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A recent review of over 40 studies and prior pandemics offers useful insights.
COVID-19 came upon the world cloaked in ambiguity—the medical presentation poorly characterized, the expert advice about safety from infection a moving target.
Initially thought to be primarily a respiratory virus, we saw that the novel coronavirus affected other organ systems, causing vascular and clotting problems, resulting in strokes and pulmonary emboli, heart problems, strange skin rashes including the iconic “COVID toes,” suspicious neurological symptoms like sudden loss of sense of smell and taste, and an ability to spread more easily than initially thought.
A crashing wave?
The psychiatric consequences of COVID-19 are similarly emerging. There is concern that we may be facing a “crashing wave of neuropsychiatric” symptoms, according to a paper by Emily Troyer, Jordan Kohn, and Suzi Hong (2020), including brain inflammation, immunological damage to nerve cells, direct infection of the brain, and related factors.
Because COVID-19 virus enters cells via ACE2 receptors, it may affect stress and mood via the “Renin-Angiotensin-Aldosterone System” (RAAS), which regulates blood pressure, electrolyte balance, and other key regulatory systems, along with the more familiar “Hypothalamic-Pituitary-Adrenal” (“HPA Axis”) cortisol/adrenaline stress-response system.
Because there are cardiovascular, blood pressure, and clotting issues with COVID-19, there has been interest in whether medications affecting RAAS such as ACE inhibitor blood pressure and related medications may help manage infection. These same types of medications are possibly effective in depression and anxiety, further suggesting a potential direct biological link between COVID-19 virus and mental health.
Lessons from SARS and MERS
Information about mental health in SARS and MERS is useful, if not directly applicable, due to their similarity with the COVID-19 coronavirus. A recent meta-analysis in Lancet Psychiatry (2020) described psychiatric symptoms in those harbingers. Common symptoms included:
- Confusion (27.9 percent)
- Depressed mood (32.6 percent)
- Anxiety (35.7 percent)
- Memoryproblems (34.1 %)
- Insomnia(41.9 percent)
In the post-infection stage:
- Depressed mood (10.5 percent)
- Insomnia (12.1 percent)
- Anxiety (12.3 percent)
- Irritability (12.8 percent)
- Memory problems (18.9 percent)
- Fatigue (19.3 percent)
A small percentage (0.7 percent) of patients experienced steroid-induced mania and psuchosis, a known adverse reaction to this class of medications.article continues after advertisement
The estimated rate of post-illness PTSD(posttraumatic stress disorder) was 32.2 percent, for depression 14.9 percent, and anxiety disorders 14.8 percent. It took patients on average 35.3 months to return to work.
Learning from these prior infections, and others, helping with what to consider for COVID-19 while anticipating differences.
Early work on neuropsychiatric issues in COVID-19 has shown the presence of strokes (cerebrovascular accidents or “CVAs”) including tiny strokes due to low blood flow, agitation, abnormal reflexes, and related neurological findings, encephalitis (inflammation of the brain), and delirium.
Researchers found that during recovery 33 percent experienced a “dysexecutive” syndrome with symptoms including difficulty with physical coordination, paying attention, and disorientation (2020).
Professionally, I’ve heard multiple anecdotes of people with substantial ongoing problems with personality change and execution function post-COVID, suggesting what urban dictionaries call “COVIDBrain”; a possible post-viral traumatic brain injury and/or chronic infection. Cases of children developing an autoimmune-like syndrome make it easier to imagine unexpected COVID-specific neuropsychiatric effects.
A recent chilling case report from Downstate and Kings County Hospital in Brooklyn presented a patient becoming rapidly suicidalduring the early stage of infection with COVID-19. This 53-year-old man was brought to the Emergency Department after voices commanded him to drink bleach or jump from a bridge, without depression or other psychiatric symptoms.article continues after advertisement
Thankfully, he survived the potentially lethal consequence of drinking bleach. In a short period of time he developed infection symptoms, testing positive. After recovery from COVID-19, the suicidal thoughts did not return. Notably, this was well before Donald Trump’s infamous comments regarding injecting bleach into the human body as a remedy.
