COVID-19 Infection: A Neuropsychiatric Perspective
Abstract
CNS Manifestations of COVID-19
Neurological Manifestations
Anosmia and ageusia.
Stroke.
Epilepsy.
GBS and other neuromuscular disorders.
Neuropsychiatric Sequelae of COVID-19
Encephalopathy or delirium.
Neuropsychiatric symptoms and syndromes.
Maladaptive coping styles.
Late Neuropsychiatric Sequelae
Neurodegenerative/Neuroimmunological Disorders
Meta-Analyses
Study | Number and type of studies | Patients | Outcome | Comments |
---|---|---|---|---|
Rogers et al. (8) | 72 (47 studies involved SARS-CoV, 2,068 patients; 13 studies were of MERS-CoV, 515 cases; 12 studies described SARS-CoV-2, 976 patients; 6,390 control subjects) Cohort, cross-sectional, qualitative, case series | 3,559 (patients with SARS, MERS, or SARS-CoV-2) | Patients with COVID-19: delirium: confusion in 26 (65%) of 40 ICU patients and agitation in 40 (69%) of 58 ICU patients in one study; altered consciousness in 17 (21%) of 82 patients who subsequently died in another study. At discharge: 15 (33%) of 45 patients had a dysexecutive syndrome in one study. Two reports of hypoxic encephalopathy. One report of encephalitis. | Patients with SARS or MERS had confusion (27.9%), depressed mood (32.6%), anxiety (35.7%), impaired memory (34.1%), insomnia (41.9%), and steroid-induced mania and psychosis (0.7%). In the postillness stage: depression: 35 (10.5%) of 332 patients; insomnia: 34 (12.1%) of 280; anxiety: 21 (12.3%) of 171; irritability: 28 (12.8%) of 218; memory impairment: 44 (18.9%) of 233; traumatic memories: 55 (30.4%) of 181; sleep disorder: 14 (100%) of 14. Point prevalence of PTSD: 32.2% (121 of 402 patients from four studies); depression: 14.9% (77 of 517 patients from five studies); anxiety disorders: 14.8% (42 of 284 patients from three studies). |
Wang et al. (9) | 41 (20 reporting unspecific neurological symptoms, 20 reporting specific neurological symptoms, and one reporting both; 26 case series, one cohort study, 14 case reports) | 4,700 (patients with COVID-19) | Anosmia (35.7%–85.6%) and dysgeusia (33.3%–88.8%), especially in mild cases GBS Acute inflammation of the brain, spinal cord, and meninges repeatedly reported after COVID-19. | Possible underlying mechanisms can include both direct invasion and maladaptive inflammatory responses. |
Deng et al. (10) | 31 (28 cross-sectional studies, three cohort studies) | 5,153 (patients with COVID-19) | Pooled prevalence of depression: 45% (I2=96%); anxiety: 47% (I2=97%); and insomnia: 34% (I2=98%). | No significant differences in the prevalence estimates between genders; however, the depression and anxiety prevalence estimates varied based on different screening tools. |
Agyeman et al. (26) | 24 (five objective assessments, 19 self-reports) | 8,438 (patients with COVID-19) | Pooled proportions of patients presenting with olfactory dysfunction (41%) and gustatory dysfunction (38.2%). | Increasing mean age correlated with lower prevalence of olfactory (coefficient=−0.076; p=0.02) and gustatory (coefficient=−0.073; p=0.03) dysfunctions. There was a higher prevalence of olfactory dysfunctions with the use of objective measurements compared with self-reports (coefficient=2.33; p=0.01). No significant influence of sex. |
Hawkins et al. (44) | 229 studies/77 patient reports (37 case reports and case series, 40 observational cohort studies) | 12,971 (patients with COVID-19) | Delirium affected >50% of all patients with COVID-19 admitted to ICU (range: 65%–79.5%). | Higher rates were reported in those with severe respiratory disease (disorder of consciousness: 38.9% versus 7.2%; OR=8.18; acute confusional syndrome: 14.9% versus 3.9%; OR=4.31; p<0.001; confusion: 18.5% versus 0%; p<0.01; impaired consciousness: 14.8% versus 2.4%; p<0.001). Similarly, studies of older adults found that significant proportions experienced delirium while hospitalized with COVID-19, often associated with age and frailty, ranging from 29% to 40%. |
Tsai et al. (68) | 50 (11 cohort studies, 11 case series, 28 case reports) | 1,326 (patients with COVID-19) | Olfactory/taste disorders: 35.6% Myalgia: 18.5% Headache: 10.7% Acute CVA: 8.1% Dizziness: 7.9% Altered mental status: 7.8% Seizure: 1.5%. | Other manifestations (case reports): encephalitis, neuralgia, ataxia, GBS, Miller-Fisher syndrome, intracerebral hemorrhage, polyneuritis cranialis, and dystonic posture. |
Brown et al. (54) | 14 (five cross-sectional studies, one survey, one cohort study, one case series, two case reports, three chart reviews, one service evaluation) | 14,465 (one cohort chart review: 13,783 psychiatric patients and 35,909 control patients) | 0.9%–4% incident cases of psychosis in people infected with COVID-19. | Likely associated with steroid or viral exposure, pre-existing vulnerability, and psychosocial stress. |
