Psychiatric presentation of patients with acute SARS-CoV-2 infection: a retrospective review of 50 consecutive patients seen by a consultation-liaison psychiatry team

Onset of bipolar disorder by COVID-19: The roles of endogenous ouabain and the Na,K-ATPase

Bipolar Disorder (BD) is a psychiatric disorder marked by mood swings between manic and depressive episodes. The reduction in the Na,K-ATPase (NKA) enzyme activity and the inability of individuals with BD to produce endogenous ouabain (EO) at sufficient levels to stimulate this enzyme during stressful events are factors proposed for BD etiology. According to these hypotheses, reduction in NKA activity would result in altered neuronal resting potential, leading to BD symptoms. Recently, damage to the adrenals (EO synthesis site) in coronavirus disease (COVID-19) patients has been reported, however studies pointing to the pathophysiological mechanisms shared by these two diseases are scarce. Through a literature review, this study aims to correlate COVID-19 and BD, focusing on the role of NKA and EO to identify possible mechanisms for the worsening of BD due to COVID-19. The search in the PubMed database for the descriptors ("bipolar disorder" AND "Na,K-ATPase"), ("bipolar disorder" AND "endogenous ouabain"), ("covid-19" AND "bipolar disorder") and ("covid-19" AND "adrenal gland") resulted in 390 articles. The studies identified the adrenals as a vulnerable organ to SARS-CoV-2 infection. Cases of adrenal damage in patients with COVID-19 showing lower levels of adrenal hormones were reported. Cases of COVID-19 patients with symptoms of mania were reported worldwide. Given these results, we propose that adrenal cortical cell damage could lead to EO deficiency following neuronal NKA activity impairment, with small reductions in activity leading to mania and greater reductions leading to depression.

Situation Analysis of Suicide and Self-Harm in the WHO Eastern Mediterranean Region

OBJECTIVE

An estimated 41,000 lives are lost to suicide each year in World Health Organization Eastern Mediterranean Region Office (WHO EMRO) countries. The objective of this study was to conduct a situation analysis for suicide and self-harm in the WHO EMRO region.

METHODS

Data on suicide were obtained from the WHO Global Health Estimates for the years 2000-2019. Information on risk groups efforts to prevent self-harm and suicide in the EMRO region were retrieved through scientific studies, grey literature, and public websites.

RESULTS

During 2000-2019, the age-standardized suicide rate was 6.7 per 100,000 inhabitants, albeit there are concerns regarding data quality. Self-harm and suicide remain criminal acts in more than half of the countries. Few countries have a national plan for prevention of suicide. Toxic agents, such as pesticides and black henna, are easily available and frequently used for suicide in some areas, as are firearms and self-immolation. Successful prevention measures include means restriction and psychosocial interventions after self-harm.

CONCLUSION

Many WHO EMRO countries remain underserved in terms of mental health care. Decriminalization of suicide and means restriction might be further promoted. Online-based tools for mental health literacy and psychosocial therapy are other options to explore.

Clinical Features and Prognosis of Coronavirus Disease 2019-Related Psychosis: A Retrospective Case Series

Background

It has been reported that coronavirus disease 2019 (COVID-19) may cause psychiatric disorders, but there are too many confounding factors in the various studies, making it difficult to draw accurate conclusions.

Methods

We analyzed the clinical features and treatment of patients with non-severe COVID-19 who were hospitalized in neurology and psychiatry departments due to acute psychiatric disorders and performed a descriptive analysis.

Results

Of the 57 patients included, 65% were hospitalized in the neurology department. Eighty-two percent of the patients exhibited abnormal mental behavior 1 week or less after COVID-19 diagnosis, and more than 60% of the patients had normal electroencephalogram (EEG), head imaging, autoimmune encephalitis antibody, and cerebrospinal fluid (CSF) results. Abnormal EEG results included an increase in nonspecific slow waves, abnormal imaging results included small ischemic areas and lacunar infarctions, and abnormal CSF results included a slight increase in cell numbers and protein levels and an increase in pressure. After administering antipsychotic drugs and/or immunotherapy, 67% of the patients experienced improvement in their psychiatric disorders by the time of discharge. Thirty-nine percent of the patients were discharged without antipsychotic medication and experienced no relapse of psychiatric symptoms.

Conclusion

Patients with non-severe COVID-19 and psychiatric disorders usually have a good prognosis and do not require long-term antipsychotic medication. Patients with uncontrollable mental symptoms experienced rapid remission after immunotherapy, suggesting that inflammation or the immune response may play an important role in the occurrence of simple acute psychiatric disorders caused by COVID-19.

First-Onset Psychosis After COVID-19 Infection: A Systematic Review of the Literature

BACKGROUND

The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP).

OBJECTIVE

The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP.

METHODS

A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria.

RESULTS

Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms.

CONCLUSIONS

This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly.

Acute Onset of Mania and Psychosis in the Context of Long-COVID: A Case Study

Acute phase COVID-19 has been associated with an increased risk for several mental health conditions, but less is known about the interaction of long COVID and mental illness. Prior reports have linked long COVID to PTSD, depression, anxiety, obsessive compulsive symptoms, and insomnia. This case report describes a novel presentation of mania arising in the context of long COVID symptoms with attention given to possible interacting etiological pathways. The case report also highlights the need for integrated, multidisciplinary treatment to support patients whose alarming, confusing, and multidetermined symptoms increase risk of psychological deterioration.

