key: cord-0821496-4oghtx7p
authors: Danenberg, Renana; Shemesh, Sharon; Tsur-Bitan, Dana; Maoz, Hagai; Saker, Talia; Dror, Chen; Hertzberg, Libi; Bloch, Yuval
title: Attitudes of patients with severe mental illness towards COVID-19 vaccinations: A preliminary report from a public psychiatric hospital
date: 2021-08-20
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2021.08.020
sha: 40509fb89037bb472824571085c4692a8be22ff5
doc_id: 821496
cord_uid: 4oghtx7p

BACKGROUND: As patients with severe mental illness are at increased risk for COVID-19 mortality, the issue of willingness to be vaccinated is of extreme importance. METHODS: During February 2021 Shalvata Mental Health hospital provided Covid-19 vaccines to its patients. Fifty one patients suffering from severe mental illness, out of 196 patients hospitalized in closed, open or day wards during that period, signed the informed consent and were assessed for their clinical condition (OQ-45), fear of Covid-19 (FCV-19S) and approach to the vaccine (C19-VHS). All patients who were not vaccinated in February 2021 (baseline) were re-approached a month later to assess whether they had gotten vaccinated since. RESULTS: Patients who were not vaccinated at baseline had an oppositional approach to the vaccine, and did not significantly differ in their fear of Covid-19 levels or in levels of clinical severity (t(49) = 2.51, p = 0.02) from those who were vaccinated. From the 29 patients who were not vaccinated at baseline approach to the vaccine was a good predictor to getting vaccinated after one month (79% positive predictive value). CONCLUSIONS: The majority of patients suffering from a severe mental illness are willing to get vaccinated, and their decision of whether or not to get vaccinated is based on their viewpoint on the vaccine rather than being an outcome of their level of distress (OQ-45). It is important to allow vaccine accessibility to hospitalized patients, to consider their opinions and to provide useful information to lower vaccine hesitancy and improve vaccination rates.

As patients with severe mental illness are at increased risk for COVID-19 mortality, the issue of 10 willingness to be vaccinated is of extreme importance. and approach to the vaccine 16 (C19-VHS). All patients who were not vaccinated in February 2021 (baseline) were re-17 approached a month later to assess whether they had gotten vaccinated since.

18 Results 19 Patients who were not vaccinated at baseline had an oppositional approach to the vaccine, and 20 did not significantly differ in their fear of Covid-19 levels or in levels of clinical severity 21 (t(49)=2.51, p=0.02) from those who were vaccinated. From the 29 patients who were not 22 vaccinated at baseline approach to the vaccine was a good predictor to getting vaccinated after 23 one month (79% positive predictive value).

24 Conclusions 25 The majority of patients suffering from a severe mental illness are willing to get vaccinated, and 26 their decision of whether or not to get vaccinated is based on their viewpoint on the vaccine 27 rather than being an outcome of their level of distress (OQ-45). It is important to allow vaccine 28 accessibility to hospitalized patients, to consider their opinions and to provide useful 29 information to lower vaccine hesitancy and improve vaccination rates. (Walker, McGee, and 48 Druss 2015; Wang, Xu, and Volkow 2021) , potentially presenting a risk for Covid-19 severity.

49 Indeed, recent studies have demonstrated higher risks for morbidity and mortality due to Covid-50 19 in people suffering from severe mental illnesses (Lee et al. 2020; Li et al. 2020; Wang, Xu, 51 and Volkow 2021) . The pandemic carries mental health consequences, especially for people with 52 previous mental health difficulties Hao et al. 2020) . The use of social distancing 53 as a central mean to protect from infection has posed additional stress and challenges for social 54 support and mental health services (Sole et al. 2021 J o u r n a l P r e -p r o o f to all adult Shalvata patients who were willing to be vaccinated and had no contraindications, 85 and were first administered on January 11 th , 2021. Some patients were admitted after already 86 being vaccinated by their health care providers and others were discharged before the vaccines 87 were given, thus not having the opportunity to be vaccinated during their hospitalization period.

88 Vaccines were initially given only to certain high risk populations in Israel, such as medical 89 workers and tenants of nursing homes and psychiatric wards, and later to the entire Israeli 90 population over the age of 16 years. For this reason, even patients who were not able to get the 91 vaccine during their hospitalization, had the opportunity to be vaccinated after returning to their 92 homes.