Bueno-Notivol et al. (46) | 12 (online questionnaires) | 600–7,236 (non-COVID individuals) | Depression: prevalence rates of 7.45%–48.30%; pooled prevalence of depression was 25%, with significant heterogeneity between studies (I2=99.60%, p<0.001). | Compared with a global estimated prevalence of depression of 3.44% in 2017, a pooled prevalence of 25% is 7 times higher, thus suggesting an important impact of the COVID-19 outbreak on people’s mental health. |
Ren et al. (47) | 12 (cross-sectional studies) | 27,475 (21,377 general public/6,098 health care professionals) | Incidence of anxiety (25%; 95% CI=0.19–0.32) and depression (28%; 95% CI=0.17–0.38). | Significant heterogeneity was detected across studies regarding these incidence estimates (I2=99.4%). |
Pinzon et al. (69) | 33 (19 cohort studies, 10 retrospective case series or cross-sectional studies, four case reports) | 7,559 (patients with COVID-19) | Muscle injury or myalgia was the most common (19.2%) neurologic symptom of COVID-19, followed by headache (10.9%), dizziness (8.7%), nausea with or without vomiting (4.6%), concurrent cerebro-vascular disease (4.4%), and impaired consciousness (3.8%). | Most of the included studies were from China: 29 (88%). Underlying cerebrovascular disease was found in 8.5% of the studies. |
Nepal et al. (70) | 37 (12 retrospective studies, two prospective studies, 23 case reports/series) | 2,647 (patients with COVID-19) | The most commonly reported neurological manifestations of COVID-19 were myalgia (11%–44%), headache (7%–14%), altered sensorium (7%–9%), and hyposmia/hypogeusia (5%–6%). | Uncommonly, COVID-19 can also present with CNS manifestations, such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis; PNS manifestations, such as GBS and Bell’s palsy; and skeletal muscle manifestations, such as rhabdomyolysis. |
Collantes et al. (71) | 49 (one prospective study, 35 retrospective studies, 13 case reports/series) | 6,335 (patients with COVID-19) | Proportional point estimates (95% CI): Headache: 0.12 (0.10–0.14; I2=77%); Dizziness: 0.08; (0.05–0.12; I2=82%); Headache plus dizziness: 0.09 (0.06–0.13; I2=0%); Nausea: 0.07 (0.04–0.11; I2=79%); Vomiting: 0.05 (0.03–0.08; I2=74%); Nausea plus vomiting: 0.06 (0.03–0.11; I2=83%); Confusion: 0.05 (0.02–0.14; I2=86%); and Myalgia: 0.21 (0.18–0.25; I2=85%). | The most common neurological complication associated with COVID-19 infection was vascular disorders (n=23). Other associated conditions were encephalopathy (n=3), encephalitis (n=1), oculomotor nerve palsy (n=1), isolated sudden-onset anosmia (n=1), GBS (n=1), and Miller-Fisher syndrome (n=2). |
Abdullahi et al. (72) | 60 (review) 51 (meta-analysis) (46 cohort or cross-sectional studies, four case series, 10 case reports) | 11,069 (patients with COVID-19) | Prevalence of neurological/musculoskeletal manifestations was for smell impairment (35%), taste impairment (33%), myalgia (19%), headache (12%), back pain (10%), dizziness (10%), acute cerebrovascular disease (3%), and impaired consciousness (2%). | The majority (58/60) of the studies had excellent methodological quality. |
Luo et al. (15) | 62 | 162,639 (COVID and non-COVID individuals) | Pooled prevalence of anxiety (33%) and depression (28%). Prevalence of anxiety (56%) and depression (55%) was the highest among patients with preexisting conditions and COVID-19 infection, and it was similar between health care workers and the general public. | Studies from China, Italy, Turkey, Spain and Iran reported higher pooled prevalence among healthcare workers than the general public. Common risk factors included being a woman or nurse, having lower socioeconomic status, having high risk of contracting COVID-19, and social isolation. Protective factors included having sufficient medical resources and up-to-date and accurate information, and taking precautionary measures. |
Panda et al. (73) | 26 (21 prospective/ retrospective/case series, five case reports) | 3,707 (children with COVID-19) | Nonspecific neurological manifestations: headache, myalgia, and fatigue (16.7%). Specific neurological complications: 42 children (1%); encephalopathy (n=25), seizure (n=12), and meningeal signs (n=17). | Rare neurological complications: intracranial hemorrhage, cranial nerve palsy, GBS and vision problems. All children with acute symptomatic seizures survived, suggesting a favorable short-term prognosis. |
Panda et al. (74) | 15 (cross-sectional studies examining the psychological impact of COVID-19 pandemic) | 22,996 (non-COVID children) | Anxiety (34.5%), Depression (41.7%), Irritability (42.3%), and Inattention (30.8%). Behavior/psychological state was affected negatively by the pandemic and quarantine (79.4%). Fear of COVID-19 (22.5%); boredom (35.2%); and sleep disturbance (21.3%). | Caregivers developed anxiety (52.3%) and depression (27.4%), while being in isolation with children. |
Neuroimaging
Neuropsychiatric Adverse Effects of COVID-19 Treatment
Health Care Workers
Psychosocial Impact
Conclusions
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