Looking into the Abyss

The mental health implications of infection with COVID-19.

Posted Jan 11, 2021

Woman with migraine
Source: Prostock-studio/Shutterstock

In April 2020, I published a post: “Does Coronavirus Cause Anxiety and Depression?” It was the beginning of the pandemic and not many things were known.  I made my assertions based on what was known about other infectious diseases on the brain and what I could reasonably assume would happen due to the hypoxemia rated to COVID-19. It had over 45,000 views on Psychology Today, which represented my most viewed article.  

Now I am reflecting back on the assumptions and evaluating what was correct and also incorrect. What was wrong: I asserted that time will heal. I was surprised to learn that in many cases, even mild cases of COVID-19, some of the mental health implications linger. Anecdotally, I have friends and patients who continue to have excruciating headaches months after the resolution of the infection. Other patients speak of continued issues with anosmia and chronic fatigue. 

We do not know all we need to know and guessing as to what is to come is like looking into the abyss. What can science tell us? We can make some general inferences such as looking at earlier outbreaks caused by different types of Coronavirus (CoV) (Severe Acute Respiratory Syndrome, SARS and Middle East Respiratory Syndrome, MERS) have produced varied neuropsychiatric manifestations. It is logical to assume that COVID-19 carries the same risk of acute meningoencephalitis, anosmia, manic-depressive disorders, agitation, and delirium.1

There are effects that the trauma from being critically ill may have in terms of development of mental health symptoms. The possibility of post-traumatic stress disorder which may arise after being subjected to the trauma of almost dying.  PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge.2 

In another study of critical care patients, 15 of 45 (33%) of COVID-19 patients who were assessed had a dysexecutive syndrome with symptoms such as inattention, disorientation, or poorly organized movements in response to command.3

In regards to the infection sequelae on the brain, The New York Times wrote an alarming piece about previously symptomatic COVID-19 patients months later who developed very disturbing and unrelenting psychosis which we are only beginning to understand. Case reports show patients who were asymptomatic for COVID-19 physical symptoms but who presented with new-onset psychotic symptoms and who tested positive for COVID-19. The patients had elevated peripheral inflammatory markers, particularly C-reactive protein (CRP), and responded to medical and psychiatric support and modest doses of antipsychotic medication.4

In one study of 402 COVID-19 cases, a significant proportion of patients self-rated in the psychopathological range: 28% for PTSD, 31% for depression, 42% for anxiety, 20% for OC symptoms, and 40% for insomnia. Overall, 56% scored in the pathological range in at least one clinical dimension. 5

There are many factors at play when it comes to the neuropsychiatric complications of COVID-19.  It makes sense that a virus that can enter the brain and cause anosmia can also have mental health implications due to the infection of the central nervous system (CNS).  Also the inflammation caused by the immune response which has been known to cause neuropsychiatric complications in many other infections like Lyme diseases.  Then there are the complications due to hypoxia and their effect on the brain.  The trauma of becoming critically ill in terms of causing depression or PTSD.   Lastly, the complications due to the treatment of the infection like high dosage steroids which has been known to cause depression, mania, and psychosis.

All practitioners need to be aware that COVID-19 might be a risk factor for mental illness. All of these create the abyss in which we are now seeing the neuropsychiatric complications of COVID-19 and creating even more of a reason to avoid getting this disease and a compelling one to get vaccinated as soon as possible.


1 Honigsbaum M. Vol. 30. IB Tauris; 2013. (A History of the Great Influenza Pandemics: Death, Panic and Hysteria, 1830-1920). [Google Scholar]

2 Righy, C., Rosa, R. G., da Silva, R., Kochhann, R., Migliavaca, C. B., Robinson, C. C., Teche, S. P., Teixeira, C., Bozza, F. A., & Falavigna, M. (2019). Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis. Critical care (London, England), 23(1), 213. https://doi.org/10.1186/s13054-019-2489-3

3 61. Helms J, Kremer S, Merdji H. Neurologic features in severe SARS-CoV-2 infection. N Engl J Med. 2020 doi: 10.1056/NEJMc2008597. published online April 15. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

4 Ferrando, S. J., Klepacz, L., Lynch, S., Tavakkoli, M., Dornbush, R., Baharani, R., Smolin, Y., & Bartell, A. (2020). COVID-19 Psychosis: A Potential New Neuropsychiatric Condition Triggered by Novel Coronavirus Infection and the Inflammatory Response?. Psychosomatics, 61(5), 551–555. https://doi.org/10.1016/j.psym.2020.05.012

5 Mazza, M. G., De Lorenzo, R., Conte, C., Poletti, S., Vai, B., Bollettini, I., Melloni, E., Furlan, R., Ciceri, F., Rovere-Querini, P., COVID-19 BioB Outpatient Clinic Study group, & Benedetti, F. (2020). Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain, behavior, and immunity, 89, 594–600. https://doi.org/10.1016/j.bbi.2020.07.037