Ramadan M, Malaka L, Ghabrah R, Sulimani A, Aljadani F, Al Dosari L, Alsiary R. Risk of neurological and psychiatric diagnoses in COVID-19 survivors: A multicenter retrospective cohort study using electronic health records. World J Psychiatry 2025; 15(12): 109680 [PMID: 41357944 DOI: 10.5498/wjp.v15.i12.109680]
Corresponding Author of This Article
Majed Ramadan, PhD, Senior Researcher, Department of Population Health, King Abdullah International Medical Research Center, Ar Rimayah, Riyadh 22490, Riyadh, Saudi Arabia. ramadhanm@kaimrc.edu.sa
Research Domain of This Article
Ecology
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Retrospective Cohort Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Dec 19, 2025 (publication date) through Dec 9, 2025
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World Journal of Psychiatry
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2220-3206
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Ramadan M, Malaka L, Ghabrah R, Sulimani A, Aljadani F, Al Dosari L, Alsiary R. Risk of neurological and psychiatric diagnoses in COVID-19 survivors: A multicenter retrospective cohort study using electronic health records. World J Psychiatry 2025; 15(12): 109680 [PMID: 41357944 DOI: 10.5498/wjp.v15.i12.109680]
Majed Ramadan, Department of Population Health, King Abdullah International Medical Research Center, Riyadh 22490, Riyadh, Saudi Arabia
Lara Malaka, Remaz Ghabrah, Aljodi Sulimani, Farah Aljadani, Lama Al Dosari, College of Medicine, King Abdulaziz University, Jeddah 22490, Makkah al Mukarramah, Saudi Arabia
Rawiah Alsiary, Department of Cancer, King Abdullah International Medical Research Center, Jeddah 22490, Makkah al Mukarramah, Saudi Arabia
Author contributions: Ramadan M conceptualized and designed the study, drafted the manuscript, supervised data collection, and oversaw the analytical strategy; Ramadan M and Alsiary R developed the methodological framework, verified analytic consistency, and contributed to interpretation of the qualitative data; Malaka L, Ghabrah R, Sulimani A, Aljadani F, and Al Dosari L contributed to data collection, transcription, preliminary coding, participated in literature review, coding validation, and theme refinement; all authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.
Institutional review board statement: The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and approved by the Institutional Review Board of King Abdullah International Medical Research Center (Approval No. SPJ24/008/7).
Informed consent statement: This is a retrospective study, the requirement for informed consent was waived by the Institutional Review Board at King Abdullah International Medical Research Center.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The data supporting the findings of this study are available from the corresponding author upon reasonable request. Access to the data may be subject to institutional or ethical restrictions.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Majed Ramadan, PhD, Senior Researcher, Department of Population Health, King Abdullah International Medical Research Center, Ar Rimayah, Riyadh 22490, Riyadh, Saudi Arabia. ramadhanm@kaimrc.edu.sa
Received: May 18, 2025 Revised: June 2, 2025 Accepted: October 13, 2025 Published online: December 19, 2025 Processing time: 193 Days and 19.1 Hours
Abstract
BACKGROUND
The neurological and psychiatric sequelae of coronavirus disease 2019 (COVID-19) have been documented, yet further data are needed to thoroughly evaluate the impact of COVID-19 on brain health years after the infection.
AIM
To examine whether COVID-19 infection is associated with exacerbation, recurrence, or progression of pre-existing neurological or psychiatric disorders - a high-risk population that is underrepresented in COVID-19 outcome research in National Guard Health Affair patients in 4-years following a COVID-19 diagnosis.
METHODS
For this multicenter retrospective cohort study, we used data from the National Guard hospitals electronic health records network (BestCare) with over 10 million patients. Our cohort comprised patients who had a COVID-19 diagnosis; a matched control cohort included patient did not expose to COVID-19 in same period. Age and sex were matching factors. We estimated the incidence of 14 neurological and psychiatric outcomes in nearly 4 years after a confirmed diagnosis of COVID-19. Using a multiple logistic regression, we compared incidences with those in propensity score-matched cohorts of patients with no exposure to COVID-19.
