Author Archives: Zuzanna Walter

Psychiatric Disorders and COVID-19 Mortality Rates, Outcomes

October 21, 2020

Psychiatric disorders have a documented association with lower life expectancy – in some cases shortening lifespan by as much as 10 years – as well as increased risk of comorbid medical conditions. In light of the persisting COVID-19 public health crisis, experts are concerned that psychiatric comorbidity may increase virus-related mortality and predispose patients to poorer outcomes.

Ongoing and emerging research efforts aim to investigate the implications of prior psychiatric diagnoses on COVID-19-related mortality and health outcomes. According to data from a recent Yale University study, patients suffering from mental illnesses may face a higher risk for severe COVID-19 outcomes including death.

Psychiatric Comorbidity and COVID-19 Mortality


Researchers from the Yale University School of Medicine evaluated data obtained from the Yale New Haven Health System. Overall, the study included clinical data from 1,685 patients hospitalized with COVID-19 infection between February 15 and April 25, 2020.

Within that cohort, those who had been diagnosed with prior psychiatric disorders had a significantly elevated mortality risk compared with patients without a diagnosis after controlling for demographic characteristics, comorbidities, and hospital location. Of the 1,685 total participants, 473 (28%) received psychiatric diagnoses prior to hospitalization. This group was significantly older and more likely to be female, non-Hispanic white, and to have medical comorbidities. Overall, 318 patients or nearly 19% of the cohort died. The highest risk for COVID-19 mortality was reported among patients with a psychiatric diagnoses at 2 weeks after their index hospitalization, as well as at 3 and 4 weeks.

South Korean Cohort Study

In a similar study conducted by South Korean researchers, a cohort of patients with mental illness did not have an increased risk for testing positive for COVID-19 compared with the general population. However, the findings, published in Lancet Psychiatry, reveal that patients with a severe mental illness diagnosis had a greater risk of severe COVID-19 outcomes – including death, intensive care unit admission, and use of mechanical ventilation.

In this study cohort, groups with and without mental illness were matched demographically and by the presence of comorbid conditions.

Association Between Psychiatric Diagnosis and COVID-19 Outcomes

The latest studies are the first to characterize the association of psychiatric diagnosis with COVID-19 mortality. Their findings are similar to previous scientific results, confirming that individuals with comorbid psychiatric and medical diagnoses had poorer outcomes and higher mortality rates. However, the reasons underlying this association remain unclear at this time.

“Psychiatric symptoms may arise as a marker of systemic pathophysiologic processes, such as inflammation, that may, in turn, predispose to mortality,” the U.S. study’s authors wrote in the research letter. “Similarly, psychiatric disorders may augment systemic inflammation and compromise the function of the immune system, while psychotropic medications may also be associated with mortality risk.”

The Yale University study’s authors acknowledged their trial’s limitations, including the fact that individuals not hospitalized for COVID-19 as well as those who died outside of the hospital were not included in the dataset. Furthermore, diagnosis codes were used to determine psychiatric diagnosis, which do not account for the status of treatment or whether the patient had an active, in-remission, or recovered psychiatric disorder in both of the studies.

Neither study took obesity or cigarette smoking into account, nor socioeconomic status or patient education level, which may be confounding factors.

Medical experts believe that an underlying biological mechanism related to the immune system may provide an explanation for this association although, further research is needed to confirm.

The author’s stress the importance of the consequences of mental illness as related to poorer health and decreased life expectancy, which may be in part due to reduced access to medical care and treatment adherence. Many individuals with psychiatric disorders lack health insurance or adequate coverage which may delay them seeking medical care; these patients may present at the hospital with more advanced stages of COVID-19. Clinicians should take these factors into consideration when treating patients with COVID-19 and remain aware of the multifactorial risks associated with pre-existing mental illness. 

Most Effective Strategies for Optimizing Patient Engagement

October 15, 2020

There is a growing recognition of the importance of patient engagement as the key component of high-performing, cost-efficient healthcare systems which increase treatment adherence and self-monitoring as well as improve population health outcomes. Healthcare organizations who prioritize a strong team-based care infrastructure are better positioned to optimize patient engagement programming – broadly defined as the process of actively involving patients in their care and treatment decisions.

New research reveals that it is a relationship-based approach that builds trust and promotes patient autonomy, while organizational and administrative factors provide the foundation for such patient engagement. Organizations and health systems with provider champions, clear-cut staff duties, team performance improvement meetings, and staff dedicated to patient engagement tend to be more successful, according to findings published in the Annals of Family Medicine.

Optimizing Patient Engagement 

The recent study aimed to identify specific organizational factors that were associated with a greater adoption of patient engagement care practices within Veterans Health Administration (VA) primary care clinics. At these locations, patient engagement efforts were centered on the Patient-Aligned Care Team (PACT) initiative, which leverages aspects of the patient-centered medical home model to deliver comprehensive and continuous team-based care to veterans.

Investigators evaluated the adoption of PACT protocols across the VA primary care clinic system by analyzing responses from a survey completed by 2,500 clinicians at over 600 locations across the nation. Their results revealed that respondents at high-performing clinics were more likely to report regular team meetings aimed at discussing performance improvement and dedicated leadership responsible for the implementation of PACT best practices. High performance was also associated with fully-staffed PACT teams and clearly defined staff roles.

