Aparna Das, MD, and Prasad Padala, MD, MS, FACHE
Dr. Das is a fourth-year resident in psychiatry and Dr. Padala is Professor of Psychiatry and Geriatrics, both at the University of Arkansas for Medical Sciences (UAMS) in Little Rock, Arkansas, USA
Most of us have pondered if physical ailments contribute to psychiatric syndromes or vice versa—the chicken or egg question of psychiatry. The COVID-19 pandemic has brought this question to the forefront as we struggle to explain to our patients whether COVID-19 causes/ worsens mental illness or mental illness increases the risk of contracting COVID. In this commentary, we tackle this very question based on a study of over 62,000 COVID-19 cases (Taquet et al., 2020).
A brief summary of the study
The study looked at two broad questions (phrased in our words):
1. Are persons with a history of a mental disorder significantly more likely to contract COVID-19?
To answer this question, the authors analyzed data from over 1.7 million adults, comparing those who had a documented mental disorder in the previous year (based on ICD-10 codes in the database) to those who did not.
2. What about the opposite? Are persons who contract COVID-19 infection significantly more likely to then develop a new-onset mental disorder?
To answer this question, the study compared over 62,000 COVID-19 patients to six other acute health events, some similar and some different from COVID-19 illness. These six conditions for comparison were influenza, other respiratory tract infections, skin infection, gall bladder stones, urinary stones, urolithiasis, and fracture of a large bone.
When comparing groups, the subjects were matched for 50 different risk factors for COVID-19. That is, the authors tried to make the groups similar in every respect except for the variable being evaluated. For the first question noted above, the variable that differed between the groups was whether or not they had a documented history of a mental disorder in the previous year. For the second question, the groups differed on the presence or absence of COVID-19 infection.
Strengths of the study
The study had several strengths. It used large-scale real-world data and well-defined inclusion and exclusion criteria and attempted to control for about 50 variables that could potentially influence the apparent association between COVID-19 and mental illness.
Does pre-existing mental disorder increase the risk of contracting COVID-19?
The main findings were:
1) People with a documented mental disorder in the previous year had a 1.65 times increased risk of COVID-19 as compared to people without psychiatric illnesses.
2) Within the group with a history of documented mental disorder in the previous year, those with chronic mental disorders had a higher risk of COVID-19 compared to those with a new-onset mental disorder in the previous year.
3) A small difference in the risk of COVID-19 was observed between different psychiatric illnesses. People with psychotic disorders had a slightly higher risk of COVID-19 when compared to those with mood or anxiety disorders.
4) Also, the risk was slightly higher in older adults.
Does COVID-19 increase the risk of subsequent mental disorders?
To answer this question, the primary outcome that the authors looked at was the incidence of mental disorders 14 to 90 days after the diagnosis of COVID-19. About 6% of persons diagnosed with COVID -19 had a new diagnosis of a mental disorder during this period compared to about 3% of patients in comparison groups.
The probability of a new-onset psychiatric diagnosis following COVID-19, in decreasing order of frequency, was as follows (as percentages of patients with COVID-19):
– Anxiety: about 5%
– Mood disorder: about 2%
– Insomnia: about 2%
– Dementia (in those 65 years or older): about 1.5%
– Psychosis: 0.1 %.
The most common anxiety disorder diagnoses that were noted after the diagnosis of COVID-19 were adjustment disorder, generalized anxiety disorder, and to a lesser extent, post-traumatic stress disorder and panic disorder.
Depressive disorder was the most common mood disorder noted after the diagnosis of COVID-19.
Another study on this topic
A cross-sectional study (Zhang et al., 2020) compared the prevalence and severity of psychological distress between three groups:
– Patients newly recovered from COVID-19 infection
– Persons under quarantine
– The general public.
The study found that patients newly recovered from COVID-19 infection were more likely to:
– Be depressed (29%) compared to those who were in quarantine and the general public
– Have severe depressive symptoms compared to those in quarantine.
Bottom line and implications for clinical practice
The answer to the two questions raised above is that BOTH are true. The relationship between COVID-19 and mental disorders appears to be BIDIRECTIONAL.
For mental health clinicians
Patients with psychiatric illnesses are at a higher risk of COVID-19, so special attention should be paid to this issue by mental health clinicians.
1. It is very important that we educate patients with mental disorder and their family members and caregivers about the increased risk of COVID-19 in these patients and strongly encouraging them to follow the public health recommendations regarding reducing the risk of infection.
2. Mental health clinicians have a role in helping patients and their caregivers in accessing and understanding the relevant public health information. Patients may need to be told information in simple language that is tailored to their educational and cognitive level.
3. Re-emphasizing adherence to treatment, especially during this pandemic, is important. If there is a relapse of the mental disorder, the person’s ability to follow public health recommendations about COVID-19 may become even worse and this may increase the risk of COVID-19.
For primary care clinicians and non-mental health clinicians
It is imperative to take a psychiatric history if a patient is diagnosed with COVID-19. Even if there is no past psychiatric history, patients are at a higher risk of developing psychiatric illness after COVID-19 infection. It is important for physicians to be aware of this increased risk and to be watchful so that appropriate help can be offered in a timely manner and, in some cases, prophylactically, for example, behavioral management/sleep hygiene for insomnia.
Primary care clinicians may consider using simple screening tools like PHQ-2 for depression, GAD-7 for anxiety, Pittsburgh Insomnia Rating Scale (PIRS) for insomnia, and MoCA for cognitive impairment. Aftercare plans may also include follow up with a mental health clinician if needed.
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Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, Hu Y, Luo X, Jiang X, McIntyre RS, Tran B, Sun J, Zhang Z, Ho R, Ho C, Tam W. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun. 2020 Jul;87:100-106. doi: 10.1016/j.bbi.2020.04.069. Epub 2020 Apr 27. PMID: 32353518; PMCID: PMC7184991. Not discussed on this page.
Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: a study of 62,354 COVID-19 cases. Pre-print available at: https://www.medrxiv.org/content/10.1101/2020.08.14.20175190v1
Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, Du B. The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav Immun. 2020 Jul;87:49-50. doi: 10.1016/j.bbi.2020.04.031. Epub 2020 Apr 15. PMID: 32304883; PMCID: PMC7156946.
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