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Pandemic and Psychiatry - Complex Biopsychosocial Interactions During COVID-19
*Corresponding author: Seshadri Sekhar Chatterjee, Department of Psychiatry, Queensland Health, Rockhampton, Queensland, Australia. drsschatterjee@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Chatterjee SS, Mitra S, Das S, Singh OP. Pandemic and Psychiatry - Complex Biopsychosocial Interactions During COVID-19. Bengal J Psychiatry. doi: 10.25259/BJPSY_1_2025
Abstract
The world has not been the same since the COVID-19 pandemic. From acute exacerbations to long COVID, from managing resources to collaborating with other specialties, and from core clinical impacts to broader social narratives—the consequences have been profound and far-reaching. In this context, we present five case reports covering steroid-induced psychosis, drug-drug interaction, anxiety disorder, long COVID, and recurrent catatonia in the setting of the COVID-19 pandemic. These cases offer unique insights into the clinical, pharmacological, and psychosocial intricacies of COVID-19’s impact. We then discuss the challenges and key learning points derived from these cases, supported by a relevant literature review.
Keywords
Anxiety
Catatonia
COVID-19
Depression
Psychopharmacology
INTRODUCTION
As the world navigated through the COVID-19 pandemic, we gained many lessons and insights that are not only relevant to this context but also applicable to any future pandemic or health crisis. The evidence base for the pandemic’s impact on mental health grew considerably during this period, and a complex bidirectional interaction between the virus and psychiatric disorders became apparent. However, anecdotal information is essential to understand the nuanced and often multifaceted nature that psychiatrists face in these situation.1 However, anecdotal information is essential for understanding the nuanced and often multifaceted challenges psychiatrists face in these situations. In this paper, we describe five unique case vignettes—ranging from steroid-induced psychosis to drug interactions, autoimmune encephalopathy, mass hysteria due to oxygen deprivation, catatonic depression, and COVID-related dysautonomia—where COVID-19 and psychiatric disorders coexisted. We then discuss the multifaceted interaction between clinical psychiatry and pandemic situations and the lessons learned through the process.
CASE SERIES
Steroid-induced Psychosis During COVID-19 Treatment
A 42-year-old male was admitted on his eighth day of positive reverse transcription polymerase chain reaction (RT-PCR) for COVID-19, with persistent fever and peripheral oxygen saturation (SpO2) of 82%. He had no past psychiatric history except a year-long harmful use of cannabis 3 years ago. From the fourth day of being started on bilevel positive airway pressure (BiPAP) ventilation along with intravenous dexamethasone [12 mg two times daily (BD)], he developed frank psychosis with symptoms of fearfulness, irritability, delusions of persecution, and auditory verbal hallucinations. His mental state worsened rapidly, requiring intensive observation and intervention.
There was no evidence of delirium, psychosis due to hypoxia, or metabolic abnormalities. Laboratory tests were essentially normal. His psychotic symptoms initially escalated, with episodes of agitation and resistance to care. A short course of Olanzapine (5 mg BD), along with gradual tapering and eventual stoppage of steroids, ameliorated his symptoms over the next 4 days. At follow-up 2 weeks later, the patient reported complete resolution of psychotic symptoms and no residual cognitive deficits.
Steroid Interaction with Mood Stabilizer in a COVID-19 Patient
A 36-year-old female was started on a 5-day course of oral methylprednisolone by her general practitioner following a diagnosis of clinically mild RT-PCR-positive COVID-19. She had a known history of bipolar affective disorder (BAD) and had been in remission for 8 months on sodium valproate (1000 mg/day). However, after completing her steroid course, she relapsed into a manic episode characterized by elevated mood, excessive spending, pressured speech, grandiosity, and decreased need for sleep. Her family noted an abrupt behavioral change, prompting psychiatric intervention.
A detailed psychiatric evaluation was carried out, and valproate was increased to 1250 mg/day. Risperidone (2 mg/day) was also initiated. Within 7 days, her symptoms significantly improved, and she regained insight into her condition. This case highlights the risk of steroid-induced mania and the enzyme-inducing potential of steroids, which may lower the effective serum valproate level, thereby precipitating a relapse.
