Psychosis in Patients in COVID-19-Related Quarantine: A Case Series

Psychosis in Patients in COVID-19-Related Quarantine:

A Case Series

Francesco Finatti, MDa; Giorgio Pigato, MDb; Chiara Pavan, MD, PhDa,b; Tommaso Toffanin, MD, PhDb,*; and Angela Favaro, MD, PhDa,b

While the long-term mental health effects of previous pandemics and related quarantines have been reported in the literature,1 research is scarce with regard to the first stages of this type of emergency situation. Sudden social isolation, societal restrictions, and virus-related fears may serve as precipitating factors in vulnerable individuals for many types of psychiatric conditions. The literature reports that individuals who are mentally vulnerable to environmental stressors can be deeply affected by quarantines,2 but no data are yet available regarding the collateral effects of the coronavirus disease 2019 (COVID-19) infection on the onset of acute psychosis.

We describe 3 clinical cases of patients admitted to the psychiatric ward of the Padua University Hospital, Padua, Italy, following the enactment of quarantine measures in the Veneto region of northeastern Italy. All 3 admissions occurred in a period of less than a week (March 20-25, 2020), starting 10 days after initiation of strict societal restrictions in the country.

Case Reports

Case 1. A 30-year-old, unmarried, white man was quarantined for 14 days after his parents were diagnosed with COVID-19 and admitted to the hospital’s infectious disease unit. During home isolation, he gradually developed marked feelings of hopelessness and loss, severe insomnia, and, finally, an abrupt onset of delusions about his parents (that their health had recovered or that they had perished) and thoughts of persecution (quarantine as a scheme to keep him contained, feeling of being in a show). At the same time, bursts of aggressiveness, rage, and destructive fury associated with visual hallucinations were reported by his sister.

Case 2. During the quarantine, a 40-year-old, married, white woman from Romania started manifesting bizarre behaviors (forbid people from ever exiting the house, prayed obsessively, imposed religious rituals on her husband), delusions of lack of freedom (impossibility of returning to her country of origin and her family, thoughts about being forced to return to Romania), and marked insomnia. The clinical picture rapidly evolved to psychomotor agitation with narrowing of consciousness field (she thought that thieves were hidden in her house and that some relatives had been substituted).

Case 3. A 40-year-old, married, white man recently lost his younger brother in a car accident. His wife soon noticed a worsening in mood, with delusions of loss, ruin, and guilt (he felt responsible for his brother’s death); feelings of persecution (fear of being influenced by technological devices or being killed by others); and unstructured suicidal ideation. During the quarantine, his condition worsened, and he frequently felt the need to escape the house, wherein he was constantly reminded of his loss.

None of these patients had a history of psychiatric disorders. They were treated with risperidone (range, 2-5 mg), diazepam (range, 2-6 mg), and paroxetine (20 mg in case 3) with a complete remission of acute psychotic symptoms within a few days. In all 3 cases, our diagnosis was brief psychotic disorder, according to DSM-5 criteria.3

Discussion

Few data are currently available in the medical literature regarding the effects of the coronavirus infection on mental health.4 Even less is known about the mental effects of quarantine on previously healthy individuals.1,2,5 To find similar cases, we conducted a systematic search in PubMed and Scopus for the terms [psychosis OR psychotic symptoms OR mental illness OR delusion OR fear OR mental health] and [covid OR coronavirus AND quarantine].

One case report4 described a fear-related new-onset psychosis that ended in suicide. Of the other few articles that we found, some described the impact on mental health at the beginning of the epidemic in China,6,7 while others dealt with the psychological and psychiatric impact of the epidemic8,9 and the correlated fears.10

Our case series of 3 patients is of particular interest as it reports the risk of developing acute-onset psychosis in individuals with no psychiatric history. The onset of symptoms was correlated to the quarantine, which generated a sense of loss of agency and limited self-determination. Clinical psychiatrists and mental health professionals should be mindful of the possible increase in presentation of acute quarantine-related brief psychotic onsets in the following months and should carry out more focused diagnostic and therapeutic strategies.

Received: April 17, 2020.

Published online: May 14, 2020.

Potential conflicts of interest: None.

Funding/support: None.

Patient consent: Consent was received from the patients to publish these case reports, and information has been de-identified to protect anonymity.

REFERENCES

1.Huremović D. Psychiatry of Pandemics A Mental Health Response to Infection Outbreak. Cham, Switzerland: Springer Nature Switzerland; 2019.

2.Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-920. PubMed CrossRef

3.American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

4.Xiang YT, Yang Y, Li W, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-229. PubMed CrossRef

5.Goyal K, Chauhan P, Chhikara K, et al. Fear of COVID 2019: first suicidal case in India! Asian J Psychiatr. 2020;49:101989. PubMed CrossRef

6.Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729. PubMed CrossRef

7.Yao H, Chen JH, Xu YF. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4):e21. PubMed CrossRef

8.Carvalho PMM, Moreira MM, de Oliveira MNA, et al. The psychiatric impact of the novel coronavirus outbreak. Psychiatry Res. 2020;286:112902. PubMed CrossRef

9.Lima CKT, Carvalho PMM, Lima IAAS, et al. The emotional impact of coronavirus 2019-nCoV (new coronavirus disease). Psychiatry Res. 2020;287:112915. PubMed CrossRef

10.Asmundson GJG, Taylor S. Coronaphobia: fear and the 2019-nCoV outbreak. J Anxiety Disord. 2020;70:102196. PubMed CrossRef