COVID-19 and psychosis risk: Real or delusional concern?

[Interaction of somatic findings and psychiatric symptoms in COVID-19. A scoping review]

An infection with SARS-CoV‑2 can affect the central nervous system, leading to neurological as well as psychiatric symptoms. In this respect, mechanisms of inflammation seem to be of much greater importance than the virus itself. This paper deals with the possible contributions of organic changes to psychiatric symptomatology and deals especially with delirium, cognitive symptoms, depression, anxiety, posttraumatic stress disorder and psychosis. Processes of neuroinflammation with infection of capillary endothelial cells and activation of microglia and astrocytes releasing high amounts of cytokines seem to be of key importance in all kinds of disturbances. They can lead to damage in grey and white matter, impairment of cerebral metabolism and loss of connectivity. Such neuroimmunological processes have been described as a organic basis for many psychiatric disorders, as affective disorders, psychoses and dementia. As the activation of the glia cells can persist for a long time after the offending agent has been cleared, this can contribute to long term sequalae of the infection.

Psychosis secondary to COVID-19 in pediatric sickle cell disease

Key Clinical Message

COVID-19 psychosis is a potential long-term sequela of COVID-19. Vulnerable populations, such as individuals with sickle cell disease, are at high risk for psychosis. Given the limited number of cases, more investigations in the etiopathology and management of this new disease is needed.

Abstract

We report a case of a 15-year-old female with a past medical history of depression who developed psychosis post-SARS-CoV-2 infection (COVID-19). After an initial moderate COVID-19 infection, the patient appeared to recover and was discharged home. Four weeks later, she presented with symptoms of psychosis and symptoms of cognitive impairment. Imaging studies did not show any evidence of stroke and toxicology studies were negative. She was treated with antipsychotics and required inpatient neuropsychiatric rehabilitation. Acute psychotic syndrome resolved after 3 weeks, antipsychotics were weaned, and an antidepressant was initiated. Mild cognitive impairment with significant memory loss persisted for about 1 year. Thereafter, she returned to her baseline but remains on an antidepressant. Some studies have previously reported the occurrence of psychosis in individuals with COVID-19. This report is the first outline of severe prolonged post-COVID-19 psychosis in a child with sickle cell disease. Given the neurologic vulnerability of children with sickle cell disease, these individuals should be monitored for neuropsychiatric symptoms post COVID-19.

The role of sense of coherence in workplace violence directed at nurses in the shadow of COVID-19: A cross-sectional study

AIMS

To explore (a) the associations between sense of coherence (SOC), previous exposure to COVID-19, and the intention to act violently towards nurses, and (b) the role of SOC and sociodemographic variables as risk or protective factors involved in the intention to act violently.

DESIGN

A cross-sectional study with a convenience sample.

METHODS

A structured self-report questionnaire was distributed from February to March 2022. The questionnaire included socioeconomic variables, previous exposure to COVID-19, and a validated questionnaire on SOC. Three vignettes (online shaming, verbal and physical violence) describing nurse-patient communication conflicts were presented to participants. A multinomial logistic regression was conducted to explore the associations with acting violently by comparing three options of no/sometimes/high intention to act violently. The study adhered to STROBE guidelines.

RESULTS

Questionnaires were completed by 808 adults. SOC and religiosity were revealed as protective factors in the three vignettes. Verbal violent behaviour was found to be a risk factor for online and physical violent behaviour intention. Previous exposure to COVID-19, non-academic education, and ethnicity were found to be risk factors for the intention to behave violently toward nurses.

CONCLUSION

The findings suggest that training nurses in practical SOC dimensions (enhancing comprehensible, manageable and meaningful treatment processes) may reduce patients' lack of understanding and frustration and, in turn, reduce the tendency to behave violently.

IMPACT

This study focused on SOC as a variable that may affect the intention to act violently towards nurses. The results reveal that SOC may be a protective factor, where people with higher SOC will have less intention to behave violently towards nurses. The results can provide an insight for nurses, nurse leaders and policymakers, towards supplying coherent and cultural competency treatment processes for patients and assisting nurses in dealing with stressful situations during normal routines and pandemics.

PATIENT OR PUBLIC CONTRIBUTION

The questionnaire was distributed among the general public by master's degree nursing students. The students distributed the questionnaires among their friends and acquaintances using a snowball-sampling approach.

Progressive Neuropsychiatric Symptoms Following Recurrent COVID-19 Infections in a Previously Healthy Adolescent

This is the almost 2-year-long course of a 16-year-old male without significant psychiatry history who abruptly developed symptoms of obsessive-compulsive disorder (OCD) and psychosis following a confirmed coronavirus disease 2019 (COVID-19) infection. His symptoms worsened following a confirmed reinfection with COVID-19. He responded poorly to treatment with selective serotonin reuptake inhibitors, antipsychotics, and benzodiazepines. This case highlights an emerging phenomenon of post-COVID-19 neuropsychiatric sequelae and presents a complicated diagnostic and treatment challenge. The differential for this patient was explored and outlined in detail, and the medical workup recommendations for new-onset mental status changes were reviewed as they pertain to the patient's assessment and treatment course. While there are several case reports of adolescents with abrupt-onset OCD and psychosis symptoms following COVID-19 infections, none of these reports include worsening of symptoms following reinfection, and few reports follow patients beyond initial hospitalization and treatment.

Neurological manifestations of COVID-19 in adults and children

Different neurological manifestations of coronavirus disease 2019 (COVID-19) in adults and children and their impact have not been well characterized. We aimed to determine the prevalence of neurological manifestations and in-hospital complications among hospitalized COVID-19 patients and ascertain differences between adults and children. We conducted a prospective multicentre observational study using the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) cohort across 1507 sites worldwide from 30 January 2020 to 25 May 2021. Analyses of neurological manifestations and neurological complications considered unadjusted prevalence estimates for predefined patient subgroups, and adjusted estimates as a function of patient age and time of hospitalization using generalized linear models. Overall, 161 239 patients (158 267 adults; 2972 children) hospitalized with COVID-19 and assessed for neurological manifestations and complications were included. In adults and children, the most frequent neurological manifestations at admission were fatigue (adults: 37.4%; children: 20.4%), altered consciousness (20.9%; 6.8%), myalgia (16.9%; 7.6%), dysgeusia (7.4%; 1.9%), anosmia (6.0%; 2.2%) and seizure (1.1%; 5.2%). In adults, the most frequent in-hospital neurological complications were stroke (1.5%), seizure (1%) and CNS infection (0.2%). Each occurred more frequently in intensive care unit (ICU) than in non-ICU patients. In children, seizure was the only neurological complication to occur more frequently in ICU versus non-ICU (7.1% versus 2.3%, P < 0.001). Stroke prevalence increased with increasing age, while CNS infection and seizure steadily decreased with age. There was a dramatic decrease in stroke over time during the pandemic. Hypertension, chronic neurological disease and the use of extracorporeal membrane oxygenation were associated with increased risk of stroke. Altered consciousness was associated with CNS infection, seizure and stroke. All in-hospital neurological complications were associated with increased odds of death. The likelihood of death rose with increasing age, especially after 25 years of age. In conclusion, adults and children have different neurological manifestations and in-hospital complications associated with COVID-19. Stroke risk increased with increasing age, while CNS infection and seizure risk decreased with age.

