Department of methodology and innovation in prevention, Bordeaux University Hospital, Bordeaux, France.
University of Bordeaux, Inserm UMR 1219-Bordeaux Population Health, Bordeaux, France.
PLoS Med. 2023 Feb 6;20(2):e1004134. doi: 10.1371/journal.pmed.1004134. eCollection 2023 Feb.
Meta-analyses have shown that preexisting mental disorders may increase serious Coronavirus Disease 2019 (COVID-19) outcomes, especially mortality. However, most studies were conducted during the first months of the pandemic, were inconclusive for several categories of mental disorders, and not fully controlled for potential confounders. Our study objectives were to assess independent associations between various categories of mental disorders and COVID-19-related mortality in a nationwide sample of COVID-19 inpatients discharged over 18 months and the potential role of salvage therapy triage to explain these associations.
We analysed a nationwide retrospective cohort of all adult inpatients discharged with symptomatic COVID-19 between February 24, 2020 and August 28, 2021 in mainland France. The primary exposure was preexisting mental disorders assessed from all discharge information recorded over the last 9 years (dementia, depression, anxiety disorders, schizophrenia, alcohol use disorders, opioid use disorders, Down syndrome, other learning disabilities, and other disorder requiring psychiatric ward admission). The main outcomes were all-cause mortality and access to salvage therapy (intensive-care unit admission or life-saving respiratory support) assessed at 120 days after recorded COVID-19 diagnosis at hospital. Independent associations were analysed in multivariate logistic models. Of 465,750 inpatients with symptomatic COVID-19, 153,870 (33.0%) were recorded with a history of mental disorders. Almost all categories of mental disorders were independently associated with higher mortality risks (except opioid use disorders) and lower salvage therapy rates (except opioid use disorders and Down syndrome). After taking into account the mortality risk predicted at baseline from patient vulnerability (including older age and severe somatic comorbidities), excess mortality risks due to caseload surges in hospitals were +5.0% (95% confidence interval (CI), 4.7 to 5.2) in patients without mental disorders (for a predicted risk of 13.3% [95% CI, 13.2 to 13.4] at baseline) and significantly higher in patients with mental disorders (+9.3% [95% CI, 8.9 to 9.8] for a predicted risk of 21.2% [95% CI, 21.0 to 21.4] at baseline). In contrast, salvage therapy rates during caseload surges in hospitals were significantly higher than expected in patients without mental disorders (+4.2% [95% CI, 3.8 to 4.5]) and lower in patients with mental disorders (-4.1% [95% CI, -4.4; -3.7]) for predicted rates similar at baseline (18.8% [95% CI, 18.7-18.9] and 18.0% [95% CI, 17.9-18.2], respectively). The main limitations of our study point to the assessment of COVID-19-related mortality at 120 days and potential coding bias of medical information recorded in hospital claims data, although the main study findings were consistently reproduced in multiple sensitivity analyses.
COVID-19 patients with mental disorders had lower odds of accessing salvage therapy, suggesting that life-saving measures at French hospitals were disproportionately denied to patients with mental disorders in this exceptional context.
荟萃分析表明，先前存在的精神障碍可能会增加严重的 2019 年冠状病毒病（COVID-19）结局，尤其是死亡率。然而，大多数研究都是在大流行的头几个月进行的，对于几种类别的精神障碍的结果尚无定论，并且没有完全控制潜在的混杂因素。我们的研究目的是评估在法国全国范围内 COVID-19 住院患者出院后 18 个月的 COVID-19 住院患者样本中，各种类别的精神障碍与 COVID-19 相关死亡率之间的独立关联，并评估抢救治疗分类的潜在作用，以解释这些关联。
我们分析了 2020 年 2 月 24 日至 2021 年 8 月 28 日期间法国大陆因有症状的 COVID-19 出院的所有成年住院患者的全国回顾性队列。主要暴露是从过去 9 年记录的所有出院信息中评估的先前存在的精神障碍（痴呆、抑郁症、焦虑症、精神分裂症、酒精使用障碍、阿片类药物使用障碍、唐氏综合征、其他学习障碍和其他需要精神科病房入院的障碍）。主要结局是在记录的 COVID-19 住院后 120 天评估的所有原因死亡率和抢救治疗（重症监护病房入院或挽救生命的呼吸支持）的获得。使用多变量逻辑模型分析独立关联。在有症状的 COVID-19 住院患者中，有 153870 例（33.0%）有精神障碍史。几乎所有类别的精神障碍都与更高的死亡率风险（除阿片类药物使用障碍外）和更低的抢救治疗率（除阿片类药物使用障碍和唐氏综合征外）独立相关。在考虑了从患者脆弱性预测的基线死亡率风险（包括年龄较大和严重的躯体合并症）后，在医院的病例量激增中，无精神障碍患者的超额死亡率风险为+5.0%（95%置信区间（CI），4.7 至 5.2），而精神障碍患者的死亡率风险显著更高（预测风险为 21.2% [95% CI，21.0 至 21.4]）。相比之下，在医院的病例量激增中，抢救治疗率明显高于无精神障碍患者的预期（+4.2%[95% CI，3.8 至 4.5]），而精神障碍患者的抢救治疗率则低于预期（-4.1%[95% CI，-4.4%至-3.7%]），预测率在基线时相似（18.8%[95% CI，18.7%至 18.9%]和 18.0%[95% CI，17.9%至 18.2%]）。我们研究的主要局限性在于在 120 天评估 COVID-19 相关死亡率和记录在医院索赔数据中的医疗信息可能存在编码偏倚，尽管主要研究结果在多项敏感性分析中得到了一致再现。
患有精神障碍的 COVID-19 患者获得抢救治疗的可能性较低，这表明在这一特殊情况下，法国医院的救生措施不成比例地拒绝了精神障碍患者。
