Excess COVID mortality in severe mental illness never came down

Design

retrospective, whole-country linked electronic health record cohort with Cox regression, stratified by pandemic stage

Population

13,463,945 people in England with COVID-19, including 160,190 with severe mental illness

Primary outcome

all-cause and COVID-19 mortality after SARS-CoV-2 infection

Effect

all-cause mortality aHR 1.56 (95% CI 1.53 to 1.59); COVID-19 mortality aHR 1.25 (1.17 to 1.34) after accounting for vaccination

A whole-country study linked primary care records for more than 99% of the population of England, following 13,463,945 people who had COVID-19 between January 2020 and June 2023, of whom 160,190 (1.19%) had a severe mental illness - schizophrenia, schizoaffective disorder, bipolar disorder, or another affective or non-affective disorder with psychosis.

All-cause mortality after infection was higher in the severe mental illness group throughout: adjusted hazard ratio 1.56 (95% CI 1.53 to 1.59) overall. The stage pattern is the finding. In the first pandemic stage the excess was 1.27 (1.22 to 1.32); during vaccine roll-out it rose to 1.56 (1.51 to 1.61) and after roll-out stayed at 1.55 (1.50 to 1.59). Vaccination started ahead - 73.2% in this group during roll-out against 67.4% without - and finished behind, 79.4% fully vaccinated against 87.2%. Adjusting for vaccination partially attenuated the excess COVID mortality risk, to 1.25 (1.17 to 1.34).

The implication is uncomfortable and specific. An intervention that worked at population scale did not close this gap; it widened it, because the early advantage was not sustained and the later doses were not taken up. The action is not a new programme but an old one done properly: every psychiatric contact is a vaccination and physical health opportunity, and a patient whose antipsychotic is being monitored monthly should not be someone whose vaccination status is unknown. Check it, offer it in the mental health setting rather than referring elsewhere, and treat a missed booster with the same follow-up energy as a missed depot.

• Record vaccination status in the psychiatric record and review it like any other observation
• Offer or arrange vaccination at the mental health contact rather than signposting to another service
• Chase non-attendance for boosters with the systems already used for depot clinics
• Bundle the check with the physical health review - blood pressure, lipids, glucose, smoking
• In Indian practice the same logic applies to routine adult immunisation and TB screening in long-term care

Why it matters

A preventive measure that reached this group first still left them dying at a higher rate - which points at follow-through, not access.

Don't overread it

This is observational; it cannot show that closing the vaccination gap would have removed the excess mortality, only that vaccination explained part of it.

The statistics, in plain English

A hazard ratio of 1.56 means roughly a 56% higher rate of death over follow-up after adjustment, and with intervals of 1.53 to 1.59 on 13 million people the estimate is precise; the uncertainty here is about confounding, not sampling. That the ratio rose between stages does not mean absolute deaths rose - overall COVID mortality fell sharply - it means the gap between groups widened. Residual confounding by deprivation, smoking and comorbidity is likely, and part of the excess is not about the diagnosis itself.

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