Can bupropion treat COVID-19-induced brain fog? A case series

COVID-19-induced neurocognitive complications that include brain fog have affected a large portion of individuals who survived COVID-19. These symptoms can include inattention, mental fatigue, forgetfulness, amotivation, and distractibility. This can cause significant anxiety and depression, which may worsen disease progression. To date, there are no known specific treatments that target COVID-19-related brain fog. Here, two patients are presented that develop symptoms of brain fog that persisted after they recovered from an acute COVID-19 infection. Both had memory impairment, mental exhaustion, and inattention with associated depressed mood. They were given bupropion extended release and though varied with dosing and time to resolution, they recovered dramatically. The dopamine and norepinephrine reuptake inhibitor is known to have effects on the brain that may treat symptoms of brain fog including blocking hippocampal cell loss, increased neural activity in the cingulate cortex, and decreasing proinflammatory cytokines. Bupropion may be a possible option for those suffering from this growing and debilitating post-COVID-19 complication.

Neuropsychiatric symptoms in the psychiatric counseling of patients admitted with COVID-19 infection

BACKGROUND

Covid-19 patients suffer from psychiatric disorders too. The present study was designed to investigate the rate of psychiatric consultation requests in a general hospital. Reasons for consultation requests, types of psychiatric diagnoses, and factors in consultation requests were also investigated.

METHODS

This cross-sectional study included all patients admitted with Covid-19 and referred to psychiatric consultation service in a major Covid-19 center in Tehran, Iran (2020). After acceing patients' electronic files, records of patients' demographic information, positive psychiatric symptoms, past psychiatric history and DSM5 diagnoses were made. Statistical analyses were done in SPSS 26 using descriptive statistics and chi-square and Fisher's exact test (p<0.05).

RESULTS

Out of 1791 Covid-19 hospitalized patients, 132 patients (7.3%) had been referred to psychiatric consultation service. The most common reason for requests were restlessness and aggression (23.5%). Meanwhile, 92.4% of the patients were diagnosed to suffer from at least one psychiatric disorder including insomnia (64%), delirium (30.3%), anxiety due to hypoxia (15.3%) and generalized anxiety disorder (10.6%).

CONCLUSION

Although studies report a high prevalence of psychiatric disorders in Covid-19 patients, requests for psychiatric consultations and consideration of psychiatric disorders are still remarkably low. The most common disorders appeared to be insomnia, delirium and anxiety.

A comparative neuroimaging perspective of olfaction and higher-order olfactory processing: on health and disease

Olfactory dysfunction is often the earliest indicator of disease in a range of neurological and psychiatric disorders. One tempting working hypothesis is that pathological changes in the peripheral olfactory system where the body is exposed to many adverse environmental stressors may have a causal role for the brain alteration. Whether and how the peripheral pathology spreads to more central brain regions may be effectively studied in rodent models, and there is successful precedence in experimental models for Parkinson's disease. It is of interest to study whether a similar mechanism may underlie the pathology of psychiatric illnesses, such as schizophrenia. However, direct comparison between rodent models and humans includes challenges under light of comparative neuroanatomy and experimental methodologies used in these two distinct species. We believe that neuroimaging modality that has been the main methodology of human brain studies may be a useful viewpoint to address and fill the knowledge gap between rodents and humans in this scientific question. Accordingly, in the present review article, we focus on brain imaging studies associated with olfaction in healthy humans and patients with neurological and psychiatric disorders, and if available those in rodents. We organize this review article at three levels: 1) olfactory bulb (OB) and peripheral structures of the olfactory system, 2) primary olfactory cortical and subcortical regions, and 3) associated higher-order cortical regions. This research area is still underdeveloped, and we acknowledge that further validation with independent cohorts may be needed for many studies presented here, in particular those with human subjects. Nevertheless, whether and how peripheral olfactory disturbance impacts brain function is becoming even a hotter topic in the ongoing COVID-19 pandemic, given the risk of long-term changes of mental status associated with olfactory infection of SARS-CoV-2. Together, in this review article, we introduce this underdeveloped but important research area focusing on its implications in neurological and psychiatric disorders, with several pioneered publications.

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.

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.

Liaison psychiatry before and after the COVID-19 pandemic

INTRODUCTION

the COVID-19 pandemic had an impact on hospital admissions. The clinical profiles of patients referred to liaison psychiatry teams (LPT) remained stable over the last few decades. We postulate changes in patient profiles due to the COVID-19 pandemic.

MATERIALS AND METHODS

a total of 384 patients admitted to a tertiary care University Hospital in Madrid (Spain) and referred to LPTs were recruited. Patients referred 5 months before and after the first admission for COVID-19 were included. Clinical and sociodemographic characteristics were collected, and non-parametric hypothesis contrast tests were used to study possible differences between both periods.

RESULTS

patients referred during the pandemic were significantly older (U = 2.006; p = .045), most of them were admitted to medical hospitalization units (χ2 (2) = 5.962; p = 015), and with a different reason for admission. There was an increase in the rate of adjustment disorders (χ2 (1) =7.893; p = 005) and delirium (χ2 (1) =9.413; p = 002), as well as psychiatric comorbidity (χ2 (2) = 9.930; p = .007), and a reduction in the proportion of patients treated for substance misuse (χ2 (5) = 19.152; p = .002). The number of deaths increased significantly (χ2 (1) = 6.611; p = .010). In persons over 65 years inappropriate prescription was significantly lower (χ2 (1) = 8.200; p = .004).