93 94 The patients were recruited from January 6 th to February 2 nd , 2021from two closed wards, one 95 open ward, and one day ward. Out of 196 patients hospitalized in these four wards during the 96 relevant time frame, 51 patients were able and willing to participate in the study, and after 97 signing the informed consent form, they were handed out a copy of the questionnaires and a 98 short demographical questionnaire (baseline; Time 1). None of the patients had a legal guardian.

99 Since even those patients who were hospitalized against their will were not forced to get 100 vaccinated, the informed consent for participating in a non-interventional study about their 101 attitudes towards being vaccinated was considered valid. Patients' main diagnosis was taken 102 from the hospital's medical records. (Table 1 ). Most of the participants were severely mentally 103 ill patients (most prevalent diagnoses were psychotic spectrum and personality disorders, with 104 comorbidities) in acute decompensation. All patients were asked dichotomously (yes/ no) if they 105 had been vaccinated, and in case they had not been vaccinated, whether they intend to get 106 vaccinated. Their answers were verified against the medical files in the ward. 107 108 Among 51 recruited patients, 22 patients had already been given the first vaccine shot when they 109 participated in the study, and 29 were not vaccinated. A month later we contacted the 110 participants who were not vaccinated at baseline to inquire if they did or did not vaccinate (Time 111 2). Two out of 29 patients who had not been vaccinated before recruitment were excluded from 112 the statistical analysis due to lack of certainty about their willingness to get vaccinated. There 113 were 27 to 47 days between Time 1 and Time 2 (Mean= 38.18. SD=6.97). One patient who failed 114 to complete the questionnaire was removed from some of the between-group analysis.

115 116 Participants:

117 There was no significant difference between the two groups in patients' age (mean ± SD 37.22 118 ± 16.12), sex (54.9% were male), country of birth (74.5% were born in Israel), socioeconomic 119 status or marital status. More than forty percent (40.9%) of the vaccinated group suffered from 120 anxiety, compared to 10.3% in the unvaccinated group (p<0.005). The majority of patients in the 121 unvaccinated group had completed high-school education (65.5%), with only 13.8% having a 122 higher education, while in the vaccinated group 45.5% had a higher education. We assessed group differences in Time 1 using Independent sample t tests. Power analysis 162 conducted using G*Power software, as post-hoc expected achieved power, and at alpha error 163 probability of 0.05, indicated that the sample was sufficiently powered (1-α=0.79) to detect large 164 effect sizes for a given measure. Due to small sample size of participants who did not get 165 vaccinated (n=29), group differences in Time 2 were reported using the effect size of the 166 dependent measures (Cohen's D). All statistical procedures were conducted using SPSS version 167 25. In addition, sensitivity, specificity, positive and negative predictive value of the C- 19 177 178 Among the unvaccinated participants, 14 stated they were willing to get vaccinated later on, 179 while 12 stated they had no such intention. An effect size calculation was performed to assess 180 for differences between participants who intended to get vaccinated and participants who did 181 not. As shown in Table 3 , a small to medium effect size was found in C-19 VHS scores (Cohen's 182 d=3.47) while no effect sizes were found in the Fear of Covid-19 mean score or in the OQ-45 183 mean score. Once again, participants who indicated they have an intention to get vaccinated had 184 higher C-19 VHS mean scores (Mean=4.09, SD=0.57) compared to participants who did not 185 intend to get vaccinated (Mean=2.18, SD=0.53).

186 187 We analyzed the data of 26 patients who did not get vaccinated while participating in the study 188 (Time 1) and completed the questionnaires (Time 2). As can be seen in Figure 1 , 20 out of 26 189 respondents (77%) acted in a manner corresponsive to their initial intention. Altogether, out of 190 51 patients 39 were vaccinated (76%).

191 192 For patients who were not vaccinated when recruited, we compared the predication of being 193 vaccinated based on having a higher than median C-19 VHS score. It had 65% sensitivity, 73% 194 specificity, 79% positive predictive value (PPV), and 57% negative predictive value (NPV). The 195 straightforward inquiry i.e., expressing an intention to get vaccinated at a later time had 75% 196 sensitivity, 80% specificity, 86% PPV, and 67% NPV. 197 198 199 J o u r n a l P r e -p r o o f Discussion 200 First, the current pilot study shows that vaccinating psychiatric inpatients in the psychiatric 201 wards is feasible and, in our view, an important contribution to patients' health and safety during 202 the Covid-19 pandemic. Our study aimed at a unique, hard to recruit, vulnerable patient group.

