A greater likelihood of hospitalization exists for patients with COVID-19 and with both psychiatric disorder and substance use disorder (SUD) compared with individuals with COVID-19 and with neither disorder or with either disorder alone, according to study findings published in the Journal of the American Medical Association Psychiatry.

Investigators sought to evaluate the association of comorbid psychiatric disorder and SUD with the probability of hospitalization among patients with COVID-19 in the emergency department (ED). The primary endpoint was any hospitalization determined by billing codes .

They conducted a retrospective cross-sectional study that included more than 1.2 million patients with COVID-19 treated in 1 of 970 US EDs and inpatient hospitals from April 2020 to August 2021. Primary exposures were any past diagnosis of psychiatric disorder (post-traumatic stress disorder [PTSD], major depression or other mood disorder, bipolar disorder, anxiety, attention-deficit/hyperactivity disorder [ADHD], or schizophrenia) and/or SUD (cocaine, sedatives, cannabis, alcohol, stimulants, opioids, or other substances). The investigators calculated differences in the probability of hospitalization to evaluate its association with both SUD and psychiatric disorder compared with SUD alone, psychiatric disorder alone, or neither condition. Nicotine dependence was treated as a comorbid covariate vs a primary exposure variable. Independent variables consisted of sex, race and ethnicity, age, primary insurance, and the US Census region of the hospital.

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The investigators analyzed discharge data using the Premier PINC AI Healthcare Data Special Release COVID-19 (PHD-SR COVID-19) edition (release date, September 14, 2021), a 48-state, all-payer longitudinal electronic health record database that included 1,274,219 adult patients with COVID-19 at least 18 years of age (mean age, 54.6±19.1 years; 52.4% women) and found 4.6% had an SUD (mean age, 50.1 years; 38.3% women), 18.6% had a psychiatric disorder (mean age 59.0 years; 62.3% women), and 2.3% had both (mean age, 50.4 years; 46.9% women).

There were 567,766 (44.6%) patients hospitalized directly from the ED. Hospitalized patients vs those not admitted were more likely men (52.4%), older (mean age 63.6 vs 47.4 years), insured by Medicare, living in urban areas, or living in the Northeast. Among the hospitalized patients, about three-fourths had a chronic disease vs one-third of patients with COVID-19 who were discharged from an ED.

Alcohol (2.1%), cannabis (1.3%), opioids (1.0%), and multiple (≥2) SUDs (0.9%) were the most common SUDs. Anxiety (12.9%), major depression (9.8%), multiple (≥2) psychiatric disorders (6.4%), and schizophrenia (1.4%) were the most prevalent psychiatric disorders. Among patients with ADHD, PTSD, other mood disorders, or schizophrenia, prevalence of SUD exceeded 21%. Hospitalized patients vs those discharged from the ED were more likely to have an SUD (6.1% vs 3.4%), a psychiatric disorder (26.5% vs 12.2%), or both an SUD and a psychiatric disorder (3.1% vs 1.6%). The investigators found SUD vs psychiatric disorder appeared to have a stronger association with the likelihood of hospitalization.

The investigators noted the probability of hospitalization of those with both an SUD and a psychiatric disorder was higher by a weighted mean of 20 percentage points (range, 6-36; interquartile range [IQR], 16-25) than those with neither condition, by 12 percentage points (range, -4 to 31; IQR, 8-16) than those with a psychiatric disorder alone, and by 4 percentage points (range, -7 to 15; IQR, -2 to 7) than those with an SUD alone, based on specific SUD-psychiatric disorder pairs (Q <.05 [P value adjusted for false discovery rate]).

Study limitations include the nature of retrospective cross-sectional design, not designed to be a probability sample, social desirability bias, undercoding, about one-third of patients with secondary discharge of COVID-19 inflating hospitalization numbers, misclassification by including SUD inactive condition or excluding SUD with an undetermined degree of activity, and asymptomatic patients with COVID-19 not identified nor were those treated out-of-network or in a non-ED setting. Additionally, patients were only included if they sought emergency care in 48 states, a shortage of hospital beds may have postponed hospitalization, and an accurate determination of vaccine attenuation though a vaccine was not available during the initial 8 months of the study.

Among “emergency department patients with COVID-19, patients with both psychiatric disorder and substance use disorder had a greater probability of hospitalization, compared with those with psychiatric disorder alone, substance use disorder alone, or neither disorder,” the investigators concluded. They added, “Substance use disorders appear to have a greater association than psychiatric disorders with the probability of hospitalization.” They suggest screening and evaluation for SUDs and psychiatric disorders are necessary to better estimate the likelihood of hospitalization among patients in the ED with COVID-19 and coexisting SUD and psychiatric disorder.


Schieber LZ, Dunphy C, Schieber RA, Lopes-Cardozo B, Moonesinghe R, Guy GP Jr. Hospitalization associated with comorbid psychiatric and substance use disorders among adults with COVID-19 treated in US emergency departments from April 2020 to August 2021JAMA Psychiatry. Published online February 15, 2023. doi:10.1001/jamapsychiatry.2022.5047

This article originally appeared on Psychiatry Advisor