Asim Shah, MD

Starting as a mysterious pneumonia in Wuhan, China, the newly named COVID-19 has resulted in a worldwide outbreak, causing morbidity and mortality as well as potentially disrupting the global economy. The World Health Organization (WHO) has declared this a global pandemic; to date (as this article goes to press), there are more than 80,000 reported cases worldwide (72,506 from Mainland China, Hong Kong, and Macau), and COVID-19 has claimed more than 2700 lives. (For more information, please see 

https://www.cdc.gov/coronavirus/ 2019-ncov/summary.html

Although pharmaceutical companies and countries are looking into vaccinations and curative treatment for coronavirus infection, currently there is nothing available; thus, precautions against transmission and early supportive treatment is key. Psychiatrists must have a basic understanding of the pathophysiology of coronaviruses in order to be able to accurately explain and discuss those issues with their patients, especially as mental health ramifications are expected.

Coronaviruses, belonging to the Coronaviridae family, are singleâstranded positiveâsense ribonucleic acid (RNA) viruses that thrive in animals, which are their natural carriers. The only coronaviruses previously known to infect humans were HCoVâ229E, HCoVâOC43, HCoVâNL63, andHKU1, as well as the two infamous relatives of 2019-nCoV-the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), responsible for outbreaks in 2002-2003 and 2012, respectively. Alphacoronaviruses and betacoronaviruses infect mammals (eg, bats) whereas gammacoronaviruses and deltacoronaviruses are more prone to cause fish and bird infections (Table). Animal to human-zoonotic-transmission is not the norm for coronaviruses, but prior coronavirus outbreaks in animals have been economically damaging.

have been occurring of late. However, it is hypothesized that global climate factors may be related and similar to viral mutations linked to pandemic capacity (ie, genetic drifts in a wide outbreak in animals may essentially lead to better virus survival rates in humans).

In the case of COVID-19, the transmission is 

to have occurred at the Wuhan Huanan Seafood Wholesale Market, although the exact carrier species has not been determined.

 From this point, the main 2019-nCoV contagion has been human-to-human transmission. Symptoms have ranged from mild to severe, with most patients reporting fever, dry cough, myalgia, fatigue, and diarrhea.

 Gastrointestinal symptoms have been present, although less frequent than with SARS.

Why do some people get sicker than others? Coronaviruses have an RNA genome, similar to the influenza virus (responsible for the flu) or the respiratory syncytial virus (RSV). The immune system recognizes the RNA as foreign and triggers the immune response responsible for fighting the virus (ie, production of interferons and pro-inflammatory cytokines), and then clearing the foreign entity out of the body. A review of the exact immune responses are beyond the scope of this manuscript. However, the reader is encouraged to remember that the immune system is highly adaptable and modifies its metabolism and existing balance to fight expected threats (for an excellent review, see Kikkert

). Unfortunately, the virus exploits the host’s immune system, mimicking certain innate components to hide while replicating, which makes the immune system less able to effectively fight the invasion. Viruses may also halt cellular replication and use existing cellular resources to prioritize viral replication. The balance between immune response and viral replicative success ultimately determines disease outcome.

Certain populations are known to be vulnerable to COVID-19, such as infants, the elderly, and those with immunocompromised systems or pre-existing medical issues, who are at increased risk for severe repercussions from infections and, thus, more likely to develop sepsis and possibly death; worse outcomes could also be 

 Cytokine storm, a term referring to over-production of inflammatory cytokines, was found more often in patients suffering from COVID-19 who ended up in intensive care, but causal factors are not fully understood.

 Thus far, there is no way to predict who will have an exaggerated immune response besides looking for the previously noted clinical, non-specific factors.

Prevention, treatment, mental health implications >

Cleaning and disinfection to prevent transmission

Concern arises about transmission between various individuals but also about persistence of the virus on inanimate surfaces, such as mailed packages or in health care settings. As such, WHO has provided a set of recommendations for disinfecting surfaces.9 While the persistence of 2012-nCoV is not fully understood, it has been shown that other strains of coronaviruses stay viable for up to 9 days on surfaces (unless disinfected).

