May 18, 2020

expert reaction to systematic review and meta-analysis of studies on mental health effects following severe coronavirus (SARS, MERS and COVID-19) infection

A study, published in The Lancet Psychiatry, looked at the mental health effects following severe coronavirus (SARS, MERS and COVID-19) infection.

Prof Dame Til Wykes FMedSci, Vice Dean Psychology and Systems Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:

“The paper is a good analysis of the evidence so far on emerging psychiatric problems following coronavirus infection. It also sets out what we do not know.”

“Data from studies of SARS and MERS were investigated to estimate how prevalent the mental health problems are. But these studies have many limitations for understanding the effects in those who contract COVID-19. This is not just because the data is of poor quality, but also because COVID-19 survivors may suffer from different physical and mental problems even after recovering from the acute phase. They also return to a different environment – with a continuing “stay at home if you can” message, potential financial worries and a much reduced social support network. These additional social effects may double the mental health difficulties. Alternatively the fact that we are “all in this together”, may provide community support which can lessen the psychiatric effects.”

“The data so far tell us that there are potential negative effects but they are probably not of the catastrophic proportions seen in recent headlines. Following SARS and MERS a minority had long term mental health problems, but we don’t know who they will be. We need longitudinal, high quality investigations of diverse populations to monitor emerging problems so that we can begin to target psychological support and eliminate negative mental health consequences.”

Prof Gitte Moos Knudsen, Chair if the Department of Neurology and Neurobiology Research Unit, Copenhagen University Hospital, said:

“These are early days for a follow-up on (long-term) neuropsychiatric consequences of covid-19 infection, but the paper sets the scene for a comparison with another corona virus, from the SARS epidemic. The theme is of high interest, because of the potential long-term effects after the pandemic has resolved.

“Any condition associated with hospitalization, fever, depletion of sensory inputs – particularly in the elderly – carries an increased risk for delirium. In COVID-19 patients that have been artificially ventilated, a PTSD condition may arise; but we do not have evidence that the frequency is higher in COVID-19 patients than in any other disorder. The few data that we currently have available does not suggest the presence of SARS-CoV-2 RNA in cerebrospinal fluid of covid-19 patients which means that a direct effect of the virus on brain tissue is less likely. What we do know, is that many recovered COVID-19 patients have a continued loss of smell sense which impacts quality of life significantly. In fact, a well-known rodent model of depression involves bulbectomy after which the rodents display a depression-like behaviour. Given that the pandemic only has lasted for less than six months, it is too early to say if COVID-19 is associated with longer-lasting neurological or psychiatric symptoms. New follow-up studies will tell us more about that.”

Dr Michael Bloomfield, UCL Excellence Principal Clinical Research Fellow and Head of Translational Psychiatry Research Group, Division of Psychiatry, University College London, and Consultant Psychiatrist, The Traumatic Stress Clinic, Camden and Islington NHS Foundation Trust, said:

“This is important and well-conducted research. This study provides further evidence that the harm caused by COVID-19 extends beyond the widely reported effects on the lungs. This study tells us that COVID can have profound effects on mental health. Of particular cause for alarm is the finding that a third of patients from previous epidemics experienced post-traumatic stress disorder and it seems reasonable to anticipate similar rates of PTSD in people who have had life-threatening COVID. 

“The COVID trauma response working group (www.traumagroup.org) has identified survivors of severe COVID-19 as one of five groups at high risk of PTSD. Other high risk groups include healthcare workers, people who have lost loved ones, people with existing PTSD and people who are experiencing psychological trauma indirectly resulting from social distancing including victims of abuse.

“Current clinical guidelines for PTSD indicate that patients should be actively monitored for symptoms of PTSD. One way to pick up potential cases of PTSD is to screen patients who have been in hospital COVID. However, at the moment there is no dedicated additional funding for treating PTSD in survivors of COVID and other high risk groups. Extra resources are immediately needed for specialist psychological trauma services in order to offer treatment for PTSD through any potential PTSD screening programme.”

Prof Tom Dening, Professor of Dementia Research, University of Nottingham, said:

“It’s an important paper as we need to know as much as possible about the mental health consequences of COVID-19 infections. These are likely to be common and have lasting affects for people beyond the time they are in hospital.

