What can psychiatrists learn from SARS and MERS outbreaks?
Authors: Iris E Sommer, P Roberto Bakker
Journal: The Lancet Psychiatry (2020)

While standard care for patients with psychiatric disorders must continue during the current COVID-19 pandemic, psychiatrists also need to treat psychiatric complications of patients with this new disease. An estimation of expected prevalences of psychiatric disorders occurring in this group would help to redistribute mental health personnel between old and new tasks to serve the needs of both groups optimally. In The Lancet Psychiatry, Jonathan Rogers and colleagues1Rogers JP Chesney E Oliver D et al.Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.Lancet Psychiatry. 2020; (published online May 18.)https://doi.org/10.1016/S2215-0366(20)30203-0Summary Full Text Full Text PDF PubMed Scopus (1309) Google Scholar report the results of their systematic review and meta-analysis of psychiatric sequelae in patients admitted to hospital with severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19 in the acute and post-illness stages of disease. The systematic review showed that most patients with SARS or MERS do not develop psychiatric disorders, but a significant minority exhibits 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). The meta-analysis showed that the point prevalence in the post-illness stage was 32·2% (95% CI 23·7–42·0) for post-traumatic stress disorder, 14·9% (12·1–18·2) for depression, and 14·8% (11·1–19·4) for anxiety. As the COVID-19 pandemic is so recent and ongoing, few studies reported on psychiatric disorders complicating this particular disease and those that did reported only short-term aspects. Rogers and colleagues circumvented this knowledge gap by taking together the few studies on psychiatric disorders in patients with COVID-19 with the much larger body of literature on psychiatric disorders accompanying two previous coronavirus epidemics: the 2002 SARS and the 2012 MERS outbreaks. From a biological perspective, it makes sense to merge data on SARS coronavirus 2 (SARS-CoV-2), which causes COVID-19, infections with those of SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV) infections because resemblance between these three types of coronaviruses is high.2Adhikari SP Meng S Wu YJ et al.Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review.Infect Dis Poverty. 2020; 9: 29Crossref PubMed Scopus (1243) Google Scholar SARS-CoV-2 is structurally and genetically highly homologous to MERS-CoV (>50% similarity) and SARS-CoV (>79% similarity).3Desforges M Le Coupanec A Dubeau P Bourgouin A Lajoie L Dubé M Talbot PJ Human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system?.Viruses. 2019; 12: 14Crossref PubMed Scopus (629) Google Scholar Even the spike proteins that SARS-CoV and SARS-CoV-2 use to attach to the target cell membrane (spike protein S, which interacts with the angiotensin-converting enzyme 2 receptor) are largely similar.4Petrosillo N Viceconte G Ergonul O Ippolito G Petersen E COVID-19, SARS and MERS: are they closely related?.Clin Microbiol Infect. 2020; (published online March 28.)DOI:10.1016/j.cmi.2020.03.026Summary Full Text Full Text PDF Scopus (691) Google Scholar Coronaviruses have been shown to be potentially neuroinvasive, neurotropic, and neurovirulent. For SARS-CoV and MERS-CoV, the presence of virus in the brain has been confirmed with RT-PCR, immunohistochemistry, and in-situ hybridisation.3Desforges M Le Coupanec A Dubeau P Bourgouin A Lajoie L Dubé M Talbot PJ Human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system?.Viruses. 2019; 12: 14Crossref PubMed Scopus (629) Google Scholar Such confirmations have not yet been provided for SARS-CoV-2, but symptoms such as confusion, seizures, and anosmia during acute infection might reflect CNS involvement. Thus, in terms of virus properties, SARS-CoV-2, SARS-CoV, and MERS-CoV are largely comparable.4Petrosillo N Viceconte G Ergonul O Ippolito G Petersen E COVID-19, SARS and MERS: are they closely related?.Clin Microbiol Infect. 2020; (published online March 28.)DOI:10.1016/j.cmi.2020.03.026Summary Full Text Full Text PDF Scopus (691) Google Scholar However, treatment of patients admitted to the hospital for SARS-CoV-2 infection seems to be different from treatment of those admitted for SARS-CoV and MERS-CoV infections. Furthermore, the social situation to which COVID-19 survivors return is completely different from that of SARS and MERS survivors. These differences are relevant for the prevalence of psychiatric disorders in both acute and post-illness stages. Patients with COVID-19 who are admitted to hospital might be older than patients admitted for SARS2Adhikari SP Meng S Wu YJ et al.Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review.Infect Dis Poverty. 2020; 9: 29Crossref PubMed Scopus (1243) Google Scholar, 4Petrosillo N Viceconte G Ergonul O Ippolito G Petersen E COVID-19, SARS and MERS: are they closely related?.Clin Microbiol Infect. 2020; (published online March 28.)DOI:10.1016/j.cmi.2020.03.026Summary Full Text Full Text PDF Scopus (691) Google Scholar (although not all studies show this5Li TS Gomersall CD Joynt GM Chan DP Leung P Hui DS Long-term outcome of acute respiratory distress syndrome caused by severe acute respiratory syndrome (SARS): an observational study.Crit Care Resusc. 2006; 4: 302-308Google Scholar), and the mean duration of their stay in the intensive care unit (ICU) is longer.2Adhikari SP Meng S Wu YJ et al.Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review.Infect Dis Poverty. 2020; 9: 29Crossref PubMed Scopus (1243) Google Scholar, 4Petrosillo N Viceconte G Ergonul O Ippolito G Petersen E COVID-19, SARS and MERS: are they closely related?.Clin Microbiol Infect. 2020; (published online March 28.)DOI:10.1016/j.cmi.2020.03.026Summary Full Text Full Text PDF Scopus (691) Google Scholar In the COVID-19 era, unlike the previous SARS and MERS outbreaks, fear for shortage of medical facilities such as ventilators can further increase stress. All three factors increase the risk for psychiatric complications such as anxiety and delirium in the acute stage for patients with COVID-19 compared with those with SARS or MERS. Staying at the ICU is a risk factor for developing psychiatric disorders by itself. In 2018, a large study among almost 5000 ICU survivors showed that prevalence of post-traumatic stress disorder was 46%, that of anxiety was 40%, and that of depression was 22%.6Hatch R Young D Barber V Griffiths J Harrison DA Watkinson P Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study.Crit Care. 2018; 22: 310Crossref PubMed Scopus (188) Google Scholar These prevalences are well above the upper ranges of the confidence intervals reported by Rogers and colleagues. As prolonged ICU stay and use of mechanical ventilation are both risk factors for psychiatric disorders,7Jackson P Khan A Delirium in critically ill patients.Crit Care Clin. 2015; 3: 589-603Summary Full Text Full Text PDF Scopus (70) Google Scholar patients with COVID-19 who need admission to an ICU are an ultra-high-risk group for developing acute psychiatric disorders, especially delirium.8Kotfis K Williams Roberson S Wilson JE Dabrowski W Pun BT Ely EW COVID-19: ICU delirium management during SARS-CoV-2 pandemic.Crit Care. 2020; 24: 176Crossref PubMed Scopus (285) Google Scholar Finally, COVID-19 survivors, unlike SARS and MERS survivors, return to a society in deep economic crisis, with shortage of basic needs such as food in some countries and other countries still in lockdown and enforcing physical isolation. These social adversities will keep stress levels after somatic recovery high, and further increase patients' risk for long-term psychiatric complications such as anxiety and depression. We conclude that findings from previous coronavirus outbreaks are useful,4Petrosillo N Viceconte G Ergonul O Ippolito G Petersen E COVID-19, SARS and MERS: are they closely related?.Clin Microbiol Infect. 2020; (published online March 28.)DOI:10.1016/j.cmi.2020.03.026Summary Full Text Full Text PDF Scopus (691) Google Scholar but might not be exact predictors of prevalences of psychiatric complications for patients with COVID-19. The warning from Rogers and colleagues that we should prepare to treat large numbers of patients with COVID-19 who go on to develop delirium, post-traumatic stress disorder, anxiety, and depression is an important message for the psychiatric community. Reported prevalence estimates in this Article should be interpreted with caution, as true numbers of both acute and long-term psychiatric disorders for patients with COVID-19 might be considerably higher. We declare no competing interests. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemicIf 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. Full-Text PDF Open Access