Virus World

The Coronavirus Disease 2019 (COVID-19) pandemic has threatened global mental health, both indirectly via disruptive societal changes and directly via neuropsychiatric sequelae after SARS-CoV-2 infection. Despite a small increase in self-reported mental health problems, this has (so far) not translated into objectively measurable increased rates of mental disorders, self-harm or suicide rates at the population level. This could suggest effective resilience and adaptation, but there is substantial heterogeneity among subgroups, and time-lag effects may also exist. With regard to COVID-19 itself, both acute and post-acute neuropsychiatric sequelae have become apparent, with high prevalence of fatigue, cognitive impairments and anxiety and depressive symptoms, even months after infection.

To understand how COVID-19 continues to shape mental health in the longer term, fine-grained, well-controlled longitudinal data at the (neuro)biological, individual and societal levels remain essential. For future pandemics, policymakers and clinicians should prioritize mental health from the outset to identify and protect those at risk and promote long-term resilience. This Review discusses the impact of COVID-19 on mental health, from pandemic-related societal effects to direct infection-related neuropsychiatric sequelae, highlighting the lessons learned and outstanding knowledge gaps.

Published in Nature Medicine (Oct. 3, 2022):

https://doi.org/10.1038/s41591-022-02028-2 

Anxiety disorders, depression, and insomnia were the most common disorders reported after people developed the disease. People across the world have been experiencing a higher level of stress due to the pandemic, but researchers at the University of Oxford have found the link between COVID-19 and mental illness may be more direct than initially thought. A study published in The Lancet found one in five people diagnosed with COVID-19 developed some form of mental illness 90 days after being diagnosed with the disease caused by the novel coronavirus. The patients had not had mental health disorders prior to contracting the coronavirus.  The study analyzed data from 69 million people in the United States, 62,000 of whom were COVID-19 patients. Anxiety disorders, depression, and insomnia were the most common disorders reported after people developed the disease. 

The virus attacks the central nervous system

The authors of the study said they were unsure why the virus would increase mental health problems in people with otherwise no history of mental illness, and that more research is needed.Simon Wessely, a psychiatry professor at King's College London who was not involved in the study, told Reuters the link between mental health and COVID-19 might be explained by how COVID-19 attacks the central nervous system.  Michael Bloomfield, a consultant psychiatrist at University College London, added the effects of the coronavirus coupled with the external stress of the pandemic might be why this correlation between COVID-19 and mental illness exists. "This is likely due to a combination of the psychological stressors associated with this particular pandemic and the physical effects of the illness," Bloomfield told Reuters. 

Previous research found COVID-19 can lead to lasting cognitive effects 

Mental health consequences aren't the only neurological symptoms exhibited by COVID-19 patients. A study published in the Annals of Clinical and Translational Neurology in October found 80% of people hospitalized with COVID-19 had neurological symptoms like muscle aches, dizziness, and confusion. It also found one-third of COVID-19 patients sustained encephalopathy, a broad term for damage to the brain.  The study published in The Lancet found that in addition to mental illness, people over the age of 65 who developed COVID-19 were more likely to receive their first diagnosis of dementia, a neurological disorder, within 90 days. 

People with previous mental illness were 65% more likely to develop COVID-19

The study authors said they were also surprised to find how vulnerable mental illness made people to contracting COVID-19. People who had mental health conditions prior to the pandemic were 65% more likely to develop COVID-19.  "This is important when we think of the people at risk which should receive the vaccine first. It might be that a history of mental illness should be considered in this decision," Dr. Maxime Taquet, lead author of the study, told Insider. 

Study cited published in The Lancet (Nov. 9, 2020):

