Clinicians Must Be Aware of COVID-19 Patients Possibly Presenting with Neuropsychiatric Disorders Such as Depression, and PTSD Following Recovery (Updated)

UPDATED 5-26-20: See Perspective from Dr. Payal Kohli at the end of the article.

Clinicians should be cognizant of the potential for recovered COVID-19 patients presenting  neuropsychiatric side effects such as depression, anxiety, and post-traumatic stress disorder (PTSD) in the longer term, according to the findings of a new study published in The Lancet Psychiatry.

In this systematic review and meta-analysis, researchers combed MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases from inception until March 18, 2020, as well as medRxiv, bioRxiv, and PsyArXiv between Jan 1, 2020, and April 10, 2020. They focused on studies or preprints that reported on patients with a confirmed diagnosis of SARS coronavirus, MERS coronavirus, or COVID-19 that presented with neuropsychiatric irregularities. The study endpoints were defined as psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment. In total, the investigators included 65 peer-reviewed studies and seven preprints comprised 3,559 coronavirus cases in their analysis.

According to the results of the review, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27.9%; 95% CI 20.5 to 36.0), depression (42 [32.6%; 95% CI, 24.7 to 40.9), anxiety (46 [35.7%; 95% CI, 27.6 to 44.2), impaired memory (44 [34.1%; 26.2 to 42.5] of 129), and insomnia (54 [41.9%; 22.5 to 50.5] of 129).

Regarding COVID-19, the researchers observed evidence of delirium/confusion data for patients with COVID-19 were examined (including preprint data), altered consciousness. Following recovery, the researchers observed that 33% of 45 patients with COVID-19 who were evaluated presented with dysexecutive syndrome in one study. The investigators noted that at the time of writing this analysis, there were two reports of hypoxic encephalopathy and one report of encephalitis in SARS-CoV-2 patients.

[Articles] Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic https://t.co/5yeYj3dv4F pic.twitter.com/mJoIXFDHFW

— Dr Christian Schulz-Quach (he/him) (@Dr_SchulzQuach) May 18, 2020

The authors wrote in conclusion that “although there are many ways in which mental health might be adversely affected by a pandemic, this review suggests, first, that most people do not suffer from a psychiatric disorder following coronavirus infection, and second, that so far there is little to suggest that common neuropsychiatric complications beyond short-term delirium are a feature.”

They added that clinicians “must be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the aftermath. The quality of studies to date has been variable, and ongoing surveillance is essential.”

Perspective from Payal Kohli, MD

Flattening the curve of the medical morbidity and mortality from the pandemic has been effective thus far with the extreme lockdown and social distancing measures we have enacted.  But, as Americans contract and recover from the virus and we start to transition back to “normal” life again, we will have to consider the long-term psychological impact the past several weeks have had.  This includes those who directly contract the virus, the healthcare workers who have cared for them as well was the others in society.

This systematic review and meta-analysis is key in highlighting that the virus itself can result in short-term delirium and also raises the possibility that there may be rarer neuropsychiatric syndromes in the aftermath.  Studies have shown that direct neuronal inflammation may be responsible for the anosmia and aguesia that has been observed as a presenting symptom in this infection.  It remains to be seen whether such inflammation could also result in neuropsychiatric symptoms.   Additional longer term follow-up will be necessary to see whether late-presenting neuropsychiatric effects may emerge in the aftermath of this virus.

With respect to healthcare workers who have cared for patients with COVID-19, data is more limited.  From studies of 2003 SARS epidemic, it has been reported that moderate to severe depression occurs in 23% of hospital employees three years later, with all combine all mental health issues occurring in up to 33% of hospital employees.  The anticipated burden of the COVID-19 epidemic is expected to be at least as much, if not greater.

For those not infected by the virus directly or those caring for the infected, the social distancing has been certainly shown to impose a psychological toll with a growing incidence of loneliness, substance abuse and related mental health concerns, such as anxiety and depression.

To truly understand the psychological impact of this pandemic, the totality of the mental health fallout must be considered.

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Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic https://t.co/bBefDNdgyF

— Kelly A. Hogan Ph.D. (@Loose_Lab_Rat) May 19, 2020

Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic – The Lancet Psychiatry https://t.co/3dh7juaHXh

— Prof Marios Adamou OBE (@DrMariosAdamou) May 20, 2020