CONCLUSIONS

the pandemic had an impact on the activity of the LPTs due to the change in the clinical profile and evolution of referred patients, maintaining standards of care that are reflected through prescription.

Effect of acute depression associated with COVID-19 infection on health-seeking behaviour: a psychiatrist's personal account and case report

BACKGROUND

Despite the abundant research on COVID-19-related mental health problems, little attention has been paid to acute depression occurring concurrently with the infection as a neuropsychiatric manifestation. This is important because depression is known to adversely affect help-seeking. Decreased help-seeking is likely to be aggravated by the isolation measures demanded as part of fighting the pandemic, given the disruption of social support networks.

AIMS

To study the effects of acute depression associated with COVID-19 infection on help-seeking behaviour.

METHOD

We present a case report and personal account of a patient psychiatrist who developed a first onset of acute depression as part of COVID-19 infection.

RESULTS

Despite being a mental health expert the patient lacked insight into his mood change and its negative effect on help-seeking behaviour, resulting in reliance on a family caregiver to raise the alarm.

CONCLUSIONS

For those experiencing this complex interaction between COVID-19 infection and the brain, social support will be needed to ensure timely presentation to the healthcare system. Greater attention to behavioural change as part of COVID-19 infection is needed to optimise treatment outcome.

Unbalanced IDO1/IDO2 Endothelial Expression and Skewed Keynurenine Pathway in the Pathogenesis of COVID-19 and Post-COVID-19 Pneumonia

Despite intense investigation, the pathogenesis of COVID-19 and the newly defined long COVID-19 syndrome are not fully understood. Increasing evidence has been provided of metabolic alterations characterizing this group of disorders, with particular relevance of an activated tryptophan/kynurenine pathway as described in this review. Recent histological studies have documented that, in COVID-19 patients, indoleamine 2,3-dioxygenase (IDO) enzymes are differentially expressed in the pulmonary blood vessels, i.e., IDO1 prevails in early/mild pneumonia and in lung tissues from patients suffering from long COVID-19, whereas IDO2 is predominant in severe/fatal cases. We hypothesize that IDO1 is necessary for a correct control of the vascular tone of pulmonary vessels, and its deficiency in COVID-19 might be related to the syndrome’s evolution toward vascular dysfunction. The complexity of this scenario is discussed in light of possible therapeutic manipulations of the tryptophan/kynurenine pathway in COVID-19 and post-acute COVID-19 syndromes.

Initial Presentation of OCD and Psychosis in an Adolescent during the COVID-19 Pandemic

The COVID-19 pandemic is unparalleled in recent history when accounting for the true disease burden and dramatic impact on physical and mental health. Due to its infectious pathology, COVID-19 presents with a variety of symptoms including neuropsychiatric complications. Moreover, factors such as quarantine, social isolation, and fear of illness have negatively impacted the health of non-COVID-19 patients. There has been significant literature reporting new-onset psychiatric illness in all global populations including those without history of psychiatric illness. This report discusses an adolescent male without prior psychiatric history presenting with new onset symptoms of obsessive-compulsive disorder and psychosis in the context of COVID-19. There are considerable reports describing new-onset obsessive-compulsive disorder, albeit conflicting in terms of prevalence and exacerbations in the setting of COVID-19 in both adult and adolescent populations but limited reports of new-onset psychosis in those same populations and setting.

Sleep disturbances during the COVID-19 pandemic: A systematic review, meta-analysis, and meta-regression

This systematic review and meta-analysis evaluated the extent of sleep disturbances during the COVID-19 pandemic. Eleven databases and six preprint repositories were searched for the period from November 1, 2019, to July 15, 2021. The DerSimonian and Laird method was used to develop random-effect meta-analyses. Two hundred and fifty studies comprising 493,475 participants from 49 countries were included. During COVID-19, the estimated global prevalence of sleep disturbances was 40.49% [37.56; 43.48%]. Bayesian meta-analysis revealed an odds of 0.68 [0.59; 0.77] which translates to a rate of approximately 41%. This provides reassurance that the estimated rate using classical meta-analysis is robust. Six major populations were identified; the estimated prevalence of sleep problem was 52.39% [41.69; 62.88%] among patients infected with COVID-19, 45.96% [36.90; 55.30%] among children and adolescents, 42.47% [37.95; 47.12%] among healthcare workers, 41.50% [32.98; 50.56%] among special populations with healthcare needs, 41.16% [28.76; 54.79%] among university students, and 36.73% [32.32; 41.38%] among the general population. Sleep disturbances were higher during lockdown compared to no lockdown, 42.49% versus 37.97%. Four in every ten individuals reported a sleep problem during the COVID-19 pandemic. Patients infected with the disease, children, and adolescents appeared to be the most affected groups.

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.

Narrative review of the COVID-19, healthcare and healthcarers thematic series

This review covers the thematic series of 22 papers selected from among manuscripts published by BJPsych Open concerning coronavirus disease 2019 (COVID-19) and healthcare. We report nine papers that cover concepts and epidemiology relating to the public and patients. We review 11 papers about the impact of COVID-19 on healthcare services and their staff in 15 countries. Two papers consider the psychosocial impact on staff working in mental health services in the UK. Most papers report cross-sectional analyses of data collected from convenience samples by self-reported surveys conducted at single times. They have limitations of generalisability, do not enable conclusions about diagnosis or causality, and many are likely to have attendant bias and noise. BJPsych Open published these papers to meet requirements for early indications of the mental health impact of COVID-19 on the public and on healthcare staff. They claim high prevalence of symptoms of anxiety, depression and post-traumatic stress. We contrast these findings with selected reports of studies with different methodologies published elsewhere. We emphasise the need for longitudinal clinical studies with refined sampling and methodological rigour. We identify several longitudinal research programmes; two in this series. We advocate tuning advice offered about caring for the public and healthcare staff to the realities of their circumstances and their perceptions of need in the context of findings from further longitudinal studies. We draw attention to the importance of the social, relationship and environmental circumstances of the public and healthcare staff in order to understand their distress and their risks of developing mental health disorders.

