March 26, 2021

'The most terrifying thing': Some Covid-19 patients are suffering severe psychosis

Daily Briefing

    Around the world, providers are reporting a small but increasing number of cases in which Covid-19 patients with no previous history of mental health issues develop severe psychosis weeks or months after recovering from the virus, Pam Belluck writes for the New York Times.

    How Covid-19 will impact behavioral health services

    'There's something happening'

    As Belluck explains, while the virus that causes Covid-19 was initially considered primarily a respiratory disease, more and more patients are reporting a host of other symptoms, including neurological, cognitive, and psychological effects. And among these cases is a small but growing number of patients who are experiencing severe "post-Covid psychosis," providers say.

    For example, a patient named Ivan Agerton—a 49-year-old documentary photographer living in Seattle, who had no personal or family history of mental illness—began experiencing crippling paranoia and auditory hallucinations weeks after recovering from a mild case of Covid-19. He believed that his neighbors were spying on his family and that police were tracking his movements.

    "Like a light switch—it happened this fast—this intense paranoia hit me," Agerton said. "It was really single-handedly the most terrifying thing I've ever experienced in my life."

    In another case, Hisam Goueli, a psychiatrist, helped treat a physical therapist in her early 40s who sought help at South Oaks Hospital in New York after she started to hear a voice telling her to kill herself and harm her children. The woman, who had never experienced psychiatric symptoms before, said the symptoms started just months after recovering from a mild case of Covid-19.

    Goueli said he was initially unsure whether her case was Covid-related. "But then," he said, "we saw a second case, a third case and a fourth case, and we're like, 'There's something happening.'"

    Indeed, while the overall number of these cases remains low—and experts expect the cases to remain rare—the reports aren't merely anecdotal, Belluck reports. A British study of neurological and psychiatric symptoms among 153 Covid-19 patients found that 10 study participants presented with "new-onset psychosis." Similarly, another study identified 10 such patients at a hospital in Spain.

    Much about the condition remains a mystery, experts say

    While experts don't think this trend is unique to Covid-19—psychotic episodes have sporadically occurred amid other viruses, including the 1918 flu and the SARS and MERS coronaviruses—they note that much about post-Covid psychosis remains a mystery, Belluck writes.

    Currently, experts hypothesize that this condition may be associated with how the immune system responds to the virus, including vascular issues or inflammation. "Some of the neurotoxins that are reactions to immune activation can go to the brain, through the blood-brain barrier, and can induce this damage," said Vilma Gabbay, a co-director of the Psychiatry Research Institute at Montefiore Einstein, who has treated two patients with post-Covid psychosis.

    As Robert Yolken, a neurovirology expert at Johns Hopkins University School of Medicine, explained, the immune systems of some patients who've physically recovered from Covid-19 remain activated because of "delayed clearance of a small amount of virus."

    And that continuing activation of the immune system, according to Emily Severance, an expert in schizophrenia at Johns Hopkins, is currently the leading hypothesis into other brain-related symptoms of Covid-19, such as brain fog and memory loss. It's reasonable to think that post-Covid psychosis may stem from "something similar happening in the brain," she said.

    In fact, the variety of symptoms may depend on what part of the brain is affected by the ongoing immune response, Yolken said. He noted that "some people have neurological symptoms, some people psychiatric and many people have a combination."

    A different expression of psychosis—and an ambiguous recovery

    According to experts, the experience of psychosis among Covid-19 patients seems to differ significantly from how psychosis typically presents.

    For instance, while paranoid delusions typically accompany schizophrenia during late adolescence or dementia in elder adults, post-Covid-19 psychosis so far seems to primarily affect patients in their 30s, 40s, and 50s. "It's very rare for you to develop this type of psychosis in this age range," Goueli said.

    In addition, while most people experiencing psychosis generally "don't have insight into their symptoms," several patients with post-Covid psychosis were aware that something was off, according to Veronika Zantop, a psychiatrist who helped treat Agerton.

    There's also little consistency in symptoms among those affected by post-Covid-19 psychosis, Belluck writes, although several patients reported experiencing only mild Covid-19. For example, some patients experiencing post-Covid-19 psychosis feel urges to hurt themselves or others, much like Goueli's patient, while others—such as Agerton—experience deep paranoia rather than any violent impulses.

    Moreover, while some patients require weeks of hospitalization to identify the right medications, others improve relatively quickly. Goueli's patient, for instance, was hospitalized for four weeks before doctors found a regimen of medicine that alleviated her symptoms and enabled her to return home. She's currently "95% perfect," Goueli said.

    And while some patients seem to experience just a one-off episode, others struggle with relapses. For his part, Agerton was hospitalized in a psychiatric ward twice for his psychosis. While he's now returned home and says he's improving, he's still not 100%. "There's this fear of how long is this going to happen," he said. "How long am I going to live with this?"

    Ultimately, however, experts hope that studying these individual cases and larger pieces of research can shed light on what remains a challenging and difficult situation. "We don't know what the natural course of this is," Goueli said. "There are just so many unanswered questions" (Belluck, New York Times, 12/28/2020; Belluck, New York Times, 3/22).

    How Covid-19 will impact behavioral health services

    Highest-priority behavioral health moves amid Covid-19 crisis

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    The Covid-19 pandemic is rapidly increasing the need for behavioral health services. But there are significant gaps and barriers that stand in the way of people getting the help they need. Download our take to learn how health systems can prioritize addressing the immediate needs of both staff and patients, especially those with preexisting behavioral health needs or comorbid conditions.

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