The impact of the COVID-19 pandemic on mental health is hard to quantify, but anecdotal reports suggest that rates of PTSD, depression, and anxiety have risen significantly during the year-and-a-half period since the beginning of the outbreak.

For people with preexisting psychiatric disorders, the pandemic has posed new challenges and potentially compounded old ones. Experts note that utilization of psychiatric services has declined, and that reduced access to healthcare, social isolation, and reduced physical activity create conditions in which pre-pandemic symptoms may be exacerbated in some patients.

A research team led by 2018 BBRF Young Investigator Gregory P. Strauss, Ph.D., of the University of Georgia, has spent the last year closely studying this possibility in a particular subset of patients: people diagnosed with schizophrenia and schizophrenia spectrum disorders, as well as individuals considered at "clinical high risk" (CHR) for developing psychosis.

Reporting in the European Archives of Psychiatry and Clinical Neuroscience, Dr. Strauss and colleagues focus on the pandemic's impact on schizophrenia's negative symptoms, which include flattened emotions, reduced motivation, difficulty speaking, and a disinclination to socialize or to seek pleasure.

"It is vital to determine whether these symptoms have been exacerbated compared to pre-pandemic times because they are so critically linked to poor community-based functioning, reduced rates of recovery, low psychological well-being, and illness liability," the researchers point out.

One common therapeutic approach to help patients with negative symptoms seeks to "induce behavioral activation"—i.e., to get the patient to identify activities and set goals. But shelter-in-place orders, quarantine, self-isolation, and physical and social distancing policies "by their very nature induce behavioral aspects of negative symptoms," the team notes, and could have the effect of making negative symptoms even more problematic for some individuals.

The team sought to investigate this possibility in people with schizophrenia, and to explore whether people at high risk of developing psychosis might be more likely under pandemic conditions to experience a first psychotic episode, which often marks the onset of schizophrenia. They studied 32 outpatients with chronic schizophrenia or schizoaffective disorder, and 25 individuals at clinically high risk, comparing each group with matched healthy control subjects. Each participant was rated on the Brief Negative Symptom Scale (BNSS), a clinical interview adapted to be administered online in view of pandemic conditions. The schizophrenia patients and CHR participants had been rated on this scale in in-person interviews prior to the pandemic, providing a basis of comparison with their current negative symptom scores.

A majority of the participants were female; those with schizophrenia were aged 40, on average, and had spent an average of 145 days sheltering in place due to the pandemic. The CHR group was aged 22 on average and had spent an average of 139 days sheltering in place.

Negative symptoms were exacerbated in each measured category among those in the study with schizophrenia or schizoaffective disorder. Increases in anhedonia (inability to seek pleasure) avolition (reduced motivation), asociality (disinclination to socialize) and alogia (difficulty speaking) were most evident; increases in blunted affect were also noted, but were less severe.

A different pattern was seen in the individuals at high risk for psychosis, in whom anhedonia and asociality were intensified during the pandemic, but other negative symptoms were not meaningfully changed.

The researchers were not able to say why results differed in the two groups. They suggested that in schizophrenia patients, the chronic or long-term nature of the illness "may lead negative symptoms to be more entrenched, and therefore more likely to increase" following a challenge such as that posed by the pandemic.

They also noted: "There is evidence that certain environmental deprivation factors are associated with negative symptoms in schizophrenia," including under-stimulating environments, smaller social networks and "minimal care and attention" in group-home settings. The latter are either not experienced or less likely to be experienced by CHR individuals. It is also possible, the researchers said, that biological mechanisms underlying negative symptoms may differ in schizophrenia and CHR.

Despite these differences, the team concluded that during the pandemic, negative symptoms were increasing in both schizophrenia patients and those at high risk of psychosis, albeit in a less pronounced way in the latter group. "These effects appear profound and highlight the need to assess environmental contributions to negative symptoms," the team noted.

Dr. Strauss said the results tend to support a “bioecosystem theory” he has recently proposed, which focuses on environmental contributions to negative symptoms. "The COVID-19 pandemic was an unintended test of this theory in that it has induced environmental resource depletion, providing new evidence for an under-recognized role of environmental factors on negative symptoms that had previously largely been considered primarily neurobiological."