First episode psychosis during the Covid-19 pandemic in Milan, Italy: Diagnostic outcomes at 1-year follow-up

An influence of the Covid-19 pandemic on First Episode Psychosis (FEP) has been hypothesized. We previously reported an increase of FEP during the early stages of the pandemic in Milan, Italy. Here we report a 1-year follow-up of the same cohort and comparison with a FEP cohort from 2019. The higher proportion of non-chronic psychoses observed during the pandemic (58.62% in 2020 vs 43,75% in 2019) should be confirmed in larger cohorts over a longer follow-up period.

New-Onset Hyperreligiosity, Demonic Hallucinations, and Apocalyptic Delusions following COVID-19 Infection

Background

Neuropsychiatric sequelae of COVID-19 have been documented, including delusions, hallucinations, agitation, and disorganized behavior. Although the mechanisms for these symptoms remain unclear, there has been an increasing body of literature suggesting a correlation between COVID-19 infection and psychosis. Here, we illustrate the case of a 34-year-old female with no previous psychiatric history who contracted COVID-19 and subsequently developed severe symptoms of psychosis. After presenting to the emergency department with one month of worsening mood, auditory hallucinations, intrusive thoughts, and hyperreligiosity, she was admitted to the inpatient psychiatric unit. The patient was treated with multiple antipsychotic medications and was discharged in stable condition with resolution of her auditory hallucinations; however, her delusions, hyperreligiosity, and negative psychotic symptoms persisted, resulting in a second inpatient psychiatric admission eight days after discharge, during which she again did not reach full remission.

Objectives

With this information, we hope to increase awareness of COVID-induced psychosis and further discuss the relationship between COVID-19 infection and neuropsychiatric symptoms.

Conclusions

Although there has been increasing research about the COVID-19 pandemic, there is much to be elucidated regarding the neuropsychiatric symptoms related to these infections. Similar to previous studies, our case describes a patient with no previous psychiatric history who developed severe psychotic symptoms after COVID-19 infection and was admitted to the inpatient psychiatric unit. These symptoms resulting from infection can be severe or debilitating for the patient. Therefore, physicians should be aware of these potential neuropsychiatric sequelae when treating patients with active COVID-19 infections, and treatment with antipsychotics or acute inpatient psychiatric admission should be considered.

Schizophrenia as metabolic disease. What are the causes?

Schizophrenia (SZ) is a devastating neurodevelopmental disease with an accelerated ageing feature. The criteria of metabolic disease firmly fit with those of schizophrenia. Disturbances in energy and mitochondria are at the core of complex pathology. Genetic and environmental interaction creates changes in redox, inflammation, and apoptosis. All the factors behind schizophrenia interact in a cycle where it is difficult to discriminate between the cause and the effect. New technology and advances in the multi-dispensary fields could break this cycle in the future.

COVID-19 and New-Onset Psychosis: A Comprehensive Review

Psychosis is a multifactorial condition that typically involves delusions, hallucinations, and disorganized thought, speech or behavior. The observation of an association between infectious epidemics and acute psychosis dates back to the last century. Recently, concerns have been expressed regarding COVID-19 and the risk for the development of new-onset psychosis. This article reviewed the current evidence of a possible link between SARS-CoV-2 and risk of psychosis as an acute or post-infectious manifestation of COVID-19. We here discuss potential neurobiological and environmental factors as well as a number of challenges in ascribing a causal pathogenic relationship between SARS-CoV-2 infection and new-onset psychosis.

First-episode psychotic disorders in the wake of the COVID-19 pandemic: a descriptive review of casereports

OBJECTIVE

Since the onset of COVID-19 pandemic, many case reports and case series dealt with new-onset psychotic disorders in patients either infected with SARS-CoV-2 or thematically linked to the pandemic, but without an infection. Our aim was to provide a comprehensive collection of these reports to illustrate the nature of these psychoses.

METHODS

We conducted a literature search in MEDLINE, Embase, PsycINFO, using search terms regarding first-episode psychotic disorders in the context of corona.

RESULTS

96 case reports or case series covering 146 patients (62 without and 84 with SARS-CoV-2 infection) were found. Compared to patients without infection, patients with infection showed significantly more often visual hallucinations (28.6% vs 8.1%), confusion (36.9% vs 11.3%), an acute onset of illness (88.5% vs 59.6%) and less often depression (13.1% vs 35.5%) and a delusional content related to the pandemic (29.5% vs 78.3%). Both groups had an equally favourable outcome with a duration of psychosis ≤2 weeks in half and full remission in two-thirds of patients. In patients with infection, signs of inflammation were reported in 78.3% and increased CRP in 58.6%. While reports on patients with infection are continuously published, no report about patients without infection was found after July 2020.

CONCLUSION

Cases without infection were considered reactive and originated all from the first wave of the corona pandemic. In cases with infection, inflammation was considered as the main pathogenetic factor but was not found in all patients. Diagnosis was impeded by the overlap of psychosis with delirium.

New-onset psychosis following COVID-19 infection in a patient with no psychiatric history: A longitudinal case report

Background

Viral infection, including COVID-19, has been implicated as a potential cause of various neurobehavioral issues. An increasing number of case reports suggest that current or recent COVID-19 infection may cause new onset of psychotic symptoms in some individuals, potentially related to viral inflammation or infection of the nervous system.

Case presentation

A 26-year-old woman with no psychiatric history presented with severe psychotic symptoms days after recovery from a mild COVID-19 infection. No other etiologies for psychosis were identified via diagnostic testing, review of medical history, or interviews with family. Her symptoms persisted for approximately two months, requiring three inpatient admissions, various medication trials, and ongoing outpatient follow-up. With continued use of quetiapine and lithium, she returned to living independently and working full-time, and discontinued all medication approximately nine months after symptom onset.

Conclusion

The psychiatric and cognitive effects of COVID-19 infection are not yet fully understood. Given the widespread and ongoing nature of this pandemic, this remains an important focus of further investigation, especially within the context of potential long-term complications.