Mania and hypomania associated with COVID-19: a series of 15 cases seen by the consultation-liaison psychiatry service in Qatar

Background: A range of neuropsychiatric diagnoses have been reported in association with coronavirus disease 2019 (COVID-19). However, only sporadic cases of mania or hypomania have been reported in patients with COVID-19. This study aimed to report clinical characteristics of 15 consecutive cases of COVID-19-associated mania or hypomania seen in three general hospitals in Qatar in the early months of the pandemic in 2020.

Methods: This study is a retrospective case-note review of 15 cases of COVID-19-associated mania or hypomania (confirmed by polymerase chain reaction test), seen as inpatient consultations out of the first 100 consecutive patients managed by consultation-liaison psychiatric teams in Qatar between 2 March 2020 and 7 July 2020.

Results: The mean age of the 15 patients was 40 years. Twelve patients had mania, and three had hypomania. Regarding the physical severity of COVID-19, 10 patients were asymptomatic, two had upper respiratory tract symptoms alone and three had pneumonia. None of the patients were intubated. Potential risk factors for mania/hypomania included pandemic-related psychosocial stress before admission (n = 9), past history of mania/bipolar disorder (n = 6) or psychosis (n = 2), raised inflammatory markers (n = 7) and steroid use (n = 3). None had a history of recent substance misuse. Other than one patient with advanced cancer, none had comorbidity regarded as likely to have caused mania or hypomania. Three patients had mild white matter ischaemic changes on brain imaging. Standard pharmacological treatment for mania (i.e. antipsychotic medication supplemented by prn benzodiazepines) was effective. Ten patients were discharged home from the COVID-19 facility where they presented, but five required transfer to Qatar's psychiatric hospital for further treatment of mania.

Conclusion: The association of mania or hypomania with COVID-19 may be spurious (e.g. representing an initial presentation of bipolar disorder) or causal. The reported cases illustrate a range of potential aetiological mechanisms by which COVID-19 could cause mania or hypomania. Cohort studies are necessary to determine the incidence, aetiology and prognosis of COVID-19-associated mania/hypomania.

Emerging Psychiatric Themes in Post-COVID-19 Patients on a Psychiatry Consultation-liaison Service

The need for consultation-liaison psychiatry on COVID-19 wards has substantially increased since the start of the pandemic. In this cross-sectional study, we aimed to summarize the characteristics of patients admitted to the post-COVID-19 ward of the American University of Beirut Medical Center who received a psychiatric consultation. We collected relevant sociodemographic and medical data, information about past psychiatric history, psychiatry consultation details, hospital course, and disposition outcome. We also conducted chi-square and binary logistic regression analyses to assess the association between the different variables and disposition outcome. A total of 52 patients (mean age 57.33 years; equal gender distribution) were seen by the psychiatry consult-liaison team. Most had medical comorbidities and 21.2% required intubation. The most prevalent psychiatric diagnoses were delirium (30.8%), major depressive episode (15.4%), and other anxiety disorder (15.4%). Pharmacological management was implemented in 90.4% of cases and mainly included second-generation antipsychotics (36.5%). Non-pharmacological interventions consisted of those related to delirium and therapy for anxiety. Only intubation was significantly associated with disposition outcome (p = 0.004). This study highlights the various psychiatric themes emerging during the acute and post-acute periods of hospitalization for COVID-19. Hospitalized individuals recovering from the infection should be diligently screened and referred to the psychiatry consultation-liaison team to ensure the implementation of appropriate interventions.

Delirious mania in a patient with COVID-19 pneumonia

Delirious mania (the coexistence of delirium and mania) is described in the literature but not recognised in standard nosologies. We report a woman in her late 30s, with no psychiatric history, who presented with concurrent symptoms of mania and delirium. She was diagnosed with COVID-19 pneumonia (positive reverse transcription-PCR test). There was no history of substance misuse or concurrent medical illness. CT head scan was normal as were blood investigations, other than elevated inflammatory markers. She received standard treatment for COVID-19 pneumonia and lorazepam and quetiapine to treat her neuropsychiatric symptoms. She made a full recovery after 9 days. She was apyrexial with normal oxygen saturation throughout her illness. The case shows that severe neuropsychiatric symptoms can complicate otherwise mild COVID-19 pneumonia with neuroinflammation being a possible mechanism. A diagnosis of delirious mania appears to better capture the complexity of the presentation than a diagnosis of mania or delirium alone.

A living systematic review of the psychological problems in people suffering from COVID-19

OBJECTIVES

We aimed to investigate the psychological problems on people infected with SARS-CoV-2 during the pandemic.