COVID-19-Related Anxiety and Oxygen Shortage Fears
A man in his 40s with a comorbid diagnosis of chronic obstructive pulmonary disease (COPD) experienced acute shortness of breath and air hunger at the peak of COVID-19-related mass anxiety in India. During this period, media reports amplified fears surrounding oxygen shortages, which led to widespread distress. The patient, already managing COPD with intermittent home oxygen therapy, self-administered unsupervised oxygen supplementation through a facemask despite normal oxygen saturation levels. His breathing became increasingly erratic, leading to hyperventilation, a carbon dioxide washout, and subsequent oxygen toxicity.
As he developed confusion and respiratory distress, his family rushed him to the hospital, where he was diagnosed with respiratory failure and required intensive care management. His COVID-19 status was negative. Collateral history and multidisciplinary discussion suggested he had a chronic anxiety disorder, which had been exacerbated by widespread panic and misinformation. This case underscores the importance of addressing mass anxiety, ensuring accurate public health messaging, and reinforcing psychiatric care during health crises.
Relapse of Depression with Catatonia Triggered by COVID-19 Infection
A 56-year-old medical doctor with a history of recurrent depressive disorder (RDD) presented with his fourth depressive episode, accompanied by psychotic and catatonic symptoms. His past treatment included trials of escitalopram and desvenlafaxine, but he had been stabilized on mirtazapine (30 mg) and lithium (300 mg) for the past year. Following a positive RT-PCR test for COVID-19 and mild symptoms, his psychotropic medications were abruptly stopped without psychiatric consultation upon hospital admission.
By the seventh day, his condition deteriorated—he exhibited mutism, posturing, and markedly reduced oral intake. Initially suspected to have viral encephalitis, MRI brain, and cerebrospinal fluid analyses were conducted, which returned negative results. A psychiatric consultation confirmed a relapse with catatonia. He was restarted on bupropion (150 mg), and his catatonic symptoms improved with a short course of lorazepam (2 mg BD). At a 3-month follow-up, he remained stable and functional. This case highlights the risks of abrupt discontinuation of psychiatric medications and the potential immunogenic contribution of COVID-19 to catatonic states.
Panic Disorder Following Recovery from COVID-19
A 32-year-old female with severe COVID-19 symptoms responded well to supportive management. However, in the weeks following her recovery, she developed sudden and recurrent panic attacks characterized by severe palpitations, restlessness, chest tightness, and a sense of impending doom. She experienced multiple episodes of dizziness, fluctuating blood pressure, excessive sweating, and heat intolerance, suggestive of autonomic instability.
She presented to the emergency department with severe tachycardia (HR 140 bpm) and transient ST segment depression. on ECG. Suspecting post-COVID cardiac complications, a detailed cardiological workup, including echocardiography and 24-hour Holter monitoring, was performed, all of which were normal.
Given the episodic nature of her symptoms and normal cardiac workup, she was diagnosed with panic disorder in the context of post-COVID dysautonomia. She was started on desvenlafaxine (initially 50 mg, titrated to 100 mg) and propranolol (80 mg SR). Over long-term follow-up, she demonstrated a marked reduction in panic episodes and stabilization of autonomic symptoms. This case underscores the need for greater recognition of psychiatric sequelae in post-COVID patients and the complex interplay between autonomic dysfunction and anxiety disorders.
DISCUSSION
COVID-19 has changed the world in many ways and also exposed us to many unique challenges. In hospital psychiatry settings, mental health presentations have become increasingly complex. Compiling these clinical vignettes offers valuable insights and raises awareness of the multifaceted ways in which COVID-19 interacts with mental health. We anticipate that understanding these interactions will enhance clinical practice and improve management in future clinical practice.