Cardiovascular, Pulmonary, and Neuropsychiatric Short- and Long-Term Complications of COVID-19

Beginning with the various strategies of the SARS-CoV-2 virus to invade our bodies and manifest infection, and ending with the recent long COVID, we are witnessing the evolving course of the disease in addition to the pandemic. Given the partially controlled course of the COVID-19 pandemic, the greatest challenge currently lies in managing the short- and long-term complications of COVID-19. We have assembled current knowledge of the broad spectrum of cardiovascular, pulmonary, and neuropsychiatric sequelae following SARS-CoV-2 infection to understand how these clinical manifestations collectively lead to a severe form of the disease. The ultimate goal would be to better understand these complications and find ways to prevent clinical deterioration.

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

Covid-19, not your normal flu: A case report on Covid-19 psychosis and mania in a Malaysian hospital

Evidence suggests that acute severe coronavirus disease 2019 (COVID-19) may be associated with neuropsychiatric symptoms. This is a case report of a patient who had recently been infected with COVID-19 and had no history of psychiatric disorders presenting a few days after inpatient discharge from COVID-19 treatment with acute onset of psychosis and manic symptoms. This case illustrates the psychiatric presentation, possible causes, and management of post-COVID-19 psychosis.

COVID-19-induced psychosis: two case reports and narrative literature review

Introduction: SARS-CoV-2 infection might be presented in many various specific and non-specific manifest and symptoms from different systems. Also, the psychotic symptoms are documented but the explanation for their pathophysiology remains debatable and a complex matter. The main objective of this paper is to present cases of patients without a history of psychiatric disorders who developed the first episode of psychosis during the SARS-CoV-2 infection.

Material and methods: Two cases of not-related patients with no previous psychiatric history developed psychotic episodes during COVID-19 infection. In both cases chronologically first they experienced symptoms of infection, secondly, delusions and psychomotor agitation that required psychiatric hospitalization. Full remission was observed after antipsychotic treatment in both cases.

Results: Even though the pathophysiology of the post-COVID-19 psychiatric symptoms remains unclear, some reports that indicate associations between the infection and the onset of such symptoms. The infection itself, by the induction of cytokine storm followed by the excessive release of pro-inflammatory cytokines, is considered to stimulate the potential onset of the psychosis, however, other factors such as medications used during treatment (with a particular emphasis on glucocorticosteroids) or psychological factors should be considered as well.

Conclusions: Patients infected with SARS-CoV-2 might develop serious psychotic episodes even without a prior psychiatric history. Besides, psychiatric symptoms might be the first the even the only manifestations associated with the active SARSCoV-2 infection which seems to be very challenging especially in cases of rapid psychotic episodes without any clear respiratory symptoms.

The Trilemma of Today’s Aging Population in the Time of Pandemic: A Case Study of Pre-existing Psychiatric Illness and Cognitive Deficits, COVID-19, and Further Cognitive Decline

Care for geriatric patients can be difficult due to the complex nature of age-related comorbidities, multiple medications, and cognitive decline; this hardship multiplies when psychiatric illness or dementia are present and often exacerbates existing issues. Millions of lives have been lost in the COVID pandemic, and it has also severely harmed our collective mental health and cognition. The elderly population has felt that this impact the greatest as they are at the highest risk of isolation, cognitive inactivity, loneliness, and depression, all of which are risk factors for dementia. Studies associate loneliness with a 40% increase in the risk of dementia; thus, this pandemic and resulting isolation have likely caused an increase in cognition loss of the elderly. Furthermore, there is a documented bidirectional relationship between COVID-19 and psychiatric illness, both of which increase the likelihood of the other and are associated with worsening mental cognition. We present a case series of two patients with pre-existing psychiatric illness and cognitive decline, both exacerbated by COVID-19 infection, causing further decline in cognition.

Psychosis during the COVID-19 pandemic: A systematic review of case reports and case series

BACKGROUND

Preliminary data suggest that patients with COVID-19 may experience psychiatric symptoms, including psychosis. We systematically reviewed the literature to evaluate the concurrence of new-onset psychosis or exacerbation of clinically stable psychosis through case reports and case series.

METHODS

Six databases were searched, followed by an electronic and manual search of the relevant articles. Studies were identified using predetermined eligibility criteria. We evaluated the demographic characteristics, clinical history, course of illness, management, and prognosis of the patients in these studies.

RESULTS

Case reports and case series, altogether consisting of 57 unique cases were included. The mean patient age for onset of psychotic symptoms was 43.4 years for men and 40.3 years for women. About 69% of patients had no prior history of psychiatric disorders. Most patients had mild COVID-19-related symptoms, with only 15 (26.3%) presenting with moderate to severe COVID-19-related disease and complications. The most commonly reported psychotic symptoms were delusions and hallucinations. Patients with psychotic symptoms were treated with antipsychotics, benzodiazepines, valproic acid, and electroconvulsive treatment. In 36 cases, psychotic symptoms resolved completely or improved significantly. Ten cases had partial improvement with residual psychotic symptoms, and one patient died due to cardiac arrest.

CONCLUSION

Most patients responded to a low-to-moderate dose of antipsychotics with a quick recovery. However, the residual psychiatric symptoms highlight the need for careful monitoring and longer follow-up. Clinicians should be mindful of the occurrence of psychosis due to COVID-19 infection in a subset of COVID-19 patients that can be misdiagnosed as a psychotic disorder alone.

Post COVID-19 Infection Psychosis: Could SARS-CoV-2 Virus Infection Be a Neuropsychiatric Condition That Triggers Psychotic Disorders? - A Case-Based Short Review

Corona virus (COVID-19) is an epidemy of respiratory disease caused by a novel corona virus and it was declared by the World Health Organization (WHO) to be a global health pandemic emergency. Due to the neuropsychiatric manifestation of Covid-19 that have been associated with psychotic disorders, in this paper we choose to present a case from “Elena Doamna” Psychiatric Hospital from Galati, Romania and to correlate it with other cases from literature in a mini review presentation. In our paper, we present the case of a patient of 44-year-old men, with no past psychiatric history whose behavior included psycho-motor agitation, perception and thinking disorders, disorganized behaviour, attempted suicide by stabbing. The last perspectives from the two years of pandemic together with psychiatric disease linked the virus infections with psychosis to the main concern that Covid-19 could determine psychiatric disorders. There were also presented same literature studies of patients with no personal pathological history in the psychiatric field which developed psychiatric disorders after COVID-19 infection. SARS-CoV-2 has a psychological impact on the mental health status of the worldwide and, especially when it is associated with psychotic symptoms and can affect the quality-of-life. In some cases, the virus affected the brain and as a result, the psychosis symptoms could be an emerging phenomenon associated with the corona virus. Based on the DSM V and ICD-10 criteria, the diagnosis was of acute psychiatric disorders with symptoms of schizophrenia (F23.1). The case report and review reliefs that there is a causal link between the SARS CoV-2 infection and mental disorders, which is currently being investigated.

