Covid 19 Infection linked to dementia, depression, anxiety and PTSD: Lancet

Most people admitted to hospital with severe COVID-19 should recover without experiencing mental illness if infection with SARS-CoV-2 follows a similar course to the coronavirus epidemics of severe acute respiratory syndrome (SARS) in 2002 and Middle East respiratory syndrome (MERS) in 2012, according to the first systematic review and meta-analysis looking at the psychiatric consequences of coronavirus infections in over 3,550 patients hospitalised with SARS, MERS, and COVID-19, published in The Lancet Psychiatry journal.

Nevertheless, the findings suggest that delirium may be common in hospitalised patients in the acute stages of SARS, MERS, and COVID-19 illness.

The study looks at severe cases in which individuals have been treated in hospital, and does not apply to milder cases or asymptomatic cases.

In the longer-term, the analysis suggests that SARS and MERS survivors may be at risk for mental illnesses such as depression, anxiety, fatigue, and post-traumatic stress disorder (PTSD) in the months and years following discharge from hospital. While there are no available data on these diagnoses in COVID-19 patients, the authors say that the medical community should be aware of the potential for high rates of these common mental problems in the aftermath of the current pandemic.

The authors caution that given that the majority (68/72) of studies included in the analysis were of either low or medium quality, and mainly involved data on patients with SARS and MERS treated in hospital, the true mental health effects of COVID-19 infection cannot be precisely predicted and will require ongoing research.

"Our analysis of more than 3,550 coronavirus cases suggests that most people will not suffer from mental health problems following coronavirus infection", says Dr Jonathan Rogers from University College London, UK, who co-led the research. "While there is little evidence to suggest that common mental illnesses beyond short-term delirium are a feature of COVID-19 infection, clinicians should monitor for the possibility that common mental disorders such as depression, anxiety, fatigue, and PTSD could arise in the weeks and months following recovery from severe infection, as has been seen with SARS and MERS." [1]

He continues, "With few data yet for COVID-19, high quality, peer-reviewed research into psychiatric symptoms of patients infected with SARS-CoV-2 as well as investigations to mitigate these outcomes is needed. Monitoring for the development of symptoms should be a routine part of the care we provide." [1]

There are several reasons why severe coronavirus infections might have psychiatric consequences, including possible direct effects of viral infection (including on the central nervous system), the degree of physiological compromise (eg, low blood oxygen), the immune response, and medical interventions. Other reasons relate to the wider social impact, including social isolation, the psychological impact of a novel severe and potentially fatal illness, concerns about infecting others, and stigma.

Although the COVID-19 pandemic has affected a large proportion of the world's population, relatively little is known about its potential effects on mental health.

To provide more evidence, the authors of the new study conducted a systematic review and meta-analysis of all studies and preprint articles (reporting data on the psychiatric and neuropsychiatric features of individuals with suspected or laboratory-confirmed coronavirus infection (SARS, MERS, or SARS-CoV-2) [2].

In total, 65 peer-reviewed studies up to March 18, 2020, and seven preprints between January 1 and April 10, 2020, reporting outcomes for patients admitted to hospital were included in the analyses. Pooled point prevalence (the proportion of people affected at a given time) from seven articles were included in the meta-analysis.

Analysis of data from two studies that systematically assessed common symptoms of patients admitted to hospital with SARS and MERS found that confusion occurred in 28% (36/129) of patients, suggesting delirium was common during acute illness (table 2). There were also frequent reports of low mood (42/129; 33%), anxiety (46/129; 36%), impaired memory (44/129; 34%), and insomnia (34/208; 12%) during the acute stage.

Twelve studies focusing on COVID-19 seemed to show a similar picture, with evidence of delirium (confusion in 26/40 intensive care unit patients, 65%; agitation in 40/58 ICU patients, 69%; and altered consciousness in 17/82 patients who subsequently died, 21%) while acutely ill (table 5).

Six studies looking at SARS and MERS patients after recovery from initial infection found frequent reports of low mood (35/332 patients, 11%), insomnia (34/208, 12%), anxiety (21/171, 12%), irritability (28/218, 13%), memory impairment (44/233, 19%), fatigue (61/316, 19%), and frequent recall of traumatic memories (55/181, 30%) over a follow-up period ranging from 6 weeks to 39 months (table 2).

The researchers estimate that the prevalence of PTSD among SARS and MERS survivors was 33% at an average of 34 months after the acute stage of illness (121/402 cases in four studies), whilst rates of depression and anxiety disorders was around 15% at an average of 23 months (77/517 cases from five studies) and one year (42/284 cases from three studies) after the acute stage respectively (figure 2).

However, the authors warn that these may be overestimates of the true mental health burden resulting from these outbreaks.

"It is likely that the apparently high rates of anxiety disorders, depression, and PTSD seen in SARS and MERS patients overestimate the actual burden", says co-lead author Dr Edward Chesney from King's College London, UK. "The lack of adequate comparison groups or assessment of patients' previous psychiatric history means that it is hard to separate the effects of coronavirus infections from pre-existing conditions, the impact of an epidemic on the population as a whole, or that selection bias (the possibility that patients were recruited into studies on the basis of factors that were associated with subsequent development of psychiatric illness) led to high prevalence figures."[1]