Individuals with schizophrenia have experienced an increase in psychiatric, medical, and treatment risks because of the COVID-19 pandemic.
Individuals with schizophrenia have experienced an increase in psychiatric, medical, and treatment risks because of the COVID-19 pandemic. The following is an overview of risk factors and an example of patient-centered, collaborative care that promotes stabilization and safety while providing available treatment options for cooccurring diagnoses of COVID-19 and schizophrenia spectrum disorder.
The stress of the COVID-19 crisis crashed in waves across the United States and its care continuum. Hospitals, medical offices, and care centers were all impacted significantly, and the psychiatric service line was unquestionably negatively affected. Modifications in mental health services occurred in response to growing concerns related to the pandemic and the impacted workforce.
Access to psychiatric community-based services that many patients relied on—such as in-person care, outreach, and transport mechanisms—was reduced. There were additional barriers to usual services, such as lab studies and electroconvulsive therapy, especially during viral surges in communities. Issues with admission procedures and delays in hospitalizations increased emergency room overcrowding and length of time in hospitals without the comprehensive treatment a patient would receive in a designated psychiatric unit.
Then, during the height of the pandemic, changes to improve patient safety through upgrades to the US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Program (REMS) for clozapine temporarily complicated dispensing and receiving of the most effective antipsychotic.1
The updated REMS requirements increased protection in identifying potential for compromised immune responses. However, the increased demand for phlebotomy and updates to monitoring systems came when clinicians, hospital laboratories, pharmacies, and patients were already overloaded with new data and restrictions set in place to prevent the spread of the virus. Recognizing complications in the community and serious issues associated with abrupt discontinuation of the gold standard in antipsychotic medication, the FDA exercised discretion in enforcing all requirements to ensure continuity of treatment with clozapine.1
During swells of the pandemic, many patients with chronic mental illness were seemingly marooned by a fragmented system. Increased barriers and strained systems put patients at risk for further decompensation and symptomatology.
As researchers, health officials, and clinicians feared additional problems would affect patients with chronic mental illness, data surfaced verifying the legitimacy of concerns. Research results noted that patients with schizophrenia spectrum disorders have a significantly higher risk of morbidity and mortality as a result of COVID-19.2 Risk factors of morbidity associated with individuals with schizophrenia spectrum disorders are listed in Table 1.2,3
However, additional psychosocial and socioeconomic factors also may be linked to a higher correlation of morbidity and mortality associated with COVID-19 and schizophrenia spectrum disorders. These factors include limitations related to “fair and equitable resource allocation”3 and access to care and living situations that diminish social distancing, because a disproportionate share of individuals with schizophrenia live among the homeless, are incarcerated, or reside in congregate living situations.3,4 These factors, along with difficulties in the appraisal of health information and lack of adherence to practices aimed at reducing transmission, may increase the risk of the onset of illness and complications.3,4
The COVID-19 pandemic increased risks but also provided opportunities for increased interdisciplinary collaboration to respond to challenges more effectively and to advocate for the appropriate availability of resources. Schizophrenia and other severe, persistent mental health disorders needed to be discussion topics regarding the risk-benefit analysis of vaccines and antiviral medication. There is a need for individualized education for preventative and clinically appropriate care for this vulnerable population. In addition, significant and potentially life-threatening complications of antiviral medications with psychotropics have been identified.
Call for Collaborative Care
A thoughtful, patient-centered, collaborative approach to mitigating symptoms and risks of medical complications while maintaining psychiatric stability is vital to providing optimal care in complex situations. The case presented in this article shows how consideration of, preparation for, and administration of antiviral agent nirmatrelvir/ritonavir (Paxlovid) are best completed in a collaboration among psychiatry, medicine, pharmacy, nursing, and patients.
Paxlovid is an antiviral agent used to treat mild to moderate symptoms of COVID-19.5 Paxlovid consists of a 5-day course that is started within the first 5 days of symptoms of a confirmed COVID-19 diagnosis. Nirmatrelvir and ritonavir are protease inhibitors. Ritonavir, a pharmacokinetic enhancer, must be coadministered with nirmatrelvir to achieve the concentration required for sufficient desired therapeutic effects. Ritonavir is mainly a substrate of CYP3A4 and, to a lesser extent, CYP2D6; it has inhibitory effects on CYP3A and, to a lesser extent, on CYP2D6.
Nirmatrelvir is a substrate of PGP and CYP3A4, with no induction or inhibitor effects of P450 isoenzymes. CYP3A4 metabolizes many psychiatric medications. Therefore, combining Paxlovid with certain psychotropics can lead to a synergistic effect that can potentially be dangerous to patients.6 Safety related to dosing, discontinuation, and alternative medications must be considered when prescribing Paxlovid when a psychiatric medication regimen is being utilized based on the risk-benefit analysis for the patient.
