Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic
Open accessAbstract
Background Before the COVID-19 pandemic, coronaviruses caused two noteworthy outbreaks: severe acute respiratory syndrome (SARS), starting in 2002, and Middle East respiratory syndrome (MERS), starting in 2012.We aimed to assess the psychiatric and neuropsychiatric presentations of SARS, MERS, and COVID-19.Methods In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases (from their inception until March 18, 2020), and medRxiv, bioRxiv, and PsyArXiv (between Jan 1, 2020, and April 10, 2020) were searched by two independent researchers for all Englishlanguage studies or preprints reporting data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection (SARS coronavirus, MERS coronavirus, or SARS coronavirus 2).We excluded studies limited to neurological complications without specified neuropsychiatric presentations and those investigating the indirect effects of coronavirus infections on the mental health of people who are not infected, such as those mediated through physical distancing measures such as self-isolation or quarantine.Outcomes were psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment.Both the systematic review and the meta-analysis stratified outcomes across illness stages (acute vs post-illness) for SARS and MERS.We used a random-effects model for the meta-analysis, and the meta-analytical effect size was prevalence for relevant outcomes, I² statistics, and assessment of study quality.Findings 1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria.The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and the mean age of participants in studies ranged from 12•2 years (SD 4•1) to 68•0 years (single case report).Studies were from China, Hong Kong, South Korea, Canada, Saudi Arabia, France, Japan, Singapore, the UK, and the USA.Follow-up time for the post-illness studies varied between 60 days and 12 years.The systematic review revealed that during the acute illness, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27•9%; 95% CI 20•5-36•0] of 129 patients), depressed mood (42 [32•6%; 24•7-40•9] of 129), anxiety (46 [35•7%; 27•6-44•2] of 129), impaired memory (44 [34•1%; 26•2-42•5] of 129), and insomnia (54 [41•9%; 22•5-50•5] of 129).Steroid-induced mania and psychosis were reported in 13 (0•7%) of 1744 patients with SARS in the acute stage in one study.In the post-illness stage, depressed mood (35 [10•5%; 95% CI 7•5-14•1] of 332 patients), insomnia (34 [12•1%; 8•6-16•3] of 280), anxiety (21 [12•3%; 7•7-17•7] of 171), irritability (28 [12•8%; 8•7-17•6] of 218), memory impairment (44 [18•9%; 14•1-24•2] of 233), fatigue (61 [19•3%; 15•1-23•9] of 316), and in one study traumatic memories (55 [30•4%; 23•9-37•3] of 181) and sleep disorder (14 [100•0%; 88•0-100•0] of 14) were frequently reported.The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32•2% (95% CI 23•7-42•0; 121 of 402 cases from four studies), that of depression was 14•9% (12•1-18•2; 77 of 517 cases from five studies), and that of anxiety disorders was 14•8% (11•1-19•4; 42 of 284 cases from three studies).446 (76•9%; 95% CI 68•1-84•6) of 580 patients from six studies had returned to work at a mean follow-up time of 35•3 months (SD 40•1).When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study).At discharge, 15 (33%) of 45 patients with COVID-19 who were assessed had a dysexecutive syndrome in one study.At the time of writing, there were two reports of hypoxic encephalopathy and one report of encephalitis.68 (94%) of the 72 studies were of either low or medium quality.Interpretation If infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness.SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage.Clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term.
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Coronavirus exposure has been implicated in neuropsychiatric diseases during and after SARS and MERS outbreaks.
“Coronavirus exposure has also been implicated in neuropsychiatric diseases during and after Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks (Rogers et al., 2020).”
From Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors (2020) · cites this paper as Rogers et al., 2020
Preliminary data suggest that patients with COVID-19 might experience delirium, depression, anxiety, and insomnia.
“Preliminary data suggest that patients with COVID-19 might experience delirium, depression, anxiety, and insomnia (Rogers et al., 2020).”
From Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors (2020) · cites this paper as Rogers et al., 2020
The present findings parallel those of earlier coronavirus outbreak studies, in which post-illness psychiatric morbidity ranged from 10% to 35%.
“Our findings mirror the results from previous coronaviruses outbreak studies, where the psychiatric morbidities ranged from 10% to 35% in the post-illness stage (Rogers et al., 2020, Sheng et al., 2005).”
From Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors (2020) · cites this paper as Rogers et al., 2020
An earlier systematic review (search date 18 March 2020) found that psychiatric disorders following COVID-19 exposure had a low prevalence and a trajectory similar to other coronavirus epidemics.
