Psychiatric and neuropsychiatric syndromes in presentations of... · Varatharaj et al, JAMA...
Transcript of Psychiatric and neuropsychiatric syndromes in presentations of... · Varatharaj et al, JAMA...
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Psychiatric and
neuropsychiatric syndromes in
coronavirus infectionsDr Jonathan Rogers MRCP MRCPsych
Wellcome Trust Clinical Training Fellow, UCL Division of Psychiatry
Specialty Registrar in GA/OA Psychiatry, SLAM
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Outline
Coronaviruses
Reason for concern
Systematic search
Acute presentations
Post-illness presentations
Implications
Further reading
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Coronaviruses
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Coronaviruses
Common forms (HCoV-229E, -OC43, -NL63, -HKU1)
SARS (SARS-CoV, 2002)
MERS (MERS-CoV, 2012)
COVID-19 (SARS-CoV-2, 2019)
Lu R, Zhao X, Li J, et al. Lancet 2020; 395: 565–74.
Desforges M, Le Coupanec A, Dubeau P, et al. Viruses 2019; 12.
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Coronaviruses and psychiatry
2 case control studies
Antibodies against common coronavirus subtypes
Okusaga et al.: mood disorder vs healthy controls
OR 2.7 (1.9-3.9) for HCoV-NL63 infection
Severance et al.: psychotic disorders vs healthy controls
OR 1.3 (1.0-1.7) for HCoV-HKU1 infection
OR 2.4 (1.3-4.7) for HCoV-NL63
Okusaga O, Yolken RH, Langenberg P, et al. Association of seropositivity for influenza and coronaviruses with history of mood disorders and suicide attempts. J Affect Disord 2011; 130: 220–5.
Severance EG, Dickerson FB, Viscidi RP, et al. Coronavirus Immunoreactivity in Individuals With a Recent Onset of Psychotic Symptoms. Schizophr Bull 2011; 37: 101–7.
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Reason for concern
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Encephalitis lethargica?
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Psychological impact
Severe illness
Mass anxiety
Isolation
Difficulties communicating with staff
Employment & financial difficulties
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Iatrogenic impact
Intubation
Sedation (different agents)
Corticosteroids
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Does SARS-CoV-2 affect the CNS?
Retrospective review notes of 214 consecutive hospitalised patients in Wuhan
36.4% ‘had neurologic manifestations’
Dizziness 16.8%
Headache 13.1%
Impaired consciousness 7.5%
Altered smell 5.1%
Associations with neuro Sx: older, more comorbidity, fewer typical COVID symptoms
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Does SARS-CoV-2 affect the CNS?
‘Although there are
reports of neurological
complications in
patients with COVID-19,
it is unclear if SARS-
CoV-2 is neurotropic in
humans.’
Enters cells via ACE2 receptor
Neurons
Microglia
Astrocytes
Oligodendrocytes
Plausible routes of entry:
Transsynaptic transfer
Entry via olfactory nerve
Infection of vascular endothelium
White cell migration across BBB Zubair et al, JAMA Neurology 2020
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Systematic search
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Search strategy
MEDLINE, Embase, PsycINFO, CINAHL
Pre-print databases (medRxiv, bioRxiv, PsyArXiv)
Suspected or confirmed coronavirus infection + (neuro)psychiatric
complications
Cut-off: April 10, 2020
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Results
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Acute impact
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SARS/MERS: qualitative data
Loneliness, boredom and frustration
Concern about infecting family members
Gratitude for the support they received
Almutairi AF, Adlan AA, Balkhy HH, Abbas OA, Clark AM. J Infect Public Health 2018; 11: 187–91.
Koller DF, Nicholas DB, Goldie RS, Gearing R, Selkirk EK. Qual Health Res 2006; 16: 47–60.
Maunder R, Hunter J, Vincent L, et al. CMAJ 2003; 168: 1245–51.
Mok E, Chung BP, Chung JW, Wong TK. Int J Nurs Pract 2005; 11: 150–60.
Tiwari A, Chan S, Wong A, et al. Severe acute respiratory syndrome (SARS) in Hong Kong: patients’
experiences. Nurs Outlook 2003; 51: 212–9.
