INTRODUCTION
Vaccination has emerged as an essential preventive strategy against the COVID-19 vaccine. A recent review of the literature reported the presence of 11 reports presenting 14 cases of psychiatric manifestations after the COVID-19 vaccinations, with psychosis (n = 5) being the most common manifestation, followed by altered mental states (n = 3), functional neurological disorder (n = 3), mania (n = 2), and depression (n = 1). Most of these cases were reported after the first dose of the vaccine (n = 10), and the age range of the sufferers varied from 18 to 74 years.[1] Considering that there is still limited data on the COVID-19 vaccination and psychiatric manifestations, we present a case of the unmasking of schizophrenia following COVID-19 vaccination with the Covishield vaccine.
CASE DESCRIPTION
A 40-year female, unmarried, post-graduate, and unemployed, who was premorbidly well adjusted, with no past or family history of mental disorder, with no history of COVID-19 infection, was vaccinated with 1st dose of COVID-19 vaccine (Covishield) in mid-2021. On the evening of the day of the vaccination, she started complaining of headache associated with palpitations and discomfort in the chest. On the same night, she was not able to sleep properly. From the next day, she was observed to be fearful and restless. On the second night, she was also unable to sleep and kept pacing throughout the night. From the next day, she started expressing fearfulness and suspiciousness. On the third day, she was seen by a psychiatrist, and a diagnosis of acute transient psychotic disorder was considered and started on tablet olanzapine 5 mg per day. However, her symptoms kept worsening, and from the fourth day, additionally started voicing delusions of persecution against her sister-in-law (i.e., planning to harm her) and reported commanding auditory hallucinations which were present for most part of the day, and were very distressing to the patient. These symptoms led to marked psychosocial dysfunction. Over the next ten days, the symptoms kept increasing, and she stopped olanzapine after a week due to weight gain (about 2 kilograms over 10 days) and sedation. The symptoms worsened despite being given olanzapine 5 mg/day surreptitiously for the next three months. Following this, she was brought to our setting.
After a detailed assessment a diagnosis of schizophrenia (as per the ICD-10 criteria) was considered. Her routine investigations in the form of hemogram, liver function test, renal function test, fasting blood glucose levels, lipid profile, thyroid function test, and neuroimaging in the form of magnetic resonance imaging of the brain did not reveal any abnormality. She also had no evidence from physical examination and investigations to support systemic lupus erythematosus, Wilson’s disease, and porphyria. An autoimmune panel could not be done due to affordability issues and the local non-availability of the testing facility. She was given adequate trials of olanzapine and aripiprazole, with no significant improvement and intolerable side effects (excessive sedation, weight gain, and amenorrhea with olanzapine and no improvement with aripiprazole, although did not experience side effects). Later, she was started on clozapine and increased to the dose of 75 mg/day, with which she showed significant improvement in psychopathology and her functioning improved. She is currently on regular follow-up and maintaining well on clozapine 75 mg/day. The patient did not receive the second dose of the vaccine.
DISCUSSION
Previous case reports which have reported psychiatric manifestations following COVID-19 vaccinations have reported the occurrence of psychosis, mania, functional neurological symptoms, and depression.[1] However, all these reports have reported the short-term outcome of the association. As in the written case reports, in the index case, the psychotic symptoms emerged immediately after the first dose of the vaccine. In contrast to a previous report that documented the onset of schizophrenia after vaccination in a patient with premorbid schizotypal traits,[2] the index case did not have any such predisposing factor. The first psychotic breaks infrequently occur at this age, and our patient did not exhibit thought disorganization. Her predominant symptoms were auditory hallucinations and persecutory delusions, to which she demonstrated poor insight on initial evaluation.
The previous reports that have reported the occurrence of psychosis following vaccination have noted the emergence of symptoms on the day of vaccination to as late as 12 days.[3] In the index case, the signs emerged on immunization day and persisted for more than five months. In contrast to the previously reported cases, the index case developed long-term psychosis, which was resistant to antipsychotics and required clozapine. As per the Naranjo scale,[4] the score of the patient was 6 (previous conclusive reports: +1; adverse event appear after the suspected drug was administered: +2; Adverse reaction improve when the drug was discontinued or a specific antagonist was administered: +1; No alternative causes other than the drug that could on their own have caused the reaction: +2), suggesting a probable adverse reaction.
To conclude, it can be said that the COVID-19 vaccine can rarely unmask psychosis in some persons. However, because only a handful of cases of psychiatric manifestations following COVID-19 vaccination have been reported in the literature, the general public should not be hesitant to receive COVID-19 vaccination.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Balasubramanian I, Faheem A, Padhy SK, Menon V. Psychiatric adverse reactions to COVID-19 vaccines:A rapid review of published case reports. Asian J Psychiatr 2022;71:103129.
2. Reinfeld S, Cáceda R, Gil R, Strom H, Chacko M. Can new-onset psychosis occur after mRNA-based COVID-19 vaccine administration?A case report. Psychiatry Res 2021;304:114165.
3. Borovina T, Popović J, Mastelić T, SučevićErcegovac M, Kustura L, Uglešić B, et al. First episode of psychosis following the COVID-19 vaccination-A case series. Psychiatr Danub 2022;34:377–80.
4. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. Amethod for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–45.
