Psychosis spectrum disorders during and after the COVID-19 pandemic: Warning signs of "stress incubation".

Dear Editor,

Psychosocial stressors stemming from SARS-CoV-2 (COVID-19) pandemic may profoundly impact population mental health, with a predicted increase in incident cases of psychosis spectrum disorders (PSDs) whose careful management is of paramount importance (Brown et al., 2020). This is a relevant topic since PSDs could represent a considerable challenge for psychiatrists and potentially hamper infection control risk.

Apart from individuals who are spared from infection, clinicians have to keep in mind the possible neuropsychiatric presentations associated with coronavirus diseases, including the ongoing COVID-19 pandemic. These disorders have been object of a review and put in relationship with a composite etiology encompassing the direct effects of the central nervous system viral penetration, the degree of immunological response, the cerebrovascular dysfunction secondary to the procoagulant state, the multi-organ compromise, and the medical interventions (Rogers et al., 2020).

A specific consideration deserves to survivors of critical illness that are at risk of various post-infectious sequelae and persistent psychiatric disorders after discharge from hospital (Rogers et al., 2020). Prototypical PSD manifestations could be observed after the COVID-19 storm, particularly if social impairment and economic difficulty would not be properly counterbalanced by protective factors such as inter-individual support, solidarity, and higher human cohesion. During the current crisis, national governments and health authorities are required to strengthen the surveillance on mental disorders and coverage of dedicated services, based on the assumption that new-onset PSDs are strictly linked with maladaptive reactions to stressful life events (Horan et al., 2005).

Besides the possibility of exerting detrimental effects on individuals with no mental illness, COVID-19 pandemic may exacerbate PSD-related triggers and configure an adverse environment to vulnerable groups, including those with prodromal symptoms and schizophrenic patients. Attention must be paid to physical distancing, unemployment, relationship breakdown, social inequities, and other immediate and long-term COVID-19 effects on people with or at risk of PSDs (Anglin et al., 2020).

A recent survey was conducted in a non-clinical university student population based on two-wave panel data collected in the pre-COVID-19 era (October 2018) and during full health emergency (April 2020) (Hajdúk et al., 2020). The authors importantly showed a mediating role of negative affectivity, especially depression, in the relationship between stressful life events and psychotic experiences at follow-up. This finding reinforces the notion that elevated trait negative affectivity and neuroticism seem to produce a driving effect on PSDs (Horan and Blanchard, 2003) and stresses the need for enhancing clinicians’ awareness about the possibility that ‘minor’ mental disorders may unmask serious psychotic episodes in the medium-term period and afterwards. Despite the corrected model did not find differences in the emersion of psychotic symptoms across time, loneliness and perceived stress were related to psychotic symptoms both longitudinally and cross-sectionally in the sample (Hajdúk et al., 2020).

Of note, reports of a positive correlation between new-onset PSDs and exposure to COVID-19 outbreak are accumulating worldwide (Brown et al., 2020), suggesting that further research is mandatory to clarify the role of major environmental stressors in PSD development and to solidify preventive approaches and evidence-based diagnostic tools. Although related to limited geographical areas, growing observations on the negative impact of COVID-19 on quality of in-hospital care and territorial services introduce a warning message and hint at possible consequences in terms of increased disability burden and social problems.

From a historical perspective, past and present catastrophic events like wars and epidemics teach us that huge psychological stressors have the potential to exert mental effects whose onset is often delayed by at least few months, if not more. In this scenario, a prompt detection of de novo psychotic experiences and relapses cannot disregard from priorities such as long-lasting sanitary surveillance and mass sensitization program, thus avoiding harmful underestimates of negative affective states (e.g. fear, anger, anxiety, depressed mood, etc.) and other putative factors involved in PSD pathogenesis.

Author statement

All authors equally contributed to the final version of the manuscript.

Declaration of Competing Interest

Authors do not report conflicts of interest related to the content of this letter.