First-episode psychotic disorders in the wake of the COVID-19 pandemic: a descriptive review of casereports

Abstract

Objective: Since the onset of COVID-19 pandemic many case reports and case series dealt with new onset psychotic disorders in patients either infected with SARS-CoV-2 or thematically linked to the pandemic, but without an infection. Our aim was to provide a comprehensive collection of these reports to illustrate the nature of these psychoses. Methods: We conducted a literature search in Medline, EMBASE, PSYCHINFO, using search terms regarding first episode psychotic disorders in the context of corona. Results: 96 case reports or case series covering 146 patients (62 without and 84 with SARS-CoV-2 infection) were found. Compared to patients without infection, patients with infection showed significantly more often visual hallucinations (28.6% vs 8.1%), confusion (36.9% vs 11.3%), an acute onset of illness (88.5% vs 59.6%) and less often depression (13.1% vs 35.5%) and a delusional content related to the pandemic (29.5% vs 78.3%). Both groups had an equally favourable outcome with a duration of psychosis ≤2 weeks in half and full remission in two thirds of patients. In patients with infection signs of inflammation were reported in 78.3% and increased CRP in 58.6%. While reports on patients with infection are continuously published, no report about patients without infection was found after July 2020. Conclusion: Cases without infection were considered reactive and originated all from the first wave of the Corona pandemic. In cases with infection, inflammation was considered as the main pathogenetic factor but was not found in all patients. Diagnosis was impeded by the overlap of psychosis with delirium.

New-onset psychosis following COVID-19 infection in a patient with no psychiatric history: A longitudinal case report

“…The patient presented with new-onset psychosis approximately two weeks after diagnosis with COVID-19, consistent with the average timeline in similar cases ( Rittmannsberger et al, 2022 ). However, this case has notable differentiators, including the absence of certain risk factors and length of treatment.…”

“…Severe symptoms persisted for nearly two months, requiring three separate admissions, various medication trials, and regular outpatient follow-up with continued antipsychotic use for over six months after discharge. While some post-COVID psychosis patients have required treatment over several weeks [e.g., 9, 13, 14] many recovered more quickly ( Smith et al, 2021 , Rittmannsberger et al, 2022 , Al-Busaidi et al, 2021 , Ferrando et al, 2020 , Lu et al, 2020 ), with one review noting ≤2 weeks of symptoms in over 50% of cases and >2 months of symptoms in less than 5% ( Rittmannsberger et al, 2022 ). Most patients are noted to have fully recovered; however, very few existing case reports provide long-term follow-up details with which to compare the full timeline presented here ( Rittmannsberger et al, 2022 ).…”

“…Pandemic-related societal stressors have impacted population mental health; however, evidence also suggests that viral infection increases the risk of various psychiatric complications, including psychosis ( Lee et al, 2004 , Rogers et al, 2020 , Sultana and Ananthapur, 2020 , Troyer et al, 2020 ). Although the etiology of such complications is not fully established, coronaviruses are known to invade CSF and brain tissue ( Desforges et al, 2019 , Moriguchi et al, 2020 ) and inflammatory immune response to infection may also cause disruption ( Kepinska et al, 2020 , Lim et al, 2020 , Watson et al, 2021 , Smith et al, 2021 , Rittmannsberger et al, 2022 ).…”

“…New-onset psychosis concurrent with or immediately following COVID-19 infection has been documented in a growing number of case reports; these etiologies are often posited, though not always supported by diagnostic evidence (e.g., elevated inflammatory markers) ( Watson et al, 2021 , Smith et al, 2021 , Rittmannsberger et al, 2022 ). Some reports are also confounded by medications used in COVID treatment (e.g., corticosteroids) or prior psychiatric or substance use history, as well as possible delirium ( Watson et al, 2021 , Smith et al, 2021 , Rittmannsberger et al, 2022 ). Many cases have also been noted to resolve fairly rapidly with treatment, although, given the recency of this pandemic, few provide long-term follow-up details ( Smith et al, 2021 , Rittmannsberger et al, 2022 ).…”

“…Some reports are also confounded by medications used in COVID treatment (e.g., corticosteroids) or prior psychiatric or substance use history, as well as possible delirium ( Watson et al, 2021 , Smith et al, 2021 , Rittmannsberger et al, 2022 ). Many cases have also been noted to resolve fairly rapidly with treatment, although, given the recency of this pandemic, few provide long-term follow-up details ( Smith et al, 2021 , Rittmannsberger et al, 2022 ). We present the first known case in the midwestern United States—a patient with no psychiatric history who required three inpatient admissions over two months and outpatient follow-up for approximately seven months after discharge.…”