Comorbidity of Psychiatric Disorders in COVID-19

While many studies initially described mild and transient depressive or anxiety mood symptoms in people infected with or recovering from COVID-19, few studies have focused on patients with severe psychiatric symptoms. New evidence now suggests that in addition to mild mood changes, patients with COVID-19 may be indeed at higher risk for more severe psychiatric symptoms. This week, I would like to focus on a study published in Translational Psychiatry, in which Xie et al. conducted an electronic medical records-based study in Wuhan, China and details psychiatric conditions in patients with COVID-19.

In this study, the authors compared psychiatric presentations in patients who were positive (n=25) or negative (n=55) for COVID-19. COVID-19 diagnosis was confirmed by RNA test before or after hospitalization. The authors included “ICD-10 diagnoses of mental disorders, psychiatric and respiratory symptoms, treatments, and outcomes” (Xie et al., 2020). Their results demonstrate that in the COVID-19 positive group, patients were more likely to experience adjustment disorder (14.0%), acute and transient psychotic disorders, “with associated acute stress” (24.0%), insomnia (72.0%), aggression (64.0%), delusion (50.9%), and abnormally elevated mood (47.3%). On the other hand, in the COVID-19 negative group, the most common clinical diagnoses included  “schizophrenia (24.5%), acute and transient psychotic disorders, without associated acute stress (23.6%), mood disorders (20.0%), and alcohol use disorders (10.9%).” None of the patients in the COVID-19 positive group were diagnosed with mood or alcohol use disorders.

These data reveal that COVID-19 patients suffer from psychiatric symptoms that may be  different from those typically observed in COVID-19 negative patients with first-time psychiatric  disorders. The authors argue that while some causes for the presenting psychiatric symptoms in COVID-19 patients may be due to COVID-related inflammation (eg delirium due to infection) or from the treatments (eg chloroquine-induced psychosis), the medical setting where patients are being treated may actually contribute toward development of psychiatric symptoms. For example, in a stressful ICU setting, where patients require respiratory treatments, patients tend to experience more psychological and environmental stressors. On the other hand, if patients are hospitalized in a psychiatric ward, it may be difficult for the clinical staff to manage COVID-19 as ICU level resources are not available. Additionally, the authors note that COVID-19 positive patients with psychiatric symptoms had a longer hospital stay compared to COVID-19 positive patients without psychiatric symptoms.

This study poses an interesting dilemma about how we as a society could create better environments in the clinical setting for treating both respiratory and psychiatric symptoms during the pandemic. Some potential considerations may include development of psychiatric ICUs, where both medical and psychiatry nurses and physicians can work closely to take care of COVID-positive patients with psychiatric conditions. In addition, development of more specific antiviral drugs that do not contribute to delirium would be helpful, as well as development of measures to decrease delirium in the clinical setting such as increasing virtual contact with family members through technology.

Further research is much needed to tackle this important problem and to help manage and prevent psychiatric symptoms in patients treated for COVID-19 and other infections.