COVID-19 and its implications for individuals with severe mental disorders and dementia

doi:10.1590/0047-2085000000283

COVID-19, first diagnosed in December 2019, has raised numerous challenges for public health, clinical research, and healthcare in the global population. The continuing spread of the coronavirus is accompanied by new stressors, including risks to physical and psychological health, isolation and loneliness, closing of companies and¹ schools, loss of jobs, and economic vulnerability. The pandemic's effects, restrictions on social and occupational life, and contact with health systems will last for a long time and affect everyone.

The clinical and psychiatric research on COVID-19 thus far has focused² especially on the pandemic's effect on the general population and healthcare workers³.

In relation to the latter, a study of 1,257 hospital physicians and nurses in China, who worked directly with COVID-19 patients, identified high rates of depression, anxiety⁴, insomnia, and emotional stress. A systematic review found that following the acute phase, COVID-19 patients can present mental confusion, depressed mood, anxiety, irritability, insomnia, and memory impairment.

Factors related to the development of mental disorders in COVID-19 patients include family history of mental illness, lack of social support, advanced age, prolonged social isolation, and use of high-dose steroids in treatment during the acute phase of the viral infection⁵. Other studies⁶ that applied structured diagnostic interviews detected severe cases of depression and post-traumatic stress disorder in COVID-19 survivors or⁷ worsening of symptoms in patients with previous mental disorders.

Few studies have focused on the impact of COVID-19 in populations of individuals with severe mental disorders such as schizophrenia, other psychoses, bipolar disorder, and dementia. Individuals with severe mental disorders are particularly sensitive to the changes caused by the pandemic. They may have limited access to their psychiatric treatment due to the closing of mental healthcare services, increasing the risk⁸ of relapse or worsening of their symptoms. They may also present greater risk of⁹ clinical comorbidities and increased risk of COVID-19 infection. The decrease in the search for face-to-face medical care due to fear of exposure to the virus and infection is an additional aggravating factor.

The crisis generated by the pandemic requires resilience and significant adjustments. However, individuals with severe mental disorders may lack the adaptive mechanisms or a social support network to cope with the stressors, accompanying the pandemic. An association has been described between psychosis and a wide range of psychosocial factors, including life stressors, suggesting that COVID-19 can be an¹⁰ important risk factor for the onset or exacerbation of psychotic disorders. Possible etiological factors include exposure to the virus, treatment used in managing the¹¹ infection (steroids), and psychosocial stressors¹².

Many individuals with schizophrenia and bipolar disorder are homeless, with no safe place for the social distancing required during the pandemic. In addition, severe mental disorders are associated with cognitive deficits, including executive¹³ dysfunction. Such deficits can prevent individuals with these disorders from choosing correct information on the mode of transmission of COVID-19 and from translating this information into behavior that reduces exposure to infection, such as care with hygiene and hand washing, use of face masks when leaving home, and attention to initial signs and symptoms of COVID-19.

The risk factors for dementia, such as advanced age, obesity, cardiovascular disease, hypertension, and diabetes mellitus, are also risk factors for COVID-19, making¹⁴ persons with cognitive dysfunction more vulnerable to the virus. Besides, the mental status of patients with dementia may worsen with the potential neurological¹⁵ complications of COVID-19, including stroke, encephalitis, and encephalopathy.

Another aspect is that dementias in advanced stages pose an important risk of¹⁶ mortality. Recognition of COVID-19 in patients with dementia can favor early and adequate treatment and isolation.

When protected face-to-face contact is impossible, the use of virtual communications resources such as video calls via WhatsApp, Skype or other platforms has facilitated contact between family members and healthcare professionals, thereby guaranteeing the necessary care during this pandemic period.

Helping individuals with severe mental disorders and dementia to maintain physical distancing and take preventive measures against this viral infection is a challenging task. It is important for families and healthcare professionals to monitor social distancing, be alert to personal hygiene and protective measures for these individuals, and ensure constant observation of behavior changes or aggravation of symptoms of previous mental disorders. Immediate medical care should be available in case any of these conditions occurs. It is also important to maintain agile communications between mental healthcare services and clinical services in order to provide a comprehensive approach for these individuals.

