It is thought that long COVID-19 or post-COVID-19 syndrome is being felt by more than three million Americans. Long COVID-19 is when symptoms do not go away after the acute period of illness, which, in mild to moderate cases lasts about two weeks. And while the physical symptoms present in those with long COVID-19 (COVID-19 “long-haulers”), get the most attention, more and more, psychiatrists find themselves treating post-COVID-19 syndrome too. This is due to the sometimes severe, psychiatric symptoms present in long COVID-19. Psychologists, too, find a place in treating long COVID-19 symptoms. But what are the mental and emotional symptoms of post-COVID-19 syndrome that require treatment by psychologists and psychiatrists and what do we know about what causes them?
What Is Long COVID-19, Post-COVID-19 Syndrome
It is thought at about 10 percent of people who have had COVID-19 eventually experience post COVID 19 syndrome. COVID-19 long-haulers don’t have live coronavirus causing illness in their bodies and, in fact, would test negative for the virus; however, they might be severely debilitated, nonetheless. One study out of Wuhan, China found that six months after acute infection and hospitalization, 63 percent of people reported fatigue or muscle weakness, 26 percent reported sleep difficulties, and 23 percent reported anxiety or depression. Some with long COVID-19 even require readmission to the hospital. It’s not known how long COVID-19 long-haulers may suffer as most people are only a year or so into recovery.
While it is known that certain risk factor, such as smoking and obesity, can cause a more severe form of COVID-19 initially, the risk factors for long COVID-19 aren’t known. Even people with a mild case of COVID-19 can develop post-COVID-19 syndrome and this syndrome may be worse than the acute phase of the illness. According to the Centers for Disease Control and Prevention (CDC), the most common symptoms of long COVID-19 are fatigue, shortness of breath, cough, joint pain, and chest pain, although psychiatric and cognitive symptoms like brain fog, insomnia, and anxiety also come up quite often.
Overall, the physical symptoms of long COVID-19 can include:
• Breathing issues such as shortness of breath or getting winded easily
• Lingering heart problems which can cause things like heart palpitations and rapid heartbeat
• Lingering kidney damage
• Loss or distorted sense of smell and taste
• Neurological symptoms like postural orthostatic tachycardia syndrome (POTS) which affects blood circulation and insomnia
• Diabetes
The Mental Health Issues During Long COVID-19
If any of the above symptoms are present, they will be treated by one of various doctors; however, there are many long COVID-19 symptoms that need to be treated by a psychiatrist (a medical doctor that specializes in mental health) or a psychologist (a person with a doctorate in psychology).
The relationship between mental health and long COVID-19 is complex. For example, people who get COVID-19 often experience long periods of isolation, stress, and grief thanks to things like possible job loss and the loss of their health. These stressors can make things like pain and weakness worse and are related to the experience of depression and anxiety. Those who have spent time in the hospital may be at particular risk as they are known to sometimes experience post-intensive care syndrome (PICS) which carries a higher risk for difficulties with mental health, cognition, and physical recovery.
A May 2021 study found that one third of COVID-19 patients had been diagnosed with neurological or psychological symptoms in the six months after contracting COVID-19. These symptoms included:
• Anxiety
• Depression
• Posttraumatic stress disorder (PTSD) symptoms
• Psychosis
Many of these patients may be sub-syndromal in that they have symptoms of the illness but not to the extent that they meet the complete diagnosis as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Nevertheless, they still need treatment and support to recover fully. Additionally, it’s important to keep in mind that while some people will get a new psychiatric diagnosis due to long COVID-19, it’s also the case that those with existing psychiatric diagnoses may experience a worsening of their mental illnesses.
Prolonged periods in the intensive care unit (ICU) are known to cause delirium, which, according to the Mayo Clinic, is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. A rehabilitation psychologist from Johns Hopkins Medicine, Megan Hosey, Ph.D., says the strange surroundings, multiple mind-altering medications, isolation and loss of control can leave patients with lasting and recurrent sensations of terror or dread, including post-traumatic stress disorder (PTSD).
She adds:
“Many patients have hallucinations where they believe that medical providers are trying to harm them . . . We've had patients tell us things like ‘I thought I was being buried alive’ when they were being put into an MRI.”
Additionally, the uncertainty of this illness with the unknowns in symptoms, treatment, and duration, can also be difficult to bear.
