Journal Article Annotations
2020, 4th Quarter

Neuropsychiatry

Annotations by Brandon Francis, MD, MPH
December, 2020

Neurological manifestations of COVID-19 and other coronaviruses: A systematic review
Association between mental illness and COVID-19 susceptibility and clinical outcomes in South Korea: a nationwide cohort study.

PUBLICATION #1 — Neuropsychiatry

Neurological manifestations of COVID-19 and other coronaviruses: A systematic review

Alyne Oliveira Correia, Pedro Walisson Gomes Feitosa, Jorge Lucas de Sousa Moreira, Samuel Átila Rodrigues Nogueira, Ricardo Brandão Fonseca, Maria Elizabeth Pereira Nobre

Abstract: Neurol Psychiatry Brain Res. 2020 Sep;37:27-32. doi: 10.1016/j.npbr.2020.05.008. Epub 2020 May 31.

Objective:
To describe the main neurological manifestations related to coronavirus infection in humans.

Methodology:
A systematic review was conducted regarding clinical studies on cases that had neurological manifestations associated with COVID-19 and other coronaviruses. The search was carried out in the electronic databases PubMed, Scopus, Embase, and LILACS with the following keywords: “coronavirus” or “Sars-CoV-2” or “COVID-19” and “neurologic manifestations” or “neurological symptoms” or “meningitis” or “encephalitis” or “encephalopathy,” following the Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results:
Seven studies were included. Neurological alterations after CoV infection may vary from 17.3% to 36.4% and, in the pediatric age range, encephalitis may be as frequent as respiratory disorders, affecting 11 % and 12 % of patients, respectively. The Investigation included 409 patients diagnosed with CoV infection who presented neurological symptoms, with median age range varying from 3 to 62 years. The main neurological alterations were headache (69; 16.8 %), dizziness (57, 13.9 %), altered consciousness (46; 11.2 %), vomiting (26; 6.3 %), epileptic crises (7; 1.7 %), neuralgia (5; 1.2 %), and ataxia (3; 0.7 %). The main presumed diagnoses were acute viral meningitis/encephalitis in 25 (6.1 %) patients, hypoxic encephalopathy in 23 (5.6 %) patients, acute cerebrovascular disease in 6 (1.4 %) patients, 1 (0.2 %) patient with possible acute disseminated encephalomyelitis, 1 (0.2 %) patient with acute necrotizing hemorrhagic encephalopathy, and 2 (1.4 %) patients with CoV related to Guillain-Barré syndrome.

Conclusion:
Coronaviruses have important neurotropic potential and they cause neurological alterations that range from mild to severe. The main neurological manifestations found were headache, dizziness and altered consciousness.

Annotation

The finding:
This article identifies the neurological manifestations of SARS-CoV-2.

Strength and weaknesses:
One of the strengths is that this is one of the early papers organizing data regarding the effects of SARS-CoV-2 on the central nervous system. The challenge is that the knowledge of this virus and its consequences are still in their infancy. Over 900 papers met initial inclusion criteria and only 7 total papers were included in the final analysis. This means that there are likely more effects than is known currently and that clinical vigilance is the only way to identify additional, not previously documented effects. Another weakness is the lack of data on specific psychiatric symptoms including anxiety, depression, and psychosis.

Relevance:
In an environment where the population we treat may have varying degrees of understanding and acceptance of the existence of SARS-CoV-2, it is paramount that we as clinicians are aware of what the data are and are not. SARS-CoV-2 is a respiratory virus that has significant extrapulmonary manifestations. The virus seems to have an affinity for the central nervous system which may, at least in part, contribute to its neurologic effects. We should be aware of the neurologic effects and be mindful of where there may be important psychiatric components to the clinical picture. Encephalitis, stroke, seizures, altered consciousness, encephalopathy and headache have all been described.

Type of study (EBM guide):
Systematic review or meta-analysis

PUBLICATION #2 — Neuropsychiatry

Association between mental illness and COVID-19 susceptibility and clinical outcomes in South Korea: a nationwide cohort study

Seung Won Lee, Jee Myung Yang, Sung Yong Moon, In Kyung Yoo, Eun Kyo Ha, So Young Kim, Un Min Park, Sejin Choi, Sang-Hyuk Lee, Yong Min Ahn, Jae-Min Kim, Hyun Yong Koh, Dong Keon Yon

Abstract: Lancet Psychiatry. 2020 Dec;7(12):1025-1031. doi: 10.1016/S2215-0366(20)30421-1. Epub 2020 Sep 17.

Background:
Evidence for the associations between mental illness and the likelihood of a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result and the clinical outcomes of COVID-19 is scarce. We aimed to investigate these associations with data from a national register in South Korea.

Methods:
A nationwide cohort study with propensity score matching was done in South Korea using data collected from the Health Insurance Review and Assessment Service of Korea. We defined mental illness as present if one of the relevant ICD-10 codes was recorded at least twice within 1 year for an outpatient or inpatient. Severe mental illness was considered as non-affective or affective disorders with psychotic features. We included all patients aged older than 20 years who were tested for SARS-CoV-2 through services facilitated by the Korea Centers for Disease Control and Prevention, the Health Insurance Review and Assessment Service of Korea, and the Ministry of Health and Welfare, South Korea. We investigated the primary outcome (SARS-CoV-2 test positivity) in the entire cohort and the secondary outcomes (severe clinical outcomes of COVID-19: death, admission to the intensive care unit, or invasive ventilation) among those who tested positive.

Findings:
Between Jan 1 and May 15, 2020, 216 418 people were tested for SARS-CoV-2, of whom 7160 (3·3%) tested positive. In the entire cohort with propensity score matching, 1391 (3·0%) of 47 058 patients without a mental illness tested positive for SARS-CoV-2, compared with 1383 (2·9%) of 48 058 with a mental illness (adjusted odds ratio [OR] 1·00, 95% CI 0·93-1·08). Among the patients who tested positive for SARS-CoV-2, after propensity score matching, 109 (8·3%) of 1320 patients without a mental illness had severe clinical outcomes of COVID-19 compared with 128 (9·7%) of 1320 with a mental illness (adjusted OR 1·27, 95% CI 1·01-1·66).

Interpretation:
Diagnosis of a mental illness was not associated with increased likelihood of testing positive for SARS-CoV-2. Patients with a severe mental illness had a slightly higher risk for severe clinical outcomes of COVID-19 than patients without a history of mental illness. Clinicians treating patients with COVID-19 should be aware of the risk associated with pre-existing mental illness.

Annotation

The finding:
People with mental illness seem to be at similar risk for contracting SARS-CoV-2 as those without mental illness. However, patients with mental illness seem to be at increased risk for severe adverse outcomes related to COVID-19. Limited social support systems, limited clinical resources, local infectious epidemiologic patterns and comorbid medical illness may all increase the risk of mortality in patients with severe mental illness.

Strength and weaknesses:
This is a large study, including > 200,000 people. However, it is exclusively a Korean population, and the number of persons with both severe mental illness and also COVID-19 is small. Additionally, the precise mechanism for reported worsened outcomes in patients with COVID-19 and severe mental illness have not been well defined.

Relevance:
This article encourages us to be aware of the additional challenges that may face COVID-19 patients who have severe mental illness. Consult-liaison psychiatrists are often placed in clinical situations where other specialty providers are asking for assistance regarding cohesive, multidisciplinary management plans for patients with complex medical illness. This article may inform our thought process regarding recommendations for continued follow up care and case management resource requirements.

Type of study (EBM guide):
Cohort study