“The study makes the assumption that it is reasonable to gather together studies from the other two major coronavirus epidemics of the last 20 years – SARS and MERS – and to combine these with the relatively limited data so far available about the effects of COVID-19 upon mental health. It is probably legitimate to do so but a casual glance at the paper may suggest that the paper is mainly about COVID-19, whereas most of the data come from the earlier virus outbreaks. For COVID-19, 12 papers were reviewed of which seven were pre-prints, i.e. not peer-reviewed.

“The paper discusses post-infection outcomes but these are really limited to the SARS and MERS cases. Also, the SARS and MERS patients were significantly younger than the COVID-19 patients, which could make a difference in terms of symptom profile.

“Also worth noting is that the paper discusses severe infections, and therefore is likely to include groups of patients treated in hospital. We know much less about the prevalence of mild or asymptomatic COVID-19 and it is likely that the mental health consequences will be less in milder cases, especially delirium, which is generally a marker for severe physical illness.

“The authors draw attention to how delirium is an important and common feature in people admitted to hospital with coronaviruses. In some situations, probably more so in older people, delirium may even be the presenting feature of a severe COVID-19 infection, so it’s important that health professionals and care home staff are aware of this possibility.

“It is likely that severe COVID-19 infections will have similar rates of PTSD to SARS and MERS. This is entirely understandable when one considers how terrifying the experience must be – extreme breathlessness and a sense that one may be about to die. Or becoming increasingly breathless and in dread of needing to be ventilated. Plus the effects of being in a strange environment in an intensive care unit attended by masked and gowned staff. PTSD is even more likely to occur in patients who have been placed into induced coma and ventilated, since they will have a long gap in their experience that they will be unable to recover. This can be a very unsettling experience for anyone. Previous research has indeed shown that rates of PTSD are high (approaching 50%) after prolonged ICU admissions from whatever cause and especially after mechanical ventilation, so it isn’t clear that coronavirus infections are any different from other serious acute illnesses in that regard.

“The SARS and MERS studies showed that memory impairment was a feature during the illness in about a third of cases and persisted in almost 20% afterwards. Given the older average age of patients with severe COVID-19, it will be important to look at whether they sustain a higher rate of cognitive impairment post illness.

“As is pointed out, most people will not develop major mental health symptoms, but for those that do, the impact may be life-changing. For patients in hospital, probably the main thing is to ensure that staff talk to them, explain clearly what is going on, and if possible, provide opportunities for them to link with family members. Also, there should be greater awareness of support groups for people who have survived being in intensive care, e.g. ICUsteps  https://icusteps.org/support.” 

Prof David Nutt The Edmond J Safra Chair and Head of the Centre for Neuropsychopharmacology, Imperial College London, said:

“It’s a sensible and timely paper with adequate methodology for even though there have been relatively few COVID-19 cases reported as yet to discuss, the back reference to other similar epidemics offers additional evidence – and all point to taking the issue of post-illness psychiatric complications seriously.

“Many infections leave a psychiatric legacy. I have already had several patients email me asking for support after their recovered depressions have returned following COVID-19 infection.  After the 1957 UK flu epidemic a number of cases of severe and treatment-resistant depression emerged and some came under my care in the 1980s. We hope that the “sleeping sickness”  that followed the 1918 pandemic leaving some patients dopamine depleted won’t be seen – but it’s important to consider that in some cases post-COVID-19 depression might result from a neurotoxic effect of either the virus or the immune response to it. In which case these might require quite intensive antidepressant therapy – perhaps with combinations of medicines that target noradrenaline and dopamine as well as serotonin.”

“Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic” by Jonathan Rogers et al. was published in The Lancet Psychiatry at 23:30 UK time on Monday 18 May.

All our previous output on this subject can be seen at this weblink: www.sciencemediacentre.org/tag/covid-19

Declared interests

Dr Michael Bloomfield: I have conducted consultancy work for Spectrum Therapeutics.

Prof Tom Dening: No conflicts of interest

Prof David Nutt: No conflicts of interest

None others received.