Source/Disclosures
Disclosures: Rogers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Bakker and Sommer report no relevant financial disclosures.
May 22, 2020
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Researchers predict psychiatric burden of COVID-19 using insights from past coronavirus outbreaks

Source/Disclosures
Disclosures: Rogers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Bakker and Sommer report no relevant financial disclosures.
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Insights from past coronavirus outbreaks may help predict the psychiatric burden of the COVID-19 pandemic, according to results of a systematic review and meta-analysis published in The Lancet Psychiatry.

Researchers noted that most individuals hospitalized with severe COVID-19 likely will recover without experiencing associated mental illness if infection with SARS-CoV-2 follows a course similar to that of the severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) coronavirus outbreaks. However, SARS-CoV-2 may cause delirium among a significant proportion of patients in the acute stage, and it may also be linked to depression, fatigue, anxiety, PTSD and rarer neuropsychiatric syndromes in the longer term.

“Although there has never been pandemic quite like this before, we wanted to explore the psychiatric consequences of infection in other coronavirus outbreaks,” Jonathan P. Rogers, MRCPsych, of the division of psychiatry at University College London, told Healio Psychiatry. “SARS and MERS are fairly recent history, so there are a lot of comparisons to be made. The advantage of this study is that it includes some long-term follow-up data up to 12 years, which allows us to anticipate what some of the implications of COVID-19 might be further down the line.”

Rogers and colleagues noted that prior studies of influenza pandemics reported associations between the pandemics and long-lasting neuropsychiatric consequences, which raises the possibility that other large scale viral infections, such as the ongoing COVID-19 pandemic, could cause sustained mental morbidity. Specific psychiatric consequences in the era of COVID-19 relate to social impact and the governmental response, including quarantine and physical distancing measures, as well as widespread anxiety, social isolation, stress, unemployment and financial difficulties, according to the investigators. Moreover, central nervous system infection, immune response and medical therapy may have neuropsychiatric consequences, with researchers from Wuhan reporting that 36% of patients admitted to the hospital for infection with SARS-CoV-2 had neurological features.

infographic with study author Jonathan Rogers and quote about asking for mental health symptoms along with respiratory symptoms
Source: Rogers JP, et al. Lancet Psychiatry. 2020;doi:10.1016/S2215-0366(20)30203-0.

In the current study, the investigators sought to assess the psychiatric and neuropsychiatric presentations of SARS, MERS and COVID-19. Two independent researchers searched multiple databases for all English-language studies or preprints that reported data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection. Outcomes included psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-4 or the Chinese Classification of Mental Disorders (third edition), or psychometric scales; quality of life; and employment. The systematic review and meta-analysis stratified outcomes across acute vs. post-illness stages for MERS and SARS. For the meta-analysis, the investigators used a random-effects model, and the meta-analytical effect size was prevalence for relevant outcomes, I2 statistics and assessment of study quality.

Among 65 peer-reviewed studies and seven preprints, there were 3,559 coronavirus cases, ranging from one to 997, with a mean participant age range of 12.2 years to 68 years. Studies were conducted in Canada, China, France, Hong Kong, Japan, Saudi Arabia, Singapore, South Korea, the U.K. and the U.S. Post-illness study follow-up times ranged between 60 days and 12 years.

According to results of the systematic review, common acute illness symptoms among patients admitted to hospital for SARS or MERS included confusion (27.9%), depressed mood (32.6%), anxiety (35.7%), impaired memory (34.1%) and insomnia (41.9%). The researchers observed psychosis and steroid-induced mania among 13 (0.7%) of 1,744 patients with SARS in the acute stage in one study. Frequently reported conditions in the post-illness stage included depressed mood (10.5%), insomnia (12.1%), anxiety (12.3%), irritability (12.8%), memory impairment (18.9%) and fatigue (19.3%), as well as traumatic memories (30.4%) and sleep disorder (100%) in one study.

The meta-analysis revealed the following point prevalence rates in the post-illness stage:

  • PTSD = 32.2%;
  • depression = 14.9%; and
  • anxiety disorders = 14.8%.

Among 580 patients included in six studies, 446 (76.9%) had returned to work at a mean follow-up time of 35.3 months. Upon examination of data for patients with COVID-19, the researchers observed evidence for delirium. Further, 15 (33%) of 45 patients with COVID-19 who were assessed in one study had a dysexecutive syndrome at discharge. The researchers noted two reports of hypoxic encephalopathy and one report of encephalitis. Of the 72 studies, 68 (94%) were either of low or medium quality.

“Delirium is a serious problem among patients admitted to the hospital with COVID-19,” Rogers told Healio Psychiatry. “Delirium is associated with prolonged inpatient admission and raised mortality, so we need to be screening for this and managing it proactively. Further, many patients with SARS described receiving great care for their initial illness, but they were stigmatized in the aftermath and said that clinicians did not take their longer-term symptoms seriously. We need to make sure we don’t make the same mistake with COVID-19. In particular, we should be following up people who have a severe infection. When we ask patients about respiratory symptoms, we should also inquire about low mood, anxiety and psychological trauma.”

In a related editorial, Iris E. Sommer, PhD, of the department of biomedical sciences of cells and systems at University Medical Center Groningen in the Netherlands, and P. Roberto Bakker, MD, PhD, of the department of psychiatry and psychology at Maastricht University Medical Centre in the Netherlands, noted that any assumptions from these findings should be drawn with caution.

“Findings from previous coronavirus outbreaks are useful, but might not be exact predictors of prevalences of psychiatric complications for patients with COVID-19,” they wrote. “The warning from Rogers and colleagues that we should prepare to treat large numbers of patients with COVID-19 who go on to develop delirium, [PTSD], anxiety and depression is an important message for the psychiatric community. Reported prevalence estimates in this article should be interpreted with caution, as true numbers of both acute and long-term psychiatric disorders for patients with COVID-19 might be considerably higher.” – by Joe Gramigna

Disclosures: Rogers reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Bakker and Sommer report no relevant financial disclosures.