RESULTS
Our primary cohort comprised 4437 patients diagnosed with COVID-19, and our propensity-score 1:1 matched control cohort comprised 4437 individuals. Nearly two-third of the COVID-19 cohort (71%) were diagnosed in 2020, and 2021. The most prevalent diagnoses for both cohorts were epilepsy 30.68%, mood disorder 23.92%, and nerve plexus disorder 22.13%. Dementia was nearly 4 times higher among COVID-19 cohort (8.27%) compared to the control cohort (2.57%). Five neurological and psychiatric outcomes had odds ratios (OR) that were significantly higher than 1 for people who had COVID-19 compared to people who had never been infected. These outcomes were cognitive deficit OR = 1.54, 95% confidence interval (CI): 1.23-1.91, P = 0.0001; nerve plexus disorder OR = 1.13, 95%CI: 1.01-1.25, P = 0.02; substance use disorder OR = 1.95, 95%CI: 1.12-3.38, P = 0.01; mood disorder OR = 1.16, 95%CI: 1.05-1.29, P = 0.003; and anxiety disorder OR = 1.39, 95%CI: 1.07-1.79, P = 0.01.
CONCLUSION
The study highlights the persistent risk of neurological and psychiatric conditions in COVID-19 survivors up to four years post-infection. Although the incidence was lower than in previous large studies, long-term consequences remain significant, emphasizing the need for ongoing monitoring and support in mental health and neurological care.
Core Tip: This multicenter retrospective cohort study used electronic health records from the National Guard Health Affairs system in Saudi Arabia to evaluate long-term neurological and psychiatric outcomes in coronavirus disease 2019 (COVID-19) survivors. Among 4437 COVID-19 patients matched 1:1 by age and sex with uninfected controls, several conditions - such as cognitive deficit, mood and anxiety disorders, and substance use - were significantly more common up to four years post-infection. This study provides one of the longest follow-up assessments to date and highlights the enduring burden of COVID-19 on brain health, underscoring the need for extended mental and neurological surveillance in affected population.
Citation: Ramadan M, Malaka L, Ghabrah R, Sulimani A, Aljadani F, Al Dosari L, Alsiary R. Risk of neurological and psychiatric diagnoses in COVID-19 survivors: A multicenter retrospective cohort study using electronic health records. World J Psychiatry 2025; 15(12): 109680
The emergence of the coronavirus disease 2019 (COVID-19) pandemic on March 11, 2020, has raised significant concern regarding the increased risk of affecting cognitive, behavioral, and perceptual domains[1-3]. Viral infections are widespread, with some known to target and impact the central nervous system, causing neuropsychiatric syndromes[3,4]. In addition, coronaviruses have been detected in both the brain and cerebrospinal fluid of individuals presenting with neurological conditions such as seizures, encephalitis, and encephalomyelitis[4]. Also, concerns have been highlighted regarding the psychiatric sequelae of COVID-19, with evidence indicating that COVID-19 survivors are at an elevated risk for developing mood and anxiety disorders within the first three to six months following infection[5]. Some of these psychiatric disorders are attributed to the psychological impact of the COVID-19 social and financial trauma[6]. However, it is uncertain whether the risk of psychiatric disorders persists even after the end of the pandemic. Therefore, large-scale, robust, and long-term data are needed to assess and quantify the impact of the COVID-19 pandemic on brain health. This information is essential for effective service planning and identifying key research priorities in the near future.
During the first two years of the COVID-19 pandemic, significant psychiatric effects were observed in both COVID-19 survivors and individuals not directly exposed to the virus. These effects were largely driven by the broader societal impacts of the pandemic and government interventions, such as physical distancing, lockdowns, and quarantine measures[7,8]. Both COVID-19 infected and non-infected populations were vulnerable to heightened anxiety, social isolation, stress among healthcare and essential workers, as well as unemployment and financial difficulties[8,9]. Numerous studies have since confirmed an increased risk of mood and anxiety disorders following severe acute respiratory syndrome coronavirus 2 infection[9,10]. Rogers and colleagues found that the risk of these psychiatric disorders peaked during the acute phase of infection but returned to baseline levels comparable to control groups within a few months[10]. However, it remains unclear whether the observed decline in the incidence of psychiatric disorders is directly attributable to the viral infection itself or to external factors related to the pandemic, such as social and economic disruptions. Therefore, assessing the long-term risk of psychiatric disorders beyond the pandemic restrictions is crucial to determine whether COVID-19 infection has a sustained impact on the incidence of these conditions.
