Psychosis Related to COVID-19: Reports of a Disturbing New Complication

As physical debilitation and death from coronavirus infection continue to plague the world, reports are surfacing of a disturbing potential complication—psychosis. Most cases of psychotic disorder described in these new reports are found in individuals with no personal or family history of mental illness. In this month’s editorial, I will highlight what is known about psychosis that has developed in individuals during or after COVID-19. It is far too early to precisely identify risk factors (such as age or gender), but all psychiatric nurses need to become familiar with the symptoms in order to engage in community education, case-finding, and appropriate therapeutic interventions with symptomatic individuals.

Based on current reports, onset of psychotic symptoms varied from days to weeks, or even months, after recovery from the physical manifestations of COVID illness (Belluck, 2020). The somatic symptoms of COVID had tended to be rather mild. Delusions were the dominant psychosis symptom, and the search for effective psychotropic medications was challenging (as many as eight medications being tried). Many patients were in the 30s to 50s age range. Beyond these commonalities, published cases display considerable variability. Some patients cried for days, others became violent (e.g., a 30-year-old man who tried to strangle his cousin, whom he imagined was planning to murder him).

Smith et al. (2020, p. 1) claimed credit for presenting “the first case of COVID-19-associated psychosis in a patient with no personal or family history of a severe mood or psychotic disorder.” Their case, seen at Duke University Medical Center, was a 36-year-old African American woman who developed persecutory delusions (e.g., being tracked by cellphones, fear that her children would be kidnapped) 4 days after the onset of the respiratory symptoms of COVID. Unresponsive to olanzapine, she improved rapidly on risperidone and was discharged from the hospital in one week.

A much lengthier psychotic episode was described by Lim et al. (2020), whose patient was a 55-year-old White woman in the UK who had survived acute COVID infection but returned to the hospital with persistent paranoid delusions and florid hallucinations (e.g., nurses were devils, monkeys were jumping out of a medical bag). She was not clear of psychotic symptoms for 40 days. Prior to developing COVID, this woman was healthy, taking no medications, and had no history of mental illness. She was successfully treated first with haloperidol and later risperidone. The authors proposed that an inflammatory state (indicated by elevated tumor necrosis factor) caused or contributed to the psychosis.

A larger study in the UK, conducted by the CoroNerve Study Group, described neurological and neuropsychiatric complications of COVID in 153 patients. Of the 153, 10 patients had new-onset psychosis, six had a dementia-like syndrome, and seven had “other psychiatric disorder” (e.g., catatonia or mania) (Varatharaj et al., 2020). A descriptive study from Spain described 10 patients with no previous psychiatric history who presented to emergency and psychiatric departments at least 2 weeks after experiencing the somatic symptoms of COVID-19. The most frequent presentation was delusions (Parra et al., 2020).

The reader is cautioned that the published reports focus mainly on patients who were hospitalized during psychotic episodes and treated by neurologists and psychiatrists. Therefore, a gap in knowledge exists about cases that could have been less severe and managed by primary care providers—or not brought to the attention of the health care system at all.

The etiology of the COVID-related psychosis remains unclear, although most authors propose persistent immune activation and surges of inflammation. Much more research is needed about etiology, manifestations, and pharmacotherapeutics. Psychiatric-mental health nurses must continue to track the literature and contribute to it. I invite submission of your manuscripts to Issues in Mental Health Nursing.