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SARS/MERS: systematic assessment of
symptoms
Studies (n) Cases (n) Sample (n)
Prevalence
(%)
Insomnia 2 54 129 41.9%
Anxiety 2 46 129 35.7%
Depressed mood 2 42 129 32.6%
Pressured speech 1 21 102 20.6%
Euphoria 1 8 102 7.8%
Aggression 1 2 27 7.4%
Irritability 1 5 102 4.9%
Auditory hallucinations 2 6 129 4.7%
Persecutory ideas 1 4 102 3.9%
Visual hallucinations 1 2 102 2.0%
Suicidality 1 2 102 2.0%
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Studies (n) Cases (n) Sample (n)
Prevalence
(%)
Impaired
concentration/attention 1 39 102 38.2%
Impaired memory 2 44 129 34.1%
Confusion 2 36 129 27.9%
Emotional lability 1 30 102 29.4%
Altered consciousness 1 17 82 20.7%
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David AS, 2020,
Lancet Psychiatry. *Joint 1st authors
Kim H-C, Yoo S-Y, Lee B-H, Lee SH, Shin H-S. Psychiatry Investig 2018; 15: 355–60.
Sheng B, Cheng SKW, Lau KK, Li HL, Chan ELY. Eur Psychiatry 2005; 20: 236–42.
DELIRIUM
SARS/MERS: systematic assessment of
symptoms
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SARS/MERS: psychiatric diagnoses
Depression (2 cases)
Anxiety disorder (2)
Acute stress reaction (2)
Psychotic depression (1)
Deterioration of dementia (1)
Psychotic disorders (16)
CHENG SKW, WONG CW, TSANG J, WONG KC. Psychol Med 2004; 34: 1187–95.
Kim H-C, Yoo S-Y, Lee B-H, Lee SH, Shin H-S. Psychiatry Investig 2018; 15: 355–60.
Lee DTS, Wing YK, Leung HCM, et al. Clin Infect Dis 2004; 39: 1247–9.
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SARS: acute psychosis
15 cases of psychosis (0.9% of cases of SARS). Compared to 30 age- &
sex-matched SARS patients. 13/15 diagnosed by psychiatrist with
steroid-induced mania/psychosis.
Risk factors for psychosis: family psychiatric history (5/15 vs 0/30),
higher cumulative corticosteroid dose
Some evidence that steroids associated with poorer outcomes in
COVID-19, but RECOVERY trial is using dexamethasone
Lee DTS, Wing YK, Leung HCM, et al. Factors Associated with Psychosis among Patients with Severe
Acute Respiratory Syndrome: A Case-Control Study. Clin Infect Dis 2004; 39: 1247–9.
https://www.recoverytrial.net/
https://www.recoverytrial.net/
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Delirium in COVID-19?
2 studies have systematically assessed neuropsychiatric Sx
1. 58 ITU patients in France after extubation.
Agitation: 40/58
Confusion: 26/40
At discharge, 5/45 had a dysexecutive syndrome (inattention, disorientation etc)
2. 82 patients who subsequently died in Wuhan
17/82 had ‘altered consciousness’
4 other studies reported confusion (not systematically): 2.0 – 22.2%
Helms J, Kremer S, Merdji H, et al. N Engl J Med 2020; : NEJMc2008597.
Zhang B, Zhou X, Qiu Y, et al. medRxiv 2020; : 2020.02.26.20028191.
Huang Y, Yang R, Xu Y, Gong P. medRxiv 2020; : 2020.02.27.20029009.
Chen N, Zhou M, Dong X, et al. Lancet (London, England) 2020; 395: 507–13.
Qi D, Yan X, Tang X, et al. medRxiv 2020; : 2020.03.01.20029397.
Leung KS-S, Ng TT-L, Wu AK-L, et al. medRxiv 2020; : 2020.03.30.20045740.
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Delirium in COVID-19?
UK data from International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC):
20,133 hospitalised patients
Used routine health records
Docherty et al, BMJ 2020
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Delirium as a presenting feature of
COVID-19?