Investigating the risk of neurological and psychiatric disorders among individuals infected with COVID-19 years after the pandemic remains critically important. As millions of COVID-19 survivors suffer from long COVID, a post-acute infection syndrome called long COVID that often includes nervous system dysfunction[11]. This overlaps with post-intensive care syndrome, putting those who had severe COVID-19 at high risk for long-term neurological complications. As long-term sequelae of COVID-19, particularly neurological and psychiatric disorders, may persist or emerge months or even years after the viral infection[12,13]. While the immediate effects of the virus have been studied, the delayed and potentially long-term impacts on brain health have yet to be fully understood. In this study, we utilized an electronic health records network to examine the likelihood of developing neurological and psychiatric conditions in survivors up to four years following a confirmed COVID-19 infection. We also compared these risks to individuals who had never contracted COVID-19. This study will provide essential data to examine exacerbation, recurrence, or progression of pre-existing neurological or psychiatric disorders - a high-risk population that is underrepresented in COVID-19 outcome research informing public health planning, resource allocation, and guiding future research into the long-term effects of both the infection and the pandemic itself.
MATERIALS AND METHODS
Study design and data collection
For this multicenter retrospective cohort study, we used BestCare system, a National Guard Health Affair (NGHA) system recording data from electronic health records in 21 healthcare facilities including 16 primary care clinics and 5 medical centers located in all 13 provinces of the Kingdom of Saudi Arabia comprising nearly 10 million patients. The extracted data include demographics, diagnoses [using codes from International Classification of Diseases, 10th revision (ICD-10)]. The Institutional Review Board approval obtained for this study from King Abdullah International Medical Research Center ensures (Approval No. SPJ24/008/7), they possess all necessary rights, consents, and authorizations to provide the data. Names, medical record numbers, and any other identification of the patient remain anonymous as the data is strictly used for research purposes. The data management team at King Abdullah International Medical Research Center developed a comprehensive anonymous database of all NGHA patients, allowing for the creation of cohorts based on predefined inclusion and exclusion criteria.
Inclusion and exclusion criteria
The primary cohort included 80391 adult patients (aged ≥ 18 years) with preexisting diagnoses of at least one of 14 neurological or psychiatric disorders, recorded in the electronic health records system between January 2016 and August 2024. From this group, 48987 patients were diagnosed with at least one of the 14 conditions on or after March 10, 2020 - the date of the first confirmed COVID-19 case in Saudi Arabia. Among these, 4437 patients had a confirmed diagnosis of COVID-19 (ICD-10 code U07.1) and developed one or more of the 14 neurological or psychiatric outcomes after their first positive COVID-19 test. These patients formed the COVID-19 cohort. All were aged ≥ 18 years at the time of diagnosis and were alive as of the analysis cutoff date, August 20, 2024 (Figure 1).
Figure 1 Cohort selection flowchart for the risk of neurological and psychiatric diagnoses following coronavirus disease 2019 infection.
COVID-19: Coronavirus disease 2019.
A 1:1 matched control cohort was created, comprising 4437 individuals diagnosed with at least one of the 14 neurological or psychiatric conditions after March 10, 2020, but with no history of COVID-19. Matching was based on age and sex. Patients were excluded from the control cohort if any of the following diagnostic codes or test results were recorded on or after March 20, 2020: (1) U07.2: COVID-19, virus not identified; (2) J12.81: Pneumonia due to severe acute respiratory syndrome-associated coronavirus; (3) B97.29: Other coronavirus as the cause of disease classified elsewhere; (4) B34.2: Coronavirus infection, unspecified; and (5) Positive test results for severe acute respiratory syndrome coronavirus 2 RNA in respiratory, unspecified, or nasopharyngeal specimens. The follow-up duration depended on the timing of the index event (first COVID-19 diagnosis or matching diagnosis for controls). Patients with index events occurring prior to the analysis date were followed for up to 44 months.
