Introduction: Neuropsychiatric manifestations of the coronavirus disease 2019 (COVID-19) have been described, including anosmia, ageusia, headache, paresthesia, encephalitis and encephalopathy. Little is known about the mechanisms by which the virus causes central nervous system (CNS) symptoms, and therefore little guidance is available regarding potential workup or management options. Cases: We present a series of four consecutive cases, seen by our psychiatry consultation service over a one-week period, each of which manifested delirium as a result of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Discussion: The four cases highlighted here all occurred in older patients with premorbid evidence of cognitive decline. Unique features seen in multiple cases included rigidity, alogia, abulia, and elevated inflammatory markers. In all four cases, a change in mental status was the presenting symptom, and three of the four cases lacked significant respiratory symptoms. In addition to discussing unique features of the cases, we discuss possible pathophysiologic explanations for COVID-19 delirium. Conclusions: Delirium should be recognized as a potential feature of infection with SARS-CoV-2 and may be the only presenting symptom. Based on the high rates of delirium demonstrated in prior studies, hospitals should consider adding mental status changes to the list of testing criteria. Further research is needed to determine if delirium in COVID-19 represents a primary encephalopathy heralding invasion of the CNS by the virus, or a secondary encephalopathy related to systemic inflammatory response or other factors.

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The findings suggest an unfavorable cost/benefit ratio for antidepressant treatment of bipolar depression.

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Objective: To assess depressive features of a proposed definition of bipolar spectrum disorder (BSD). Methods: Thirty-six patients with bipolar disorder type I or II were compared to 37 patients with unipolar major depressive disorder through patient interview and chart review. Results: Univariate analysis suggests that 7 of 12 (recurrent major depressive episodes, brief major depressive episodes, atypical depressive symptoms, early age of onset, family history of bipolar disorder, antidepressant tolerance, and antidepressant-induced mania) features of major depressive episodes were more likely to occur in bipolar versus unipolar patients. After adjustment in a multivariable regression model, however, the five most powerful predictors of bipolar disorder were brief major depressive episodes, early age of onset, antidepressant- induced mania, postpartum depression, and atypical depressive symptoms. Conclusions: This preliminary study supports the idea that bipolar disorder is characterized by some depressive features less likely to be found in unipolar depression. Further prospective study needs to be conducted comparing BSD with unipolar depression.

More than 30 years after its introduction by George Engel, the biopsychosocial model exerts a major influence on the rhetoric and intentions of academic medicine. However, advocates of the model do not feel that it has significantly altered the practice of physicians, whom they portray as tightly clinging to a biomedical approach. Using Engel's original writings, those of his successors, and the work of medical historians, the author asserts that biopsychosocial advocates use clinical biomedicine as a straw man to support their argument. Proceeding from that point, the author attempts to demonstrate that excessive focus on this straw man has inhibited critique of the biopsychosocial model and the argument supporting it. He identifies failures to address clinical medicine's functional specificity and relationship with broader social trends as contributors to the biopsychosocial model's stagnation. The author proposes that it would be more productive to view clinical biomedicine as an epiphenomenon of the human traits of overenthusiasm and the need for security. Recognizing that medicine is made up of heterogeneous tasks, he observes that no one model, including the biopsychosocial model, tends to all of them. The biopsychosocial model would be best served by shedding the biomedical straw man and modifying its ambitions.

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