https://doi.org/10.1016/S2215-0366(20)30462-4

Cases of major depressive disorder and anxiety disorders increased by more than a quarter worldwide in 2020 due to the COVID-19 pandemic, according to the first global estimates of impacts of the pandemic on mental health, published in The Lancet. In 2020, cases of major depressive disorder and anxiety disorders increased by 28% and 26%, respectively. Women were affected more than men, and younger people were more affected than older age groups. Countries with high COVID-19 infection rates and major reductions in the movement of people—a consequence of measures such as lockdowns and school closures—had the greatest increases in prevalence of major depressive disorder and anxiety disorders. Even before the COVID-19 pandemic, major depressive disorder and anxiety disorders—which can increase the risk of other health outcomes such as suicide—were major contributors to the global burden of disease, affecting millions of men and women of all ages around the world. Lead author Dr. Damian Santomauro, of the Queensland Centre for Mental Health Research, School of Public Health, University of Queensland, Australia, said: "Our findings highlight an urgent need to strengthen mental health systems in order to address the growing burden of major depressive disorder and anxiety disorders worldwide. Promoting mental wellbeing, targeting factors contributing to poor mental health that have been made worse by the pandemic, and improving treatment for those who develop a mental disorder should be central to efforts to improve support services. Even before the pandemic, mental health-care systems in most countries have historically been under-resourced and disorganised in their service delivery. Meeting the added demand for mental health services due to COVID-19 will be challenging, but taking no action should not be an option."  Until now, no studies had analysed the global impact of the COVID-19 pandemic on prevalence of major depressive disorder and anxiety disorders in 2020. Most previous work consisted of surveys in specific locations over a short time period. The new study is the first to assess global impacts of the pandemic on major depressive disorder and anxiety disorders, quantifying the prevalence and burden of the disorders by age, sex, and location in 204 countries and territories in 2020.

A systematic literature review was performed to identify population survey data published between January 1, 2020, and January 29, 2021. Eligible studies reported prevalence of depressive or anxiety disorders that were representative of the general population and had a pre-pandemic baseline. Using a disease modelling meta-analysis tool, data from eligible studies was used to estimate changes in prevalence of major depressive disorder and anxiety disorders due to COVID-19 based on age, sex, and location, including in locations for which no eligible studies were available. Estimates of daily COVID-19 infection rate and movement of people were used as indicators of the impact of the pandemic on populations. The systematic review identified 5,683 unique data sources, of which 48 (one of which reported across two regions) met inclusion criteria. Most studies were from Western Europe (22) and high-income North America (14), with others from Australasia (5), high-income Asia Pacific (5), East Asia (2), and central Europe (1). The meta-analysis indicates that increased COVID-19 infection rate and reduced movement of people were associated with increased prevalence of major depressive disorder and anxiety disorders, suggesting that countries hit hardest by the pandemic in 2020 had the greatest increases in prevalence of the disorders. In the absence of the pandemic, model estimates suggest there would have been 193 million cases of major depressive disorder (2,471 cases per 100,000 population) globally in 2020. However, the analysis shows there were 246 million cases (3,153 per 100,000), an increase of 28% (an additional 53 million cases). More than 35 million of the additional cases were in women, compared with close to 18 million in men.

Model estimates suggest there would have been 298 million cases of anxiety disorders (3,825 per 100,000 population) globally in 2020 had the pandemic not happened. The analysis indicates there were in fact an estimated 374 million cases (4,802 per 100,000) during 2020, an increase of 26% (an additional 76 million cases). Almost 52 million of the additional cases were in women, compared with around 24 million in men. Younger people were more affected by major depressive disorder and anxiety disorders in 2020 than older age groups. The additional prevalence of these disorders peaked among those aged 20-24 years (1,118 additional cases of major depressive disorder per 100,000 and 1,331 additional cases of anxiety disorders per 100,000) and declined with increasing age. Co-author Alize Ferrari, GBD mental disorders team lead at the Queensland Centre for Mental Health Research, School of Public Health, University of Queensland, Australia, said: "The COVID-19 pandemic has exacerbated many existing inequalities, and social determinants of mental health. Sadly, for numerous reasons, women were always more likely to be worse affected by the social and economic consequences of the pandemic. Additional caring and household responsibilities tend to fall on women, and because women are more likely to be victims of domestic violence, which increased at various stages of the pandemic. "School closures and wider restrictions limiting young people's ability to learn and interact with their peers, combined with the increased risk of unemployment, also meant that young people were also more heavily impacted by major depressive disorder and anxiety disorders during the pandemic. It is crucial that policymakers take underlying factors such as these into account as part of measures to strengthen mental health services."