203 Although in a rather small patient group, the findings suggest that the majority of patients 204 suffering from a severe mental illness are willing to get vaccinated. Many of those who did not 205 vaccinate immediately were willing to vaccinate later while hospitalized or in their respective 206 communities.

207 208 Although the study population was composed of highly distressed patients, it is important to 209 stress that patients who were willing to get vaccinated were not different from those who chose 210 not to get vaccinated in terms of clinical condition as reported by the patients (OQ-45), level of 211 symptoms or fear of Covid-19. These data support the understanding that the patients' decision 212 of whether or not to get vaccinated is based on their viewpoint. In this respect, psychiatric 213 inpatients seem to be similar to the general population. These preliminary findings support the 214 ethics of providing the vaccine voluntarily while being hospitalized.

215 216 The willingness of the general population to get vaccinated is considered to have a pivotal role 217 in dealing with the Covid-19 pandemic, and has become a focus in recent research (Freeman et 218 al. 2020; Finney Rutten et al. 2021; Coustasse, Kimble, and Maxik 2021) . The influence of 219 mistrust towards society and authorities, suspiciousness, and disregarding scientific evidence 220 have been marked as central contributors to the hesitance (Germani and Biller-Andorno 2021; 221 Freeman et al. 2020) . Since many of these attitudes are common in severe mental states, 222 especially in psychotic disorders and severe personality disorder, it was likely to see an effect 223 on opposing the vaccine. The results of the present study do not support such an effect. As a 224 group, the attitude of our patients was not affected by the severity of their symptomatology as 225 they perceived it., and having a psychotic, bipolar or personality spectrum disorder was not a 226 predictor of attitude towards being vaccinated. However, this observation should be taken with 227 a grain of salt, as the diagnostic groups are very small. Still, even with these small groups, there 228 were significantly more patients suffering from anxiety who did get vaccinated, supporting a 229 possible connection between fear of Covid-19 and the attitude towards being vaccinated. In our 230 study, the "fear of Covid-19" was not linked to the attitude towards being vaccinated. Thus, the 231 attitude of our patient group to vaccination is very similar to that of the general population, with. 232 70% of patients in the study group being vaccinated or intended to be vaccinated, similar to 233 survey findings in the general population (Freeman et al. 2020) , including in Israel {Dror, 234 2020;Shmueli, 2021}. As in the general population, the decision was related mainly to the 235 attitude towards the vaccination itself, rather than the fear of Covid-19 (Karlsson et al. 2021) .

236 237

In addition to the questionnaires, patients were asked if they had an intention to get vaccinated.

238 Their answers seem to be a good predictor of their actual decisions, providing valuable 239 information for planning the number of vaccines needed. An encouraging detail is that some of 240 the patients who initially had no intention to get vaccinated, did opt to get vaccinated eventually, 241 without any further solicitation or compulsion.

242 243 As previously mentioned, patients suffering from severe mental illness are physically and 244 socioeconomically vulnerable to infection, and morbidity and mortality due to Covid-19. Our 245 study demonstrates the importance of providing vaccination accessibility to hospitalized 246 patients, and more so, the need to consider their viewpoints and opinions. Since it seems that 247 vaccination hesitancy is an important factor in the decision whether to get vaccinated, it is 248 imperative to target the different components of attitude against vaccination as reflected in the 249 C19-VHS questionnaire, such as lack of confidence in the need to be vaccinated, risk perception 250 and fear of side effects. Further large scale studies are needed to investigate the reasons for 251 patients' attitude towards being vaccinated, possibly studying whether specific items in the 252 C19-VHS reflect specific viewpoints or disinformation and can guide attempts to lower 253 hesitancy and improve vaccination rates. 254 255 Study limitations:

256 The main limitation of the study is its small sample size, enabling to detect a large effect only.

257 Additionally, we lack information about what persuaded those who were reluctant to vaccinate.

258 259 

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