Emerging Link Between COVID-19 and Psychosis: A Review of Current Research and Future Directions

Psychosis is a complex condition characterized by delusions, hallucinations, and disorganized thinking, speech, or behavior. The connection between infectious outbreaks and acute psychosis has been recognized since the previous century. Recently, there has been growing apprehension about the potential association between COVID-19 and the emergence of new-onset psychosis. This article examines the existing evidence regarding a potential connection between SARS-CoV-2 and the risk of psychosis, whether as an acute manifestation or a post-infectious consequence of COVID-19.

Unraveling the Connection: Psychosis and SARS-CoV-2

While past viral pandemics suggest increased psychosis, but linking it definitively to SARS-CoV-2 is complex. Consequently, reports of psychosis in COVID-19 patients emerge, yet face challenges like small samples and unaddressed confounding factors.

Unraveling the Causes:

The mechanisms behind this link remain under investigation, but several theories hold promise:

Direct Viral Invasion:

The SARS-CoV-2 virus, responsible for COVID-19, can invade the central nervous system, potentially leading to inflammation and disruptions in brain function, contributing to psychosis.

Immune Response:

The body’s response to the virus, including the release of inflammatory molecules, could indirectly trigger psychotic symptoms.

Psychological Stress:

The pandemic’s emotional and social stressors, including isolation, grief, and uncertainty, can exacerbate pre-existing mental health conditions and potentially trigger new episodes of psychosis.

Medication Interactions:

Certain medications used to treat COVID-19, particularly corticosteroids, have been linked to the development of psychosis in some cases.

Recognizing the Symptoms:

Identifying symptoms of Covid psychosis is crucial for timely intervention. Common signs include:

Delusions:

Fixed, false beliefs not based on reality, such as paranoia about being poisoned or controlled by others.

Hallucinations:

Experiencing sensory perceptions that are not real, such as hearing voices or seeing things that aren’t there.

Disorganized thinking and speech:

Difficulty forming coherent thoughts or communicating effectively.

Changes in behavior and emotions:

Withdrawal from social interactions, erratic behavior, or sudden mood swings.

Treatment and Support:

If you suspect someone experiencing Covid psychosis, seeking professional help is essential. Early intervention is key to managing symptoms and improving outcomes. Treatment typically involves a combination of:

Antipsychotic medication:

To stabilize brain chemistry and reduce psychotic symptoms.

Psychotherapy:

To address underlying psychological factors and develop coping mechanisms.

Social support:

Building a strong support system of family, friends, and healthcare professionals is therefore crucial for recovery.

Insights from a Retrospective Cohort Study

A retrospective cohort study, examining the neurological and psychiatric consequences among 236,379 COVID-19 patients over a 6-month follow-up, revealed intriguing findings. An estimated 0.42% incidence for a first diagnosis of psychotic disorder was reported, alongside a significantly elevated hazard risk (HR) for presenting psychotic symptoms compared to patients with influenza (HR 2.27) or other respiratory tract infections (HR 1.49) during the same period.

Navigating Confounding Factors

Interpreting these findings requires caution due to potential confounders, particularly among hospitalized COVID-19 patients. Factors such as misdiagnosis of delirium, undocumented prior mental illness, and iatrogenic influences should be considered, shedding light on the complexity of attributing psychotic symptoms solely to the virus.

Insights from Systematic Review

To address these concerns, Chaudhary et al. conducted a systematic review, focusing specifically on case reports and case series exploring new-onset psychosis or exacerbation of stable psychosis in COVID-19 patients. Moreover, the review excluded studies involving delirium, encephalitis, steroid use, and other medical conditions contributing to psychotic symptoms.

Patient Profiles and Symptomatology

The systematic review included 57 unique cases, revealing that 66.7% of these patients had no prior psychiatric history. Significantly, most patients exceeded the typical age of psychosis onset, with mean ages of 43.4 years for men and 40.3 years for women. Furthermore, the majority experienced mild COVID-19-related respiratory illnesses, neurological issues, or psychotic symptoms, with around 26.3% presenting moderate-to-severe COVID-19-related disease and complications.

Psychotic Symptoms: Prevalence and Response to Treatment

Predominant psychotic symptoms included delusions and hallucinations. Notably, 72% of the sample achieved complete recovery with low-to-moderate antipsychotic doses, highlighting the potential for successful intervention in addressing COVID-19-related psychosis.

Increased Psychosis Rates in COVID-19 Populations

Several studies have highlighted a higher incidence of psychosis in populations with elevated rates of COVID-19 infection. This phenomenon may be linked to the neuropsychological stress associated with the diagnosis and the use of corticosteroids during treatment, potentially inducing psychosis during either an acute or postinfectious state. Thus, there are reports of patients experiencing psychotic symptoms, including paranoia, delusions of persecution, and hallucinations, even in the absence of systemic symptoms of SARS-CoV-2 infection.

Neurological Mechanisms of Psychosis in COVID-19

Researchers have identified various mechanisms through which COVID-19 can invade the brain. These include the olfactory neural pathway and brain capillary endothelial cells via transmembrane ACE-2 receptors, resulting in a significant inflammatory response, neurotransmitter depletion, and neuronal dysfunction and loss. The consequential neuroinflammatory response, combined with systemic inflammation and hypoxic injury, may contribute to the onset or exacerbation of psychiatric diseases.

Anti-NMDA Receptor Encephalitis and Psychiatric Changes

Reports have surfaced regarding anti-NMDA receptor encephalitis with mood and behavioral changes in individuals infected with SARS-CoV-2. Hence, the connection between viral infections and their impact on the central nervous system has been explored in the context of influenza, H1N1, and previous coronaviruses like SARS and MERS. These viruses have been documented to induce psychotic symptoms, even in patients with no prior psychiatric conditions. The rising case count, therefore, presents the challenge and likelihood of an increasing number of neuropsychiatric manifestations in affected individuals. This section presents a case of a patient with no prior psychiatric history who developed psychosis following COVID-19 infection.

Conclusion

In conclusion, this case highlights the unknowns in COVID-19’s impact on body and brain. The patient’s journey, lacking typical psychosis risk factors but worsened by stress, emphasizes the need for detailed, long-term follow-up to understand the virus’s long-term complications. Thus, the effectiveness of dexamethasone and lithium in treatment illustrates the evolving nature of COVID-related psychiatric care. Additionally, investigating inflammatory proteins as markers in post-COVID psychiatric conditions appears promising. However, it’s crucial to also consider other causes like delirium. Hence, this case stresses the importance of ongoing research into COVID-19’s neurological effects, laying a groundwork for accurate diagnosis and management of potential post-COVID complications.

Looking Ahead:

While research on Covid psychosis is still evolving, understanding this potential link is crucial for improving mental health care during and after pandemics. Further research is needed to establish definitive causal mechanisms, identify risk factors, and develop effective prevention strategies. Additionally, increasing public awareness and destigmatizing mental health issues are essential for individuals experiencing Covid psychosis to seek the help they need

References

Runyan, M., Fawver, J., Coupe, A., & Drouin, M. (2022). New-onset psychosis following COVID-19 infection in a patient with no psychiatric history: A longitudinal case report. Psychiatry Research, 1(2), 100035.

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