Journal Article Annotations
2020, 2nd Quarter
Annotations by Aum A. Pathare, MD
27 June, 2020
PUBLICATION #1 — Infectious Diseases
The finding
In this study, patients with encephalitis were recruited from National Health Service (NHS) hospitals to undergo psychometric testing. Patients were broadly differentiated into groups with Herpes simplex virus (HSV), other infections or autoimmune causes (Other), and encephalitis of unknown cause (Unknown). The HSV group had the greatest deficits overall, and in the short- and medium-term assessments (4 months to a year), showed problems with memory, executive function, verbal IQ, and naming. In the long-term (>1 year) group, these had narrowed down to impaired anterograde and autobiographical memory. Self-rated problems in memory, language, tiredness, processing speed, attention, as well as depressed mood were seen early on, and persisted for more than a year.
The two remaining groups also showed more impairment in memory relative to other cognitive functions. They also experienced subjective problems with cognition, anxiety, depression, and tiredness. The autoimmune group reported higher rates of depression, whereas the unknown group described more anxiety. Increased time to treatment, and length of hospital stay correlated with worse outcomes across all groups.
Strength and weaknesses
The study was conducted across a national health system, with careful recruitment of cases and controls. Difficulties were encountered with recruitment, especially in the autoimmune group, but comprehensive neuropsychological testing, and follow up at three different points of time contributed to the robustness of data. Limitations include the inclusion of two distinct cohorts: the long-term (>1 year) group was different than the short- and medium-term group. There was also uncertainty about completion of testing for cell-surface antibodies, and the increased representation of HSV cases due to a possible response bias. As a result, the diagnostic proportions in this study would be inaccurate with estimating true prevalence rates.
Relevance
Recovery for patients with encephalitis varies with etiology, and these data are an important guide to direct early rehabilitation efforts. C-L psychiatrists can engage in early screening of these deficits and advocate for targeted neurorehabilitation, as increased time to treatment was related to worse outcomes. Perceptions about cognition, fatigue, and nonspecific anxiety and depressive complaints increase over time. Longitudinal follow up, or including this higher risk population in a registry while providing integrated care may be helpful in ensuring that these issues are adequately addressed.
Type of Study
Multi-Centre Case-Control Study
The finding
This systematic review and meta-analysis examined the psychiatric sequelae of coronavirus infections, to construct a gestalt for the potential impact of COVID-19 based on the SARS and MERS epidemics. The authors focused on neuropsychiatric presentations, while excluding purely neurological issues, or the impact of the disease and disease related measures on people who were uninfected. Delirium was common in the acute stage of SARS, MERS, and COVID-19, occurring in nearly a third of the patients. Symptoms of depression, anxiety, fatigue, and post-traumatic stress were seen in the post-illness stage of previous epidemics up to a year after infection, but mean scores could be below clinical cutoffs for a specific diagnosis. Mania and psychosis were infrequent, and related to corticosteroid use. After recovery from the infection, sleep disorders, frequent recall of traumatic memories, emotional lability, impaired concentration, fatigue, and impaired memory were reported in more than 15% of patients for up to 3 years. Health related quality of life was worse throughout al groups.
Strength and weaknesses
This is an early effort to systematically examine the initial and delayed effects of infection from coronaviruses that includes data from previous epidemics. Most of the included studies were based in hospitals, which increases comparability among different infections. Limitations include lack of adequate comparison groups or assessments of past psychiatric diagnoses. Scores on symptom scales do not necessarily assess prevalence of disorders, and systematic evaluation of psychiatric symptoms was rare. Formal neuropsychological testing was not conducted outside one case. Non-English language articles were excluded, and most studies were of low or moderate quality. Biological specimens, studies, and imaging were rarely included.
Relevance
This study presents an intuitive finding—that delirium may occur in a large proportion of people with coronavirus infections. This is an issue that C-L psychiatrists everywhere are grappling with at this time. It also raises several important questions. Although mental health might have been impacted by the pandemic, this review suggests most people may not manifest symptoms that reach the level of an easily diagnosable psychiatric disorder following a coronavirus infection. However, C-L psychiatrists must be aware of the possibility of worsening depression, anxiety, fatigue, and post-traumatic stress, especially in populations with a history of related diagnoses. Exposure to steroids was associated with psychosis and mania, an issue which could emerge with the possibility of increased use of dexamethasone in hospital settings for COVID-19. This study provides direction for future research, emphasizing the need to establish prospective cohorts, the value of measures of mental health before infection, and the potential for markers of infection severity that could correlate with the psychiatric impact of these infections.
Type of Study
Systemic review and meta-analysis