30-12-2020

WEDNESDAY, DECEMBEr 30, 2020
5
Post-Covid syndromes include Psychotic Symptoms
5
Pam Belluck
Almost immediately, Dr. Hisam Goueli could tell that the
patient who came to his psychiatric hospital on Long Island
this summer was unusual.The patient, a 42-year-old physical
therapist and mother of four young children, had never had
psychiatric symptoms or any family history of mental illness.
Yet there she was, sitting at a table in a beige-walled room at
South Oaks Hospital in Amityville, N.Y., sobbing and saying
that she kept seeing her children, ages 2 to 10, being
gruesomely murdered and that she herself had crafted plans
to kill them.
"It was like she was experiencing a movie, like 'Kill Bill,'"
Dr. Goueli, a psychiatrist, said.The patient described one of
her children being run over by a truck and another
decapitated. "It's a horrifying thing that here's this wellaccomplished
woman and she's like 'I love my kids, and I
don't know why I feel this way that I want to decapitate
them,'" he said.
The only notable thing about her medical history was that
the woman, who declined to be interviewed but allowed Dr.
Goueli to describe her case, had become infected with the
coronavirus in the spring. She had experienced only mild
physical symptoms from the virus, but, months later, she
heard a voice that first told her to kill herself and then told her
to kill her children.
At South Oaks, which has an inpatient psychiatric
treatment program for Covid-19 patients, Dr. Goueli was
unsure whether the coronavirus was connected to the
woman's psychological symptoms. "Maybe this is Covidrelated,
maybe it's not," he recalled thinking.
"But then," he said, "we saw a second case, a third case and
a fourth case, and we're like, 'There's something
happening.'"Indeed, doctors are reporting similar cases
across the country and around the world. A small number of
Covid patients who had never experienced mental health
problems are developing severe psychotic symptoms weeks
after contracting the coronavirus.
A 36-year-old nursing home employee in North Carolina
who became so paranoid that she believed her three children
would be kidnapped and, to save them, tried to pass them
through a fast-food restaurant's drive-through window.
A 30-year-old construction worker in New York City who
became so delusional that he imagined his cousin was going
to murder him, and, to protect himself, he tried to strangle
his cousin in bed.
A 55-year-old woman in Britain had hallucinations of
monkeys and a lion and became convinced a family member
had been replaced by an impostor.Beyond individual reports,
a British study of neurological or psychiatric complications in
153 patients hospitalized with Covid-19 found that 10 people
had "new-onset psychosis." Another study identified 10 such
patients in one hospital in Spain. And in Covid-related social
media groups, medical professionals discuss seeing patients
Severe psychotic symptoms are being reported worldwide.
with similar symptoms in the Midwest, Great Plains and
elsewhere. "My guess is any place that is seeing Covid is
probably seeing this," said Dr. Colin Smith at Duke
University Medical Center in Durham, who helped treat the
North Carolina woman. He and other doctors said their
patients were too fragile to be asked whether they wanted to
be interviewed for this article, but some, including the North
Carolina woman, agreed to have their cases described in
scientific papers.
Medical experts say they expect that such extreme
psychiatric dysfunction will affect only a small proportion of
patients. But the cases are considered examples of another
way the Covid-19 disease process can affect mental health
and brain function. Although the coronavirus was initially
thought primarily to cause respiratory distress, there is now
Photo: Internet
ample evidence of many other symptoms, including
neurological, cognitive and psychological effects, that could
emerge even in patients who didn't develop serious lung,
heart or circulatory problems. Such symptoms can be just as
debilitating to a person's ability to function and work, and it's
often unclear how long they will last or how to treat them.
Experts increasingly believe brain-related effects may be
linked to the body's immune system response to the
coronavirus and possibly to vascular problems or surges of
inflammation caused by the disease process.