METHODS

In this living systematic review and meta-analyses, we searched seven electronic databases for cross-sectional studies and longitudinal studies on psychological problems on COVID-19 patients from Jan 1, 2020 to Oct 7, 2020. The primary outcome was prevalence of various psychological problems such as anxiety, depression, stress, insomnia, somatization, and fear. We pooled data for prevalence with their 95% confidence interval (CI) using random effect models and assessed the study quality based on the 11-item checklist recommended by the Agency for Healthcare Research and Quality.

RESULTS

Fourty-four studies, including studies from China(35), Italy(2), Iran(2), India(1), Korea(1), Ecuador(1), Switzerland(1), Germany(1), were identified by comprising a total of 8587 completed questionnaires and 38 studies for meta-analyses. The prevalence of anxiety, depression, post-traumatic stress disorder(PTSD), insomnia, somatization, and fear in patients with COVID-19 was 16.6% (10.1%-23.1%), 37.7% (29.3%-46.2%), 41.5% (9.3%-73.7%), 68.3% (48.6%-88.0%), 36.5% (20.2%-52.8%), 47.6% (9.4%-85.7%), respectively. The prevalence of anxiety, depression, and insomnia in severe COVID-19 patients (intensive care unit inpatients) was higher than mild or clinically stable COVID-19 patients.

LIMITATIONS

A significant degree of heterogeneity in terms of populations, sampling methods, scales was noted across studies.

CONCLUSIONS

There existed high proportions of COVID-19 patients with psychological problem. The prevalence of psychological problems was closely related to the patients themselves, their surroundings and social support. It is imperative to provide ontime psychological care service for COVID-19 patients and to follow-up them for a longer period.

Cerebrospinal fluid cytokine, chemokine, and SARS-CoV-2 antibody profiles in children with neuropsychiatric symptoms associated with COVID-19

Background

Neuropsychiatric symptoms and CSF cytokine, chemokine, and SARS-COV-2 antibody profiles are unknown in pediatric patients with COVID-19 or multisystem inflammatory syndrome (MIS-C), (NP-COVID-19).

Methods

Children at a single pediatric institution quaternary referral center with laboratory-confirmed COVID-19 or MIS-C and neuropsychiatric symptoms were included in this retrospective case series. Clinical symptoms, ancillary testing data, treatments and outcomes are described. Multiplexed electrochemiluminescence assays for cytokines, chemokines and SARS-CoV-2 antibodies were tested in the CSF NP-COVID-19 patients compared to five controls and were analyzed using the Student's t-test.

Results

Three of five NP-COVID-19 patients had psychiatric symptoms, and two patients had encephalopathy and seizures. All patients had full or near resolution of neuropsychiatric symptoms by discharge. One patient received intravenous steroids for treatment for psychiatric symptoms; 3/5 other patients received immunotherapy for MIS-C, including IVIG, high-dose steroids, anakinra, and tocilizumab. Pro-inflammatory chemokines, including MIG, MPC, MIP-1β, and TARC were significantly elevated in NP-COVID-19 patients compared to controls. Two of five patients had elevated CSF neurofilament light chain. CSF SARS-CoV-2 antibody titers to the full-length spike, receptor binding domain and N-terminal domain were significantly elevated. SARS-CoV-2 antibody titers strongly correlated with pro-inflammatory chemokines/cytokines, including IL-1β, IL-2, IL-8, TNF-α, and IFN-γ (P≤0.05 for all).

Conclusions

A spectrum of neuropsychiatric clinical manifestations can occur in children with SARS-CoV-2 infection. CSF pro-inflammatory chemokines and SARS-CoV-2 antibodies may serve as biomarkers of SARS-CoV-2 mediated NP-COVID-19. Additional study is required to understand the pathophysiologic mechanisms of neuroinflammation in children with COVID-19 and MIS-C.

Evaluation of Psychiatric Morbidity in COVID-19-Positive Inpatients Referred to Consultation Liaison Psychiatry in a Tertiary Care Hospital

BACKGROUND

The COVID-19 pandemic has led to the risk of common mental illnesses. Consultation liaison psychiatry has been one of the most requested services in the face of this pandemic. We aimed to assess (a) the prevalence of psychiatric illness, (b) different types of psychiatric diagnoses, (c) presenting complaints, (d) reasons for psychiatric referrals, and (e) psychiatric intervention done on COVID-19 positive inpatients referred to consultation liaison psychiatry at tertiary care hospital.

METHOD

This was a retrospective study of data collected from April 1, 2020, to September 15, 2020. Total 300 patients were referred and diagnosed with clinical interview and Diagnostic and Statistical Manual for Mental Disorder Fifth Edition criteria. Analysis was done using chi-square test, Kruskal-Wallis test, and fisher exact test.

RESULTS

Out of 300 patients, 26.7% had no psychiatric illness. Adjustment disorder was the commonest psychiatric diagnosis (43%), followed by delirium (10%). Statistically significant differences were found for parameters like Indian Council of Medical Research Category 4 of the patient, (hospitalized severe acute respiratory infection) (P value < 0.001), medical comorbidity (P value = 0.023), and past history of psychiatric consultation (Fisher exact test statistic value <0.001). Behavioral problem (27.6%) was the commonest reason for psychiatric referral. Worrying thoughts (23.3%) was the most frequent complaint. A total of 192 (64.3%) patients were offered pharmacotherapy.

CONCLUSIONS

Psychiatric morbidity was quite high (73.3%) among them and adjustment disorder was the commonest (43%) psychiatric diagnosis followed by delirium (10%). Pharmacotherapy was prescribed to 64.3% patients and psychosocial management was offered to most of the referred patients.

Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase

COVID-19 is associated with neuropsychiatric complications, the most frequent one being anxiety. Multiple biological and psychosocial factors contribute to anxiety in COVID-19. Among the biological factors, stress, genetics, gender, immune system, resilience, anosmia, hypogeusia, and central nervous system infection with SARS-CoV-2 are key. Anxiety is a complication of COVID-19 that may exacerbate the infection course, and the infection may exacerbate anxiety. We present the mechanisms of anxiety in symptomatic or asymptomatic COVID-19. We discuss the presentation of anxiety in patients without or with prior psychiatric illness, and with co-morbidities. Timely diagnosis and management of anxiety in COVID-19 patients is important. Given the frequent complication of COVID-19 with Acute Respiratory Distress Syndrome and Intensive Care Unit stay, anxiety may be a long-term complication. We review the diagnostic tools for anxiety in COVID-19, and summarise pharmacologic and non-pharmacologic treatments. We provide recommendations for diagnosis, treatment, prevention and follow up of anxiety in COVID-19.Key pointsPatients with COVID-19 (symptomatic or asymptomatic) exhibit a high frequency of neuropsychiatric complications with highest percentage attributed to anxiety.Multiple biological and psychosocial risk factors for anxiety exist in COVID-19-ill individuals. Biological risk factors include stress, resilience, genetics, gender, age, immune system, direct infection of the central nervous system (CNS) with SARS-CoV-2, comorbid psychiatric and general medical illnesses, ARDS and ICU stay. Anosmia and hypogeusia are COVID-19-specific anxiety risk factors. Knowledge of the anxiety risk factors is essential to focus on timely interventions, because anxiety may be a complication of and exacerbate the COVID-19 course.An inverse correlation exists between resilience and anxiety because of COVID-19, and therefore efforts should be made to increase resilience in COVID-19 patients.In COVID-19, important anxiety mechanism is neuroinflammation resulting from activation of the immune system and an ensuing cytokine storm.The general approach to management of anxiety in COVID-19 should be compassionate, similar to that during trauma or disaster, with efforts focussed on instilling a sense of hope and resilience.In selecting pharmacological treatment of anxiety, the stress response and immune system effects should be key. Medications with cardio-respiratory adverse effects should be avoided in patients with respiratory problems.Anxiety is a disorder that will require for long-term follow up at least one month after COVID-19.

Agitation in schizophrenia: origins and evidence-based treatment

PURPOSE OF REVIEW

Agitation associated with schizophrenia remains an important clinical concern and if not managed effectively, can escalate into aggressive behavior. This is a review of the recent biomedical literature on agitation in individuals with schizophrenia.

RECENT FINDINGS

Themes in the recent literature include consideration of comorbidities such as cigarette smoking and cannabis use. Surveys reveal that pharmacological approaches to manage agitation have changed little, with haloperidol remaining in common use and intramuscular administration of antipsychotics and/or benzodiazepines being frequently administered to more severely agitated/aggressive individuals. Of note, ketamine has been recently adopted for use in severe agitation in medical emergency departments, but the risk of this medication for people with schizophrenia is unclear. At present, inhaled loxapine remains the only rapidly acting noninjectable FDA-approved treatment for agitation associated with schizophrenia. In development is an intranasal formulation for olanzapine (a well characterized atypical antipsychotic already approved to treat agitation) and a sublingual film for dexmedetomidine (an α2-adrenergic agonist used as an anesthetic and now being repurposed).

SUMMARY

Comorbidities can contribute to agitation and can make an accurate differential diagnosis challenging. The ongoing development of rapidly acting novel formulations of antiagitation medications, if successful, may facilitate clinical treatment by providing additional options.

Characteristics and outcomes of COVID-19 inpatients who underwent psychiatric consultations

Patients hospitalized with COVID-19 are at risk of developing many neuropsychiatric disorders, due to the effects of the disease on the brain and the psychosocial pressures of having the disease. The aim of the present study was to evaluate the characteristics and outcomes of patients who were hospitalized with a diagnosis of COVID-19, who underwent psychiatric consultations. The medical records of 892 patients hospitalized due to COVID-19 and the 89 among them who requested psychiatric consultations were analyzed retrospectively. After the psychiatric consultations, patients were most frequently diagnosed with delirium (38.2 %), adjustment disorder (27.0 %), depressive disorder (19.1 %) and anxiety disorder (11.2 %). Patients with delirium had longer hospital stays (p < 0.001), were transferred more frequently to intensive care units (p < 0.001), and had higher mortality rates during their hospital stays (p < 0.001), than all other patients. The need for oxygen (p < 0.001) and mechanical ventilation (p < 0.001) was also significantly higher in delirium patients, as well as in patients who received other psychiatric diagnoses. Neuropsychiatric disorders develop in patients receiving inpatient treatments in COVID-19 wards, and these disorders negatively affect the prognosis of COVID-19. Our findings suggest that the presence of neuropsychiatric disorders in in-patients with COVID-19 might be associated with the negative outcomes of the disease.

The roles of a psychiatrist in the COVID-19 pandemic

The COVID-19 pandemic and its restrictions have strained personal psychological resilience, tested family relationships, fragmented local communities, disrupted schools and other educational institutions, exhausted health and social services, and drained national economies. Initial concerns necessarily focused on the ability of primary care services and general hospitals to cope with a potentially overwhelming wave of physically unwell patients. Attention is now being drawn to adverse effects of the pandemic on individual and societal mental health. Mental health services have important roles in mitigating the adverse effects of the pandemic and associated measures such as enforced isolation and regional lockdown on individual mental health, in supporting the recovery of psychologically affected individuals and an exhausted health workforce, and in fostering community resilience and cohesiveness.

