New-Onset Psychosis Associated With COVID-19

Psychiatric syndromes can occur in people hospitalized for COVID-19.

Posted Aug 05, 2020

Are psychiatric symptoms directly associated with COVID-19? A recent study published in Lancet Psychiatry by Aravinthan Varatharaj and colleagues examined neurological and neuropsychiatric complications of COVID-19 in patients hospitalized in the United Kingdom. These authors established “an online network of secure rapid-response case report notification portals across the spectrum of major UK neuroscience bodies.” Members of professional societies that included physicians specializing in neurology, stroke, psychiatry, and intensive care were able to use this online system to quickly report cases. The authors analyzed data from 125 patients entered into the network between April 3 and April 26, 2020. Infection with SARS-CoV-2, the coronavirus that causes COVID-19, was confirmed in 92% of these patients. The other patients met criteria for probable or possible infection.

Seventy-seven patients (62%) had a cerebrovascular event, predominantly strokes, while 39 (31%) had altered mental status, defined as “an acute alteration in personality, behavior, cognition, or consciousness.” Sixteen of the patients with altered mental status showed clinical signs of encephalopathy (a general term for disease affecting brain function often presenting with confusion), including seven who met the clinical definition of encephalitis (defined as encephalopathy with evidence of inflammation in the central nervous system). However, the majority (59%) of those with altered mental status met clinical definitions for psychiatric diagnoses: ten had new-onset psychosis, six had a neurocognitive (dementia-like) syndrome, and seven had other psychiatric disorder, including mania and catatonia. Only two of these 23 patients experienced exacerbation of previously diagnosed mental illness.

The researchers found age-related differences in the types of symptoms patients had. Interestingly, fewer than 20% of those who experienced strokes were younger than 60, whereas almost half of those with altered mental status were younger than 60. Patients in the 20-to-40-year-old age range with brain-related symptoms mostly presented with neuropsychiatric syndromes.

The goal of this study was to rapidly gather information about the types of brain-related complications occurring in patients hospitalized with COVID-19. Given the study design, the percentages of patients with various syndromes should be considered rough estimates. The authors point out that “confirmation of the link between COVID-19 and new acute psychiatric and neuropsychiatric complications in younger patients will require detailed prospective longitudinal studies.” Nevertheless, the approximations reported in this paper are clinically important. Prior to this study, information about COVID-19-related neurologic and psychiatric syndromes was available only from individual case reports.

It is clear that the virus causing COVID-19 has the ability to cause neuropsychiatric symptoms, and such symptoms are more common than strokes in younger patients. How can a virus trigger psychiatric syndromes? It is presently unclear whether these symptoms/syndromes result from direct effects of the virus or secondary immune or other medical complications of the infection. Do patients experiencing such symptoms have predisposing factors that increase their risks? What treatments alleviate psychotic symptoms in these patients? What is the course of such syndromes — i.e., do psychiatric symptoms decrease in the same time frame as other symptoms of the infection? Are there long-term consequences of having neuropsychiatric symptoms? These are but a few of the questions raised by the provocative data in this study.

This column was written by Eugene Rubin, MD, Ph.D. and Charles Zorumski, MD.

References

Varatharaj, A., Thomas, N., Ellul, M.A., Davies, N.W.S., Pollak, T.A., Tenorio, E.L., Sultan, M., et al. (2020 June 25). Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. Lancet Psychiatry. S2215-0366(20)30287-X.  doi: 10.1016/S2215-0366(20)30287-X. [Online ahead of print.]