"Some of the neurotoxins that are reactions to immune
activation can go to the brain, through the blood-brain
barrier, and can induce this damage," said Dr. Vilma Gabbay,
a co-director of the Psychiatry Research Institute at
Montefiore Einstein in the Bronx.
Brain scans, spinal fluid analyses and other tests didn't find
any brain infection, said Dr. Gabbay, whose hospital has
treated two patients with post-Covid psychosis: a 49-year-old
man who heard voices and believed he was the devil and a
34-year-old woman who began carrying a knife, disrobing in
front of strangers and putting hand sanitizer in her food.
Physically, most of these patients didn't get very sick from
Covid-19, reports indicate. The patients that Dr. Goueli
treated experienced no respiratory problems, but they did
have subtle neurological symptoms like hand tingling,
vertigo, headaches or diminished smell. Then, two weeks to
several months later, he said, they "develop this profound
psychosis, which is really dangerous and scary to all of the
people around them."
Also striking is that most patients have been in their 30s,
40s and 50s. "It's very rare for you to develop this type of
psychosis in this age range," Dr. Goueli said, since such
symptoms more typically accompany schizophrenia in young
people or dementia in older patients. And some patients - like
the physical therapist who took herself to the hospital -
understood something was wrong, while usually "people
with psychosis don't have an insight that they've lost touch
with reality."
Some post-Covid patients who developed psychosis
needed weeks of hospitalization in which doctors tried
different medications before finding one that helped.Dr.
Robert Yolken, a neurovirology expert at Johns Hopkins
University School of Medicine in Baltimore, said that
although people might recover physically from Covid-19, in
some cases their immune systems, might be unable to shut
down or might remain engaged because of "delayed
clearance of a small amount of virus."
Persistent immune activation is also a leading explanation
for brain fog and memory problems bedeviling many Covid
survivors, and Emily Severance, a schizophrenia expert at
Johns Hopkins, said post-Covid cognitive and psychiatric
effects might result from "something similar happening in
the brain."
Amid pandemic make vaccination
a priority
Paula Span
Peggy Stein, 68, a retired teacher in
Berkeley, Calif., skipped a flu shot this
year. Her reasoning: "How could I get
the flu if I'm being so incredibly careful
because of Covid?"Karen Freeman, 74,
keeps meaning to be vaccinated against
shingles, but hasn't done so. A retired
college administrator in St. Louis, she
quipped that "denial has worked well
for me these many years."
Sheila Blais, who lives on a farm in
West Hebron, N.Y., has never received
any adult vaccine. She also has never
contracted the flu. "I'm such an
introvert I barely leave the farm, so
where's my exposure?" said Ms. Blais,
66, a fiber artist. "If it's not broke, don't
fix it."
While older adults await vaccination
against Covid-19, public health officials
also worry about their forgoing,
forgetting, fearing or simply not
knowing about those other vaccines -
the ones recommended for adults as we
age and our immune systems weaken.
"There's a lot of room for
improvement," said Dr. Ram Koppaka,
associate director for adult
immunization at the Centers for
Disease Control and Prevention.The
proportion receiving the shingles
vaccine, a fairly recent addition to the
list, has inched up, but by 2018 only
34.5 percent of people over 60 had
been vaccinated.
Moreover, Dr. Koppaka pointed out:
"When you look deeper, there are
longstanding, deep, significant
differences in the proportion of Black
and Hispanic adults getting vaccines
compared to their white counterparts.
It's really unacceptable." Close to 40
percent of non-Hispanic whites had
been vaccinated against shingles, for
instance, compared with fewer than 20
percent of Blacks and Hispanics.One
might expect a group who can recall
polio fears and outbreaks of whooping
cough to be less hesitant to get
vaccinated than younger cohorts.
"You'll probably have a different
concept of vaccination from someone
who never experienced what a serious
viral illness can do," Dr. Koppaka said.
