Reply to article: Alarming levels of psychiatric symptoms and the role of loneliness during the COVID-19 epidemic: A case study from Hong Kong

Dear Editors,

The article mentioned above addresses a subject of extreme relevance nowadays, since the measures implemented to contain the COVID-19 pandemic have affected the mental health of the entire world population. The present study, carried out in Hong Kong, revealed that 65.6% of the interviewees reported signs of depression, anxiety and / or stress, and 22.5% showed risk signs of psychosis (Tso; Park, 2020), this last one being an even more critical data within the pandemic context.

The relationship between pandemics and psychosis is not a recent phenomenon. In reality, this association was first reported after the influenza pandemic of 1889-1892, and has been documented during numerous other pandemics, such as the Spanish Flu of 1918, the Asian influenza of 1957 and the influenza of 2009 (Kepinska et al., 2020). From this, it is possible to extract from similar events in the past, knowledge applicable to the current situation, in order to collaborate with the understanding of the impact that pandemics have on psychosis (Brown et al., 2020).

Currently, there are many theories that aim to explain the mechanism by which psychotic symptoms can arise concurrently with COVID-19. Three of them stand out: the direct invasion of the Central Nervous System; systemic inflammatory processes; the adverse reaction to drugs against the virus (Victoria et al., 2020).

Regarding the hypothesis of neuronal dissemination, it can occur in two ways, hematogenous and retrograde. The first is through the passage of infected leukocytes through the blood-brain barrier or through direct infection of endothelial cells. The second arises from the olfactory or enteric nerves (Raony et al., 2020, apud Victoria et al., 2020).

Systemic inflammation, in turn, comes from the infection of the airways by the virus, followed by an acute respiratory syndrome with the consequent release of cytokines throughout the body. One way to assess this triggered state of systemic inflammation is by the NLR (ratio between neutrophils and lymphocytes), which can be calculated by blood count (Victoria et al., 2020). In a study carried out in Peru, three cases with psychotic symptoms were found in patients with COVID-19 and an increase in NLR was found (2.8, 3.7 and 4.76), which indicates a generalized inflammatory state in these circumstances (Victoria et al., 2020).

The last theory is associated, in a way, with the inflammation process. To modulate the systemic inflammatory response, the COVID-19 treatment may involve the use of high doses of steroids (Russell et al., 2020, apud Brown et al., 2020). Steroids, in turn, are known to trigger psychotic symptoms (Wada et al., 2001, apud Brown et al., 2020), which would correlate the two pathologies.

In addition, family history of mental illness and the psychosocial response may also be associated with an increased risk of psychosis. Although physical distance may be the most effective way to prevent the spread of the virus (Center for Disease Control et al., 2003, apud Brown et al., 2020), such a measure may be associated with a series of adverse psychological effects (Brooks et al., 2020; Gardner and Moallef, 2015, apud Brown et al., 2020). It is noticeable that these public health strategies severely disrupt daily social life and limit interpersonal interactions, with adverse consequences of social disconnection and loneliness (Cacioppo et al., 2015, apud Tso; Park, 2020), in addition to the physical effects of the decrease both motor activity and exposure to sunlight, and to changes in diet (Lippi et al., 2020, apud Brown et al., 2020).

Given this, the increased risk of psychosis or psychotic symptoms in people exposed to a virus during a pandemic is 0.9% and 4% (Brown et al., 2020). However, reported cases of people diagnosed with COVID-19 and also diagnosed with psychotic symptoms are still rare (Victoria et al., 2020). Even so, there is concern about a potential epidemic of mental illness in the near future, as well as the urgent need to prepare doctors, caregivers and society in general for such a situation (Tso; Park, 2020).

Therefore, it is concluded that this task requires multifaceted interventions. Public education campaigns using digital media are needed to inform people about signs of psychosis, especially those who will be in contact with young people, such as teachers, social welfare officials and the police (Sutton et al., 2018, apud O'Donoghue et al., 2020). In addition, referral and treatment services for affected individuals must be flexible, such as clinically appropriate telehealth care (Hensel et al., 2019, apud O'Donoghue et al., 2020) and other methods, such as online social therapy (Alvarez-Jimenez et al., 2013, apud O'Donoghue et al., 2020). Finally, it is important to ensure that this practice is maintained as a component of service provision and not abandoned after the pandemic ends (Torous & Wykes, 2020, apud O'Donoghue et al., 2020).

Funding source

There is no funding source.

Declaration Competing Interest

The authors declare that they have no conflicting interests.