Acute and chronic neuropsychiatric symptoms in novel coronavirus disease 2019 (COVID-19) patients: A qualitative review

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a global pandemic by the World Health Organization (WHO) on March 11th, 2020. It has had unprecedented adverse effects on healthcare systems, economies, and societies globally. SARS-CoV-2 is not only a threat to physical health but has also been shown to have a severe impact on neuropsychiatric health. Many studies and case reports across countries have demonstrated insomnia, depressed mood, anxiety, post-traumatic stress disorder (PTSD), and cognitive change in COVID-19 patients during the acute phase of the infection, as well as in apparently recovered COVID-19 patients. The goal of this narrative review is to synthesize and summarize the emerging literature detailing the neuropsychiatric manifestations of COVID-19 with special emphasis on the long-term implications of COVID-19.

Analysis of COVID-19-related psychiatric disorders: clinical manifestations and therapeutic considerations

During the COVID-19 pandemic, neuropsychiatric disorders have been diagnosed both in the acute phase, and in the aftermath of this disease. Inpatients, as well as outpatients recently diagnosed with mild, moderate or severe forms of Coronavirus infection have reported neuropsychiatric manifestations with variable duration, symptoms that could be directly or indirectly related to the viral pathogenic agent. Patients who are recovering from the acute phase of COVID-19 also may exhibit various psychopathological manifestations, during the so-called “post-COVID-19 syndrome” or “long COVID-19 syndrome”. Explanations regarding the onset of this type of clinical manifestations and the SARS-CoV-2 infection are extremely diverse, ranging from biological factors (e.g., direct central nervous system viral activity, cerebral hypo-oxygenation, high level of inflammatory response) to psycho-social stressors (e.g., isolation, fear of death, anxiety related to possible somatic complications or sequelae). Objectives: The primary objective of this article was to analyze psychiatric manifestations in patients with acute COVID-19 disease and in patients during post-COVID-19 phase. The secondary objective was to propose a conceptual framework for the evaluation and treatment of these patients. Methods: Patients included in this analysis were screened positive for COVID-19 infection in the last 6 months before their first psychiatric examination. These patients were further evaluated to detect any personal history of psychiatric disorders, somatic comorbidities, or significant concomitant pharmacological treatments. Specific scales for the measurement of symptoms severity and functional impairment were administered in all patients. Results: Five patients were included in this analysis, one during the acute phase of COVID-19 infection, and four patients were evaluated after the complete remission of this disease. Hyperactive delirium, mild neurocognitive disorder, major depressive episode, panic disorder with agoraphobia, or acute psychotic disorder were the main diagnoses in these patients. All patients received adequate treatment and they were monitored using psychological scales until symptoms remission or stabilisation. Conclusions: Psychosocial stressors, neurobiological changes, systemic inflammatory reaction, and individual vulnerability factors may contribute to a diathesis-stress model for psychiatric disorders onset within the acute phase or after the remission of acute manifestations in COVID-19-diagnosed patients

Providing Home Treatment for Acute Mental Illness During the COVID-19 Pandemic

The Intensive Home Treatment Team in Edinburgh provides care at home for those with acute and severe mental health problems. During the first COVID-19 lockdown, the team conducted and evaluated video and telephone calls but also continued seeing most patients face to face to ensure adequate care. The in-person care was achieved safely, without an increase in staff sickness events. During the lockdown, the team observed more cases of psychosis, particularly acute and transient psychosis and first-episode psychosis, particularly among women.

The potential impact of Covid-19 on CNS and psychiatric sequels

Due to its high prevalence and fatality, the current Severe Acute Respiratory Syndrome-coronavirus-2 (SARS-CoV-2) virus, which first emerged in China in 2019, quickly spread around the world and immediately became a serious global health concern. Although respiratory issues were initially the most prominent symptom of coronavirus disease 2019 (COVID-19), it became obvious rapidly that COVID-19, like many other coronavirus family members, could affect the central nervous system (CNS). During the pandemic, CNS involvement expressed itself in a variety of forms, including insomnia, anosmia, headaches, encephalopathies, encephalitis, cerebrovascular accidents, cognitive and memory impairment, and increased psychiatric disorders. Almost everyone who has been infected has at least one of these neurological symptoms, demonstrating that the virus has a high ability to impact the CNS. As the coronavirus pandemic passes its second year, the manifestations it can cause in the long run, such as its psychological sequels, have not yet been thoroughly studied. Given the high importance of this issue in today's society and due to the lack of reliable knowledge about the COVID-19 landscape on psychiatric disorders, we intend to investigate coronavirus's possible effect on mental illnesses based on available literature. Because the majority of the psychological effects of the coronavirus can continue for a long period after the pandemic ends, our research can give insight into potential psychiatric sequels associated with COVID-19.

SARS-CoV-2 and neurodegenerative diseases: what we know and what we don’t

Infection of the CNS with the SARS-CoV-2 can occur via different routes and results in para- or post-infectious manifestations with a variety of neurological symptoms. In patients with neurodegenerative diseases, SARS-CoV-2 is often associated with a higher fatality rate, which is a relevant problem in increasingly older populations. Apart from the direct consequences of an infection in patients with neurodegenerative diseases, indirect consequences of the pandemic such as limited access to care facilities and treatment have negative effects on the course of these chronic disorders. The occurrence of long-lasting neurological symptoms after infection with SARS-CoV-2 indicates a prolonged impact on the CNS. However, while it is known that SARS-CoV-2 affects neuronal populations that are relevant in the pathogenesis of neurodegenerative diseases, it is yet unclear whether an infection with SARS-CoV-2 is sufficient to trigger neurodegeneration. Reflecting on the impact of SARS-CoV-2 on neurodegeneration, we provide a concise overview on the current knowledge of SARS-CoV-2-induced pathology in the CNS and discuss yet open questions in the field.

New-Onset Mania and Psychosis in Adolescents in the Context of COVID-19 Infection

There is a growing body of evidence that coronavirus disease 2019 (COVID-19) is linked with neuropsychiatric complications such as psychosis and delirium in adults. Much less is known about the neuropsychiatric manifestations of this virus in the child and adolescent population. This case series discusses two unique adolescent patients who presented with new-onset mania and psychosis in the context of an otherwise asymptomatic COVID-19 infection, which raises several questions about whether and how the virus precipitates mania and psychosis, whether these symptoms are transient or predisposes patients to a chronic psychiatric disorder, and confounding variables that may have contributed to the symptoms. These questions can then be points for future research and longitudinal follow-up that can better improve our knowledge about the relationship between this complicated virus and how it affects children psychiatrically.