59 elderly patients in a
dementia residential home
with confirmed COVID-19
‘Delirium-onset COVID-19’
(DOC) in 21/57 (36.8%)
Mixture of
hypoactive/hyperactive
DOC associated with higher
mortality (OR 17.0, 2.8-
102.7)
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CoroNerve initial findings
Limitation: substantial reporting
bias
153 cases
Median age: 71 (IQR 58-79)
Stroke: 77 (62%)
Mostly ischaemic
Altered mental status: 39 (31%)
Encephalopathy: 9
Encephalitis: 7
Psychiatric diagnoses: 23
Psychosis: 10
Neurocognitive (dementia-like)
syndrome: 6
Affective disorder: 4Varatharaj et al, JAMA Psychiatry 2020
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GBS: a cautionary tale
‘GBS incidence fell between March
and May 2020 compared to the
same months of 2016-2019.’
No correlation with COVID-19 &
GBS incidence
No difference in clinical
presentations
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Key points
Stress of having a severe infection
Delirium is very common and may be a presenting
feature in the elderly
Specific neuropsychiatric syndromes are probably
rare
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Post-illness impactAll SARS and MERS data
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Symptoms
Signs and Symptoms Post-illness (n)
Studies (n) Cases (n) Sample (n)
Prevalence
(%)
Insomnia 4 34 280 12.1%
Anxiety 2 21 171 12.3%
Impaired concentration/attention 2 34 171 19.9%
Impaired memory 3 44 233 18.9%
Depressed mood 5 35 332 10.5%
Confusion 1 1 621 0.16%
Emotional lability 1 24 102 23.5%
Pressured speech 1 12 102 11.8%
Euphoria 1 11 102 10.8%
Aggression 1 1 102 1.0%
Irritability 3 28 218 12.8%
Auditory hallucinations 1 1 102 1.0%
Persecutory ideas 1 2 102 2.0%
Fatigue 4 61 316 19.3%
Frequent recall of traumatic memories 1 55 181 30.4%
Sleep disorder 1 14 14 100%
Psychotic symptoms (unspecified) 1 4 90 4.4%
Self-harm 1 1 102 1.0%
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Anxiety disorders
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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Depression
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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Post-traumatic stress disorder
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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Hospital Anxiety and Depression Scale
(HADS)
3 papers, n = 364
Anxiety subscale: mean 6.5 (95% CI: 3.9 to 9.1, clinical
cutoff = 8)
Depression subscale: mean 6.2 (95% CI: 3.7 to 8.6, clinical
cutoff = 8)
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Quality of life
Short Form (36) Health Survey (SF-36)
Range 0 to 100
Compared to general population
3 relevant domains: social functioning, role limitation due to
emotional problems, mental health
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SF-36: social functioning
A
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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SF-36: role limitation due to emotional
problemsB
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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SF-36: mental health
C
From Rogers J* & Chesney E*, Oliver D, Pollak T, McGuire P, Fusar-Poli P, Zandi M, Lewis G, David
AS, Lancet Psychiatry 2020. *Joint 1st authors
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Employment
76.9% (95% CI: 68.1% to 84.6%) had returned to work at
mean follow-up time of 35.3 months.
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Implications
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Limitations
Lack of control groups
Lack of data of premorbid mental health
Reporting bias
Lack of data on those who aren’t hospitalised / diagnosed
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Comparability
Mortality of those infected varies substantially
ICU admission among hospitalised patients more similar:
SARS: 12.8% (k = 5, n=37, 95% CI 6.9% to 22.5%)
MERS: 59.8% (k = 2, n=102, 95% CI 38.9% to 77.6%)
COVID-19: 18.3% (k = 4, n=93, 95% CI 13.3% to 24.6%)
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Delirium implications
Difficulties with diagnosis
Prolonged hospital stay
Protracted recovery
Implications for mental capacity and ceilings of care
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Follow-up implications
BTS guidelines
recommend asking about
psychosocial status at
follow-up
Assessing cognition
Depression
Anxiety
PTSD
Chronic fatigue
?Cognitive problems
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Further information
Video abstract: https://youtu.be/E4Dw__V2SaU
https://youtu.be/E4Dw__V2SaU
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SUMMARY
Delirium is common in patients hospitalised for COVID-19
Depression, anxiety and PTSD are likely to be significant in the follow-up
period
Specific neuropsychiatric syndromes are probably rare
Most patients will not have a mental illness after COVID-19
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