Testing of the recommend WHO formulations against various viruses revealed effectiveness.10 Ethanol, sodium hypochlorite, and glutardialdehyde have been found most effective;

 a concentration of 70% ethanol is adequate for small surface disinfection. Patients inquiring about cleaning should be cautioned about using gloves with bleach (sodium hypochlorite) and other substances. Special attention should be paid to patients with cleaning compulsions, who get skin damage from excessive cleaning product exposure. (The worsening of obsessive-compulsive disorder is discussed in the accompanying article.)

The CDC recommended precautions include the use of a facemask for suspected patients/affected individuals (not for healthy individuals) and hand washing with soap and water for 20 seconds or using any sanitizers with at least 60% alcohol content. This especially should be done after using the restroom; after blowing one’s nose, coughing, sneezing; and before and after eating.

Although the coronavirus may have infected thousands of people, it is important to put its impact into perspective. For instance, according to the CDC, influenza already has affected 19 million people this year alone, hospitalizing 180,000 and killing 10,000 individuals. Thus, although COVID-19 is a serious threat, flu continues to be the major viral respiratory threat, as it has for many decades. Prevention efforts should focus on the flu and highly prevalent infections while also keeping in mind novel outbreaks.

Testing, treatment, and prevention efforts

The presence of COVID-19 can be assessed by a newly released real time reverse transcription-polymerase chain reaction (rRT-PCR) test. Of course, here in the US, clinicians are encouraged to contact and collaborate with their state or local health department for any diagnosed or suspected cases.

While there is no specific treatment for COVID-19, WHO has issued an interim guidance document, which is available online at www.who.int/. Meanwhile, there have been treatment attempts with various antivirals (eg, remdesivir, lopinavir-ritonavir, interferon-Î± 2b) developed for previously known viral agents. None of these have been studied in randomized controlled trials for COVID-19 and results are of anecdotal quality.

for patients requiring hospitalization is isolation and supportive care, including oxygen therapy and fluid management.

 Administration of antimicrobials for treatment of secondary bacterial infections and avoiding secondary end-organ damage also may be needed for some patients.

 Care must be taken to discourage patients from seeking untested, potentially dangerous treatments such as over-the-counter concoctions.

Without specific treatments, the emphasis has been on limiting new exposures, which is where incubation and quarantines come into play. Currently, the incubation period is thought to be 2 to 14 days, so limiting exposure to individuals with suspected infection during that time, and within the active symptom period, is the first and most basic step in preventing further spread of the virus.

The working incubation period takes a few things into consideration. In a systematic review of nine viral agents of public health importance, 

 found most coronaviruses had a median incubation time of 3 to 4 days. Among affected individuals from China, the mean incubation period has been about 5 days, with a range of 4 to 7 days and a 95% percentile of 12.5 days

; thus, the typically imposed 14 - day incubation period. Athough some anectodal reports suggest a longer incubation, the CDC believes data show 14 days is the top amount needed.

The coronavirus has largely dominated the news and the minds of people across the globe for the last month. In the 

, we discuss its impact on mental illnesses, stigma, and discrimination in our communities: 

Psychiatrists Beware! The Impact of COVID-19 and Pandemics on Mental Health

is Associate Professor, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Ben Taub Adult Outpatient Services Director, Medical Director, STAR (Stabilization, Treatment, and Rehabilitation) Program for Psychosis, Houston, TX. 

is Professor & Executive Vice Chair, Barbara & Corbin J. Robertson Jr. Chair in Psychiatry at Menninger, Chief of the Division of Community Psychiatry at Baylor College of Medicine. They report no conflicts of interest concerning the subject matter of this article.

Impact of recent and future climate change on vector-borne diseases

2. Goneau LW, Mehta K, Wong J, L’Huillier AG, Gubbay JB. Zoonotic Influenza and Human Health-Part 1: Virology and Epidemiology of Zoonotic Influenzas. 

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

4. Liu J, Zheng X, Tong Q, et al. Overlapping and discrete aspects of the pathology and pathogenesis of the emerging human pathogenic coronaviruses SARS-CoV, MERS-CoV, and 2019-nCoV. J Med Virol. 2020.

The Novel Coronavirus: A Bird’s Eye View

Innate Immune Evasion by Human Respiratory RNA Viruses

7. Chousterman BG, Swirski FK, Weber GF. 

Cytokine storm and sepsis disease pathogenesis

8. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 

9. WHO. Use of disinfectants: alcohol and bleach. Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. Geneva: WHO;2014.