Overall, healthcare organizations only modestly implemented the recommended patient engagement tactics as results indicated a significantly lowered adoption of motivational interviewing and self-management programming.

“Lower use of these practices may be related to clinicians’ perceptions that some elements of the patient-centered medical home may not be entirely relevant (or may be difficult to use) for particular groups of patients during visits,” the researchers explained.

Organizational Factors

Revealing the importance of organizational elements, the study emphasizes the need to create new patient-centered relationships – that were found most effective for promoting patient engagement among high-performing clinics.

“Team-based care is a key driver of the use of patient engagement care processes and may directly affect patients’ level of engagement,” the study’s authors wrote. “Factors related to patients, team members, and workload may moderate the influence of team-based care on use of patient engagement care processes.”

Clear staffing roles were tied to better adherence to PACT, including motivational interviewing and organizational programming. Team-based huddles were essential for communicating quality improvement data: “Improved team collaboration and coordination are necessary for practices to manage the increasing complexity and unpredictability of clinical care and to become more accountable for patient-centered outcomes,” the authors concluded.

Next Steps

The latest findings emphasize the need to prioritize organizational elements of healthcare practices  and organizations in order to deliver care and achieve optimized patient engagement. Promoting fully-staffed facilities, identifying clearly defined roles of team members, more effective leadership, and a practice culture of performance improvement all may increase the efficacy of patient engagement initiatives and subsequently patient health outcomes.

While the team of researchers continues to examine the specific aspects of the patient-centered medical home model that most effectively improve engagement, the outlined organizational elements can be improved to better the functionality of primary care teams and enhance patient engagement in the medical care process.

PHD3 Loss, Fat Metabolism, and Exercise Endurance

October 1, 2020

Tolerance of exercise and endurance can both decrease with age and declining metabolic health yet physical activity remains a cornerstone of physical and mental health regardless of age. Enzyme systems have received increasing attention for their potential to reduce exercise fatigue and improve endurance by providing the body with access to energy reserves and optimizing their use. Sugars are the primary fuel of cellular processes however, when nutrients are scarce – such as in cases of starvation or extreme exertion – cells switch to breaking down fats for energy. At this time, the mechanisms behind the rewiring of cellular metabolic pathways in response to fluctuations in resource availability are poorly understood.

New research published earlier this month in Cell Metabolism suggests a surprising consequence when one such mechanism is turned off – an increased capacity for endurance exercise. Recently conducted by researchers from the Harvard Medical School, the study revealed that blocking the activity of a fat-regulating enzyme in the muscles of mice could lead to an increased capacity for endurance exercise

Boosting Exercise Endurance in Mice

Led by Marcia Haigis, professor of cell biology at Harvard Medical School, a team of researchers investigated the function of the enzyme prolyl hydroxylase 3 (PHD3) – which they believed played a role in regulating fat metabolism in certain cancers. The study’s authors investigated the impact of PHD3 inhibition in genetically modified mice by carrying out a series of endurance exercise experiments.

Under normal conditions, PHD3 chemically modifies the enzyme ACC2 which prevents fatty acids from entering mitochondria to be broken down into energy. The team of researchers found that blocking PHD3 production in mice resulted in dramatic improvements in fitness measures: mice lacking the PHD3 enzyme ran 40% longer and 50% farther on treadmills and had a higher VO2 max – indicating increased aerobic endurance – than control subjects.

After endurance experiments, the muscles of PHD3-deficient mice revealed heightened rates of fat metabolism and an altered fatty acid composition and metabolic profile. According to the authors, their findings held true in genetically modified mice demonstrating that PHD3 loss in muscle tissues may be sufficient to boost exercise capacity.

PHD3 Enzyme Regulates Metabolic Pathways

After performing a series of molecular analyses to detail precise molecular interactions allowing PHD3 to modify ACC2 and how its activity repressed by AMPK, Haigis and her team reported that PHD3 and AMPK, another enzyme, simultaneously control the activity of ACC2 to regulate fat metabolism depending on energy resource availability.

Their research identified the critical role of the enzyme prolyl hydroxylase 3 (PHD3) in sensing nutrient availability and regulating the ability of muscle cells to metabolize fats, revealing that when nutrients are abundant, PHD3 acts as a brake inhibiting unnecessary fat metabolism that is released during exercise. Whole body or skeletal muscle PHD3 loss enhances acute exercise capacity during endurance exercise experiments.

“The findings shed light on a key mechanism for how cells metabolize fuels and offer clues toward a better understanding of muscle function and fitness,” the authors wrote.

“Understanding this pathway and how our cells metabolize energy and fuels potentially has broad applications in biology, ranging from cancer control to exercise physiology,” senior author Haigis explained. Although, further research is needed to identify whether this pathway can be manipulated in humans to improve muscle function, in the treatment of various diseases, and to better understand how PHD3 inhibition improves exercise capacity.

The latest findings carry implications for a potential novel approach to enhancing exercise performance, treating muscle disorders, as well as developing therapeutic methods for certain cancers in which mutated cells express decreased levels of PHD3. At this time, whether there are any negative effects – including weight loss, blood sugar changes and other metabolic markers – associated with PHD3 loss remains unknown although, this will hopefully be elucidated by future research.