COVID-19-associated psychiatric disorders

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Synonyms and keywords: COVID-19-associated psychiatric disorders

Overview[edit | edit source]

In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time. By April 2020, stay-at-home advisories, or shelter-in-place policies were applied in 42 states of the United States affecting approximately 96% of the US population. Based on multiple studies done in early 2020, the number of internet searches for mental health symptoms have significantly increased and more people requested mental health services. Major depressive disorder, post-traumatic stress disorder, anxiety, ADHD, mood swing, panic disorder, and psychosis were among numerous COVID-19-associated mental disorders that have been reported. The pathophysiology of COVID-19-associated psychiatric disorders can be explained by the body's immunologic response to the virus or due to the psychological stressors such as isolation, loneliness, stigma, concerns about infecting others, and fear of death. COVID-19-associated psychiatric disorders must be differentiated from other diseases that cause sleep disorder, loss of appetite, altered mentation, agitation, and decreased energy. The prevalence of depression has more than doubled during the COVID-19 pandemic and the younger population were more vulnerable to develop psychiatric disorders during the COVID-19 pandemic. Furthermore, studies reported that females are more commonly affected with COVID-19-related mental disorders than males. Ethnic and racial minorities were related to a higher rate of mental health difficulties during the COVID-19 pandemic. Having low income, being single, certain occupations such as medical workers and past medical history of mental or chronic underlying medical illness are some of the reported risk factors of COVID-19-associated psychiatric disorders. The clinical presentations are strongly related to the type of the COVID-19-associated mental disorder. Appropriate treatment of the underlying COVID-19 infection is essential to address the inflammatory process due to the infection and also the fears of the patients. Moreover, standard treatments for each psychiatric disorder must be considered to control the symptoms.

Historical Perspective[edit | edit source]

• In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time.^[1]
• By April 2020, stay-at-home advisories, or shelter-in-place policies have been applied in 42 states of the United States affecting no less than 316 million people (close to 96% of the US population).^[2]
• Based on multiple studies done in early 2020, the number of internet searches for mental health symptoms had significantly increased. Furthermore, from the start of the pandemic, more people requested mental health services.^[3]

Classification[edit | edit source]

The following are COVID-19-associated mental disorders that have been reported:^{[4][5][6][7][8][9][10][11][12][13][14][15][16]}

• Depression
• Post-traumatic stress disorder
• Acute stress disorder
• Anxiety
• Somatization
• Mood swing
• Attention-deficit hyperactivity disorder (ADHD)
• Panic disorder
• Obsessive-compulsive disorder
• Psychosis
• Delirium
• Mania
• Catatonia
• Insomnia

Pathophysiology[edit | edit source]

The pathophysiology of COVID-19-associated psychiatric disorders can be explained by the body's immunologic response to the virus or due to the psychological stressors such as isolation, loneliness, stigma, concerns about infecting others, and fear of death.

Immunologic Response To the Virus[edit | edit source]

• Respiratory viral diseases are associated with psychological disorders, which can be presented both acutely and chronically.^[5]
• The coronavirus is a neurotropic virus and can cause mental disorder by affecting the central nervous system or via the immune system response.^{[7][5][17][12]}
• Some data supported the role of inflammatory biomarkers from an infection on development of depression's symptoms such as anhedonia.^[18]

Psychological Trauma[edit | edit source]

• Data from previous studies delineated the increased rate of mental disorders following major traumatic events such as natural disasters and pandemics.^[8][10]
• The unknown nature of the virus within the first months, the uncertainty of its transmission route, and the high rate of hospitalization and mortality led to serious concern and distress among individuals.^[19][20]
• Disruption of the routine day-to-day life due to strict quarantine measures, closing of schools, and cancelling all social events was one of the important determinants.^[8]
• The following concerns were associated with a higher rate of psychiatric disorders during the COVID-19 pandemic:^[21][22]
  • Fear of contracting the infection
  • Fear of death due to the infection
  • Misinformation regarding COVID-19
  • Social distancing
  • Economical difficulties
• The role of reduced physical activity, increased screen time, irregular sleep patterns, and lack of interpersonal contacts has been related to mental disorders among children and adolescents who experienced the quarantine.^[20]

Side Effects of COVID-19 Treatment[edit | edit source]

Some of the medications used for COVID-19 treatment were known to cause neuropathic and neuropsychiatric side effects.^[23][24]

• Ribavirin
• Interferon alpha
• Chloroquine
• Hydroxychloroquine

Causes[edit | edit source]