10. Siddharta A, Pfaender S, Vielle NJ, et al. Virucidal Activity of World Health Organization-Recommended Formulations Against Enveloped Viruses, Including Zika, Ebola, and Emerging Coronaviruses. 

11. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. 

12. Lessler J, Reich NG, Brookmeyer R, Perl TM, Nelson KE, Cummings DA. Incubation periods of acute respiratory viral infections: a systematic review. 

13. Serrano I, Gomes D, Ramilo D, et al. An Overview of Zoonotic Disease Outbreaks and its Forensic Management Over Time. 

Articles

Psychiatrists must have a basic understanding of the pathophysiology of coronaviruses in order to be able to accurately explain and discuss those issues with their patients, especially as mental health ramifications are expected.

The New Game of Microbiology Clue: The Who, When, Where, and Why of the Novel Coronavirus

It’s easy to blame, it’s easy to politicize, it’s harder to tackle a problem together and find solutions together.

WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc

Infectious pandemics and the spread of organisms across countries and continents have been facilitated by global changes in earth’s climate and an increase in travel and international exchange. COVID-19, the infection caused by the novel coronavirus detected in December 2019, is now affecting more than 27 countries, raising concerns of widespread panic and increasing anxiety in individuals subjected to the (real or perceived) threat of the virus. Importantly, these concerns arise with all infections, including the flu and other agents, and the same universal precautions are needed and indicated for safety and the prevention of further transmission. However, media coverage has highlighted COVID-19 as a unique threat, rather than one of many, which has added to panic, stress, and the potential for hysteria.

Pandemics are not just a medical phenomenon; they affect individuals and society on many levels, causing disruptions. Stigma and xenophobia are two aspects of the societal impact of pandemic infectious outbreaks. Panic and stress have also been linked to outbreaks. As concerns over the perceived threat grow, people may start to collect (and hoard) masks and other medical supplies. This is often followed by anxiety-related behaviors, sleep disturbances, and overall lower perceived state of health. Individuals with mental illness may be particularly vulnerable to the effects of widespread panic and threat.

Fears, Outbreaks, and Pandemics: Lessons Learned

Chronic disease, including chronic infectious diseases such as tuberculosis and 

 (HIV), are associated with higher levels of mental disorders as compared with the general population.

 Studies show depression rates usually soar after infections (eg, herpes exposure and anthrax scares).

 Although the effects of the coronavirus on mental health have not been systematically studied, it is anticipated that COVID-19 will have rippling effects, especially based on current public reactions. Psychiatrists are uniquely situated to help both their patients and the greater community understand the potential impact of the virus and help patients, families, and society deal with this latest threat.

Stigma, medical mistrust, and conspiracies

Epidemics lead to stigmatization of affected individuals, authority figures, and health care professionals; sadly, this trend has been seen in multiple countries and with multiple infectious agents.

 With COVID-19, men and women of Asian descent, specifically Chinese, are the victims of social stigma and xenophobia, with high levels of politicization and threats online and in personal interactions. As with most stigma-laden interactions, the process unfolds because of limited information, hasty and uni-dimensional assessments, and a defensive formulaic response. It is imperative that all health care professionals, especially psychiatrists, act as the voice of reason and help disseminate proper, evidence-based information.

“Medical mistrust” refers to a lack of trust in medical treatment and advances. It results in a lower use of health care resources and poorer management of health conditions (coupled with potential misuse at times of crisis). Moreover, medical mistrust has been used to explain some racial and ethnic health care disparities.

 It has been linked to a variety of diseases and conditions, including cancer, autism, and HIV.

During infectious pandemic,s medical mistrust has been linked to conspiracy theories. In one US study, up to half of those surveyed endorsed belief in at least one health-related conspiracy theory.

 At its extreme, medical mistrust can lead to movements such as anti-vaccination trends, which have been linked to measles outbreaks.

Mistrust of medical organizations can reinforce stigma and perceived discrimination and result in lower adherence to health recommendations. Clinicians must maintain a scientific, fact-based, and neutral presentation of recommendations while emphasizing the importance of overall infection control practices in the wake of COVID-19.

