Most reported cases occurred in people in their 30s, 40s, or 50s—and their psychotic events weren't related to the severity of their illness.

By Karen Pallarito
December 30, 2020
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People tend to think of COVID-19 in terms of its physical manifestations, but there’s mounting evidence that it may also mess with your mind. Odd neurological complications, from loss of taste and smell to seizures, have surfaced in some COVID patients, while so-called long haulers have complained of lingering brain fog. Now there’s a possible link between COVID and psychosis.

Doctors around the world are reporting psychotic symptoms in a small number of patients who’ve had the SARS-CoV-2 infection, The New York Times reported on Monday.

The reports are just that: individual episodes of psychosis following a bout of COVID-19. There’s no proof that coronavirus causes psychosis, at least not yet. 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, tells Health.

As lead author of one such report, Dr. Chacko is a firsthand witness to the phenomenon. He describes a 52-year-old man who believed he was the cause of the coronavirus pandemic, whose paranoid delusions led to a suicide attempt. Although two COVID tests turned up negative, his blood work revealed markers of inflammation. Subsequent testing revealed that he had antibodies for COVID-19, suggesting that he 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 raise important questions about COVID’s potential impact on the brain.

Most reported cases of post-COVID psychosis involve people in their 30s, 40s, and 50s, according to the Times. And, interestingly, their psychotic events were not related to the severity of their physical COVID symptoms. Most didn’t get very sick at all, yet their mental symptoms are striking.

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, says 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 reveal the shocking separation from reality that some people are experiencing.

A report out of London, published in the journal Brain, summarizes 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 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,” the authors write. The woman reported visual hallucinations that made her think she was seeing lions and monkeys in her house.

Another report in Neuroscience Letters presents 42 cases of psychosis reported in COVID-infected patients and examines 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, tells Health.

In fact, there’s historical precedent, according to Dr. Watson, who points 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, highlight a post-infection risk of psychotic disorders. “So a lot of us expected we might see some cases of COVID-associated psychosis,” Dr. Watson adds.

One hypothesis is that COVID triggers a “cytokine surge,” or overproduction of immune cells, that leads to an inflammatory response, Dr. Chacko explains. “The virus gets disseminated, crosses through the blood brain barrier, and you get this neurotoxicity,” he says.

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, explains why it’s difficult to tease out the relationship between COVID and psychotic symptoms. “The real problem,” he says, “is that it’s very hard to determine whether, in any one individual, COVID 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, Pollak reasons. So it’s possible the stress of living in COVID times is triggering 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,” he tells Health. Since so many people have 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,” he says. Pollak says large scale psychiatric epidemiology studies as well as additional research into the potential effects of COVID on the brain will be needed to sort out the relationship between COVID and psychosis.

Encouragingly, people experiencing these psychotic episodes do get better: “They respond to therapy,” Dr. Chacko notes. The key, he adds, 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 CDCWHO, and their local public health department as resources.

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