Although the world has been dealing with the COVID-19 pandemic for nearly three years, many questions remain. Among them: where the virus came from, why it causes such severe systemic inflammation, and exactly how long someone remains contagious. Yet another area of concern prompting study is the possible correlation between COVID and the development of post-COVID psychosis—after reports that some individuals with the virus were presenting signs of mania/psychosis.
The phenomenon has sparked questions like:
- Can COVID-19 cause a psychotic episode in people who previously never had a mental illness?
- If so, how can a virus induce psychotic or manic symptoms?
- If psychosis after COVID-19 is real, how does this happen and can it be treated with standard medications? (Afterall, mental illness is primarily a brain disease caused by an imbalance of neurotransmitters. Once the imbalance is corrected by psychoactive medications, symptoms of a mental illness often improve significantly.)
This post will provide some answers.
Symptoms of Psychosis and Mania
Symptoms of psychosis or mania in individuals who have not been infected with COVID-19 are identical to symptoms of COVID-induced mania or COVID psychosis. However, psychosis should not be confused with schizophrenia, a chronic mental illness that causes psychotic episodes. When someone is having a psychotic episode, they will experience delusions, hallucinations, and lose contact with reality. The episode may last an hour, a day, or several days.
Manic episodes come and go similar to psychotic episodes. People with COVID mania or mania attributed to a mental illness (bipolar disorder, PTSD, schizoaffective disorder) will:
- Be extremely euphoric and hyperactive
- Have unrealistic ideas or beliefs (“I’ve discovered a drug that will cure cancer! I’ll be the most famous and richest person in the world! It’s something I’ve been working on for years.”)
- Have a grandiose sense of self-esteem to the point that they think they are invincible
- Talk rapidly without allowing others to interrupt
- Rapidly change topics in mid-sentence (flight of ideas)
- Become obsessed with a specific idea or activity
- Sleep only a few hours each night, if at all
- Be unable to sit or stand without fidgeting, pacing, or making purposeless movements
People in the grip of a manic episode often make poor decisions that hurt themselves and others. For example, mania can make a person gamble large sums of money away because they believe they’ll win millions of dollars. They may meet a stranger and marry that stranger hours later because they are convinced that the stranger is their “soulmate.” Believing they are invincible can lead to the person engaging in risky behavior (driving too fast, jumping from steep heights, abusing drugs, etc.).
Psychotic episodes typically subside sooner than manic episodes. Once a manic episode is over, the person often feels embarrassed and apologetic for their behavior. Sometimes, they have only vague memories about what they did or said during a manic episode. After learning of the consequences of their manic behavior, they often experience major depression, anxiety, and suicide ideation.
How Could COVID Potentially Cause Mania/Psychosis?
Studies show that COVID-19 infiltrates the brain via the olfactory nerve, ACE-2 receptors, and capillary cells. Once inside the brain, the coronavirus provokes a severe inflammatory response from the immune system. This abnormal response not only reduces neurotransmitter levels but also leads to some brain cell loss and/or dysfunction. Researchers speculate that this extreme neuroinflammatory response, combined with decreased oxygen levels and systemic inflammation, may underlie the development of psychotic and manic symptoms.
Previous studies investigating the link between mental illness and viral infections, specifically MERS, SARS, H1N1, and influenza infections, indicate these viruses can produce symptoms of psychosis in people with no history of psychiatric conditions. In fact, scientists speculated over 50 years ago about a correlation between schizophrenia and viral infections. Advancements in neurochemistry and imaging scans are making it possible today to further examine a potential link between viruses and schizophrenia.
COVID Psychosis and Cytokines
Cytokines are proteins that help the immune system fight infections. They also signal other cells involved in weakening infections to take action. While cytokines are essential for preventing viral or bacterial infections from worsening, excess levels of inflammatory cytokines can cause numerous health issues, including the respiratory distress syndrome that forces the intubation of people with COVID-19.
The overwhelming systemic inflammatory response generated by a COVID infection produces a “cytokine storm.” Flooding the body with cytokines by overwhelming the immune system is the primary reason why COVID causes organ damage, respiratory distress syndrome, and sometimes, death. Interestingly, a similar but less intense cytokine storm is sometimes found in people with schizophrenia.
Diagnosis and Prognosis for Post-COVID Psychosis/Mania
Diagnosing a person with psychosis/mania that may be related or unrelated to a COVID-19 infection involves a comprehensive examination by a healthcare provider. A physician will look at an individual’s family history of mental illness, medical history, current medications, blood test results, and even order imaging scans to rule out brain tumors or other anomalies. Of course, the main questions needing answers are: “Have you ever been infected with COVID, and have you ever been diagnosed with a mental illness?”
Studies involving individuals with post-COVID psychosis/mania are learning that the prognosis depends on the mechanism of action. In other words, people with a genetic predisposition to mental illness who had a psychotic episode due only to the biopsychosocial stress of the pandemic will likely need long-term care for their psychosis.
Alternately, individuals experiencing psychosis/mania as a secondary symptom of a COVID-19 infection should expect their mental health to improve as the inflammation subsides. Case reports indicate that COVID-infected people with no history of mental illness but who develop psychotic symptoms typically return to normal within two months of the onset of psychosis/mania.
Neuropsychiatric Symptoms and COVID-19
Even more troubling than COVID-19 psychosis/mania is the increasing frequency of neuropsychiatric symptoms seen in COVID survivors. These include memory impairments, inability to concentrate, difficulty solving normal daily problems, and “brain fog.” Current data about the damaging effects a COVID infection potentially has on cognition indicate that neuropsychiatric symptoms may persist in some people for six months or longer following recovery. More severe symptoms of post-COVID cognitive issues include disorientation, confusion, and episodes of incoherent speech or thoughts.
How is Post-COVID Psychosis Treated?
Doctors do not know if COVID psychosis/mania or neuropsychiatric issues are something that will eventually disappear permanently or continue as a chronic condition. Longitudinal studies are necessary to determine how long these conditions last and if certain factors cause symptoms to last longer in some people but not others.
Treatment recommendations for COVID-19 psychosis involve psychotherapy, cognitive behavioral therapy, antidepressants, psychoactive medications, and cognitive remediation. If you or someone you know is suffering from post-COVID mental health problems, call FHE today. We may be able to help you better understand and manage your symptoms.