In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time.^[1] Over the course of a few months, COVID-19 quickly spread globally and turned into a worldwide pandemic. Data on September 1st, 2020 (less than eleven months after the pandemic onset) reported 28 million confirmed cases and over 900,000 deaths globally. The number of confirmed cases and deaths on the same date were 6.4 million and 19,000 in the United States, respectively.^[25] The unknown nature of the virus within the first months, the uncertainty of its transmission route, and the high rate of hospitalization and mortality led to more concern and distress among individuals.^[19] To control the infection, numerous policies and strict quarantine measures were applied in the United States and other countries; schools were closed, all social events were canceled, people were advised to stay at home and work from home if possible and wear face masks. By April 2020, stay-at-home advisories, or shelter-in-place policies have been applied in 42 states of the United States affecting no less than 316 million people (close to 96% of the US population).^[2] As a result of the COVID-19 pandemic a chain of emotional issues developed among individuals, such as guilt, anxiety, loneliness, insomnia, stigma, helplessness, anger, despair, and fear.^[26]

Differentiating COVID-19-Associated Psychiatric Disorders from Other Diseases[edit | edit source]

COVID-19-associated psychiatric disorders must be differentiated from other diseases that cause sleep disorder, loss of appetite, altered mentation, agitation and decreased energy, such as the followings:^[27][28][29]

• The COVID-19 infection of the central nervous system such as encephalitis
• Substance/medication-induced depressive disorder
• Delirium
• Acute cerebrovascular disease due to COVID-19 infection such as cerebral hemorrhage

Epidemiology and Demographics[edit | edit source]

• Based on a large national study done in the United States, the prevalence of depression has more than doubled during the COVID-19 pandemic.^[30]
• The prevalence of depression among adults older than 18 years old in the United States was estimated at 28.6%, only from April to May 2020. During this time, 8.4% of adults reported having suicidal ideation and 18.2% initiated or increased substance usage. Only three months later (September 2020) the rate of depression among American adults older than 18 years old raised to 33%, and the prevalence rate of suicidal ideation increased to 11.9% (Lee & Singh, 2021).^[31]
• Based on some evidences, 0.9% to 4% of COVID-19 patients developed psychotic spectrum disorders.^[14]

Age[edit | edit source]

• Patients of all age groups may develop mental disorder due to the COVID-19, nevertheless, younger population were more vulnerable to develop psychiatric disorders during the COVID-19 pandemic.^{[1][8][30][20][22]}
• Based on a systematic review, mental disorder due to COVID-19 pandemic was higher in the age group of 21-40 years.^[19]
• Another study which was done on 1,653 participants globally, suggested that the high rate of mental disorders among the younger population was related to poor sleep and loneliness of this population.^[3]

Gender[edit | edit source]

• Females are more commonly affected with COVID-19-related mental disorders than male.^{[32][1][8][20][22]}
• Supported by a study in Canada, young females are among the populations with a high prevalence of mental disorders during the pandemic.^[26]

Race[edit | edit source]

• Ethnic and racial minorities were related to a higher rate of mental health difficulties during the COVID-19 pandemic. Based on a large national study, Hispanics and African Americans had the highest rate of Depression in the United States, compared to other races.^[30]

Risk Factors[edit | edit source]

Common risk factors relating to COVID-19-associated psychiatric disorders:^{[26][1][31][25][8][33][34][6][35][20][36][37][21][38]}

• Economic status
  • Economic inequalities have been known as a risk factor for mood disorders, such as depression, and the COVID-19 pandemic exacerbated the economic issues of many people in the United States.^[39]
• Marital status
  • Being single (unmarried, living with parents, widow, or divorcee) is one of the factors associated with a higher rate of mental illnesses, such as depression, during the pandemic.
• Level of education
  • Based on some studies, a higher level of education has been related to a higher rate of anxiety due to the COVID-19 pandemic.
  • In contrast, other studies in the United States confirmed a significant association between lower education and a higher rate of mental disorders due to the COVID-19 pandemic.
  • A systematic review delineated that being a student is a risk factor associated with mental disorders.
• Female gender
• Certain occupations such as medical workers
• Social media exposure
  • Based on a study in China, more than two hours of exposure to COVID-19 news via social media was associated with a higher rate of depression.
• History of a chronic underlying medical illness^[8]
• History of previous mental disorder^[8][30]
• Sever pain during the COVID-19 pandemic
• Poor sleep
• Having a relative with COVID-19
• Prolonged hospitalization

Natural History, Complications and Prognosis[edit | edit source]

• The clinical presentations are strongly related to the type of the COVID-19-associated mental disorder.
• As a result of the COVID-19 pandemic the following chain of emotional issues developed among individuals:^[26][8]
  • Guilt
  • Stress
  • Loneliness
  • Stigma
  • Helplessness
  • Anger
  • Despair
  • Fear of infecion
• Behaviors such as substance abuse (such as smoking, overconsumption of alcohol, and drug abuse) has been increased during the COVID-19 pandemic in the United States.^[31][21]
• If left untreated, complications such as suicide can occur.^{[31][21][22][15]}
• Presence of some mental disorders such as bipolar disorder, unipolar depression and schizophrenia spectrum disorders was associated with poorer outcomes in COVID-19 patients.^[40]

Diagnostic Criteria[edit | edit source]

• Diagnosis can be made if a psychiatric disorder associated to the COVID-19; either in a COVID-19 patient, or in an individual who lived during the COVID-19 pandemic has been observed.