It is significant because the “command auditory hallucinations,” as they are called, were the initial presenting symptoms of COVID-19. In spite of tragic high-profile losses, so far we do not appear to be seeing sharp increases in suicide. Hopefully this will not emerge, and vigilance is required given the baseline rising rates of suicide, though the concern is present.
Review of pooled studies
There have been scores of additional studies in the last six months of the pandemic, many published quickly out of the pressing need to share information, without time to plan controlled trials. In order to extract more reliable conclusions from this pool of smaller studies, Nina Vindegaard and Michael Eriksen Benros published a systematic review of the COVID-19 mental health research (2020) in the journal Brain, Behavior, and Immunity.
After reviewing a total of 101 papers, they included 43 of high-enough quality. Two of the studies included patients with definite infections, and the rest were of people indirectly affected. About half the studies were of healthcare workers, and the other half the general public, with two studies of psychiatric patients.
Of the two studies of COVID-19-confirmed cases, the first looked at 714 hospitalized patients and found that over 96 percent had symptoms of posttraumatic stress. Of the 57 patients in early COVID-19 recovery in the second study, almost 30 percent were depressed, compared with 9.8 percent in a similar group in quarantine. Anxiety levels were the same in both groups. For those with prior psychiatric conditions, patients reported worsening of eating disorders, anxiety, and an overall increase in symptoms.
In the majority of papers, healthcare workers showed elevated problems from depression and anxiety, compared to the general public, along with decreased sleep quality. There were no differences found in posttraumatic stress symptoms (about 5 percent). Interestingly, healthcare workers reported lower levels of vicarious trauma than others.article continues after advertisement
Rates of anxiety in healthcare workers were 18.1 percent overall, with 1.8 percent reporting severe anxiety, and for depression 29.5 percent with 8.6 percent reporting moderate or severe depression. The studies did not indicate if suicidal thinking or behavior was present.
For the general public, the data was not as clear. Some studies reported worsening of psychological well-being and increased use of words signaling depression and anxiety on social media. Another study found that parents of children hospitalized with COVID-19 were more anxious than corresponding non-pandemic hospitalization. Other studies showed negative or unclear impact of COVID-19 on mental health, often with lower study quality such as a low fraction of people completing follow-up.
Vindegaard and Benros extracted the following risk factors for psychiatric symptoms:
- Sociodemographic factors, including: living alone, higher and lower educational level, being a student, not having children or have a higher number of children, living in an urban area or a rural area, and inconsistent risk with female gender and unclear impact of age.
- Current/Past medical history, including: current illness including psychiatric and substance use disorders and past medical history.
- Psychological/Social Factors including low self-rated well-being, impaired sleep, higher perceived stress, a history of distressing life events, being unprepared psychologically, low sel-efficacy in helping people with illness, lack of knowledge about COVID-19, failure to use proper precautions, and degree to which everyday life was impacted. Depression and anxiety were higher in those with people close to them with COVID-19, lower family and social support, disrupted income, and greater use of social media about the pandemic.
- Job-related factors associated with increased depression and anxiety risk included working on the frontline, intermediate hospital rank, and over 10 years of professional experience.
- Posttraumatic stress risk was increased with female gender, living near the heaviest impacted areas (e.g. in Hubei province), lower education, and poor perceived sleep quality, though age was not a risk factor.
Time will tell whether and to what extent COVID-19 causes direct neuropsychiatric effects, via what pathways, and to what extent the mental health impact is reflective of general pandemic issues related to fear and stress, uncertainty, loneliness, loss and grieving, and related factors.
Just as the high rate of medical illness burdened the acute care system, leading to the construction of field hospitals to take overflow, lack of adequate supplies, strain on providers, and loss of life, the mental health system is already strained and could be overwhelmed, a concern widely expressed.
The notion of a virus which causes depression, anxiety, and even self-destructive behavior is disturbing. By monitoring closely and planning, there is hope to mitigate the negative impact significantly while also learning for future pandemics and disasters.
In spite of concern about shortages, as is the case in community-wide crises, healthcare systems, community healthcare providers, philanthropic and not-for-profit groups, and the public are rising to the humanitarian challenge as resiliently and effectively as possible.
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