Can You Develop Severe Psychotic Symptoms From COVID-19?

People tend to think of COVID-19 in terms of its physical manifestations, but there's evidence that it may also mess with your mind. Some people experience "long COVID," which can include mood disorders, according to the Centers for Disease Control and Prevention (CDC). Odd neurological complications surfaced in some patients with COVID-19, while so-called long haulers have complained of lingering brain fog. Researchers have also studied a possible link between COVID-19 and psychosis.

Doctors around the world reported psychotic symptoms in a small number of patients who've had the SARS-CoV-2 infection, TIME reported in March 2022. The reports were about spontaneous episodes of psychosis following a bout of COVID-19. There's no proof, as of April 2022, that SARS-CoV-2 causes psychosis. It's merely an association that medical professionals have observed, albeit a worrisome one.

"I think it's very concerning because, as you're seeing and as you're reading, there are more and more case reports," Mason Chacko, MD, clinical assistant professor of psychiatry in the Department of Consultation-Liaison Psychiatry at Stony Brook University Hospital on Long Island, New York, told Health.

As lead author of one such report from September 2020 published in SN Comprehensive Clinical Medicine, Dr. Chacko was a firsthand witness to the phenomenon. Dr. Chacko described a 52-year-old man who believed he was the cause of the COVID-19 pandemic, and whose paranoid delusions led to a suicide attempt. Although two COVID-19 tests turned up negative, his blood work revealed markers of inflammation. Subsequent testing revealed that he had antibodies for COVID-19, suggesting that he had contracted the virus at some point in time. The man's psychosis was successfully treated through a combination of medications and electroconvulsive therapy, but his case and others raised important questions about COVID-19's potential impact on the brain.

Psychosis is typically characterized as a break with reality. When someone is having a psychotic episode, it can be difficult to determine what's real and what's not, said the National Alliance on Mental Illness (NAMI). Some people with psychosis have hallucinations. They might hear voices or see things that aren't really there or experience strange sensations. Others have delusions, or false beliefs, that come across as utterly irrational.

Multiple case reports in medical journals revealed the shocking separation from reality that some people were experiencing.

In a March 2022 literature review published in the International Journal of Environmental Research and Public Health, researchers noted that "The review of studies shows that this is a notable problem." They added, however, that "The main conclusions of this review should be treated with caution and future studies on this topic are needed."

A report out of London, published in the journal Brain in July 2020, summarized multiple cases of suspected COVID-related neurological disorders. In one instance, a 55 year old woman with no prior psychiatric history was admitted to the hospital after 14 days of COVID-19 symptoms. During her stay, she received minimal oxygen therapy and was discharged three days later. "The following day, her husband reported that she was confused and behaving oddly," wrote the authors. The woman reported visual hallucinations that made her think she was seeing lions and monkeys in her house.

Another November 2020 report from Neuroscience Letters presented 42 cases of psychosis reported in SARS-CoV-2-infected patients and examined possible causes.

"There's a lot of evidence now that exposure to infections, particularly viruses, is associated with the development of a psychotic disorder," lead author Cameron J. Watson, MBBS, who works in the preventive neurology unit at Queen Mary University of London, told Health.

In fact, there's historical precedent, according to Dr. Watson, who pointed to the 1918–1919 Spanish influenza pandemic. Hundreds of cases of post-influenza psychosis were reported during and after that period. More recently, large epidemiological studies using nationwide health records in countries like Denmark highlighted a post-infection risk of psychotic disorders. "So a lot of us expected we might see some cases of COVID-associated psychosis," added Dr. Watson.

One hypothesis is that COVID-19 triggers a "cytokine surge," or overproduction of immune cells, that leads to an inflammatory response, explained Dr. Chacko. "The virus gets disseminated, crosses through the blood-brain barrier, and you get this neurotoxicity," said Dr. Watson.

But is COVID-19 the cause or just a coincidence? Thomas Pollak, PhD, a clinical lecturer in psychiatry at Kings College in London and one of the authors of the Neuroscience Letters report, explained why it's difficult to tease out the relationship between COVID-19 and psychotic symptoms. "The real problem," said Pollak, "is that it's very hard to determine whether, in any one individual, COVID-19 actually caused the psychosis for that person. They may have been likely to develop psychosis at that time anyway."

The pandemic, in and of itself, is a huge psychological stressor, reasoned Pollak. So it's possible the stress of living in COVID-19 times triggers psychotic symptoms, whether or not someone had the infection.

"Even if this virus is causing psychosis, we don't yet know whether it's doing so more than other infections would," said Pollak. Since so many people had the virus, "the incidence of even very rare neuropsychiatric outcomes will be greatly increased relative to other infections, potentially giving the false impression that there's something special about COVID," said Pollak.

Pollak said large scale psychiatric epidemiology studies, as well as additional research into the potential effects of COVID on the brain, would be needed to sort out the relationship between COVID-19 and psychosis.

Encouragingly, people experiencing these psychotic episodes do get better: "They respond to therapy," noted Dr. Chacko. The key, added Dr. Chacko, is to get help early on.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.