COVID-19: Delirium first,

depression, anxiety, insomnia

later?
Publish date: May 21, 2020 By  Megan Brooks

Severe COVID-19 may cause delirium in the acute stage of illness, followed by the
possibility of depression, anxiety, fatigue, insomnia, and posttraumatic stress
disorder (PTSD) over the longer term, new research suggests.
Results from “the first systematic review and meta-analysis of the psychiatric
consequences of coronavirus infection” showed that previous coronavirus
epidemics were associated with a significant psychiatric burden in both the acute
and post-illness stages.

“Most people with COVID-19 will not develop any mental health problems, even
among those with severe cases requiring hospitalization, but given the huge
numbers of people getting sick, the global impact on mental health could be
considerable,” co–lead investigator Jonathan Rogers, MRCPsych, Department of
Psychiatry, University College London, United Kingdom, said in a news release.

The study was published online May 18 in Lancet Psychiatry.

Need for Monitoring, Support

The researchers analyzed 65 peer-reviewed studies and seven preprint articles with
data on acute and post-illness psychiatric and neuropsychiatric features of patients
who had been hospitalized with COVID-19, as well as two other diseases caused by
coronaviruses – severe acute respiratory syndrome (SARS), in 2002–2004, and
Middle East respiratory syndrome (MERS), in 2012.

“Our main findings are that signs suggestive of delirium are common in the acute
stage of SARS, MERS, and COVID-19; there is evidence of depression, anxiety,
fatigue, and post-traumatic stress disorder in the post-illness stage of previous
coronavirus epidemics, but there are few data yet on COVID-19,” the investigators
write.

The data show that among patients acutely ill with SARS and MERS, 28%
experienced confusion, 33% had depressed mood, 36% had anxiety, 34% suffered
from impaired memory, and 42% had insomnia.
After recovery from SARS and MERS, sleep disorder, frequent recall of traumatic
memories, emotional lability, impaired concentration, fatigue, and impaired
memory were reported in more than 15% of patients during a follow-up period that
ranged from 6 weeks to 39 months.

In a meta-analysis, the point prevalence in the post-illness stage was 32% for PTSD
and about 15% for depression and anxiety.

In patients acutely ill with severe COVID-19, available data suggest that 65%
experience delirium, 69% have agitation after withdrawal of sedation, and 21%
have altered consciousness.

In one study, 33% of patients had a dysexecutive syndrome at discharge,

characterized by symptoms such as inattention, disorientation, or poorly organized
movements in response to command. Currently, data are very limited regarding
patients who have recovered from COVID-19, the investigators caution.

“To avoid a large-scale mental health crisis, we hope that people who have been
hospitalized with COVID-19 will be offered support, and monitored after they
recover to ensure they do not develop mental illnesses, and are able to access
treatment if needed,” senior author Anthony David, FMedSci, from UCL Institute
of Mental Health, said in a news release.

“While most people with COVID-19 will recover without experiencing mental
illness, we need to research which factors may contribute to enduring mental
health problems, and develop interventions to prevent and treat them,” he added.

Be Prepared
The coauthors of a linked commentary say it makes sense, from a biological
perspective, to merge data on these three coronavirus diseases, given the degree to
which they resemble each other.

They caution, however, that treatment of COVID-19 seems to be different from

treatment of SARS and MERS. In addition, the social and economic situation of
COVID-19 survivors’ return is completely different from that of SARS and MERS
survivors.

Findings from previous coronavirus outbreaks are “useful, but might not be exact
predictors of prevalences of psychiatric complications for patients with COVID-19,”
write Iris Sommer, MD, PhD, from University Medical Center Groningen, the
Netherlands, and P. Roberto Bakker, MD, PhD, from Maastricht University
Medical Center, the Netherlands.

“The warning from [this study] that we should prepare to treat large numbers of
patients with COVID-19 who go on to develop delirium, post-traumatic stress
disorder, anxiety, and depression is an important message for the psychiatric
community,” they add.

Sommer and Bakker also say the reported estimates of prevalence in this study
should be interpreted with caution, “as true numbers of both acute and long-term
psychiatric disorders for patients with COVID-19 might be considerably higher.”

Funding for the study was provided by the Wellcome Trust, the UK National
Institute for Health Research (NIHR), the UK Medical Research Council, the NIHR
Biomedical Research Center at the University College London Hospitals NHS
Foundation Trust, and the University College London. The authors of the study and
the commentary have disclosed no relevant financial relationships.