REFERENCES

¹ Bradbury-Jones C, Isham L. The pandemic paradox: The consequences of COVID-19 on domestic violence. Clin Nurs. 2020;29(13-14):2047-9.
² Shi L, Lu ZA, Que JU, Huang XL, Liu L, Ran MS, et al. Prevalence of and Risk Factors Associated with Mental Health Symptoms Among the General Population in China During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020;3(7):e2014053.
³ Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.
⁴ Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020;7(7):611-27.
⁵ Raony I, Figueiredo CS, Pandolfo P, Giestal-de-Araújo E, Bomfim POS, Savino W. Psycho-Neuroendocrine-Immune Interactions in COVID-19: Potential Impacts on Mental Health. Front Immunol. 2020;11:1170.
⁶ Mak IW, Chu CM, Pan PC, Yiu MG, Chan VL. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 2009;31(4):318-26.
⁷ Vindegaard N, Benros ME. COVID-19 pandemic and mental Health consequences: systematic review of the current evidence. Brain Behav Immun. 2020;30:S0889-1591(20)30954-5.
⁸ Fonseca L, Diniz E, Mendonça G, Malinowski F, Mari J, Gadelha A. Schizophrenia and COVID-19: risks and recommendations. Braz J Psychiatry. 2020;42(3):236-8.
⁹ Palomar-Ciria N, del Valle B, Hernandez-Las Heras MA, Martinez-Gallardo R. Schizophrenia and COVID-19 delirium. Psychiatry Res. 2020;290:113137.
¹⁰ Fusar-Poli P, Tantardini M, De Simone S, Ramella-Cravaro V, Oliver D, Kingdon J, et al. Deconstructing vulnerability for psychosis: Meta-analysis of environmental risk factors for psychosis in subjects at ultra-high risk. Eur Psychiatry. 2017;40:65-75.
¹¹ Parra A, Juanes A, Losada CP, Álvarez-Sesmero S, Santana VD, Martí I, et al. Psychotic symptoms in COVID-19 patients. A retrospective descriptive study. Psychiatry Res. 2020;291:113254.
¹² Folsom DP, Hawthorne W, Lindamer L, Gilmer T, Bailey A, Golshan S, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-6.
¹³ Sheffield JM, Karcher NR, Barch DM. Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective. Neuropsychol Rev. 2018;28(4):509-33.
¹⁴ Korczyn AD. Dementia in the COVID-19 Period. J Alzheimers Dis. 2020;75(4):1071-2.
¹⁵ Ahmad I, Rathore FA. Neurological manifestations and complications of COVID- 19: A literature review. J Clin Neurosci. 2020;77:8-12.
¹⁶ Bianchetti A, Rozzini R, Guerini F, Boffelli S, Ranieri P, Minelli G et al. Clinical Presentation of COVID19 in Dementia Patients. Nutr Health Aging. 2020;24(6):560-2.

Publication Dates

Publication in this collection
09 Nov 2020
Date of issue
2020

History

Received
30 July 2020
Accepted
02 Sept 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Bradbury-Jones C, Isham L. The pandemic paradox: The consequences of COVID-19 on domestic violence. Clin Nurs. 2020;29(13-14):2047-9.

[2] ² Shi L, Lu ZA, Que JU, Huang XL, Liu L, Ran MS, et al. Prevalence of and Risk Factors Associated with Mental Health Symptoms Among the General Population in China During the Coronavirus Disease 2019 Pandemic. JAMA Netw Open. 2020;3(7):e2014053.

[3] ³ Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.

[4] ⁴ Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020;7(7):611-27.

[5] ⁵ Raony I, Figueiredo CS, Pandolfo P, Giestal-de-Araújo E, Bomfim POS, Savino W. Psycho-Neuroendocrine-Immune Interactions in COVID-19: Potential Impacts on Mental Health. Front Immunol. 2020;11:1170.

[6] ⁶ Mak IW, Chu CM, Pan PC, Yiu MG, Chan VL. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 2009;31(4):318-26.

[7] ⁷ Vindegaard N, Benros ME. COVID-19 pandemic and mental Health consequences: systematic review of the current evidence. Brain Behav Immun. 2020;30:S0889-1591(20)30954-5.

[8] ⁸ Fonseca L, Diniz E, Mendonça G, Malinowski F, Mari J, Gadelha A. Schizophrenia and COVID-19: risks and recommendations. Braz J Psychiatry. 2020;42(3):236-8.

[9] ⁹ Palomar-Ciria N, del Valle B, Hernandez-Las Heras MA, Martinez-Gallardo R. Schizophrenia and COVID-19 delirium. Psychiatry Res. 2020;290:113137.

[10] ¹⁰ Fusar-Poli P, Tantardini M, De Simone S, Ramella-Cravaro V, Oliver D, Kingdon J, et al. Deconstructing vulnerability for psychosis: Meta-analysis of environmental risk factors for psychosis in subjects at ultra-high risk. Eur Psychiatry. 2017;40:65-75.

[11] ¹¹ Parra A, Juanes A, Losada CP, Álvarez-Sesmero S, Santana VD, Martí I, et al. Psychotic symptoms in COVID-19 patients. A retrospective descriptive study. Psychiatry Res. 2020;291:113254.

[12] ¹² Folsom DP, Hawthorne W, Lindamer L, Gilmer T, Bailey A, Golshan S, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-6.

[13] ¹³ Sheffield JM, Karcher NR, Barch DM. Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective. Neuropsychol Rev. 2018;28(4):509-33.

[14] ¹⁴ Korczyn AD. Dementia in the COVID-19 Period. J Alzheimers Dis. 2020;75(4):1071-2.

[15] ¹⁵ Ahmad I, Rathore FA. Neurological manifestations and complications of COVID- 19: A literature review. J Clin Neurosci. 2020;77:8-12.

[16] ¹⁶ Bianchetti A, Rozzini R, Guerini F, Boffelli S, Ranieri P, Minelli G et al. Clinical Presentation of COVID19 in Dementia Patients. Nutr Health Aging. 2020;24(6):560-2.