The news of the first MHRA-approved vaccine for covid-19 in December 2020, with plans for large-scale implementation of a vaccination programme in the UK and other countries, has brought great hope and expectation. The success of the vaccination programme so far in the UK is encouraging as vaccination is a crucial step in reducing infection rates and offering a realistic way out of pandemic restrictions. However, there are limited supplies of vaccine, the logistics are challenging, and each country needs to prioritise who receives it first and in what order.
As the first country to approve a licensed vaccine, the UK has been at the forefront in creating and implementing a prioritisation plan. In general, two themes have emerged: to reduce spread most effectively by targeting social/health care workers, and to vaccinate the most vulnerable first.
As mental health clinicians, a key question is where people with mental health difficulties lie within this order of priority, and within this group, who should be vaccinated first. Those with a mental health diagnosis have multiple risks in the context of covid-19. Overall, they have a significantly increased risk of covid-19 infection and subsequent mortality. Physical risk factors for covid-19 infection and outcomes are increased in those with severe mental illness (SMI) including cardiovascular and respiratory disease, diabetes and obesity. Even before covid-19, mortality rates were 2-3 times higher, with 10‐20 years reduced life expectancy compared to the general population. Environmental risk factors for covid‐19 infection, such as socioeconomic deprivation, homelessness, and institutionalisation are also increased. Given these multiple and additive risk factors, how are those with mental illness represented in vaccine prioritisation?
There is no handy guide or summary to answer this question specifically for mental health. As with most guidance for healthcare and covid-19, mental health is included as part of a general list of health conditions (see here for more details). In the UK, the Joint Committee on Vaccination and Immunisation (JCVI) priority list contains nine specified categories to be followed in order before general release. The list aims to prioritise first the prevention of covid-19 mortality and the protection of health and social care staff and systems. Age was assessed as the single greatest risk for mortality and so this is prioritised before pre-existing conditions.
Priority group 4 (those who are “clinically extremely vulnerable”) is the first group based on clinical condition rather than age or setting, but common mental health conditions are not included here. Those with “severe mental illness” (SMI, defined as schizophrenia, bipolar disorder or mental illness causing severe functional impairment) will wait until priority group 6 (underlying health conditions) and come after those who are over 65 years old. This is a key point, as the UK vaccination programme identified a specific target to offer vaccination to the first four priority groups by 15 February 2021. New modelling has now been used to prioritise the next phase of the vaccination rollout.
Within the broad category of SMI, there is no specific guidance on prioritisation. Those with SMI and additional risk factors for poor outcomes (for example ethnicity, deprivation, overcrowding) will not be offered the vaccine sooner, although healthcare providers are asked to make an assertive effort to ensure they receive it. Patients in older adult mental health services will be offered the vaccine based on age rather than mental illness. Those with mental health difficulties who do not meet criteria for SMI are treated as any other person. UK guidance is one of the most detailed; that from other countries (USA, Canada, Australia and New Zealand) follows similar general principles, but they do not specifically include mental health in their priority groups.
The UK guidance, in response to advocacy from the Royal College of Psychiatrists, does specify those with SMI as a vulnerable and prioritised population. However, it still presents real world difficulties. Priority is not additive and is based on the single highest criterion met. Of course, every risk group wants to be prioritised earlier, but this linear approach particularly disadvantages those with mental health issues and multimorbidity. The JCVI guidance discusses mitigating inequalities (specifically minority ethnic groups), recognises that multiple social and societal factors contribute towards increased risk from covid-19, but does not allow for extra prioritisation either formally or by clinicians.
Mental health services should consider how to prioritise different patient groups within the larger population of those with SMI, considering multimorbidity across mental health, physical health and social settings. Extra support will be needed as this group has a low uptake of preventative healthcare programmes, such as the influenza vaccine. Mental Health Trusts are often geographically and organisationally separated and risk falling behind in the rush to vaccinate acute hospital staff. The nature of mental illness can stigmatise and impact sufferers’ ability to speak and be heard. Without more specific guidance and prioritisation, the most vulnerable mental health patients may simply get left behind. The risk of being neglected is a problem for mental health patients and also for mental health in general. Is it just by chance that mental health Trusts in some areas of the UK have not been allocated priority vaccination slots for their staff?
Andrea Cipriani, Psychiatrist and NIHR Research Professor, Department of Psychiatry, University of Oxford. Twitter: @And_Cipriani
Katharine Smith, Psychiatrist, Department of Psychiatry, University of Oxford
Orla Macdonald, Pharmacist, Oxford Health NHS Foundation Trust
James Hong, post-F2 doctor, Department of Psychiatry, University of Oxford
Edoardo Ostinelli, Psychiatrist, Oxford Health NHS Foundation Trust
Caroline Zangani, Psychiatrist, Oxford Health NHS Foundation Trust
Rob Bale, Psychiatrist, Oxford Health NHS Foundation Trust
Nick Broughton, Psychiatrist and Chief Executive, Oxford Health NHS Foundation Trust
John R Geddes, Psychiatrist and Head of Department of Psychiatry, University of Oxford
Competing interests: none declared.
Competing interests: KS, EO, OM and AC have been involved in two of the COVID-19 vaccine research studies carried out in Oxford. KS, OM, EO, NB, JG and AC have been involved in the Oxford Health NHS Trust programme for roll out of mass COVID-19 vaccination according to JCVI priority groups.
Acknowledgements: KS, EO, CZ and AC are supported by the National Institute for Health Research (NIHR) Oxford Cognitive Health Clinical Research Facility. AC is also supported by an NIHR Research Professorship (grant RP-2017-08-ST2-006), by the NIHR Oxford and Thames Valley Applied Research Collaboration and by the NIHR Oxford Health Biomedical Research Centre (grant BRC-1215-20005).
The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR, or the UK Department of Health.