The Impact of the COVID-19 Virus Pandemic on the Incidence of First Psychotic Spectrum Disorders

The effects of COVID-19 on the human body are not yet understood enough. Medical history provides information on cases of psychiatric symptoms during viral infections in the 20th century, such as the influenza pandemic. Currently, it is observed that there is an increasing number of new psychiatric disorders in previously healthy individuals. In addition, because of the decreased amount of reporting to health care providers, including psychiatrists, many physicians suggest that the number of neuropsychiatric disorders may be underestimated. In this paper, we review available studies on the occurrence of first-time psychotic spectrum disorder (PSD) in individuals related to SARS-CoV-2 infection. The reviewed studies suggest that first-time psychotic disorder in COVID-19 patients is statistically significantly more frequent compared to influenza, as well as to other respiratory infections. The emergence of new PSDs is explained by direct neurotropism of the virus on the one hand and by immunological mechanisms on the other. The main conclusions of this review should be treated with caution, and future research on this topic is needed. The authors recognize the particular need to develop standardized laboratory panels that include inflammatory markers (IL-6, TNF-α), cerebrospinal fluid (CSF) testing, and SARS-CoV-2 antibody assays to entirely understand the etiology of neuropsychiatric complications of SARS-CoV-2 infections and the pandemic itself. In addition, public health efforts are required to promote mental health, especially during COVID-19.

Correlates of psychotic like experiences (PLEs) during Pandemic: An online study investigating a possible link between the SARS-CoV-2 infection and PLEs among adolescents

BACKGROUND

This study investigated whether SARS-CoV-2 infection, depression, anxiety, sleep problems, cigarette, alcohol, drug usage contribute to psychotic-like experiences (PLEs) among adolescents during the pandemic. We also aimed to explore whether baseline inflammatory markers or the number of SARS-CoV-2-related symptoms are associated with PLEs, and the latter is mediated by internalizing symptoms.

METHODS

Altogether, 684 adolescents aged 12-18 (SARS-CoV-2 group n = 361, control group (CG) n = 323) were recruited. The Community Assessment of Psychic Experiences-42-Positive Dimension (CAPE-Pos), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Pittsburg Sleep Quality Index (PSQI) questionnaires were completed by all volunteers using an online survey. C-reactive Protein and hemogram values, and SARS-CoV-2-related symptoms during the acute infection period were recorded in the SARS-CoV-2 group. Group comparisons, correlations, logistic regression, and bootstrapped mediation analyses were performed.

RESULTS

CAPE-Pos-Frequency/Stress scores were significantly higher, whereas GAD-7-Total and PSQI-Total scores were significantly lower in SARS-CoV-2 than CG. Among the SARS-CoV-2 group, monocyte count and the number of SARS-CoV-2-symptoms were positively correlated with CAPE-Pos-Frequency/Stress scores. Besides SARS-CoV-2, cigarette use, GAD-7, and PHQ-9 scores significantly contributed to the presence of at least one CAPE-Pos "often" or "almost always". PHQ-9 and GAD-7 fully mediated the relationship between the number of SARS-CoV-2 symptoms and CAPE-Pos-Frequency.

CONCLUSIONS

This study is the first to show a possible relationship between SARS-CoV-2 infection and PLEs among adolescents. Depression, anxiety, and cigarette use also contributed to PLEs. The number of SARS-Cov-2-symptoms and PLEs association was fully mediated by internalizing symptoms, but prospective studies will need to confirm this result.

Emerging Knowledge of the Neurobiology of COVID-19

Many patients with COVID-19 will experience acute or longer-term neuropsychiatric complications. The neurobiological mechanisms behind these are beginning to emerge; however, the neurotropic hypothesis is not strongly supported by clinical data. The inflammatory response to SARS-CoV-2 is likely to be responsible for delirium and other common acute neuropsychiatric manifestations. Vascular abnormalities such as endotheliopathies contribute to stroke and cerebral microbleeds, with their attendant neuropsychiatric sequelae. Longer-term neuropsychiatric syndromes fall into 2 broad categories: neuropsychiatric deficits occurring after severe (hospitalized) COVID-19 and "long COVID," which occurs in many patients with a milder acute COVID-19 illness.

Significant cognitive impairment likely associated with COVID-19 infection with relatively nonsevere symptoms

COVID-19 infection may involve the nervous system and has been associated with a number of neuropsychiatric complications, including impairment of cognition and dementia. Such complications are more likely to occur in (but are not limited to) patients with severe COVID-19 infections and those with concomitant risk factors. In this case report, the authors describe a normally functioning 51-year-old woman who developed cognitive impairment of a degree that rendered her unable to care for herself most likely related to a relatively nonsevere infection with COVID-19 about 2 months earlier. A detailed report of her deficits of different areas of cognitive functioning is provided. This report aims to make clinicians more aware of the potential for cognitive impairment in patients who have suffered from COVID-19, including those with infections that were not severe.

Possible autoimmune pediatric encephalitis following COVID-19 infection with focal cerebral dysfunction in a young female: A case report

Introduction

Case presentation

Conclusion

The Use of Electroconvulsive Therapy in Neuropsychiatric Complications of Coronavirus Disease 2019: A Systematic Literature Review and Case Report

BACKGROUND

There is a significant prevalence of new onset neuropsychiatric symptoms (NPS), some severe and persistent, in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE

This study reports on the use of electroconvulsive therapy (ECT) to treat NPS associated with COVID-19.

METHODS

A review of the literature pertaining to the use of ECT in patients with COVID-19 and NPS was performed through PubMed, PsycINFO, and MEDLINE. Search terms included "Electroconvulsive Therapy" and "ECT," combined with "COVID-19" and "Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2)." In addition, we present a case in which ECT was used to achieve complete remission in a patient who developed new onset, treatment-resistant depression, psychosis, and catatonia, associated with COVID-19.

RESULTS

A total of 67 articles were reviewed with 3 selected for inclusion. These articles detailed 3 case reports of patients with new onset NPS (mania, psychosis and suicidality, and catatonia) that developed in the context of active COVID-19 and were treated successfully with ECT.

CONCLUSIONS

ECT, a broad-spectrum treatment that has been found to be effective in various NPS (independent of etiology), is shown in our case report and others, to be safe and effective for NPS associated with COVID-19. Although we identified only 3 other cases in the literature, we believe that the probable antiinflammatory mechanism of ECT, its safety and tolerability, and the faster time to symptom remission support the need for more research and increased clinician awareness about this life-saving procedure.