History and Symptoms[edit | edit source]

• Symptoms of the COVID-19-associated psychiatric disorders depends on the type of mental disorder, nevertheless the following are some of the general observed symptoms:^[23][41][16]
  • Anhedonia
  • Sleep difficulty
  • Reduced appetite
  • Anxiety
  • Lethargy
  • Irritability
  • Inattention

Physical Examination[edit | edit source]

• Patients with COVID-19-associated psychiatric disorders usually appear normal.

Laboratory Findings[edit | edit source]

• There are no specific laboratory findings associated with COVID-19-associated psychiatric disorders.

Electrocardiogram[edit | edit source]

There are no ECG findings associated with COVID-19-associated psychiatric disorders.

X-ray[edit | edit source]

There are no x-ray findings associated with COVID-19-associated psychiatric disorders.

Echocardiography or Ultrasound[edit | edit source]

There are no echocardiography/ultrasound findings associated with COVID-19-associated psychiatric disorders.

CT scan[edit | edit source]

There are no CT scan findings associated with COVID-19-associated psychiatric disorders.

MRI[edit | edit source]

There are no MRI findings associated with COVID-19-associated psychiatric disorders.

Other Imaging Findings[edit | edit source]

There are no other imaging findings associated with COVID-19-associated psychiatric disorders.

Other Diagnostic Studies[edit | edit source]

There are no other diagnostic studies associated with COVID-19-associated psychiatric disorders.

Treatment[edit | edit source]

Medical Therapy[edit | edit source]

• Appropriate treatment of the underlying COVID-19 infection is essential to address the inflammatory process due to the infection and also the fears of the patients.^[42]
• Standard treatments for each psychiatric disorder also must be considered to control the symptoms. For instance, in a study on the COVID-19 associated psychosis, initiation of antipsychotics controlled the symptoms successfully.^[42]

Non-Medical Therapy[edit | edit source]

Telepsychiatry[edit | edit source]

• Usage of telepsychiatry to deliver psychiatric care during the COVID-19 pandemic may help the populations who are at risk.^[37]
• The talk-based nature of most psychiatric therapies makes utilizing technological means more convenient during the quarantine.^[37]
• In addition, this method of psychiatric care can be utilized for group therapy as well.
• A systematic review, reported that video teleconference groups and in-person groups were similar in their treatment outcomes.^[43]
• Telepsychiatry is not feasible for certain cohorts of patients. The following may limit the use of telepsychiatry:^[37]
  • Not having access to internet, smartphone or computer
  • Less technologically literate patients
  • Old age
  • Patients with diminished cognition

Surgery[edit | edit source]

• There is no surgical treatment for COVID-19-associated psychiatric disorders

Prevention[edit | edit source]

• Practiced by some countries, policies and interventions can help individuals to have a better mental health status during the COVID-19 pandemic. For instance Australia developed an initiative called "Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access)" in order to provide psychological therapy sessions for patients suffering from mental disorders.^[21]
• Proposing guidelines to provide an overview regarding the COVID-19-associated psychiatric disorders for health care providers to improve their knowledge could also be helpful and has been practiced in some countries such as Singapore, India, China, and Malaysia.^[21][44][45]
• Providing accurate and reliable information regarding the COVID-19 and demolishing false information by governments and public health authorities can reduce distress and may prevent the mental disorders related to COVID-19.^[19]
• Assuring a proper supply of personal protective equipment, such as masks, and hand sanitizers to address the related concern of individuals during the pandemic.
• Utilizing electronic devices and applications by public health authorities can ensure online access to a medical provider and can secure individuals from the stresses related to the availability of medical help.^[46]
• Since financial issues were introduced as one of the most important factors associated with a higher rate of depression during the COVID-19 pandemic, financial supports such as unemployment insurance (UI) may be able to prevent depression among the population at risk.^[47]
• Governments and public health authorities can use text messages or computer-based interventions, telehealth services, and mass media campaigns to decrease the risk of mental disorders among the population at risk.^[30]
• One of the protective factors for depression during the pandemic was to construct a daily routine, including regular exercises and appropriate sleep, which can be practiced individually.^[3]

References[edit | edit source]

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