Genetic Predisposition Between COVID-19 and Four Mental Illnesses: A Bidirectional, Two-Sample Mendelian Randomization Study

Background: The outbreak of 2019 coronavirus disease (COVID-19) has become a global pandemic. Although it has long been suspected that COVID-19 could contribute to the development of mental illness, and individuals with a pre-existing mental illness may have a higher risk of and poorer outcomes from COVID-19 infection, no evidence has established a causal association between them thus far. Methods: To investigate associations in support of a causal association between the severity of COVID-19 and mental illnesses, we leveraged large-scale genetic summary data from genome-wide association study (GWAS) summary datasets, including attention-deficit/hyperactivity disorder (ADHD) (n = 55,374), schizophrenia (n = 77,096), bipolar disorder (n = 51,710), and depression (n = 173,005), based on a previous observational study. The random-effects inverse-variance weighted method was conducted for the main analyses, with a complementary analysis of the weighted median and MR-Egger approaches and multiple sensitivity analyses assessing horizontal pleiotropy and removing outliers in two different COVID-19 databases. Results: The Mendelian randomization (MR) analysis indicated that ADHD [odds ratio (OR) = 1.297; 95% confidence interval (CI), 1.029-1.634; p = 0.028] increased the risk of hospitalization due to COVID-19. A similar association was obtained in MR sensitivity analyses of the weighted median. In addition, genetically predicted COVID-19 was significantly associated with schizophrenia (OR = 1.043; 95% CI, 1.005-1.082; p = 0.027). Conclusions: Although many studies have reported a causal relationship between COVID-19 and mental illness, our study shows that this increased risk is modest. However, considering the characteristics of ADHD that might further increase the individuals' vulnerability to being infected by COVID-19, the ongoing massive worldwide exposure to COVID-19, and the high burden of schizophrenia, we believe that it is necessary to offer preventative measures to these populations and to provide more evidence in understanding the neurological impact of COVID-19.

Burden of Sleep Disturbance During COVID-19 Pandemic: A Systematic Review

Coronavirus disease 2019 (COVID-19) pandemic may exert adverse impacts on sleep among populations, which may raise awareness of the burden of sleep disturbance, and the demand of intervention strategies for different populations. We aimed to summarize the current evidence for the impacts of COVID-19 on sleep in patients with COVID-19, healthcare workers (HWs), and the general population. We searched PubMed and Embase for studies on the prevalence of sleep disturbance. Totally, 86 studies were included in the review, including 16 studies for COVID-19 patients, 34 studies for HWs, and 36 studies for the general population. The prevalence of sleep disturbance was 33.3%-84.7%, and 29.5-40% in hospitalized COVID-19 patients and discharged COVID-19 survivors, respectively. Physiologic and psychological traumatic effects of the infection may interact with environmental factors to increase the risk of sleep disturbance in COVID-19 patients. The prevalence of sleep disturbance was 18.4-84.7% in HWs, and the contributors mainly included high workloads and shift work, occupation-related factors, and psychological factors. The prevalence of sleep disturbance was 17.65-81% in the general population. Physiologic and social-psychological factors contributed to sleep disturbance of the general population during COVID-19 pandemic. In summary, the sleep disturbance was highly prevalent during COVID-19 pandemic. Specific health strategies should be implemented to tackle sleep disturbance.

COVID-19-associated psychosis: A systematic review of case reports

OBJECTIVES

To describe the comorbidities, presentations, and outcomes of adults with incident psychosis and a history of COVID-19.

METHODS

We completed a descriptive systematic review of case reports according to PRISMA guidelines, including cases of adult patients with incident psychosis and antecedent or concurrent COVID-19. We extracted patient demographics, comorbidities, clinical course, and outcomes, and assessed cases for quality using a standardized tool.

RESULTS

Of 2396 articles, we included 40 reports from 17 countries, comprising 48 patients. The mean age of patients was 43.9 years and 29 (60%) were males. A total of 7 (15%) had a documented psychiatric history, 6 (13%) had a substance use history and 11 (23%) had a comorbid medical condition. Delusions were the most common (44 [92%]) psychiatric sign and psychosis lasted between 2 and 90 days. A total of 33 (69%) patients required hospitalization to a medical service and 16 (33%) required inpatient psychiatric admission. The majority (26 [54%]) of cases did not assess for delirium and 15 (31%) cases were judged to be of high risk of bias.

CONCLUSIONS

Despite the growing awareness of COVID-19's association with incident psychosis at a population level, cases of COVID-19-associated psychosis often lacked clinically relevant details and delirium was frequently not excluded. PROSPERO registration number: CRD42021256746.

