COVID-19: From Psychological Distress to Neuropsychiatric Manifestations

In the six months since COVID-19 has transformed life across the globe, there has been a marked increase in psychological distress stemming from fear of this viral illness and the stigma associated with it, challenges related to sheltering in place and physical distancing, financial strain, isolation, and exacerbation of mental illness (including increased risk of death by suicide) and new barriers to care. Shelter-in-place rules have also raised alarms about domestic violence and child abuse.

A growing literature is helping us to better understand the virus and its impact beyond the respiratory system, neurotropic potential, and possible mechanisms of underlying pathology. The volume of the National Institutes of Health’s LitCovid has increased from 40 publications in late January 2020 to approximately 1,970 publications in early July. LitCovid is a curated literature site of the National Institutes of Health and the National Center for Biotechnology Information that tracks up-to-date scientific information about COVID-19.

Though relatively limited, articles and reports are emerging about acute neurological and neuropsychiatric manifestations of COVID-19 and possible neuropsychiatric sequelae. For example, a retrospective chart review of 214 patients in Wuhan, China, found that approximately 36% of patients had neurological manifestations such as cerebrovascular disease, impaired consciousness, and skeletal muscle injury. Other symptoms of drowsiness, edema, stroke, convulsions, and coma are also reported in literature.

An article by Troyer et al. in the July issue of Brain, Behavior, and Immunity described the emergence of neuropsychiatric symptoms such as anxiety, depression, trauma, insomnia, psychosis, delirium, and suicidality related to past viral pandemics, appearing long after the acute viral spread was over. The authors argued persuasively that physicians and health systems should monitor patients exposed to COVID-19 for neuropsychiatric sequelae.

Another recent systematic review and meta-analysis by Rogers et al. in Lancet Psychiatry reported the prevalence of delirium in the acute stage of COVID-19 infection. The authors encouraged clinicians to monitor for the emergence of depression, anxiety, posttraumatic stress disorder, and other neuropsychiatric disorders post infection.

There are also reports of anosmia/hyposmia and ageusia in patients infected with COVID-19. As such, in late March, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) launched a COVID-19 Anosmia Reporting Tool. The tool is designed to submit data confidentially to AAO-HNS for anosmia and dysgeusia related to COVID-19. Preliminary findings collected from this tool showed that “anosmia was noted in 73% of patients prior to COVID-19 diagnosis and was the initial symptom in 26.6%.” Based on these findings, it appears that anosmia may be a presenting symptom in COVID-19 before other more commonly known symptoms appear.

Proposed mechanisms for pathogenesis of neurological and neuropsychiatric manifestations related to COVID-19 include hypoxic brain injury; interaction of the COVID-19 virus spike protein with ACE-2 receptors of the cerebral capillary endothelium, resulting in damage to the endothelial lining and access to brain; cerebral edema; post-infectious autoimmunity; and immunomodulatory treatments.

As the global community continues to learn about and adjust to many emerging aspects of COVID-19, its multisystem impact is increasingly known. Awareness about neuropsychiatric manifestations related to COVID-19 could prepare the psychiatric community in managing at-risk populations. ■