COVID-19: long-term health impacts

Several studies have recently been conducted showing persistent COVID-19 symptoms in patients recovering after the acute phase of the disease. Energy imbalance plays a leading role in the pathogenesis of post-COVID syndrome. The choice of a metabolic cytoprotection drug with anti-asthenic activity will be decisive for the further tactics of managing the patient not only in the hospital, but also during the entire further period of recovery after the infection.

COVID-19 Infection and Psychotic Experiences: Findings From the Healthy Minds Study 2020

Background

Clinical reports from across the world have documented psychosis in the context of COVID-19 infection; however, there has yet to be a large-scale epidemiological study to confirm this association.

Methods

We analyzed data from the Healthy Minds Study (N = 15,935; conducted between September and December 2020), which was administered online to students attending one of 28 colleges in the United States. Using multivariable logistic regression, we examined the associations between COVID-19 infection/severity and psychotic experiences over the past 12 months, adjusting for age, gender, race/ethnicity, and international student status as well as anxiety and depression.

Results

More than one fifth of the analytic sample reported COVID-19 infection, and about one in six students with COVID-19 infection reported psychotic experiences over the past 12 months. In weighted multivariable logistic regression models, COVID-19 infection was associated with significantly greater odds of having psychotic experiences (adjusted odds ratio 1.36, 95% CI 1.19–1.48). Compared with being asymptomatic, having moderate (adjusted odds ratio 1.85, 95% CI 1.03–3.31) or severe (adjusted odds ratio 1.76, 95% CI 1.11–2.77) symptoms was associated with significantly greater odds of having psychotic experiences. These associations became statistically nonsignificant when adjusting for depression and anxiety. Hospitalization was not significantly associated with psychotic experiences among students with COVID-19 infection.

Conclusions

Psychotic experiences are associated with COVID-19 infections, though much of the association is attenuated when accounting for anxiety and depression. Findings based on this sample of college students should be replicated outside of the college context to determine whether psychosis is a neuropsychiatric symptom during and after COVID-19 infection.

Psychotropics and COVID-19: An analysis of safety and prophylaxis

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

Coronavirus infections from 2002-2021: Neuropsychiatric Manifestations

Coronaviruses have been known to infect humans for several decades and there are four endemic subtypes: HCoV (human coronavirus) −229E, -NL63, -OC43 and -HKU1. These mainly cause a mild upper respiratory illness, but occasionally in vulnerable individuals they can result in more severe respiratory disease and, rarely, CNS involvement. Prior exposure to these viruses has also been associated with an increased odds of having a major psychiatric illness. The severe acute respiratory syndrome (SARS), caused by SARS-CoV, started in 2002 and, as well as causing a more severe respiratory phenotype, was also associated with delirium and affective symptoms acutely. Psychosis occurred in about 1% of individuals and was generally thought to be due to corticosteroid administration. The Middle East respiratory syndrome (MERS), caused by MERS-CoV, revealed similar findings. Survivors of both SARS and MERS reported persistent physical and psychological symptoms at least several months after the acute illness. The reported neuropsychiatric symptoms of COVID-19 range from the common symptoms of systemic and upper respiratory infections to severe and disabling conditions. Delirium has been described using varying terminology; as well as being a possible presenting feature of COVID-19, it has also been shown to be a marker of severe disease. Stroke, both ischaemic and haemorrhagic, have been reported to be more common in COVID-19 than in other medical illnesses. Mood and anxiety disorders are likely to be common at follow-up, while psychosis remains rare and controversial. ‘Long Covid’ is likely to represent a highly clinically and aetiologically heterogeneous group.

Primary Psychosis: Risk and Protective Factors and Early Detection of the Onset

Primary psychosis, which includes schizophrenia and other psychoses not caused by other psychic or physical conditions, has a strong impact worldwide in terms of disability, suffering and costs. Consequently, improvement of strategies to reduce the incidence and to improve the prognosis of this disorder is a current need. The purpose of this work is to review the current scientific literature on the main risk and protective factors of primary psychosis and to examine the main models of prevention, especially those related to the early detection of the onset. The conditions more strongly associated with primary psychosis are socio-demographic and economic factors such as male gender, birth in winter, ethnic minority, immigrant status, and difficult socio-economic conditions while the best-established preventive factors are elevated socio-economic status and an economic well-being. Risk and protective factors may be the targets for primordial, primary, and secondary preventive strategies. Acting on modifiable factors may reduce the incidence of the disorder or postpone its onset, while an early detection of the new cases enables a prompt treatment and a consequential better prognosis. According to this evidence, the study of the determinants of primary psychosis has a pivotal role in designing and promoting preventive policies aimed at reducing the burden of disability and suffering of the disorder.

COVID-19 and Psychotic Symptoms: the View from Psychiatric Immunology

Purpose of Review

To explore the immunological underpinnings of psychosis in the COVID-19 patients.

Recent Findings

COVID-19 pandemic led to a surge in psychiatric morbidities, including psychosis. Various putative biological and psychosocial changes have been implicated in COVID-19-related psychosis. COVID-19 is a proinflammatory state. Alterations in immunological processes both as a direct consequence of infection or secondary to the hyperimmune response heuristically explain the etiopathogenesis of psychosis in the affected individual. The uses of immunosuppressant and immunomodulatory drugs may be the other moderators of a psychotic presentation in COVID-19 patients. Evidence to substantiate this hypothesis is still lacking however, which further studies should address. Because of its management implications, a better understanding of the involved immunological mechanisms becomes extremely important.

Summary

Evidence suggests a putative role of immunological alterations in the pathogenesis of COVID-19-related psychosis. The immunological abnormalities are primarily attributed to the pathophysiology of COVID-19 infection, medications used, and stress.

Maternal immune activation as a risk factor for psychiatric illness in the context of the SARS-CoV-2 pandemic

Inflammation, due to infectious pathogens or other non-infectious stimuli, during pregnancy is associated with elevated risk for neurodevelopmental disorders such as schizophrenia and autism in the offspring. Although historically identified through retrospective epidemiologic studies, the relationship between maternal immune activation and offspring neurodevelopmental disease risk is now well established because of clinical studies which utilized prospective birth cohorts, serologically confirmed infection records, and subsequent long-term offspring follow-up. These efforts have been corroborated by preclinical research which demonstrates anatomical, biochemical, and behavioural alterations that resemble the clinical features of psychiatric illnesses. Intervention studies further demonstrate causal roles of inflammatory mediators, such as cytokines, in these long-lasting changes in behaviour and brain. This review summarizes a selection of maternal immune activation literature that explores the relationship between these inflammatory mediators and the neuropsychiatric-like effects later observed in the offspring. This literature is presented alongside emerging information regarding SARS-CoV-2 infection in pregnancy, with discussion of how these data may inform future research regarding the effects of the present coronavirus pandemic on emerging birth cohorts.

