Letter to the Editor: THE IMPACT OF THE COVID-19 PANDEMIC ON SCHIZOPHRENIA PATIENTS.

Dear Editor, The Covid-19 pandemic affected human life globally, inducing much stress on daily living (Çakıroğlu et al. 2020). Although assessments of general mental health during the Covid-19 pandemic have been widely reported, there is not adequate research on how schizophrenia patients have been affected. According to the World Health Organization (2020), individuals with chronic diseases who do not pay attention to their personal hygiene and the rules of protection from COVID-19 have a higher risk of getting infected than the healthy individuals who observe these measures. It is well known that the risk of Covid-19 infection is raised among schizophrenia patients due to negligence on the requisite control of personal hygiene and health conditions related to smoking and diabetes ( Cohn et al., 2004; Dinan et al., 2004; Krieger et al. 2019). The cognitive impairment in this disorder which reduces the perceptions on the necessity of self protection and the awareness of the risks proposed to underlie this raised risk of COVID-19 positivity (Yao et al. 2020). These patients have difficulty in following the preventive regulations (Palomar-Ciria et al., 2020). Apart from the risk of infection, there is also the risk of pandemic related development of auditory or visual hallucinations and delusional symptoms by acute and chronic psychosis patients during and after the pandemic (Brown et al. 2020, Cowan 2020). Therefore, this survey has been organised to evaluate the reaction developed by schizophrenia patients to the pandemic conditions. The first Covid-19 case was reported in Turkey on 11 March 2020 (Anadolu Agency, 11.03.2020) which was followed by the gradual increase in case numbers. In order to prevent the spread of Covid-19 and maintain the existing public health, the Republic of Turkey Ministry of Health established a 'Scientific Committee'' and prepared effective strategies including social isolation, quarantine, school closures, social distancing and wearing face mask in the community. During this process, the approximately 250 schizophrenia and schizoaffective disorder patients followed up by the Psychosis Outpatient Unit of Dokuz Eylul University Hospital Psychiatry Department (DEUPD) were instructed to visit the outpatient unit only in emergency conditions. It was determined that there were 176 schizophrenia patients whose follow up visit appointments for the period of April 1 - June 22, 2020, scheduled before the announcement of the pandemic, were cancelled. Therefore, the survey reported here was conducted with the schizophrenia patients of the DEUPD online and by telephone connections during 10- 20 May, 2020, the 9th and the 10th weeks of the pandemic. Only 76 (43.19%) of the 176 patients joined the survey, since 4 (2.27%) refused to participate and 96 (54.4%) could not be contacted. The survey aimed to determine the incidence of Covid-19 diagnosis among these schizophrenia patients and their attitude to the preventive measures against the infection during the first 2 months of the pandemic, together with how they felt and their needs for psychiatric consultation on outpatient basis during this period. The surveyed 76 patients consisted of 49 (64%) males and 27 (35%) females, with 73 (96.1%) dwelling in urban and 3 (3.9%) in suburban areas; and only 11 (14.5%) employed while 65 (85.5%) were not working. Only two patients reported consulting emergency services for Covid-19 symptoms. The rest of the patients did not report consulting a healthcare facility for suspecting Covid-19 symptoms or   Table 1. Data on the demographic, clinical and social features of the schizophrenia patients during the COVID-19 pandemic   n=76           Mean SD   Gender (F/M) 27 (35.5%) / 49 (64.5%)     Age   44.54 12.21   Disease duration   16.62 9.96   Patients living /with         Alone   3 (3.9%)     Parent(s)   43 (56.6%)     Spouse/children 25 (32.9%)     Sibling (s) 1 (1.3%)     Relative(s) 2 (2.6%)     Friend(s)   2 (2.6%)           Yes No Need to see a psychiatrist     23 (30.3%) 53 (69.7%) Subjective psychiatric complaints     32 (42.1%) 44 (57.9%) Consultation with an emergency service     2 (2.6%) 74 (97.4%) Planning to go to the hospital in the post-quarantine period   58 (76.3%) 18 (23.7%) Wearing a mask in community     67 (88.2%) 4 (5.3%) Keeping social distancing     68 (89.5%) 3 (3.9%) Expressed feeling         Loneliness   26 (34.2%) 49 (64.5%) Depressed   31 (40.8%) 44 (57.9%) Despaired   22 (28.9%) 52 (68.4%) Anxious     25 (32.9%) 49 (64.5%) Difficulty of going to the hospital in the quarantine period   53 (69.7%) 23 (30.3%)   hospital admission for Covid-19 infection or psychotic attack or incidences of Covid-19 related hallucination or delusions. During this 2-month period, 4 patients had experienced fatigue, 2 had episodes of dry cough and 7 had experienced shortness of breath, which can be associated with the nature of schizophrenia, the sedentary life style.and cigarette smoking. Medication was prescribed by a psychiatrist for 10 patients and by a family doctor for 16 patients or supplied directly by pharmacies for 45 patients on the basis of prescriptions with 1-year validity issued by the hospital* (Table 1). Much as it had been aimed to contact all patients with cancelled appointments, this objective was not attainable The patients who were not reached are likely to include those with low awareness and difficulty of adapting to infection prevention strategies. On the other hand, regardless of the level of awareness of the pandemic and compliance with the rules, phone use by these patients might have been limited by economic and environmental reasons, as well as the difficulties imposed by the pandemic. In conclusion, it is possible to say that most of the patients with schizophrenia were aware of the risk of COVID-19 infection, and understood and mostly obeyed the general health rules and advices of healthcare professionals even if they had difficulty in doing so. This could also have resulted from the nature of schizophrenia with preference for social isolation even if this can worsen the prognosis. On the other hand, patients need to be in contact with a mental healthcare professional in extraordinary situations of a pandemic. This survey did not find a remarkable increase in positive symptom severity in association with COVID-19 as most patients included in the survey had not seen a psychiatrist or mental healthcare professional for two months with 53 patients stating that they did not have to need.   However, 58 patients also stated that despite planning to make a consultation after normalization of the quarantine measures, the anxiety of contagion outweighed the option of visiting outpatient clinics. This anxiety over Covid-19 infection, however, may make it difficult for patients to understand the level of the need to see a psychiatrist and may be associated with the assumption that the pandemic would be taken under control in the normalization process with a decrease in the risk of contagion. On the results of this survey, it may be concluded that strategies for prevention of COVID-19 spread were effective among schizophrenia patients and that there is need to develop a system that reaches all patients and keeps them socially connected during the COVID-19 pandemic. *In Turkey, prescription reports with 1-year validity are issued for patients with chronic disorders. The medications can only be prescribed by a specialist, and in the case of pyshchiatric disorders, by a consultant psychiatrist. When the report is confirmed by a hospital committee of specialists, a family doctor is able to issue prescriptions. According to the decision of the Ministry of Health, patients who have medication prescription reports valid for one year would be able to get their medicines directly from pharmacies without having to consult a psychiatrist or family doctor during the pandemic.               REFERENCES Anadolu Agency (2020, Mach 11). 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