Safety and Stabilization
A comprehensive review of the patient’s hepatic and renal functions, as well as a review of the patient’s current medication regimen, must be done before the patient begins taking Paxlovid. Paxlovid should be avoided in patients with severe renal impairment (estimated glomerular filtration rate [eGFR] < 30 mL/min), but it can be prescribed to patients with moderate renal impairment (eGFR > 30 mL/min to eGFR < 60 mL/min) with a dose reduction. Additionally, Paxlovid is not recommended for patients with severe hepatic impairment; no pharmacokinetic or safety data have been tested in patients with severe hepatic impairment.5
Paxlovid has an extensive interaction profile. Pharmacokinetic factors limit the immediate use of medications that are extensively metabolized by CYP3A4, such as antipsychotics pimozide and lurasidone; benzodiazepines triazolam and midazolam; and suvorexant, a drug used in the management of insomnia.5 Medications that are extensively dependent on elimination via CYP3A isoenzymes are contraindicated with using Paxlovid because of concerns related to highly elevated concentrations of these medications, which may be associated with severe, potentially life-threatening reactions.5
Access and Information: Case Study
Patients with COVID-19 and psychiatric comorbidities should be treated on an individualized basis and should not be excluded from available treatments.7
Consider this case of a 59-year-old woman as an example of the issues that arise. The patient has a psychiatric diagnosis of schizophrenia spectrum disorder, unspecified, and was taking lurasidone 60 mg daily with dinner. She tested positive for COVID-19. This patient had known significant risk factors associated with respiratory comorbidity and habitual risk factors. After onset of mild to moderate symptoms and official diagnostic confirmation of COVID-19, the patient’s psychiatric and medical clinicians considered prescribing Paxlovid.
The desire to initiate Paxlovid with rationale was discussed with the patient, and she agreed. After consultation, pharmacists provided guidance regarding the wash-out period of lurasidone to allow for safe administration of Paxlovid. Deciding when to start Paxlovid was determined by the lurasidone wash-out period time based on its particular half-life (T1/2).
In general, for medications following first-order kinetics such as lurasidone, it takes approximately 4 to 5 half-lives to eliminate 94% to 97% of a drug from the body.8 Lurasidone is metabolized extensively by CYP3A4 via oxidative reaction into 2 active (ID-14283 and ID 14326) and 2 nonactive metabolites (ID-20219 and ID-20220).9-11 The mean elimination T1/2 is 18 hours, meaning the body would completely eliminate 94% to 97% of the drug in 3 to 3.75 days.8
In this case, Paxlovid was discussed on the day it became available for a symptomatic patient with a confirmed diagnosis of COVID-19 and risk factors that warranted consideration of its use. Lurasidone was held after discussion, and Paxlovid was initiated 3 days later.
Paxlovid may be more readily utilized when lurasidone is the psychotropic prescribed and the patient can be transitioned to another drug for psychiatric stabilization. However, the situation would be different if the drug prescribed was a CYP3A inducer, such as carbamazepine, as the deinduction of CYP450 enzymes takes time after discontinuation. Specifically, the carbamazepine deinduction period after discontinuation is 2 weeks.12 Some medications—including trazodone, quetiapine, clozapine, aripiprazole, brexpiprazole, cariprazine, iloperidone, lumateperone, pimavanserin, buspirone, clorazepate, diazepam, and zolpidem, and many others—may require dose adjustment based on their primary site of metabolism by CYP3A (Table 2).
It should also be noted that ritonavir appears to induce CYP1A2, CYP2C19, CYP2C9, CYP3A, and CYP2B6, in addition to other enzymes, including glucuronosyltransferase, causing a decrease in drug concentration of bupropion and methadone.5
In this case, the antipsychotic was quickly transitioned to olanzapine. Additional concerns and cautions would need to be taken if quetiapine, aripiprazole, or clozapine were antipsychotics considered for the medication regimen.5 This patient tolerated Paxlovid and had no known adverse sequelae from COVID-19. Olanzapine demonstrated benefit for psychiatric symptom management over the following weeks.
However, if clozapine treatment was necessary for symptom management, more significant challenges could present,6 because there may not be another option to maintain adequate stabilization and the medication regimen may not be able to be readily modified. Clozapine is associated with additional risks and potential adverse events when the individual taking it is infected with COVID-19, with or without the addition of an antiviral medication.13
It is imperative to run an interaction report on recent medications and active prescriptions when considering Paxlovid to avoid interactions with current medications. There must be careful consideration given to which medications will be used to manage the psychiatric symptoms when medication changes are necessary6 to safely maintain adequate stabilization. An individualized risk-benefit analysis should always be completed when modifying treatment plans to balance the needs of safe and effective medical and psychiatric care.
Dr Sorrell is an advanced practice nurse practitioner for Dartmouth Health in Concord, New Hampshire. Dr Gibson is a clinical pharmacist at New Hampshire Hospital in Concord.
The preparation of this report was financed under a contract with the State of New Hampshire Department of Health and Human Services, with funds provided in part by the State of New Hampshire.
The authors would like to acknowledge contributions made by Karen Goodman, MSLIS, MA, medical librarian; Joseph McKee, PMHNP-BC, who assisted while he was in the student role with a literature search used in part for the final article; and Jeffrey C. Fetter MD, chief medical officer of New Hampshire Hospital, for his encouragement in writing on this subject matter.
1. FDA is temporarily exercising enforcement discretion with respect to certain Clozapine REMS program requirements to ensure continuity of care for patients taking clozapine. US Food and Drug Administration. News release. Updated November 2, 2022. Accessed December 9, 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-temporarily-exercising-enforcement-discretion-respect-certain-clozapine-rems-program
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4. Wang Q, Xu R, Volkow ND. Increased risk of COVID-19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States. World Psychiatry. 2021;20(1):124-130.
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8. Hallare J, Gerriets V. Half life. National Library of Medicine. Revised June 23, 2022. Accessed December 9, 2022. https://www.ncbi.nlm.nih.gov/books/NBK554498/
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10. Lurasidone. Lexicomp. Accessed December 9, 2022. https://online.lexi.com/lco/action/home
11. Lurasidone. Prescribing information. Sunovion; 2013. Accessed February 26, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/200603lbls10s11.pdf
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13. Veerman SRT, Bogers JPAM, Cohen D, Schulte PFJ. COVID-19: risks, complications, and monitoring in patients on clozapine. Pharmacopsychiatry. 2022;55(1):48-56.