Psychosis associated with suspected SARS-CoV-2 encephalitis with response to steroids: a case report

INTRODUCTION

The SARS-Cov-2 infection has multiple neurologic manifestations including encephalitis in multiple cases reported, however the psychosis as principal manifestation of this condition is infrequently.

CASE REPORT

We report the case of a 48-year-old woman with a confirmed diagnosis of SARS-CoV-2 who developed paranoid and self-referential ideas with behavioural alteration and multiple findings on mental examination. Encephalitis associated with Covid-19 was suspected due to the neurological clinical presentation (persistent despite resolve hypoxaemia and systemic symptoms) and brain magnetic resonance image (MRI) that showed asymmetric hippocampal hyperintensities, although cerebrospinal fluid and electroencephalogram (EEG) were normal. The patient received medical treatment with methylprednisolone for 5 days with complete resolution of her symptoms.

DISCUSSION

The current SARS-CoV-2 pandemic has neurological complications either by direct involvement or by para-infectious or post-infectious phenomena. Encephalitis occurs in a small proportion of the cases, while psychiatric symptoms have been described in a variable percentage of the events. However, a psychotic picture such as the one reported in our case is unusual. MRI, cerebrospinal fluid and EEG are important for the diagnostic evaluation of these patients but not obligatory to the diagnosis. The treatment of this condition with corticosteroids has been successful even in cases associated with Anti-NMDA. Our case is the second reported in Colombia, the first to be associated with psychosis.

[S1 Guideline Post-COVID/Long-COVID]

The German Society of Pneumology initiated the AWMFS1 guideline Post-COVID/Long-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendation describes current post-COVID/long-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an expilcit practical claim and will be continuously developed and adapted by the author team based on the current increase in knowledge.

[Neuropsychiatric Aspects of COVID-19 - A Narrative Overview]

The SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Coronavirus Type 2) and COVID-19 (Coronavirus Disease 2019) can affect numerous organ systems. In the present paper we offer an overview of the current state of knowledge about the psychiatric aspects of SARS-CoV-2 infection.Medline, Embase und LIVIVO were searched for relevant literature, the last query dating from March 2nd, 2021. Different stress factors in the context of the pandemic can lead to manifest mental illnesses. In addition, there is a risk of neuropsychological changes due to the biological effects of the virus itself.Our work describes the psychological symptoms of COVID-19 sufferers themselves and the psychological effects of the epidemic and the associated socio-economic and psychosocial stress factors on those who are not sick.The most common psychiatric complication among people with COVID-19 is delirium, while hospitalized patients seem to have an increased incidence of symptoms of anxiety, depression and PTSD. There are many case reports on psychotic disorders. In general, an existing psychiatric illness (especially dementia and psychotic disorders) also increases the risk of infection and of a more severe course of the disease. After recovery from COVID-19 infection, there is also a higher incidence of mental illnesses, in particular "Chronic Post-SARS Syndrome" with its manifestations such as fatigue, anxiety, depression and PTSD. In addition, the course of dementia seems to be negatively influenced by an infection with SARS-CoV-2.The second part deals with the effects of the epidemic as a stressor and the established socio-political measures on the mental health of people with and without previous mental illnesses. The literature currently available shows high symptom values for anxiety and depressive disorders as well as post-traumatic stress disorders, stress, suicidality, sleep disorders etc. Risk factors seem to include female gender, younger age and fewer resources, as well as previous psychiatric or physical illnesses. Extrinsic factors such as high infection rates, large numbers of deaths, long curfews/lockdowns, low trust in the government and ineffective measures against economic and social consequences increase the burden.

Schizophrenia during the COVID-19 pandemic

PURPOSE OF REVIEW

The coronavirus disease 19 (COVID-19) pandemic is having a critical impact on healthcare systems across the world, as well as on mental health in the general population; however, evidence regarding the impact of the COVID-19 pandemic on people living with schizophrenia and on the onset of psychotic symptoms is currently emerging.

RECENT FINDINGS

People living with schizophrenia are at an increased risk of COVID-19 and present worse COVID-19-related outcomes, including mortality. They show low levels of information and of concern regarding the possibility of contagion and infection but presented substantially stable levels of psychotic symptoms and even increased subjective well being during the pandemic. SARS-CoV-2, as well as the prolonged social isolation and the spread of misinformation, appear to be responsible in some cases for the onset of psychotic symptoms.

SUMMARY

Clinicians should inform and educate their patients on the risks related to SARS-CoV-2 infection and COVID-19 and on the precautions that they should adopt to avoid contagion. Particular attention should be devoted to maintaining the continuity of care, especially in frail patients. Telemedicine might represent a valid support, but face-to-face visits in some cases remain essential. The hypothesis of a direct role of viral infection on the onset of psychotic disorders is currently debated, as viral involvement of central nervous system appears to be rather infrequent in COVID-19.

6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records

BACKGROUND

Neurological and psychiatric sequelae of COVID-19 have been reported, but more data are needed to adequately assess the effects of COVID-19 on brain health. We aimed to provide robust estimates of incidence rates and relative risks of neurological and psychiatric diagnoses in patients in the 6 months following a COVID-19 diagnosis.

METHODS

For this retrospective cohort study and time-to-event analysis, we used data obtained from the TriNetX electronic health records network (with over 81 million patients). Our primary cohort comprised patients who had a COVID-19 diagnosis; one matched control cohort included patients diagnosed with influenza, and the other matched control cohort included patients diagnosed with any respiratory tract infection including influenza in the same period. Patients with a diagnosis of COVID-19 or a positive test for SARS-CoV-2 were excluded from the control cohorts. All cohorts included patients older than 10 years who had an index event on or after Jan 20, 2020, and who were still alive on Dec 13, 2020. We estimated the incidence of 14 neurological and psychiatric outcomes in the 6 months after a confirmed diagnosis of COVID-19: intracranial haemorrhage; ischaemic stroke; parkinsonism; Guillain-Barré syndrome; nerve, nerve root, and plexus disorders; myoneural junction and muscle disease; encephalitis; dementia; psychotic, mood, and anxiety disorders (grouped and separately); substance use disorder; and insomnia. Using a Cox model, we compared incidences with those in propensity score-matched cohorts of patients with influenza or other respiratory tract infections. We investigated how these estimates were affected by COVID-19 severity, as proxied by hospitalisation, intensive therapy unit (ITU) admission, and encephalopathy (delirium and related disorders). We assessed the robustness of the differences in outcomes between cohorts by repeating the analysis in different scenarios. To provide benchmarking for the incidence and risk of neurological and psychiatric sequelae, we compared our primary cohort with four cohorts of patients diagnosed in the same period with additional index events: skin infection, urolithiasis, fracture of a large bone, and pulmonary embolism.