Reduced Activity in an Inpatient Liaison Psychiatry Service During the First Wave of the COVID-19 Pandemic: Comparison With 2019 Data and Characterization of the SARS-CoV-2 Positive Cohort

Background: The COVID-19 pandemic led to changes in the way that healthcare was accessed and delivered in the United Kingdom (UK), particularly during the peak of the first lockdown period (the "first wave") beginning in March 2020. In some patients, COVID-19 is associated with acute neuropsychiatric manifestations, and there is suggestion that there may also be longer term neuropsychiatric complications. Despite this, at the time of writing there are only emerging data on the direct effects of the COVID-19 pandemic on psychiatric care. Methods: In this retrospective study we analyzed referrals to an inpatient liaison psychiatry department of a large acute teaching hospital during the first wave of covid-19 in the UK and compared this data to the same period in 2019. Results: We saw a 40% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for both psychosis or mania and delirium. Almost one third (28%) of referred patients tested positive for COVID-19 at some point during their admission, with 40% of these presenting with delirium as a consequence of their COVID-19 illness. Save delirium, we did not find evidence for high prevalence of new-onset acute mental illness in COVID-19 positive patients. Conclusion: Our data indicate decreased clinical activity in our inpatient psychiatry liaison department during the first wave of the COVID-19 pandemic, although a relative increase in relative increase in referrals for psychosis or mania, suggesting less of a relative decrease in more severe cases of mental illness. The reasons for this are likely multifactorial, including structural changes in the NHS and patient reluctance to present to emergency departments (ED) due to infection fears and Government advice. Our data also supports the literature suggesting the high relative prevalence of delirium in COVID-19, and we support integration of psychiatry liaison teams in acute general hospital wards to optimize delirium management. Finally, consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the mental health of people reluctant to visit EDs.

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

Historical epidemiological perspectives from past pandemics and recent neurobiological evidence link infections and psychoses, leading to concerns that COVID-19 will present a significant risk for the development of psychosis. But are these concerns justified, or mere sensationalism? In this article we review the historical associations between viral infection and the immune system more broadly in the development of psychosis, before critically evaluating the current evidence pertaining to SARS-CoV-2 and risk of psychosis as an acute or post-infectious manifestation of COVID-19. We review the 42 cases of psychosis reported in infected patients to date, and discuss the potential implications of in utero infection on subsequent neurodevelopment and psychiatric risk. Finally, in the context of the wider neurological and psychiatric manifestations of COVID-19 and our current understanding of the aetiology of psychotic disorders, we evaluate possible neurobiological and psychosocial mechanisms as well as the numerous challenges in ascribing a causal pathogenic role to the infection.

Why Severe COVID-19 Patients Are at Greater Risk of Developing Depression: A Molecular Perspective

The prevailing evidence suggests that patients with severe COVID-19 seem to have an overreaction of the immune system demonstrating exacerbated levels of inflammation caused by a "cytokine storm." At this early stage, the mechanisms underpinning COVID-19 are still subject to intense scrutiny and the long-term mental health consequences as a result of the disease are unknown. Here we discuss the hypothesis that patients who survive severe COVID-19 and who experience significant activation of the immune system, are at greater risk of developing depression. We posit that a phenomenon known as cytokine storm dramatically activates the enzyme indoleamine 2,3-dioxygenase (IDO-1), resulting in the increase in kynurenine metabolites. Kynurenine is metabolized by IDO-1 in the brain, producing chemokines, in which a prolonged exposure may result long-term brain impairment. In this article, we also propose the possibility that a SARS-CoV-2 neuroinvasion increases the local levels of angiotensin II by angiotensin-converting enzyme 2 down-regulation. Thereby, angiotensin II could increase kynurenine metabolites producing pro-oxidative and pro-inflammatory effects, resulting in impairment of cognitive function, enhanced oxidative stress and decreased brain-derived neurotrophic factor. It is our premise that patients who experience such a cytokine storm may be at increased risk of long-term mental illness, such as depression.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review

Background: The COVID-19 pandemic has caused morbidity and mortality, as well as, widespread disruption to people's lives and livelihoods around the world. Given the health and economic threats posed by the pandemic to the global community, there are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review (LSR) focuses on suicide prevention in relation to COVID-19, with this iteration synthesising relevant evidence up to June 7 th 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. Results: Searches identified 2070 articles, 29 (28 studies) met our inclusion criteria, of which 14 articles were research letters or pre-prints awaiting peer review. All articles reported observational data: 12 cross-sectional; eight case series; five modelling; and three service utilisation studies. No studies reported on changes in rates of suicidal behaviour. Case series were largely drawn from news reporting in low/middle income countries and factors associated with suicide included fear of infection, social isolation and economic concerns.   Conclusions:  A marked improvement in the quality of design, methods, and reporting in future studies is needed. There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. PROSPERO registration: CRD42020183326 01/05/2020.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review

Background: The COVID-19 pandemic has caused considerable morbidity, mortality and disruption to people's lives around the world. There are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review synthesises findings from emerging literature on incidence and prevalence of suicidal behaviour as well as suicide prevention efforts in relation to COVID-19, with this iteration synthesising relevant evidence up to 19 th October 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. We exclude one-off cross-sectional studies without either pre-pandemic measures or comparisons of COVID-19 positive vs. unaffected individuals. Results: Searches identified 6,226 articles. Seventy-eight articles met our inclusion criteria. We identified a further 64 relevant cross-sectional studies that did not meet our revised inclusion criteria. Thirty-four articles were not peer-reviewed (e.g. research letters, pre-prints). All articles were based on observational studies. There was no consistent evidence of a rise in suicide but many studies noted adverse economic effects were evolving. There was evidence of a rise in community distress, fall in hospital presentation for suicidal behaviour and early evidence of an increased frequency of suicidal thoughts in those who had become infected with COVID-19. Conclusions:  Research evidence of the impact of COVID-19 on suicidal behaviour is accumulating rapidly. This living review provides a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide risk as the longer term impacts of the pandemic on suicide risk are researched.