Psychotic relapse from COVID-19 quarantine, a case report

Highlights

• •The coronavirus disease 2019 (COVID-19), first reported on December 31^st, 2019 in China, has currently spread worldwide and became pandemic on March 11^th.
• •Besides causing an emotional impact in people affected, COVID-19 pandemic could specially affect people with previous mental health conditions, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population.
• •Worldwide, in different countries, among them Spain, it has been necessary to adopt confinement measures to preserve public health. These measures might represent to an extra stressful situation, particularly in vulnerable patients, such as those suffering from psychotic disorders.
• •This case report highlights the importance to developing specific support programs for this vulnerable population in an unprecedented situation such us the COVID-19 crisis. The role of telemedicine it has been suggested for that purpose.

Letter to the Editor

The coronavirus disease 2019 (COVID-19), first reported on December 31^st, 2019 in China, has currently spread worldwide and became pandemic on March 11^th, 2020, according to the World Health Organization (WHO). By May 17^th of 2020 affects more than 4.5 million people and have caused more than 300,000 deaths (Coronavirus DiseaseCOVID-19 Dashboard, 2020)

Studies about the impact of pandemics and epidemics on mental health are scarce. In a recent review on the psychological impact of quarantine periods, depressive symptoms, acute stress, post-traumatic stress, anger or insomnia are reported. Among the stressors that contribute negatively during quarantine are its duration, fear of infection, loss of activity, lack of information or supplies (Brooks et al., 2020). Besides causing an emotional impact in people affected, COVID-19 pandemic could specially affect people with previous mental health conditions, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population (Yao et al., 2020). In the current pandemic, poor sleep quality, depressive or anxious symptoms were reported by Chinese general population (Huang and Zhao, 2020).

Worldwide, in different countries, among them Spain, it has been necessary to adopt confinement measures to preserve public health. These measures might represent to an extra stressful situation, particularly in vulnerable patients, such as those suffering from psychotic disorders.

B. is a 36-year-old patient diagnosed with schizoaffective disorder in 2006. She has required three psychiatric admissions throughout her life. First of them was the debut of her disease in 2006 and then another two admissions in 2012 were required. Since 2012 the patient has remained stable and asymptomatic, being able to return to normality in her day-to-day life and even find a job as administrative assistant at a special employment center. The treatment has been satisfactorily controlled by his family with whom she lives. She was on clozapine 250 mg per day.

On March 7^th, 2020, B. presented respiratory symptoms and fever with temperature peaks above 39 celsius degrees, so that on suspicion of COVID-19, she began quarantining inside her home, remaining isolated in her room according to emergency system instructions. The patient does not express fear of COVID-19 infection and yet reports that she cannot bear isolation. After seven days of isolation, on March 14^th, B. began to show irritability, insomnia, and disorganized and aggressive behavior towards family members. In this relapse, she started to break the confinement, leaving her room and trying to go out the home ensuring that the virus did not affect her and that she had to leave. That situation endangered both the family and other members of the community. Finally, it was necessary to perform a psychiatric admission to contain and control the relapse.

During admission, COVID-19 infection was confirmed, requiring pharmacological restraint as a result of behavioral disturbance due to inability of accomplish isolation measures. Currently - by April 17^th -the patient is still hospitalized. Clozapine dose was increased to 350 mg per day and it was combined with risperidone 6 mg per day.

It is striking that the relapse started on March 14^th, when the Spanish government declared the state of alarm at national level, restricting movement and urging the population to stay home.

We are therefore presenting a case in which relapse has been related with the mandatory quarantine measures to be adopted when a COVID-19 is suspected.

The population that suffers from serious mental disorders, such as psychotic ones, are especially vulnerable to threatening situations, but also to activity restriction measures and changes in daily routines. Our case report highlights the importance to developing specific support programs for this vulnerable population in an unprecedented situation such us the COVID-19 crisis. The role of telemedicine it has been suggested for that purpose (Kavoor et al., 2020).

Declaration of Competing Interest

None of the authors has conflicts of interest in the writing of this letter to the editor