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A retrospective cohort study published in Lancet Psychiatry looks at associations between COVID-19 and psychiatric disorder.
This Roundup accompanied an SMC Briefing.
Prof Emily Holmes, Chair of MQ’s Research Committee, said:
“It is clear we need effective and accessible mental health interventions that can be delivered at scale to reach the number of people needed in order to be affective. This challenge demands research of how best to help people.
“We also urgently need investigation into the mechanisms behind these effects, in particular those mechanisms that will improve treatments.”
Dr Ciara McCabe, Associate Professor of Neuroscience, University of Reading, said:
“This is an impressive study with a large sample size and well matched control data. This study extends current knowledge by looking at the psychiatric consequences of Covid over time.
“The authors examined the risk of Covid against other infections like the flu but it would be good to compare psychiatric risk factors for covid against other health issues with similar death rates to covid which are suggested as much higher than the flu.
“This data supports the importance of examining psychiatric risk factors for poor physical health and in particular serious infections like COVID.
“As the authors note, this study cannot speak to the underlying mechanisms thus further investigation into this is urgently needed. The data suggests possible biological factors but again at present these are only speculative.
“The authors don’t mention “long covid” it would be interesting to examine how psychiatric risk factors relate to various forms of covid.”
Prof Dame Til Wykes, Vice Dean Psychology and Systems Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:
“This paper analyses a very large medical records dataset and finds an increased chance of new cases of anxiety disorders following Covid-19 compared to people with health conditions. It also reports that those previously diagnosed with psychiatric disorders are more likely to develop Covid-19.“
“We know from previous pandemics that mental health difficulties usually follow in survivors, and this study shows the same pattern after Covid-19, so it is not unexpected. But, though this is not a new finding, the data and the care with the analysis gives us more confidence in their results.”
“The study also shows that timing matters as more psychiatric disorders were reported before April 1st than after in any health condition. Presumably because all health care support changed and anxiety was higher as rates of Covid-19 were increasing.
“People with previously diagnosed mental health problems were more at risk of developing Covid-19 even after controlling for some risk factors. Like the general population, older people were more at risk. This is a novel finding and the underlying process is not clear. It might relate to medication, inflammation or some social or environmental factors – we just do not know what they are yet. We do know that people with psychiatric disorders die much earlier than the general population (known as the mortality gap). This physical health vulnerability might also make them more likely to develop Covid-19.
“The increase in mental health disorders in people who have developed Covid-19 mirrors the increases reported in the UK general population, even in well controlled longitudinal studies. So this is clearly the tip of an iceberg. We need to develop as many different, accessible forms of mental health support as possible. The UK has developed the world renowned, Increased Access to Psychological Treatment (IAPT) which needs further expansion and links into hospital care for Covid-19 patients if we are to provide adequate treatment for these and other mental health conditions.”
Dr Jo Daniels, Senior Lecturer in Clinical Psychology, University of Bath, said:
“This study uses a very large sample to address questions relating to the psychiatric outcomes of those who have been infected with COVID-19. Large cohort studies are particularly useful because they lack interference or intervention, often offer very complete data, and can mitigate against potential confounding variables or biases in sample selection that might be associated with smaller samples. It is clear from the study that one of the key methods used to calculate and assess rates of psychiatric outcomes is by comparing the COVID-19 group with outcomes of those in other medical groups.
“However, there are limitations to this approach, particularly as the comparator groups are heterogenous, the comparator conditions are not novel, broadly have treatment options, and do not represent unprecedent global health threats. These factors contribute to the psychological response to a health event – psychological responses to a imminently life threatening, previously unknown and highly contagious infectious disease will be dissimilar from that of a bone fracture or upper respiratory tract infection. It is entirely unsurprisingly that there is psychological sequale after infection with a rapidly spreading novel virus that has required substantial changes in human behaviour on a prolific level, particularly when still ongoing. It is reasonable to expect psychological distress that persists for some time following a significant health threat, particularly if over a period when stay at home orders or lockdown procedures are in place, or COVID-19 is not remitting as it still fails to do; this could be explored more fully. This paper may benefit from a more tentative interpretation of these findings; psychiatric outcomes are measured up to 90 days post-infection only, and we are not made privy to what proportion have ongoing long covid symptoms, which is known to be associated with disabling and distressing symptoms – this is highly pertinent to interpretation. The move to diagnose and pathologise normal psychological distress is common among the COVID-19 literature, and data such as this can be open to worrying misinterpretation. Indeed, we would be most interested in the outcomes after the 90 day period and when the pandemic has passed – does distress persist when there is no life threatening infectious disease proliferating? This study does not offer long-term data – this should be at the forefront of our minds when interpreting the findings – it cannot predict psychiatric outcomes at one year follow up and does not account for worrying post-covid physical symptoms that may be distressing. This is not an insignificant proportion.