FINDINGS

Among 236 379 patients diagnosed with COVID-19, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 33·62% (95% CI 33·17-34·07), with 12·84% (12·36-13·33) receiving their first such diagnosis. For patients who had been admitted to an ITU, the estimated incidence of a diagnosis was 46·42% (44·78-48·09) and for a first diagnosis was 25·79% (23·50-28·25). Regarding individual diagnoses of the study outcomes, the whole COVID-19 cohort had estimated incidences of 0·56% (0·50-0·63) for intracranial haemorrhage, 2·10% (1·97-2·23) for ischaemic stroke, 0·11% (0·08-0·14) for parkinsonism, 0·67% (0·59-0·75) for dementia, 17·39% (17·04-17·74) for anxiety disorder, and 1·40% (1·30-1·51) for psychotic disorder, among others. In the group with ITU admission, estimated incidences were 2·66% (2·24-3·16) for intracranial haemorrhage, 6·92% (6·17-7·76) for ischaemic stroke, 0·26% (0·15-0·45) for parkinsonism, 1·74% (1·31-2·30) for dementia, 19·15% (17·90-20·48) for anxiety disorder, and 2·77% (2·31-3·33) for psychotic disorder. Most diagnostic categories were more common in patients who had COVID-19 than in those who had influenza (hazard ratio [HR] 1·44, 95% CI 1·40-1·47, for any diagnosis; 1·78, 1·68-1·89, for any first diagnosis) and those who had other respiratory tract infections (1·16, 1·14-1·17, for any diagnosis; 1·32, 1·27-1·36, for any first diagnosis). As with incidences, HRs were higher in patients who had more severe COVID-19 (eg, those admitted to ITU compared with those who were not: 1·58, 1·50-1·67, for any diagnosis; 2·87, 2·45-3·35, for any first diagnosis). Results were robust to various sensitivity analyses and benchmarking against the four additional index health events.

INTERPRETATION

Our study provides evidence for substantial neurological and psychiatric morbidity in the 6 months after COVID-19 infection. Risks were greatest in, but not limited to, patients who had severe COVID-19. This information could help in service planning and identification of research priorities. Complementary study designs, including prospective cohorts, are needed to corroborate and explain these findings.

FUNDING

National Institute for Health Research (NIHR) Oxford Health Biomedical Research Centre.

Pulmonary Embolism and Acute Psychosis, a Case Report of an Outpatient with a Mild Course of COVID-19

The increased risk for thromboembolism in hospitalized COVID-19 patients has been communicated extensively. The fact that home quarantined patients can develop pulmonary embolism, however, has so far not been reported. Furthermore, attention should be brought to psychotic developments in COVID-19 patients. We report a 46-year-old previously healthy patient with a mild course of COVID-19, who developed a massive pulmonary embolism with right heart strain while being home quarantined. He was hospitalized and anticoagulant therapy was started. Nine days after admission, the patient appeared increasingly psychotic and suffered from hallucinations as well as paranoid thoughts. After treatment with risperidone and valproate, the patient's condition improved. At a follow-up 1 month after discharge, he was completely recovered regarding the respiratory, cardiac, and psychic situation. SARS-CoV-2 infection can not only increase the prevalence of thromboembolism in hospitalized patients but also in outpatients. COVID-19 also increases the risk of developing psychiatric reactions.

Abrupt Late-onset Psychosis as a Presentation of Coronavirus 2019 Disease (COVID-19): A Longitudinal Case Report

INTRODUCTION

Coronavirus Disease 2019 (COVID-19) is a pandemic infection caused by the Severe Acute Respiratory Syndrome 2 Coronavirus (SARS-2-CoV). Although most prominently associated with pulmonary manifestations, COVID-19 is increasingly implicated in neuropsychiatric complications, including delirium and psychosis. There is a potential causal link between COVID-19 infection and psychotic symptoms; however, case reports to date have been incomplete, as the patients described had known psychiatric histories or other plausible medical causes for altered mental status. We present a longitudinal case of COVID-19 psychosis in a patient who underwent comprehensive diagnostic evaluation. This case is a contribution to the inchoate characterization of neuropsychiatric manifestations of COVID-19 infection.

CASE REPORT

We present a case of late-onset psychosis in a middle-aged man with no psychiatric history who tested positive for COVID-19 on admission following a recently resolved upper respiratory illness. His acute presentation-characterized by delusions, hallucinations, and disorganized thought and behavior, for which he required inpatient medical admission and subsequent inpatient psychiatric hospitalization-was successfully treated. During his hospitalization, he underwent comprehensive medical and neurological workup (including neuroimaging; electroencephalography; and serum and cerebrospinal fluid testing) that was grossly unremarkable.

DISCUSSION

Despite myriad potential causes of the patient's psychosis, this patient's diagnostic workup was largely unrevealing, apart from his nasopharyngeal SARS-2-CoV reverse transcriptase polymerase chain reaction assay. As such, psychosis secondary to COVID-19 infection emerged as the presumptive diagnosis.

Commentary on 2 Cases of Neuropsychiatric Symptoms Occurring in Association With COVID-19

Two cases are presented involving neuropsychiatric symptoms occurring in the context of coronavirus disease 2019 (COVID-19) infections. The first case involved a middle-age man with no known psychiatric history who presented with acute psychotic symptoms (delusions, hallucinations, disorganization) after recovery from a recent respiratory illness. This patient tested positive for COVID-19 on admission. The patient's symptoms were not consistent with delirium and testing did not suggest a neurological etiology. The patient's psychosis eventually resolved 6 weeks after its abrupt onset with treatment with antipsychotic medication. The second case involved a 44-year-old man with a history of depression and psychotic symptoms who presented after a serious suicide attempt and tested positive for COVID-19 on admission. The patient had subsequent negative tests while on the inpatient psychiatric unit before again testing positive later in his admission. The patient's positive COVID-19 tests appeared to coincide with exacerbations in his mood symptoms, which led to the suicide attempt and psychotic episode that initially caused his admission. This patient was successfully treated with clozapine. In both of these cases, the question arose as to whether there was a link between the COVID-19 infections and the neuropsychiatric symptoms. Growing evidence suggests that severe neuropsychiatric sequelae can develop after COVID-19 infection.