Covariates
We utilized a set of previously established risk factors for COVID-19 that were available within the system as age, sex, overweight/obesity, hypertension, diabetes, chronic kidney disease, chronic lower respiratory diseases, ischemic heart disease, cancer, chronic liver disease, rheumatoid arthritis, psoriasis, and disorders involving an immune mechanism[14,15]. The database includes a built-in propensity score-matching algorithm to adjust for confounding variables, facilitating comparisons of outcomes of interest across specified time periods.
Outcomes
We evaluated the neurological and psychiatric sequelae of COVID-19 in terms of 14 outcomes occurring after individuals tested positive for COVID-19: Cognitive Deficit (ICD-10 code R41.84), intracranial haemorrhage (ICD-10 code I60-62); ischemic stroke (ICD-10 code I63); Parkinson’s disease and parkinsonism (ICD-10 code G20-21); Guillain-Barré syndrome (G61.0); nerve, nerve root, and plexus disorders (ICD-10 code G50-59); myoneural junction and muscle disease (neuromuscular disorders; ICD-10 code G70-73); encephalitis (ICD-10 codes G04, and G05); dementia (ICD-10 codes F01-03, G30, G31.0, or G31.83); epilepsy (ICD-10 code G40001) psychotic, mood, and anxiety disorders (ICD-10 code F20-48), as well as each category separately; substance use disorder (ICD-10 code F10-19), and insomnia (ICD-10 code F51.0). To minimize the potential selection bias, and to emphasize neurological and psychiatric disorders potentially associated with COVID-19 infection, we excluded patients who had the outcome diagnosis before tested positive for COIVD19 for all the 14 outcomes.
Statistical analysis
We employed χ2 tests and t-tests, depending on the type of variables, to assess the differences in demographics and other medical conditions between COVID-19 infected and non-infected patients. Propensity score matching was used to create cohorts with matched baseline characteristics, implemented in Statistical Analysis System (SAS Institute Inc., Cary, NC, United States). We applied 1:1 greedy nearest neighbor matching with a caliper distance of 0.1 pooled standard deviations of the logit of the propensity score[16]. The probability of occurrence for each of the 14 neurological and psychiatric disorders was estimated using multiple binary logistic regression models adjusted for confounders[17]. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, using the patient cohort as the independent variable. During the assessment of binary logistic regression assumptions, we identified moderate multicollinearity among independent variables, which was addressed by removing highly correlated predictors[18]. No other significant violations of the regression assumptions were detected. All analyses were conducted using Statistical Analysis System version 9.4 statistical software.
RESULTS
Our cohort comprised 4437 patients diagnosed with COVID-19, and our propensity-score 1:1 matched control cohort comprised 4437 individuals. Nearly two-third of the COVID-19 cohort (71%) were diagnosed in 2020, and 2021. The mean age of patients diagnosed with COVID-19 is older (49 years old) than those with control cohort (46 years old). Nearly 90% of the patients diagnosed with COVID-19 were in Central (54.13%) and Western region (33.08%; Figure 2A; Table 1). All comorbidities were statistically significantly higher in the COVID-19 patients cohort compared to the control cohort group. The percentage of comorbidity cases in the COVID-19 patients’ cohort ranging from 2 to 3 times higher than the control cohort group as shown in type 2 diabetes (31.42% COVID-19 cohort vs 15.91% control cohort; P < 0.0001), and heart diseases (16.09% COVID-19 cohort vs 5.93% control cohort; P < 0.0001) and other comorbidities (Figure 2A; Table 1). We estimated the diagnostic incidence of the neurological and psychiatric outcomes of the primary cohort after a COVID-19 diagnosis. 16.58% of the study’s population were diagnosed with a neurological or psychiatric diagnosis, where 8.86% for COVID-19 cohort and 7.72% for matched control cohort were diagnosed with a neurological or psychiatric diagnosis (Table 2). The percentage of neurological or psychiatric disorders were constantly higher in the COVID-19 cohort for all outcomes except for myoneural junction (2.07% vs 2.79%), intracranial hemorrhage (2.21 vs 2.59), Guillain-Barre syndrome (0.41 vs 0.47), epilepsy (24.34% vs 37.03%) and psychotic disorder (3.88% vs 4.73%). The most prevalent diagnoses for both cohorts were epilepsy 30.68%, mood disorder 23.92%, and nerve plexus disorder 22.13%. Dementia was nearly four times higher than COVID-19 cohort (8.27%) compared to the control cohort (2.57%; Figure 2B; Table 2).
