Psychiatric abnormalities in COVID-19 patients should prompt work-up for neuro-COVID

Letter to the editor

We read with interest the narrative review by Dehghani et al. about the psychiatric morbidities associated with central nervous system (CNS) disorders complicating SARS-CoV-2 infections (neuro-COVID) (Dehghani et al., 2022). It has been found that SARS-CoV-2 associated CNS disorders can be complicated by cognitive and memory impairment, stress-related disorders, sleep disorders, major depression, suicidal ideation, and psychosis (Dehghani et al., 2022). It was concluded that COVID-19 has a significant impact on mental health through several mechanisms, such as hyper-inflammation, penetrance of the virus into the CNS, and the psychosocial stress associated with COVID-19 and that adequate therapeutic management and prevention measures are needed to overcome this challenge (Dehghani et al., 2022). The study is attractive but raises some concerns that need to be discussed.

A psychiatric morbidity not discussed in this review is delirium (Dehghani et al., 2022). Delirium has been reported as the initial manifestation of SARS-CoV-2 associated ischemic stroke (Huang et al., 2022). Two patients, an 82yo male (case-1) and an 84yo male (case-2), were diagnosed with ischemic stroke after acute delirium had developed for seven days (case-1) and 13 days (case-2) respectively after the onset of mild SARS-CoV-2 infection (Huang et al., 2022). COVID-19 was treated with tocilizumab, dexamethasone, ceftriaxone, and remdesivir (case-1) respectively tocilizumab, dexamethasone, ceftriaxone, levofloxacin, and remdesivir (case-2) (Huang et al., 2022). In case-1 and case-2, middle cerebral artery (MCAD) ischemic stroke was diagnosed and treated appropriately, resulting in a favourable outcome.

COVID-19 can also present with delirium without underlying CNS pathology (Callea et al., 2022). In a study of 71 geriatric patients with SARS-CoV-2 pneumonia, 20 patients (28 %) developed delirium (Callea et al., 2022). Patients who developed delirium during SARS-CoV-2 infection had a higher mortality rate (25 % vs. 5.9 %) and a longer median length of hospital stay (21 days vs. 17 days) compared to patients without delirium (Callea et al., 2022).

Substance use disorder (SUD) is another neuropsychiatric condition not covered in the review. In a study of 9967 Dutch university students in the period April to June 2020, it was found that weekly cannabis use in this cohort increased from 6.7 % to 8.6 %, while the frequency of binge drinking and tobacco use remained stable (van Hooijdonk et al., 2022). In another study of 323 members of racial/ethnic minorities, alcohol consumption increased by 207–1600 % (2–3 times+/week) when comparing spring 2019 to spring 2020 periods (Hicks et al., 2022). The increase in alcohol use has been attributed to mental health and environmental factors, such as past problems with the police or increased impulsiveness since the outbreak of the pandemic (Hicks et al., 2022).

Antisocial personality disorders, which have probably increased since the outbreak of the pandemic, were also not addressed. In a recent publication on the impact of COVID-19 on the incidence of antisocial personality disorder, it was hypothesised that “Hikikomori”, a state of prolonged and severe social withdrawal lasting at least 6 months, could be considered as a growing and silent epidemic after the COVID-19 pandemic (Roza et al., 2021).

The effects of anti-SARS-CoV-2 drugs on mental health were not discussed. Of those exposed to hydroxychloroquine, some are known to have suffered severe psychiatric disorders and some have even committed suicide (Garcia et al., 2020). Neuropsychiatric adverse events have also been reported from antiretroviral drugs (remdesivir, favipiravir, lopinavir/ritonavir), biologicals (tocilizumab), antibiotics (azithromycine), and dexamethasone, which are commonly administered to treat COVID-19 (Borah et al. (2021)].

As the incidence of cerebral involvement in COVID-19 is high, it is crucial that all patients presenting with newly diagnosed psychiatric abnormalities undergo a comprehensive evaluation by not only a psychiatrist but also a neurologist. The clarification of a neurological impairment in these patients should include at least a detailed blood test, a cerebral MRI and an EEG.

Overall, the interesting review has some limitations that call the results and their interpretation into question. Clarifying these weaknesses would strengthen the conclusions and could add value to the study. Emerging or worsening known psychiatric abnormalities should prompt the treating psychiatrist to order a neurological evaluation for an underlying neuro-COVID alteration that may explain the altered mental status.

Ethics approval

Eethical Approval was in accordance with ethical guidelines. The study was approved by the institutional review board.

Financial disclsoure

The author has nothing to disclose.

Consent to participate

Consent to participate was obtained from the patient.

Consent for publication

Consent for publication was obtained from the patient.

Funding sources

No funding was received.

Author contribution

JF: design, literature search, discussion, first draft, critical comments, final approval,

Conflicts of interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Data Availability

All data are available from the corresponding author.