COVID-19 and manifest psychological morbidity: A case series

Abstract

The COVID-19 pandemic in India has been reported to be associated with numerous major mental health issues globally; the most common is – stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear. This case series presents three different cases, wherein the COVID-19 pandemic resulted not only in deterioration of previous symptoms experienced by patients (obsessive–compulsive disorder and depression) but also led to the development of new symptoms specifically related to coronavirus (Psychosis). Authors highlight the need to develop preventive strategies for vulnerable groups and try to understand the etiopathogenesis of illnesses so developing, in order to identify support systems and management strategies during the pandemicrelated crisis.

INTRODUCTION

The COVID-19 pandemic has been reported to be associated with numerous major mental health issues globally; the common is stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear.[1] For India, these are also not dissimilar, as was pointed out in a recent survey conducted by the Indian Psychiatric Society too.[2,3] In the recent months, numerous reviews, opinion pieces, and survey-based articles on COVID-19 and psychological morbidity have been published from the Indian subcontinent. Nevertheless, it is important to highlight actual case vignettes as they remain important clinical material for any reader at any level of their career development and progression.

CASE REPORTS

Case A

The patient is a 22-year-old single male, living in a nuclear family, resident of Himachal Pradesh. He had been diagnosed with obsessive–compulsive disorder (OCD) in August 2018 due to a 3-month illness of obsessive imagery of seeing Gods and Goddesses naked, along with obsessive magical thinking that if he did not pray to God then his family or he will get sick, accompanied by yielding compulsions (of praying). He responded to fluvoxamine 300 mg daily and aripiprazole 5 mg daily and became asymptomatic by November 2019. Subsequently, he stopped medications in January 2020 and remained asymptomatic till June 2020 with re-emergence of previous symptoms along with additional obsessive fear related to coronavirus. This was accompanied by excessive washing rituals and significant impairment, leading to social isolation for self and family. He refused seeking any help initially. Subsequently, teleconsultation was sought in August 2020 with trial of escitalopram 20 mg daily, Clonazepam 0.5 mg daily, and counseling for 2 months with minimal improvement. He was shifted to clomipramine 150 mg daily and responded well with 90% improvement; though coronavirus-related thoughts and related anxiety are still present to some extent.

Case B

The patient is a 55-year-old man, civil contractor, residing in Chandigarh, without any previous history of any psychiatric illness. There was no family history of mental illness. He had a past history of alcohol dependence. The patient first presented in June 2020 on the insistence of his brother in law who is a physician in a government hospital. The patient complained of persistent sadness, decreased interest in daily activities, decreased sleep, decreased appetite, crying spells, extreme fatigue, fear from dying from coronavirus infection, and thoughts about committing suicide rather than catching the infection. He would feel helpless and repeatedly ask to get a test done for coronavirus infection. The symptoms started around 3^rd week of March 2020 since the government imposed nationwide lockdown and were gradually progressive such that the patient's life had become dysfunctional. Despite the lockdown relaxation from May 8, 2020, the patient had not gone to work. He would call his son in Mumbai up to 15 times a day to enquire regarding his coronavirus status despite reassurances and would insist on him to return home due to his fear of dying and wanting to see him before that.

He had consulted various physicians and psychiatrists through teleconsultation but not experienced any relief. On June 9, 2020, he was started on mirtazapine 7.5 mg HS, buspirone 10 mg BD, and zolpidem 10 mg HS. He was counseled about the illness, its treatment, course, and prognosis and additionally how to cope with the fear of coronavirus infection. The patient followed up after 10 days with significant improvement in symptoms. He was also detected to have low Vitamin B12 and D levels, and they were added to the prescription, with previous medications being continued at the same dose. The patient revisited the clinic after 1 month (on July 9, 2020) showing continued improvement, with the presence of only occasional anxiety and sadness. On last follow-up, through teleconsultation, he reported complete remission of symptoms.

