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Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic

Research output: Contribution to journalArticle

Jonathan Rogers, Edward Chesney, Dom Oliver, Thomas Pollak, Philip McGuire, Paolo Fusar-Poli, Michael Zandi, Glyn Lewis, Anthony David

Original languageEnglish
JournalThe Lancet Psychiatry
Accepted/In press29 Apr 2020

King's Authors


Prior to the COVID-19 pandemic, coronaviruses caused two noteworthy epidemics, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). We aimed to systematically review and meta-analyse studies reporting the psychiatric and neuropsychiatric presentations of SARS, MERS and COVID-19.

MEDLINE, EMBASE, PsycINFO and CINAHL (from their inception until 18/03/2020) and MedRxiv, bioaRxiv and PsyArXiv (between 01/01/2020 and 10/04/2020) were systematically searched by two independent researchers for all English-language studies or preprints reporting data on the psychiatric presentations of any coronavirus outbreak (SARS, MERS and COVID-19). Outcomes included: psychiatric signs/symptoms, ICD-10/DSM-IV/CCMD-III diagnoses, psychiatric rating 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. The meta-analytical effect size was prevalences for relevant outcomes, I2 statistics, and assessment of study quality.

1963 studies and 87 pre-prints were identified by the systematic search, of which 65 peer-reviewed studies and 7 pre-prints met inclusion criteria. The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and mean age of participants in studies ranged from 12.2 to 72.5 years. The majority of the studies were from China and Hong Kong, South Korea, Canada, and Saudi Arabia. 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 those hospitalised for SARS or MERS include confusion, depression, anxiety and insomnia. Steroid-induced mania and psychosis were reported in a small minority in the acute stage. In the post-illness stage, fatigue, depressed mood, memory impairment, traumatic memories and sleep disturbance were frequently reported. The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32.5% (95% CI: 22.8% to 44.1%, k (studies)=4, n (cases)=121,), depression was 15.0% (95% CI: 12.2% to 18.4%, k=5, n=77) and anxiety disorders 14.8% (95% CI: 11.2% to 19.5%, k=3, n=42). The majority of coronavirus-infected patients (76.9% [95% CI: 68.1% to 84.6%, n=5]) had returned to work at follow-up. When data for COVID-19 patients were examined (which include pre-print data), there was evidence for delirium (confusion, agitation and altered consciousness) in some patients, while symptoms of anxiety and depression were also common in the acute illness. A dysexecutive syndrome may also occur after discharge from intensive care. The majority of the studies were of either low or medium quality. At the time of writing, there were sporadic reports of encephalitic presentations.

Although most patients should recover without experiencing mental illness, the COVID-19 pandemic may cause delirium in a significant proportion of patients in the acute stage and – if there is a similar course to SARS and MERS – there may be a considerable burden of psychiatric morbidity in the longer term. Research into mitigating factors and interventions is required.

Wellcome Trust, UK National Institute for Health Research, UK Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London.

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