The first case highlights the issue of steroid-induced psychosis, a well-documented phenomenon but particularly relevant in the context of the pandemic. Our patient, who developed psychosis 3–4 days after starting high-dose steroid treatment, underscores the potential risks of steroid use in COVID-19 management. High doses of steroids, commonly used to treat severe COVID-19, can precipitate psychotic symptoms, which may be exacerbated by concurrent psychiatric conditions.2 Such symptoms might be mistaken for anxiety-related issues, potentially leading to continued steroid use and worsening of the patient’s condition.3
The second case illustrates the complex interactions between steroids and psychiatric medications. The relapse of bipolar disorder following steroid treatment highlights the need for careful monitoring of drug interactions, especially during the pandemic when both steroids and psychiatric medications are frequently used. Steroids can act as enzyme inducers, potentially reducing the efficacy of psychiatric medications (here valproate) and leading to relapse.4
Our third patient’s case exemplifies a particularly complex interaction of factors that significantly impacted his health during a time of widespread public distress over oxygen shortages. The media’s portrayal of oxygen as “the only savior” contributed to mass anxiety and led many individuals, including our patient, to use oxygen therapy unsupervised. This scenario was further complicated by the patient’s existing chronic respiratory condition—chronic obstructive pulmonary disease (COPD)—and comorbid anxiety disorder. After stopping his anxiety treatment, the patient, fueled by media panic and worsened anxiety, started using oxygen therapy excessively and without medical supervision. His rapid and uncontrolled breathing further deteriorated his condition, leading to carbon dioxide washout and oxygen toxicity.5 This case underscores the dangers of mass anxiety, misinformation,6 and unsupervised medication use. It demonstrates that these factors, compounded by pre-existing anxiety symptoms, can have fatal consequences.
Our fourth case highlights two different but key issues. First, the redeployment of psychiatrists for COVID-19 duties has reduced their availability for core psychiatric care. This lack of psychiatric liaison can lead to non-psychiatrists omitting essential psychotropics, worsening symptoms. Second, catatonia may present as a symptom of autoimmune encephalitis, which is linked to significant immunogenic responses.7 As strong immunogenic interactions with cytokine release are a sine qua non of COVID-19, there is a high chance that it may also cause autoimmune encephalitis. However, due to the newness of the disease, little is known about its pathogenesis. Hence, we should exercise more caution and ensure that specialized care is readily available.
Our last patient exemplifies the Long term psychiatric consequences of COVID-19 (‘long-COVID’). As noted by other authors,8 anxiety is one of the most common symptoms associated with the pandemic. The onset and progression of panic disorder are clinically significant, especially when complicated by post-COVID autonomic dysfunction from an already weakened autonomic system. Early evidence suggests that desvenlafaxine is highly efficacious in these cases, as seen in our patient, potentially due to its additional effect on the noradrenergic system.2,8 Table 1 summarizes the five case details.
| Case ID | Age, gender | Main psychiatric issues | Management | Learning points |
|---|---|---|---|---|
| 1 | 42 years, male | Psychosis after starting intravenous (IV) dexamethasone | Tapering of steroid, low dose antipsychotics | Steroid, used for COVID management can induce or precipitate psychosis. |
| 2 | 36 years, female | Steroid decreased effective serum valproate level resulting manic relapse | Tapering of steroid, increase valproate dosage | Steroid, as enzyme inducer, has potential to increase other medicines metabolism. |
| Case ID | Age, gender | Main psychiatric issues | Management | Learning points |
| 3 | 42 years, male | Self-medication of oxygen in patients with illness anxiety disorder | Patient has lung collapse and respiratory failure | Background psychiatric morbidity, psychosocial aspects of mass anxiety should be dealt with utmost importance. |
| 4 | 56 years, male | Relapse of catatonic episode in a patient of RDD. Further complicated due to stoppage of psychiatric medicines | Treated with lorazepam and bupropion restarted. | Immunogenic reaction of COVID may precipitate catatonic symptoms. Multidisciplinary team, comprised of psychiatrist consultation are essential in these cases. |
| 5 | 32 years, female | Long COVID symptoms, dysautonomia. Patient came to ER with anxiety symptoms and arrythmia | Treated with desvenlafaxine and beta-blocker | Psychiatric symptoms of long COVID should be studied further. |
ER: Emergency department, RDD: Recurrent depressive disorder.
CONCLUSION
To conclude, in this case series, we presented five distinct and varied clinical cases to illustrate the complex ways in which a pandemic context can intersect with psychiatric practice. Moving beyond the scope of a conventional case series, our objective was to reflect the heterogeneous and multifaceted challenges that psychiatrists may face during such crises. These cases underscore the importance of maintaining clinical vigilance, recognizing atypical and evolving presentations, and engaging with broader leadership roles to facilitate improved mental health care delivery in times of systemic stress.
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
Om Prakash Singh is on the Editorial Board of the Journal.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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