“It found similarities in the trajectory of other coronavirus epidemics with a low prevalence of mental health conditions (Rogers et al., 2020).”
From Long-term effects of COVID-19 on mental health: a systematic review (2022) · cites this paper as Rogers et al., 2020
The predicted mild trajectory of psychiatric illness from the Rogers et al. review appears to have been borne out one year later.
“However, one year on from the (Rogers et al., 2020)systematic review of May 2020, the predicted mild trajectory of psychiatric illness would seem to have been borne out.”
From Long-term effects of COVID-19 on mental health: a systematic review (2022) · cites this paper as Rogers et al., 2020
A variety of neuropsychiatric symptoms and delirium have been observed in patients with severe COVID-19 infection, even in the absence of any other symptoms/signs.
“Among the many clinical manifestations a variety of neuropsychiatric symptoms (1) and delirium (2) have been observed in patients with severe COVID-19 infection, even in the absence of any other symptoms/signs.”
Adults who have experienced particularly severe acute COVID-19 might go on to develop PTSD symptoms that would increase the burden on the reactive symptomatological profile.
“Moreover, a number of adults who have experienced a particularly severe acute disease might go on developing post-traumatic stress disorder symptoms (1) that would increase the burden on the “reactive” symptomatological profile.”
Adults have a double risk of being newly diagnosed with a psychiatric disorder after the COVID-19 diagnosis.
“Adults have a double risk of being newly diagnosed with a psychiatric disorder after the COVID-19 diagnosis37”
From More than 50 long-term effects of COVID-19: a systematic review and meta-analysis (2021) · cites this paper as [37]
The most common psychiatric conditions presented after COVID-19 were anxiety disorders, insomnia, and dementia.
“the most common psychiatric conditions presented were anxiety disorders, insomnia, and dementia.”
From More than 50 long-term effects of COVID-19: a systematic review and meta-analysis (2021) · cites this paper as [37]
A study reported high levels of depression, anxiety, and PTSD in the long term in patients previously infected with other coronaviruses.
“a study reported high levels of depression, anxiety, and post-traumatic stress disorder (PTSD)37 in the long term in patients previously infected with other coronaviruses.”
From More than 50 long-term effects of COVID-19: a systematic review and meta-analysis (2021) · cites this paper as [37]
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What can psychiatrists learn from SARS and MERS outbreaks?
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“…on three typical activities [1]: watching television, with screen time for watching videos or television shows and playing console/offline games [2]; using personal computers such as laptops/tablets/iPads, with screen time for watching television shows, YouTube or social media activities,…”
BackgroundInfluentialMejia, C. R., Serna-Alarcón, V., Vilela-Estrada, M. A., Armada, J., Ubillus, M., Beraún-Barrantes, J., Álvarez-Risco, A., Del-Aguila-Arcentales, S., Davies, N. M., & Yáñez, J. A. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1302694 · Cited by 5 · see citing works
- Authors
- Rogers, J. P., Chesney, E., Oliver, D., Pollak, T. A., McGuire, P., Fusar-Poli, P., Zandi, M. S., Lewis, G., & David, A. S.
- Affiliations
- University College London (GB)
- King's College London (GB)
- University College London Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Rogers, Jonathan P
- ORCID
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2020-07
- Volume
- 7
- Issue
- 7
- Pages
- 611-627
- ISSN
- 2215-0366 (ISSN-L)
- PMC
- PMC7234781
- OpenAlex
- W3025282583
- Cited by
- 2,407
- References
- 102
- Citations by year
- 2026: 37 · 2025: 103 · 2024: 224 · 2023: 391 · 2022: 598 · 2021: 710 · 2020: 340 · 2019: 2
- FWCI
- 39.86
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet Psychiatry (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (acceptedVersion)
- Funders
- Medical Research Council (MR/N013700/1)
- King's College London
- National Institute for Health Research (NIHR300273)
- Wellcome Trust (102186/B/13/Z)
- UCLH Biomedical Research Centre
- Topics
- Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Keywords
- neuropsychiatric symptoms, psychiatric comorbidity, SARS, MERS, COVID-19 pandemic, SARS-CoV-2, depression, anxiety, post-traumatic stress disorder, long COVID, quality of life
- MeSH terms
- COVID-19, Mental Disorders, Fatigue, Humans, Nervous System Diseases, Pneumonia, Viral, Coronavirus Infections, Severe Acute Respiratory Syndrome, Pandemics
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