“There are also sub-groups more at risk which may be important here; those who are front line workers, those who are shielders, for example. The authors are correct in that psychiatric outcomes are important in shaping future services, however it is essential that findings are also interpreted in the broader context, and here, the important context is that we would expect psychological distress to be much higher in those experiencing a potentially life-threatening infectious disease that puts their family at risk, their livelihood at risk, and may leave them with worrying long-term physical symptoms and ongoing concern over re-infection while still in pandemic. Caution should be exercised in inferring that psychiatric morbidity is directly associated with COVID-19; psychiatric diagnoses where given appropriately, can offer access to appropriate help, but if given prematurely or inappropriately, diagnoses can cause unnecessary distress, stigma and may be difficult to remove. This paper makes a useful contribution to the literature and mental health is an important consideration we must make after a global crisis. The graphs reporting steep increases in mental health difficulties are indeed deeply concerning and we should be aware that poorer psychological outcomes are common in those who experience physical health problems of any nature, being acutely or chronically unwell is simply a difficult experience. However, further longer-term research is warranted before conclusions are firmly drawn, and it would benefit those most affected if as researchers, our underpinning position is to support, acknowledge and validate those experiencing ‘normal’ distress, resisting the urge to diagnose unless absolutely necessary. Education and destigmatisation of mental health is vital if we are to make gains in addressing and improving outcomes.”
Dr Michael Bloomfield, Excellence Fellow, Head of Translational Psychiatry Research Group and Consultant Psychiatrist, University College London (UCL), said:
“This well conducted study adds to a growing body of evidence that COVID increases the risk of a range of psychiatric illnesses including post-traumatic stress disorder. This is likely due to a combination of the psychological stressors associated with this particular pandemic and the physical effects of the illness, although further work is needed to understand this fully.
“Increased resources need to be immediately released to help NHS services meet the needs of patients and so that researchers can further understand the relationships between COVID and mental illnesses.”
Prof David Curtis, retired consultant psychiatrist and Honorary Professor at University College London and Queen Mary University of London, said:
“The study reports that patients have a somewhat higher risk of being diagnosed with a psychiatric illness, mainly anxiety or depression, after a COVID-19 diagnosis than after certain other medical events. For example, they show that there is an 18% chance of getting a psychiatric diagnosis after COVID-19 compared with 13% after influenza. It’s difficult to judge the importance of these findings. These psychiatric diagnoses get made quite commonly when people present to doctors and it may be unsurprising that this happens a bit more often in people with COVID-19, who may understandably have been worried that they might become seriously unwell and who will also have had to endure a period of isolation.
“The study also reports that people with a pre-existing psychiatric diagnosis are at moderately higher risk of developing COVID-19. It is well known that psychiatric illness is associated with increased risk of many other physical health issues and also that COVID-19 infection risk is associated with socioeconomic factors which may be more prevalent in people with mental illness. So again this observation is not unexpected.
“Overall, the results reported seem broadly plausible but I’m not sure that they have specific implications for patients or health services.”
Professor Sir Simon Wessely, Regius Professor of Psychiatry, King’s College London and Director, Health Protection Research Unit in Emergency Preparedness and Response and the King’s Centre for Military Health Research, KCL, said:
“We know from previous pandemics (e.g. influenza, SARS) that having for example depression before infection increases the risk of depression after infection. It would have been very surprising if this proved not to be the case for COVID-19. COVID-19 affects the central nervous system, and so might directly increase subsequent disorders. But this research confirms that is not the whole story, and that this risk is increased by previous ill health. We now have an opportunity to find out why.”
‘Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA’ by Maxime Taquet et al. was published in Lancet Psychiatry at 23:30 UK time on Monday 9 November.
DOI: https://doi.org/10.1016/S2215-0366(20)30462-4
Declared interests
Dr Ciara McCabe: “No conflicts.”
Dr Jo Daniels: “No declarations of interest.”
Dr Michael Bloomfield: “No declarations of interest.”
Prof David Curtis: “No COI.”
None others received.