Figure 2 Comparative analysis of baseline characteristics and major outcomes between the coronavirus disease 2019 and other cohorts.
A: Baseline characteristics for the coronavirus disease 2019 (COVID-19) cohort and control cohort; B: Major outcomes for the whole COVID-19 cohort, and for the non-COVID-19 control cohort. COVID-19: Coronavirus disease 2019.
Table 1 Baseline characteristics for the coronavirus disease 2019 cohort and control cohort (n = 8874), n (%).
We assessed the probability of neurological and psychiatric outcomes in COVID-19 patients and compared it to the probability of similar outcomes in the matched control cohort. Overall, there were statistically significant differences in 10 out of 14 neurological and psychiatric outcomes between the COVID-19 cohort and the matched control cohort (Table 3; Figures 3 and 4). It was found that five neurological and psychiatric outcomes had OR that were significantly higher than 1 for people who had COVID-19 compared to people who had never been infected (Table 3; Figures 3 and 4). These outcomes were cognitive deficit OR = 1.54, 95%CI: 1.23-1.91, P = 0.0001; nerve plexus disorder OR = 1.13, 95%CI: 1.01-1.25, P = 0.02; substance use disorder OR = 1.95, 95%CI: 1.12-3.38, P = 0.01; mood disorder OR = 1.16, 95%CI: 1.05-1.29, P = 0.003; and anxiety disorder OR = 1.39, 95%CI: 1.07-1.79, P = 0.01 (Figure 2A; Table 3). There were ORs that were significantly less than 1 for five neurological and psychiatric outcomes (Figures 2A and 4; Table 3). These were ischemic stroke OR = 0.72, 95%CI: 0.56-0.91, P = 0.0006; insomnia OR = 0.54, 95%CI: 0.46-0.63, P < 0.0001; parkinsonism OR = 0.61, 95%CI: 0.44-0.83, P = 0.002; intracranial hemorrhage OR = 0.59, 95%CI: 0.44-0.79, P = 0.0005; epilepsy OR = 0.79, 95%CI: 0.72-0.88, P < 0.0001 (Table 3; Figures 3 and 4).
Neurological and psychiatric complications following COVID-19 infection have been widely predicted and reported in previous studies[2,6,19,20]. The findings from the present study, leveraging a large multicenter electronic health records network, contribute to this growing body of evidence by quantifying the long-term risk and incidence of such conditions in a well-defined cohort of COVID-19 survivors compared with matched individuals who were never exposed to the virus. Our analysis reveals that individuals diagnosed with COVID-19 were at elevated risk for approximately half of the 14 investigated neurological and psychiatric disorders. Specifically, 8.86% of the COVID-19 cohort developed at least one new-onset neuropsychiatric condition during a follow-up period extending up to nearly four years after infection. This estimate, while consistent with earlier research demonstrating increased neuropsychiatric risk post-COVID-19[2,5], is notably lower than previously published figures reporting incidence rates between 20% and 30%[21,22]. This discrepancy may be attributed to the longer follow-up duration in our study and potential confounding factors such as vaccination status, regional population characteristics, or evolving clinical management of COVID-19 cases over time.
Interestingly, our findings also suggest that the risk of several neurological and psychiatric outcomes was not significantly elevated - or was even reduced - among COVID-19 survivors relative to controls. This contrasts with some earlier studies that broadly associated COVID-19 with increased neuropsychiatric burden but may reflect differences in methodology, population exposure, or temporal dynamics of post- COVID-19 sequelae. Notably, the current study offers one of the longest follow-up durations reported to date (up to 44 months), capturing delayed and possibly transient effects that shorter studies may have missed.
