaccine prioritization.

“We know that patients with SMI have less regular follow-up with primary care providers, and in many instances the psychiatrist is one of the only medical providers these patients make contact with,” said Tiffany Castillo, M.D., chief psychiatry resident of the community psychiatry program at the University of California, San Diego. “That means it’s extremely important that psychiatrists are aware of their local guidelines and how their patients can receive a vaccine. We have to make it a priority.”

Additional Barriers to Access for Patients With SMI/SUD

Castillo volunteered at a COVID-19 vaccination site at the Petco Park stadium in San Diego. As she and other resident volunteers administered vaccines, she made an observation: Her patients would not have been able to attend.

She listed the potential barriers that would stand in the way of someone with SMI receiving a vaccine at the site: “You need internet access to make an appointment. You have to be able to take time off from work to wait in a vehicle for two to three hours. A lot of these patients had family members drive them to the site, so you need a support system you can rely on—and then you need to do the whole thing again in three to four weeks for your second dose.”

Not having priority is just one of the barriers that people with mental illness face, pointed out Michael Flaum, M.D., the president of the American Association for Community Psychiatry and an emeritus professor of psychiatry at the University of Iowa Carver College of Medicine. “When we look back in two years, prioritization probably won’t be an issue, but more than likely people with mental illness will still have a lot fewer vaccines in their arms than people without mental illness,” he said. He pointed out that some studies show that only 25% of people with SMI receive flu vaccines.

Flaum noted a variety of strategies that could help ensure that people with SMI have access to COVID-19 vaccines, such as embedding vaccine clinics into mental health clinics, ensuring that psychiatrists have the COVID-19 vaccination on their checklist of topics to discuss during patient visits, or allowing psychiatrists to administer vaccines to their patients.

“As the supply of vaccines increases, how we are distributing them will become even more important,” Rafla-Yuan said. “Even if the supply of vaccines is no longer an impediment, people with SMI will continue to struggle to get vaccinated.” ■