The authors acknowledge that their study was limited by a lack of high quality data on the effects of COVID-19 pandemic on mental health in many parts of the world, particularly low- and middle-income countries. As a result, they say extrapolated estimates generated for countries where data was lacking should be interpreted with caution, and call for improved data coverage and quality globally. Most available data was based on self-reported symptom scales that only estimate probable cases of major depressive disorder and anxiety disorders. More data from diagnostic mental health surveys representative of the general population—of which only three covered the study period—will improve understanding of the pandemic's effects on mental health. The prevalence of other mental disorders—such as eating disorders—might also have been affected by the COVID-19 pandemic, and the authors say these should be assessed as new mental health surveys are undertaken. Writing in a linked Comment, Dr. Maxime Taquet and Professor Paul Harrison, from the University of Oxford, and Professor Emily Holmes, from Uppsala University and the Karolinska Institute, who were not involved in the study, said: "The first global insight into the burden of depressive and anxiety disorders during the pandemic by Santomauro and colleagues starkly highlights the impact of the pandemic on mental health globally." They echo the study authors' calls for action to strengthen mental health systems, saying: "The study should therefore urgently incentivise more research to determine the fuller geographic distribution of depression and anxiety, the prevalence of depressive and anxiety disorders, and the underpinning mechanisms to improve mental health in the context of the COVID-19 pandemic globally."

Original findings published in The Lancet (October 8, 2021):

https://doi.org/10.1016/S0140-6736(21)02143-7 

The hospitalized patients showed signs of deteriorating neurological function, ranging from confusion to coma-like unresponsiveness, new research indicates. Nearly a third of hospitalized Covid-19 patients experienced some type of altered mental function — ranging from confusion to delirium to unresponsiveness — in the largest study to date of neurological symptoms among coronavirus patients in an American hospital system. And patients with altered mental function had significantly worse medical outcomes, according to the study, published on Monday in Annals of Clinical and Translational Neurology. The study looked at the records of the first 509 coronavirus patients hospitalized, from March 5 to April 6, at 10 hospitals in the Northwestern Medicine health system in the Chicago area. These patients stayed three times as long in the hospital as patients without altered mental function. After they were discharged, only 32 percent of the patients with altered mental function were able to handle routine daily activities like cooking and paying bills, said Dr. Igor Koralnik, the senior author of the study and chief of neuro-infectious disease and global neurology at Northwestern Medicine. In contrast, 89 percent of patients without altered mental function were able to manage such activities without assistance.

Patients with altered mental function — the medical term is encephalopathy — were also nearly seven times as likely to die as those who did not have that type of problem. “Encephalopathy is a generic term meaning something’s wrong with the brain,” Dr. Koralnik said. The description can include problems with attention and concentration, loss of short-term memory, disorientation, stupor and “profound unresponsiveness” or a coma-like level of consciousness.  “Encephalopathy was associated with the worst clinical outcomes in terms of ability to take care of their own affairs after leaving the hospital, and we also see it’s associated with higher mortality, independent of severity of their respiratory disease,” he said. The researchers did not identify a cause for the encephalopathy, which can occur with other diseases, especially in older patients, and can be triggered by several different factors including inflammation and effects on blood circulation, said Dr. Koralnik, who also oversees the Neuro Covid-19 Clinic at Northwestern Memorial Hospital. There is very little evidence so far that the virus directly attacks brain cells, and most experts say neurological effects are probably triggered by inflammatory and immune system responses that often affect other organs, as well as the brain.

“This paper indicates, importantly, that in-hospital encephalopathy may be a predictor for poorer outcomes,” said Dr. Serena Spudich, chief of neurological infections and global neurology at Yale School of Medicine, who was not involved in the study. That finding would also suggest that patients with altered mental function in the hospital “might benefit from closer post-discharge monitoring or rehabilitation,” she added. In the study, the 162 patients with encephalopathy were more likely to be older and male. They were also more likely to have underlying medical conditions, including a history of any neurological disorder, cancer, cerebrovascular disease, chronic kidney disease, diabetes, high cholesterol, heart failure, hypertension or smoking. Some experts said that President Trump, who was hospitalized with Covid at Walter Reed military hospital beginning on Friday, is of the age and gender of the patients in the study who were more likely to develop altered mental function and therefore could be at higher risk for such symptoms. He also has a history of high cholesterol, one of the pre-existing conditions that appear to increase risk. But the president’s doctors have given no indication that he has had any neurological symptoms; the White House had released videos of him talking to the public about how well he was doing. And Mr. Trump returned to the White House on Monday evening....

Study published in Annals Clinica and  Translational Neurology (October 5, 2020):

https://doi.org/10.1002/acn3.51210