The current study offers a longer follow-up period, extending up to nearly four years, compared to previous studies, which typically had follow-up ranges between 6 and 24 months[12,23]. Notably, nearly two-thirds of the COVID-19 cohort in this study were infected in 2020 or 2021, providing an average follow-up period of 3 to nearly 4 years. This extended follow-up may account for some variation in findings compared to previous studies. The current study also demonstrates that the persistence of long-term conditions, such as substance use, anxiety, and mood disorders, are attributed to a prior COVID-19 infection. The impact of COVID-19 on neurological and psychiatric disorders is well-established in the literature[24], with evidence showing that even individuals with mild infections are at risk for developing long-term sequelae. This study further demonstrates that even after nearly four years of surviving COVID-19, individuals are still at elevated risk for several neurological and psychiatric disorders, particularly substance use, nerve plexus disorders, cognitive deficits, anxiety, and mood disorders. It is important to note that NGHA hospitals are major trauma centers in the Kingdom, treating nearly half of injury cases in Saudi Arabia[25]. This may explain the higher incidence of nerve plexus disorders observed among COVID-19 survivors in the NGHA population during the 44 months follow-up, potentially linked to trauma and injury rather than solely the viral infection.
Another significant factor that may explain the reduced proportion of neurological and psychiatric disorders is the widespread availability of the COVID-19 vaccination. A large prospective cohort study demonstrated that fully vaccinated individuals demonstrated lower levels of inflammatory markers, suggesting that vaccination is associated with both short-term and long-term reductions in inflammation. This decrease in inflammation may partially account for the lower rates of neurological and psychiatric disorders, as well as the reduced mortality observed in vaccinated individuals[26]. Additionally, a recent study highlighted a promising association between vaccination and reduced cognitive impairments, such as memory loss. Researchers found that prior vaccination effectively reduced brain inflammation and lowered interleukin-1β levels in an animal model. As a result, the vaccinated models experienced less cognitive decline and memory impairment, underscoring the protective effects of vaccination on brain health[27]. In Saudi Arabia, approximately 74% of the population received at least one dose of the COVID-19 vaccine in 2021[28]. This widespread vaccine coverage may help explain the observed reduction in the neurological and psychiatric impacts of COVID-19, as vaccination likely played a key role in mitigating the virus's effects on the brain.
Our findings are robust due to the relatively large sample size and the use of propensity score matching. However, they are subject to limitations common to electronic health records studies, such as potential gaps in record completeness, lack of validation for diagnoses, limited data on socioeconomic and lifestyle factors[29]. These limitations mainly impact the accuracy of incidence estimates. Additionally, the selection of comparison cohorts for COVID-19 outcomes significantly influenced the magnitude of the ORs. Another limitation is that the COVID-19 vaccination status was not included in this analysis along with other potential confounding factors such as hospitalization, intensive care unit admission, and severity of COVID-19 infection. The reasons these variables were not included were because data were not available, were inconsistent, or included a high proportion of missing or unknown values. The ICD-10 codes were used to determine COVID-19 case-patients, and misclassification bias of matched cohort is possible[30].
CONCLUSION
This study highlights the persistent risk of neurological and psychiatric conditions in COVID-19 survivors up to nearly four years post-infection, with conditions such as cognitive deficit, substance use, anxiety, mood disorders, and nerve plexus disorders being notably prevalent. While the incidence was lower than in previous large studies, long-term consequences remain significant. This underscores the need for ongoing monitoring and support for COVID-19 survivors, particularly in mental health and neurological care. Large robust longitudinal studies to better understand the factors potentially lead to lower neurological and psychiatric incidence are needed.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: Saudi Arabia
Peer-review report’s classification
Scientific Quality: Grade A, Grade B
Novelty: Grade B, Grade B
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade A, Grade B
P-Reviewer: Yi C, PhD, Assistant Professor, China S-Editor: Zuo Q L-Editor: A P-Editor: Wang WB
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