Case C

The patient is a 62-year-old female, residing in Chandigarh, India, who presented with a past history of depressive episode in 1997, which recovered following 1 year of irregular treatment. She had contracted COVID-19 in end September 2020. Her relative, and one of my colleagues from Pune, contacted the principal author (PK) in early October 2020 seeking help for the patient and referred her highly affluent daughter for further input. The daughter contacted in extreme distress that the patient, following immediate recovery from COVID-19, had been displaying symptoms of fearfulness, suspiciousness, insomnia, agitation, violence, and calling people to report that the family was planning and plotting against her. She lacked insight and refused help. Proxy consultation sought by daughter was refused; alternatives (teleconsultation and inpatient treatment) suggested were refused by daughter. The patient was seen at clinic of primary author (PK) where the reported symptoms were re-confirmed, along with the presence of persecutory delusions, auditory hallucinations, impaired judgment, and lack of insight. After counseling about post-COVID mental health issues, the patient reluctantly agreed for medications (risperidone 0.5 mg BD and lorazepam 1 mg HS). Routine investigations were normal. There was an improvement, but compliance was irregular (discontinuation of treatment following improvement; a decision supported by the family). On follow-up on November 19, 2020, she was seen with re-emergence of previous symptomatology.

The whole family was counseled about illness, treatment, course, and prognosis. The patient was shifted to aripiprazole as per her preference but showed no improvement over the next 1 week. After re-discussion, she was re-initiated on the combination of risperidone 0.5 mg BD and lorazepam 1 mg HS, with regular follow-ups every 10 days and ongoing psychoeducation of both patient and family. There was complete recovery at the time of last follow-up in end January 2021.

DISCUSSION

All three cases highlight how the COVID-19 pandemic resulted not only in the deterioration of previous symptoms experienced by patients (Cases A and B) but also led to the development of new symptoms specifically related to coronavirus (Case C).

Case A was a patient whose OCD symptoms relapsed during the pandemic. The patient had been symptom free for over 6 months, but his symptoms re-emerged along with the development of phobia related to COVID-19. Overall, an increase in obsession and compulsion severity after the beginning of the pandemic emerged. Contamination symptoms were associated with a more elevated worsening. We found that remission status on OCD symptoms before the quarantine was associated with more elevated OCD symptom worsening during the quarantine. Perhaps, the continuous catastrophic news on TV, radio, and social media combined with hygiene tips could have been a stressful situation for our patient who belongs to such a vulnerable group, particularly for those with preexisting contamination symptoms.[4] The discontinuation of medication was another factor which predisposed to re-emergence of OCD during the stress of the COVID pandemic.[5]

Case B was not unique in as much that depressive symptoms and reactions are one of the most common psychological morbidities seen with the COVID-19 pandemic.[2,3] However, it was interesting to note that the patient had no past history of any psychiatric illness, and the core psychopathology centered around “fear of getting infected and dying with coronavirus” - which was the most common stress experienced by respondents in the IPS survey during the lockdown period.[3]

Case C was unique that there was new onset psychosis in the post-COVID recovery period without any other clear vulnerability and precipitating factors. Profound inflammatory response to COVID-19 infection (”cytokine storm”) is thought responsible for the severe, sometimes fatal, pulmonary, and cardiac complications of the disease and has been postulated to produce neuropsychiatric symptoms through immunological mechanisms.[6,7] Immune-based triggers have long been implicated in the pathogenesis of psychiatric illness including depression, psychotic disorders such as schizophrenia, and neuropsychiatric manifestations of HIV infection and other viruses.[8,9] It has been hypothesized that human coronaviruses and other respiratory viruses may act as opportunistic pathogens of the central nervous system (CNS) as they have been shown to have neuroinvasive qualities, due to either autoimmunity or viral replication.[10] In fact, CNS penetration and neuroinflammation from other coronaviruses have been associated with new-onset psychotic disorders or CNS infection.[6]

Clinical implications

We can conclude that there is a need to develop preventive strategies for vulnerable groups and to try to understand the etiopathogenesis of the illnesses so developing, in order to develop support systems and management strategies during the pandemic-related crisis as steps to prevent and manage mental illness related to COVID-19.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.