This study systematically summarized the profile of psychiatric symptoms in patients with COVID-19 and SARS, during both the acute and convalescent stages. We found that all ten SCL-90-R-defined psychiatric symptoms were exhibited in acute COVID-19 patients, and nearly all these symptoms were severe. Acute SARS patients, while they had less severe psychiatric symptoms than COVID-19 patients, still presented many medium-to-severe symptoms. Thereafter, there was a trend toward overall declines in severity of psychiatric symptoms observed in survivors of both COVID-19 and SARS. However, most psychiatric symptoms of COVID-19 (i.e., phobia, anxiety, and somatization) were still mild-to-medium during very early recovery, and some symptoms of SARS, such as somatization, interpersonal sensitivity, and anxiety, still remained mild during late recovery.
The underlying physiological and psychosocial mechanisms associated with human coronavirus diseases could explain the high psychiatric symptom burden in acute patients with COVID-19 and SARS. For example, researchers have found positive SARS-CoV-2 RNA and parainfectious/postinfectious inflammatory changes in the cerebrospinal fluid of COVID-19 patients51,52, so it is possible that psychiatric symptoms are part of the neuropsychiatric complications due to the central nervous system impact of viral infection53. Second, suffering from coronavirus diseases per se, a potentially life-threatening illness, is a stressful event for patients. Due to this, fear of death, worry about the infection of family members, despair, anger, frustration, and insomnia are common stress reactions in this patient population5. Third, physical discomfort and pain caused by COVID-19 and SARS could further exacerbate emotional reactions to coronavirus diseases. Fourth, because of the isolation treatment for patients, separation from family members and friends would increase the risk of feeling lonely and other mental health problems54. Fifth, antiviral treatment may also contribute to the psychiatric manifestations of patients; for example, there is evidence that both chloroquine and steroids could induce psychotic episodes55,56. We speculate that various severe psychiatric symptoms of COVID-19 are more likely to be the result of the joint effects of the abovementioned factors.
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The relatively lower severity of psychiatric symptoms in SARS than in COVID-19 patients might be ascribed to the different psychosocial impacts of the two coronavirus diseases. For example, the SARS epidemic mainly affected people of Asian countries, but the COVID-19 pandemic has been a global crisis, affecting people of nearly all countries in the world. Compared to SARS, COVID-19 has quicker and wider transmission, disproportionate effects on older adults, and a high case-fatality rate in older adults57, and therefore, COVID-19 patients may have higher levels of psychological distress and fears of death than SARS patients. This may also explain why phobia was the most severe psychiatric symptom in COVID-19 patients. Because of physical complications and discomfort caused by coronavirus diseases, severe symptoms of somatization with acute COVID-19 and SARS are expected. In addition, unlike the SARS epidemic in 2003, the ongoing COVID-19 pandemic is occurring concurrently with an “infodemic”, where misinformation and disinformation can be easily and quickly disseminated via social media platforms58, which may further exacerbate the poor mental health of COVID-19 patients.
The reduced severity of psychiatric symptoms in COVID-19 and SARS patients from the acute stage to the late recovery stage suggests that psychiatric symptoms in the acute stage are mainly acute stress reactions and are therefore transient. These results indicate the importance of early mental health and psychosocial services at the stage of inpatient treatment. Nevertheless, the persistence of several psychiatric symptoms in SARS survivors throughout recovery might suggest the necessity of additional psychiatric symptom assessment and mental health services for the rehabilitation of COVID-19 survivors. Some postdischarge psychosocial factors may increase the risk of depression and other mental health problems in SARS survivors; for example, stigma associated with SARS and financial loss or even unemployment due to the past history of SARS infection. A recently published prognosis study reported that COVID-19 survivors were still suffering from fatigue, muscle weakness, sleep difficulties, depression, and anxiety 6 months after acute infection16. These findings are consistent with the residual psychiatric symptoms in recovered COVID-19 and SARS survivors in our study, such as somatization and anxiety.
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This study has some limitations. First, the quality assessment results of the included studies suggest that, to a certain extent, these included studies are at risk of bias, so we must be cautious in generalizing the study findings. Second, owing to the lack of SCL-90-R data from COVID-19 survivors during late recovery, and the very limited SCL-90-R data from SARS survivors during late recovery, more studies are warranted to investigate psychiatric symptoms of COVID-19 survivors, particularly long-term prospective studies. Third, since most of the included studies excluded severe or critical patients with coronavirus diseases, our study may underestimate the severity of psychiatric symptoms of patients with COVID-19 and SARS. Fourth, the present study focused on psychiatric symptoms based only on a self-rating scale only, the SCL-90-R, so data on psychiatric symptoms of COVID-19 patients who were illiterate and cognitively impaired were unavailable. Future studies using detailed comprehensive psychiatric interviews would provide a more comprehensive picture of the profile of psychiatric symptoms of COVID-19. Fifth, the participants in the studies included in this meta-analysis were all Chinese patients with coronavirus diseases. Because sociocultural factors play an important role in the clinical manifestations of mental health problems, caution is needed when generalizing our results to COVID-19 patients in countries other than China. Finally, as shown in Table 2, high levels of heterogeneity were detected in most meta-analyses. However, due to the limited number of included studies in each meta-analysis, we were not able to perform subgroup analysis to identify factors associated with the severity of each psychiatric symptom. It is worth noting that our study provided only an overall profile of the psychiatric symptoms of COVID-19, not a detailed profile of psychiatric symptoms.
In summary, a wide spectrum of severe psychiatric symptoms occur in COVID-19 patients, and most symptoms are still mild-to-medium during very early recovery. Based on SCL-90-R data from SARS patients and survivors, the severity of psychiatric symptoms of COVID-19 may decline following discharge, but some symptoms could persist for a long time during the convalescent stage. These findings suggest the urgent need of patients for extensive mental health services and psychological crisis intervention during the acute stage of COVID-19. Furthermore, it is also important to periodically monitor the psychiatric symptoms and provide psychosocial support, and psychiatric consultation and treatment (when necessary) for COVID-19 survivors during their convalescent stage. In addition, more research is needed to examine the longitudinal changes in psychiatric symptoms of COVID-19 survivors.