When it comes to the Covid-19
vaccine, for instance, only 15 percent of
those over 65 say they would definitely
or probably not get it, compared with
36 percent of those 30 to 49, a Kaiser
Family Foundation tracking poll
showed earlier this month. (Ms. Stein,
Ms. Blais and Ms. Freeman all said they
would happily accept the Covid
vaccine.)
But for other diseases, vaccination
rates lag. Given that older people are
more vulnerable to severe illness from
them, why the gaps in
coverage?Internists and other doctors
for adults don't promote vaccines
nearly as effectively as pediatricians do,
said Dr. William Schaffner, an
infectious disease specialist at
Vanderbilt University. Older patients,
who often see a variety of doctors, may
also have trouble keeping track of when
60 to 70 percent of the population needed to acquire resistance to
the coronavirus to banish it.
Photo: Collected
they got which shot.
Experts fear that vaccination rates
may have fallen further during the
pandemic, as they have among
children, if older people wary of going
to doctors' offices or pharmacies
skipped shots.Financial and
bureaucratic obstacles also thwart
vaccination efforts. Medicare Part B
covers three vaccines completely:
influenza, pneumococcus and, when
indicated, hepatitis B.
The Tdap and shingles vaccines,
however, are covered under Part D,
which can complicate reimbursement
for doctors; the vaccines are easier to
obtain in pharmacies. Not all Medicare
recipients buy Part D, and for those
who do, coverage varies by plan and
can include deductibles and co-pays.
Still, older adults can gain access to
most recommended vaccines for no or
low cost, through doctors' offices,
pharmacies, supermarkets and local
health departments. For everyone's
benefit, they should.
Influenza An annual shot in the fall -
and it's still not too late, because flu
season peaks from late January into
February. Depending on which strain is
circulating, the vaccine (ask for the
stronger versions for seniors) prevents
40 to 50 percent of cases; it also
reduces illness severity for those
infected.
Thus far this year, flu activity has
remained extraordinarily low, perhaps
because of social distancing and masks
or because closed schools kept children
from spreading it. Manufacturers
shipped a record number of doses, so
maybe more people got vaccinated. In
any case, fears of a flu/Covid
"twindemic" have not yet been realized.
Nevertheless, infectious disease
experts urge older adults (and everyone
over six months old) to get flu shots
now. "Flu is fickle," Dr. Schaffner said.
"It could take off like a rocket in
January."
Tetanus, diphtheria, pertussis. A
booster of TD vaccine every 10 years,
to prevent tetanus and diphtheria. If
you've never had the Tdap vaccine -
which adds prevention against
pertussis - that's the one you want.
Although pertussis, better known as
whooping cough, occasionally shows
up in adults, newborns are
particularly at risk. Pregnant women
will ask expectant grandparents to get
a Tdap shot. Because it is covered
under Part D, a pharmacy is the best
bet.
Pneumococcus. "It's a pneumonia
vaccine, but it also prevents the most
serious consequences of pneumonia,
including meningitis and bloodstream
infections," Dr. Koppaka said.People
over 65 should get the polysaccharide
formula - brand name Pneumovax -
but there are certain circumstances,
such as immune-compromising
conditions, to discuss with a health care
provider.
Those over 65 may choose, again in
consultation with a provider, to also get
the conjugate pneumococcal vaccine
(brand name Prevnar), which provides
some additional protection. If so,
C.D.C. guidelines specify which vaccine
to take when.
Blood samples sit alongside trays of monoclonal antibody in a lab.
Photo: Gabby Jones
How much herd immunity is enough?
Donald G. McNeil Jr.
At what point does a country achieve
herd immunity? What portion of the
population must acquire resistance to
the coronavirus, either through
infection or vaccination, in order for the
disease to fade away and life to return to
normal?
Since the start of the pandemic, the
figure that many epidemiologists have
offered has been 60 to 70 percent. That
range is still cited by the World Health
Organization and is often repeated
during discussions of the future course
of the disease. Although it is impossible
to know with certainty what the limit
will be until we reach it and
transmission stops, having a good
estimate is important: It gives
Americans a sense of when we can hope
to breathe freely again.
