Brief Psychotic Disorder During the National Lockdown in Italy

An Emerging Clinical Phenomenon of the COVID-19 Pandemic

Armando D'Agostino; Simone D'Angelo; Barbara Giordano; Anna Chiara Cigognini; Margherita Lorenza Chirico; Cristiana Redaelli; Orsola Gambini

Disclosures

Schizophr Bull. 2021;47(1):15-22. 

In This Article

Abstract and Introduction

Abstract

The impact of the COVID-19 pandemic on psychosis remains to be established. Here we report 6 cases (3 male and 3 female) of first-episode psychosis (FEP) admitted to our hospital in the second month of national lockdown. All patients underwent routine laboratory tests and a standardized assessment of psychopathology. Hospitalization was required due to the severity of behavioral abnormalities in the context of a full-blown psychosis (the Brief Psychiatric Rating Scale [BPRS] = 75.8 ± 14.6). Blood tests, toxicological urine screening, and brain imaging were unremarkable, with the exception of a mild cortical atrophy in the eldest patient (male, 73 years). All patients were negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout their stay, but 3 presented the somatic delusion of being infected. Of note, all 6 cases had religious/spiritual delusions and hallucinatory contents. Despite a generally advanced age (53.3 ± 15.6), all patients had a negative psychiatric history. Rapid discharge (length of stay = 13.8 ± 6.9) with remission of symptoms (BPRS = 27.5 ± 3.1) and satisfactory insight were possible after relatively low-dose antipsychotic treatment (Olanzapine-equivalents = 10.1 ± 5.1 mg). Brief psychotic disorder/acute and transient psychotic disorder diagnoses were confirmed during follow-up visits in all 6 cases. The youngest patient (female, 23 years) also satisfied the available criteria for brief limited intermittent psychotic symptoms. Although research on larger populations is necessary, our preliminary observation suggests that intense psychosocial stress associated with a novel, potentially fatal disease and national lockdown restrictions might be a trigger for FEP.

Introduction

At the time of writing, more than 10 million confirmed cases and several billion people under lockdown worldwide make the Corona VIrus Disease 2019 (COVID-19) pandemic an unprecedented crisis of contemporary history. Several authors have already shown concern over the potential consequences on global mental health that might substantially engage health systems in upcoming months.[1,2] One meta-analysis aimed to classify the psychiatric and neuropsychiatric complications of infected patients by pooling the first available findings together with previous literature on 2 recent coronavirus epidemics (Middle East respiratory syndrome [MERS] and severe acute respiratory syndrome [SARS]).[3] Results suggest that most patients should recover without mental health issues although depression, anxiety, fatigue, and posttraumatic stress disorder (PTSD) might occur in the long term.

Physical distancing remains the most effective prevention known for viral diffusion, albeit burdened by adverse psychological effects in infected and noninfected individuals.[4] Although large population studies are still unavailable, the incidence rates of depression, anxiety, and PTSD are expected to increase in the general population.[5,6] Evidence from MERS and SARS coronavirus outbreaks suggests that suicide rates are also likely to increase substantially.[7,8] Less is known on the impact of this unprecedented crisis on psychosis, although individuals with severe mental illness should perhaps be considered among those with the highest risk of infection and unfavorable outcomes.[9,10] Furthermore, several viral agents—including influenza viruses—have been associated with a risk of psychosis, with increased rates observed in the offspring of women with perinatal infections.[11] Notably, reports of incident cases of psychosis with COVID-19-related somatic delusions have begun to emerge worldwide.[12–16] These episodes occurred in noninfected individuals and presumably reflect the intense psychosocial stress experienced during the pandemic.[17]

Stress-related psychotic episodes are commonly described within the "acute and transient psychotic disorders" (ATPDs) (International Classification of Diseases-11th revision, ICD-11)[18] or "brief psychotic disorder (BPD)" (Diagnostic and Statistical Manual of Mental Disorders-5th edition, DSM-5)[19] nosological domains. Similar clinical syndromes have been repeatedly reconceptualized as "bouffée délirante des dégénérés," "cycloid psychoses," "reactive psychoses," "emotional psychoses," "atypical psychoses," or "schizophreniform state" in an attempt to define their nosological boundaries in relationship to other affective and nonaffective psychoses. The difficulty of clearly defining these boundaries inevitably leads to uncertainty on the condition's epidemiology, which might also depend on unique, population-level stressors such as the ongoing pandemic.

Approximately 2 months after the COVID-19 outbreak in Lombardy and 50 days into national lockdown, we began to hospitalize patients with brief psychotic episodes at a remarkable rate. We present the first 6 here and discuss the implications of this observation.

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