Anxiety and obsessive-compulsive disorders

We anticipate the effects of infectious disease threats to manifest as sheer anxiety and panic: worry about getting an infection, worry about loved ones getting ill, and worry when related symptoms-even minor-are present. The absence of a definitive treatment for coronavirus easily exacerbates anxiety. In most cases, these anxiety symptoms do not reach diagnostic thresholds for a DSM-5 diagnosis; however, patients will benefit from reassurance and education.

Contamination obsessions-unwanted, intrusive worry that one is dirty and in need of washing, cleaning, or sterilizing-are very common in patients with OCD. Perceptual experiences (eg, feeling dirt on skin) understandably would amplify obsessions. Sensory experiences (but not necessarily full tactile hallucinations) have been found in up to 75 % of patients with OCD patients.

 More intense sensory experiences (pseudo-hallucinations) are related to worsened control over compulsions and poorer insight.

 Biased information processing is associated with a tendency to overestimate threat in individuals with OCD.

 This may increase sensitivity to the panic associated with 

 and further destabilize patients and increase functional impairment.

Cleaning and washing compulsions, also a core feature of OCD, can easily be exacerbated by the threat of infectious pandemics. Complications of excessive cleaning include dry, chapped skin (which can lead to super-imposed infections). and contact and atopic dermatitis; similarly, overuse of toxic cleaning supplies can lead to inhalational injuries.

 Fear of acquiring a new, sensationalized disease may worsen negative behaviors. Clinicians in psychiatry, psycho-dermatology, and primary care practices should be alert to potential issues in patients with OCD.

Psychotic disorders: an extreme of medical mistrust?

Anecdotally, the most glaring (and maybe the most interesting) examples of medical mistrust conspiracy theories concern patients who have psychotic disorders. Typically, repeated media exposure to an alarming fact (in this case, spread of coronavirus), coupled with a distrust of organizations and government as well as misattribution of physical symptoms can result in delusions. Similarly, fears can quickly lead to clinical decompensation and must be carefully monitored.

Adding fuel to the fire are discussions of conspiracy theories related to infectious outbreaks such as HIV and Ebola in the 

 The lack of knowledge about epidemics, the increase of zoonotic infections, and the fairly complex effects of climate changes can affect patients as well as confuse even an overall healthy person.

At the intersection of psychosis and obsessiveness is delusional parasitosis, also referred to as monosymptomatic hypochondrial psychosis, Ekbom syndrome, and delusional infestation. Essentially, the patient believes that he is infected with an organism that evades detection and treatment and, thus, causes continuous suffering. This syndrome was described as early as 1636 by sir Thomas Browne, who referred to it as 

A concerning clinical feature of delusional infestation is its occurrence in multiple family members (eg, folie a deux).

Delusional infestation development in the context of pandemics has not been studied. Conceivably, increased cases may develop as more individuals focus on far-fetched, unlikely infections because of easy access to unverified information on the internet. To address delusional parasitosis, clinicians should rule out organic causes and reassure the patient that there is no infection or infestation.

The current COVID-19 outbreak is spurring fear on a societal level. On an individual level, it may differentially exacerbate anxiety and psychosis-like symptoms as well as lead to non-specific mental issues (eg, mood problems, sleep issues, phobia-like behaviors, panic-like symptoms). We urge our colleagues to spread sound infection control practices and help their communities maintain civil, courteous, and rational communication. A low index of suspicion of mental distress can help in early detection and treatment and spare patients much suffering.

 is Associate Professor, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Ben Taub Adult Outpatient Services Director, Medical Director, STAR (Stabilization, Treatment, and Rehabilitation) Program for Psychosis, Houston, TX. 

 is Professor & Executive Vice Chair, Barbara & Corbin J. Robertson Jr. Chair in Psychiatry at Menninger, Chief of the Division of Community Psychiatry at Baylor College of Medicine. They report no conflicts of interest concerning the subject matter of this article.

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Psychiatrists are uniquely situated to help both their patients and the greater community understand the potential impact of the virus and help patients, families, and society deal with this latest threat.

Author | Asim Shah, MD

Articles

The New Game of Microbiology Clue: The Who, When, Where, and Why of the Novel Coronavirus

Psychiatrists Beware! The Impact of COVID-19 and Pandemics on Mental Health