Recently, a figure to whom millions of
Americans look for guidance - Dr.
Anthony S. Fauci, an adviser to both the
Trump administration and the
incoming Biden administration - has
begun incrementally raising his herdimmunity
estimate.
In the pandemic's early days, Dr.
Fauci tended to cite the same 60 to 70
percent estimate that most experts did.
About a month ago, he began saying
"70, 75 percent" in television interviews.
And last week, in an interview with
CNBC News, he said "75, 80, 85
percent" and "75 to 80-plus percent." In
a telephone interview the next day, Dr.
Fauci acknowledged that he had slowly
but deliberately been moving the goal
posts. He is doing so, he said, partly
based on new science, and partly on his
gut feeling that the country is finally
ready to hear what he really thinks.
Hard as it may be to hear, he said, he
believes that it may take close to 90
percent immunity to bring the virus to a
halt - almost as much as is needed to
stop a measles outbreak.
Asked about Dr. Fauci's conclusions,
prominent epidemiologists said that he
might be proven right. The early range
of 60 to 70 percent was almost
undoubtedly too low, they said, and the
virus is becoming more transmissible,
so it will take greater herd immunity to
stop it. Dr. Fauci said that weeks ago, he
had hesitated to publicly raise his
estimate because many Americans
seemed hesitant about vaccines, which
they would need to accept almost
universally in order for the country to
achieve herd immunity.
Now that some polls are showing that
many more Americans are ready, even
eager, for vaccines, he said he felt he
could deliver the tough message that the
return to normal might take longer than
anticipated."When polls said only about
half of all Americans would take a
vaccine, I was saying herd immunity
would take 70 to 75 percent," Dr. Fauci
said. "Then, when newer surveys said
60 percent or more would take it, I
thought, 'I can nudge this up a bit,' so I
went to 80, 85."
"We need to have some humility
here," he added. "We really don't know
what the real number is. I think the real
range is somewhere between 70 to 90
percent. But, I'm not going to say 90
percent."Doing so might be
discouraging to Americans, he said,
because he is not sure there will be
enough voluntary acceptance of
vaccines to reach that goal. Although
sentiments about vaccines in polls have
bounced up and down this year, several
current ones suggest that about 20
percent of Americans say they are
unwilling to accept any vaccine.
Also, Dr. Fauci noted, a herdimmunity
figure at 90 percent or above
is in the range of the infectiousness of
measles."I'd bet my house that Covid
isn't as contagious as measles," he
said.Measles is thought to be the world's
most contagious disease; it can linger in
the air for hours or drift through vents
to infect people in other rooms. In some
studies of outbreaks in crowded military
barracks and student dormitories, it has
kept transmitting until more than 95
percent of all residents are infected.
Interviews with epidemiologists
regarding the degree of herd immunity
needed to defeat the coronavirus
produced a range of estimates, some of
which were in line with Dr. Fauci's. They
also came with a warning: All answers
are merely "guesstimates."
"You tell me what numbers to put in
my equations, and I'll give you the
answer," said Marc Lipsitch, an
epidemiologist at Harvard's T.H. Chan
School of Public Health. "But you can't
tell me the numbers, because nobody
knows them." The only truly accurate
measures of herd immunity are done in
actual herds and come from studying
animal viruses like rinderpest and footand-mouth
disease, said Dr. David M.
Morens, Dr. Fauci's senior adviser on
epidemiology at the National Institute
of Allergy and Infectious Diseases.
When cattle are penned in corrals, it is
easy to measure how fast a disease
spreads from one animal to another, he
said. Humans move around, so
studying disease spread among them is
far harder.The original assumption that
it would take 60 to 70 percent immunity
to stop the disease was based on early
data from China and Italy, health
experts noted.