Can COVID-19-related anxiety trigger a relapse of schizophrenia?

To the Editor

COVID-19 may have negative effects on mental health related to fear of contracting COVID-19, social distancing impacts, economic effects and continuous media coverage. Patients with schizophrenia may be particularly vulnerable to these negative effects (Holmes et al., 2020). The above is particularly relevant as face-to-face mental health contacts have reduced for patients with schizophrenia during this period.

Mr J is a 60-year-old man living in a supported residential facility, diagnosed with schizophrenia in 1983. He was commenced on clozapine in 2008, achieving remission subsequently. In late March 2020, he became increasingly agitated and presented to hospital with COVID-19-related anxiety; he had no psychotic symptoms and was not clinically depressed. He was anxious about contracting COVID-19, with prominent concerns about its worldwide effects. He had disengaged from usual social activities and was watching COVID-19 news constantly. His medication was clozapine 500 mg (adequate serum levels) and zuclopenthixol decanoate 200 mg 3-weekly. His agitation levels improved within 48 hours and he was discharged. However, he re-presented a few days later with similar concerns. In total, he had four brief admissions in 1 month with anxiety resolution in hospital likely related to reduced COVID-19 news exposure on the ward. On his fifth admission, he was acutely psychotic, presenting with agitation and persecutory delusions. During this admission, Mr J’s COVID-19-related anxiety was specifically explored with a COVID-19 fear rating scale (Ahorsu et al., 2020) scoring 20 out of 35, which was clinically significant. During this admission (10-day duration), his zuclopenthixol dose was increased to 300 mg 3-weekly and specific suggestions were made to minimise excessive COVID-19 media exposure. In the last 6 weeks, he has required no further admissions and he is now in remission, with significantly reduced anxiety levels (scoring 13/35 on the COVID-19 fear scale).

The diathesis-stress model provides an explanatory model of how environmental triggers can alter the course of schizophrenia. This is likely mediated by stress-related elevations in cortisol levels which increases dopamine release (Beards et al., 2013). This case highlights the need for health services to provide extra psychosocial support for patients with schizophrenia during this pandemic. Antipsychotic medication alone may be insufficient to prevent a relapse of psychosis related to COVID-19-related anxiety. The psychosocial impacts related to COVID-19, such as reducing social isolation and limiting exposure to pandemic news, need to be specifically addressed. It is vital that the needs of patients with schizophrenia are not ignored during this pandemic, given their particular vulnerability.