Loss of the sense of smell--anosmia--can be devastating. Without smell, patients describe feelings of emptiness, isolation, and emotional distress. Given that anosmia is a common first symptom of COVID-19 and a long-term sequela for as many as 10% of patients who have had COVID-19-related anosmia, psychiatrists need to be familiar with this symptom in order to identify and manage the associated psychological effects.
Prior to the current pandemic, anosmia and hyposmia (decreased sense of smell) received little attention in the popular press or in the non-ear, nose, and throat (ENT) medical literature. However, disturbances in the sense of smell have become a widespread focus of concern now that anosmia has emerged as a possible first symptom--and sometimes the only symptom--of infection with the SARS-CoV-2 virus.
For most individuals who have a COVID-19-related loss of smell, the deficits are short-lived. But for those individuals who do not fully recover, the neuropsychiatric consequences can be debilitating. Pleasures of eating are lost when one cannot detect the complex scents of food. Atmospheric odors disappear: the smells of the kitchen and garden, the gym, the sea. A sense of vulnerability may ensue without the ability to detect signals of danger (eg, smoke, gas, spoiled food). It is not uncommon for depression to emerge as a result. (1,2)
The pandemic-related increase in the prevalence of anosmia has thrown its debilitating effects on mood and quality of life into sharp relief and presents an opportunity for psychiatrists to help.
A Brief History Lesson
The SARS-CoV-2 virus was first reported in December 2019, although the association between anosmia and this viral infection initially was not made. Then, in late March 2020, Hopkins and Kumar sent a bulletin to Public Health England, noting high rates of COVID-19 infection "amongst ENT surgeons compared [with] other health care workers." (3) They reported that physicians and surgeons from around the world had noticed a significant increase in the number of otherwise asymptomatic individuals who were presenting with an abrupt onset of anosmia. They hypothesized that these patients could be unsuspected carriers of the SARSCoV-2 virus and advised the use of full personal protective equipment for clinicians examining any patient with anosmia. (3)
During this early stage of the pandemic, individuals across the globe did not qualify for COVID-19 testing if their only symptom was anosmia; however, in countries where testing was widespread, patients who tested positive for COVID-19 often had anosmia, and frequently anosmia was their first symptom. By April 2020, the Centers for Disease Control and Prevention had added sudden loss of smell and/or taste to the diagnostic criteria for COVID-19. Both subjective and objective evidence for olfactory dysfunction have now been documented in up to 80% of patients with COVID-19. (4)
It is now known that abrupt loss of smell may be an early, and possibly the only, symptom of SARS-CoV-2 virus infection. While anecdotal reports of anosmia abound, scientific studies of outcome are limited. Published research to date indicates that approximately 25% of individuals continue to have disturbances...