We are all experiencing the struggles that come with the existential dread of living through a pandemic, and the stressors of social distancing. For individuals with psychotic illness, this time period can pose some unique challenges. In recognition of Schizophrenia Awareness Week, which runs from May 13-19 this year, we interviewed Brooklyn Minds’ staff psychiatrist Stephen Geisler. He shared great insight into possible impacts of the pandemic on people who live with psychotic illnesses. The following interview has been lightly edited and formatted for clarity.
What risk factors are heightened for people with psychotic illnesses during a pandemic?
This is an illness where [people who have it] often have worse medical care than the general population. A lot of people with schizophrenia are not working, so they’re on disability, SSI, SSD, and many depend upon Medicaid and Medicare. They may not have the best or easiest access to healthcare. So, often, instead of going for a yearly annual physical and catching problems as they arise, they’ll end up in the emergency room with their blood sugar off the wall, or their blood pressure super high and needing to be admitted.
It’s been found that the lifespan of people with schizophrenia can be up to 20% shorter than the general population. A lot of this is about not having the same access to healthcare. Part of it might also be the illness, that people don’t have the same judgement in seeking out care when it’s needed. The biggest thing, I think, is having access to healthcare.
Also, unfortunately, a lot of antipsychotic medications, including Clozapine, can worsen a lot of other medical comorbidities such as obesity, diabetes, cardiovascular disease, etc. So these people are already at an increased risk for a lot of other medical conditions.
Have you noticed any issues with people getting the antipsychotic medications they need?
A lot of my patients are afraid to go to their local drugstore. They don’t want to go outside. And I think anyone who has any hesitancy about taking medication is going to be more vulnerable to that, too. They’re less likely to take it, whereas if you’re getting an injection, they can show up at the place they’re getting it, get the injection and then they know and their clinician knows they’re getting the medication. I think that’s an important aspect for people suffering from psychotic illnesses. Although long-acting injectable medications are becoming more commonly used, they are still underutilized.
The other medication that I mentioned, Clozapine, is a medication which is reserved for patients with schizophrenia who don’t respond to other medications. However, with Clozapine you have to have bloodwork done because of a potentially serious side effect. Every week for the first six months of medication, and then for months 7 through 12 it’s every other week. After that, if their white blood cell counts are okay, then they go once every 4 weeks. This is pretty stringent, because a pharmacy cannot give the medication to a patient unless they’ve had that blood test. The FDA, somewhat uncharacteristically, but recognizing the circumstances we are all living under during the quarantine, have loosened the regulations, leaving more up to the individual clinician’s discretion.
What risk factors make this situation more dangerous for people with psychotic illnesses?
[Smoking] makes it much more dangerous. So they’re more susceptible to getting serious forms of the viral infections and often leading to hospitalization. That’s a real concern. Many people with schizophrenia live in the more marginal parts of society. They might not have support, because part of the illness causes people to be socially isolated, they’re not as connected to people, sometimes they may not have the same connection to their families. They often live in adult homes or apartment programs. Those settings with other people may also increase their risk, because they’re in contact not only with counselors, but also with some of their fellow patients who are suffering from illnesses also.
I think a lot about how, due to the socio-economic status of a lot of these people, they might not have laptops or smartphones or other kinds of ways of communicating. So, I think they’re not going to be able to participate in telehealth as much as others who do not suffer from psychotic illnesses. I think it creates more stress, because often these are people who have trouble relating to other people, people who don’t have that network of people who are supporting them and helping them. And so the little contact they have with, for example, the secretary who checks them in, other staff that help them, or even just going to the local pharmacist, cuts many of them off even moreso, making them even more socially isolated.
Also, if somebody does get infected with coronavirus, and particularly if they have the respiratory symptoms, one of the treatments given might be steroids, to help the ability to breathe. A side effect of steroids can be psychosis. So, if someone is given steroids, and I’ve seen this in patients that have severe bronchitis, for example, they can have an increase in psychotic symptoms. Even for a person from the general population with no psychotic illness, a side effect of steroids can be psychotic symptoms.
Psychiatry and the health systems are already bracing for increased anxiety and depression as a result of the pandemic, but I think particularly people who have a psychotic illness are at an increased risk. It’s been shown that under stress, you’re more likely to have exacerbations of psychosis, and have more symptoms such as hallucinations and delusions, so it can make the illness even worse. It’s a huge stress that we’re all facing, and people who have the vulnerability of a pre-existing condition are more susceptible to this stress. That might include increased exacerbation of the symptoms, and the problem is if they’re having less contact with their clinicians, or their work programs, they may not catch it as early as they normally would. Many people with schizophrenia go into rehabilitation programs where they’re going for vocational programs, educational programs, or just social groups. And these are really important supportive communities for people who have schizophrenia in particular. Not having access to these facilities makes it so much harder, and having less contact with people, making them more isolated and that also increases stress.
Do you think losing that connection, those everyday sort of interactions with other human beings, contributes to a lack of grounding that then makes people more susceptible to having a psychotic episode?
I think it can. When someone’s going through an acute psychotic episode, they tend to be withdrawn anyway, they tend to isolate themselves. This might be due to the fact that they are having trouble trusting other people or feeling somewhat paranoid. So this kind of feeds into that same kind of modality, of being withdrawn and separated from the rest of society.
Along with the anticipated spike in anxiety and depression, among the general population, do you anticipate a spike in people having psychotic episodes?
I think unfortunately there’s more likely to be more relapses, and people not getting the help that they need. I also worry about people who might have their first break. Usually this is during the late teens and early adulthood. They often have symptoms a year or more before they actually get help. I think now they’re even less likely to get help, because who wants to go to an emergency room? Who wants to go to a hospital to get help? It’s so hard.
With only phone contact, a clinician is a little bit handicapped in trying to pick up subtle signs of someone who is having symptoms. For example, if someone has schizophrenia and they’re beginning to show symptoms leading to a psychotic break or relapse, sometimes the social isolation, the withdrawal, not engaging in regular activities, having decreased contact with their usual support network, can all be signs of an impending relapse, and ordinarily you’d think you might need to increase the medication or provide more support, more therapy, but it’s harder to detect that on a phone call. So unfortunately a lot more people might be getting ill because they’re not having that regular contact with their clinicians.
We appreciate the time Dr. Geisler took to speak with us. To learn more, join Dr. Geisler and other experts on 5/14 at 5pm EST at our webinar “Psychosis in a Pandemic.” Register here.
Brooklyn Minds offers many services for those struggling with psychotic illnesses. Therapy, psychiatry and family support are all currently available via telehealth. We offer long-acting injectable antipsychotics as well as Clozapine, and have recently partnered with Athelas to provide in-office or in-home bloodwork for Clozapine monitoring. Our Winnicott companion program can also offer extra support for those who need it.