It is understood that the mental health symptoms can worsen the physical symptoms and vice versa, so it’s critical that long COVID-19 patients be treated both by psychiatrists and/or psychologists.
Some studies have also shown that Covid affected not only the ability for the body to make serotonin by altering the gut microbes that help to make this important neurotransmitter. Other studies show that Covid affected Dopamine and acetylcholine levels as well. Two important neurotransmitters responsible for mood and cognitive function. Coronavirus: the pandemic is changing our brains – here are the remedies.
Psychiatric and Psychological Treatment of Mental Health Symptoms During Long COVID-19
There is no definitive guide on how to treat the psychological and psychiatric symptoms of long COVID-19. In fact, it can even be hard to find a place to get treatment with many clinics having a three- to four-month waiting list to be seen. Additionally, post-COVID-19 syndrome intensive care clinics are often only available in cities with large academic populations.
According to Abigail S. Hardin, PhD, an assistant professor of psychiatry and behavioral sciences at Rush University Medical Center in Chicago,
“There is no magic treatment, there is no surgery, there is no pill that we can give that will instantaneously alleviate all these symptoms.”
However, she is quick to point out that early intervention including offering practical advice on how to counter brain fog, to helping patients navigate relationship changes and overcome feelings of inadequacy over not being able to work can make a big difference.
When it comes to therapy, there are several psychotherapeutic techniques that can help people with long COVID-19. These include:
• Trauma therapy
• Cognitive behavioral therapy (CBT) to establish new behaviors such as good sleep hygiene to improve insomnia
• Acceptance and commitment therapy (ACT) to help someone struggling with the uncertainty of their illness
According to the Post COVID-19 Interdisciplinary Critical Care Network, psychiatrists should treat post-COVID-19 syndrome by:
• Screening for disorders such as anxiety, substance use disorder, and PTSD
• Screening for other harmful states such as psychosis and homicide, suicide, or self-harm ideation
• Addressing the physical symptoms (like insomnia) that may contribute to mental health symptoms
• Recommending pacing strategies such as those used in chronic fatigue syndrome like reducing activity level, taking scheduled rests, and setting limits for individual activities
• Reassuring those who do not meet the DSM-5 criteria for a mental illness and suggesting they see a psychologist and use non-pharmacological management techniques like meditation and exercise
• Treating those who do meet a DSM-5 diagnosis as usual with both pharmacological and non-pharmacological interventions. Posttraumatic stress disorder may be treated with an antidepressant medication like fluoxetine (Prozac) whereas depression may be treated with an antidepressant medication like Vortioxetine (Trintellix)
● Diet can also help with symptoms and eating a diet rich in antioxidants and foods rich in the tryptophan, the precursor for serotonin may help improve some of the depression symptoms. Foods such as walnuts, bananas and broccoli are especially rich sources of tryptophan.
Self-Help Resources for Mental Health Help in Long COVID-19
The Post COVID-19 Interdisciplinary Clinical Care Network recommends the following web resources for COVID-19 long-haulers:
• Anxiety Canada – Coping with COVID-19
• Here to Help – COVID-19 and Anxiety
• The Foundry (ages 12-24) – COVID-19 (Novel Coronavirus) Information
• Calm Videos
Support groups for COVID long-haulers can also be sought out either online or in-person. A psychiatrist or psychiatrist may be able to point you in the right direction.
The Post COVID-19 Interdisciplinary Clinical Care Network also recommends using apps for long COVID-19 self-help. Here are the recommended apps for COVID long-haulers:
• MindShift® CBT by Anxiety Canada (clinically tested)
• Breathr App by the British Columbia Children's Kelty Mental Health Resource Centre and the British Columbia Children's Centre for Mindfulness
• Mindfulness Coach by the United States Department of Veteran’s Affairs (for everyone)
• COVID Coach by the United States Department of Veteran’s Affairs (for everyone)
• Insomnia Coach by the United States Department of Veteran’s Affairs (for everyone)
• Wysa – A chatbot with free features backed up by optional live (paid) therapists (clinically tested)
• Woebot – A chatbot (clinically tested)
Psychiatric and Psychological Symptoms During Post COVID-19 Syndrome
The important thing to remember is that physical, psychiatric, psychological, and cognitive symptoms are to be expected if you experience post-COVID-19 syndrome. If you do experience any mental health or cognitive symptoms, remember that you aren’t alone. Many COVID long-haulers are having the same experience as you. Reach out for help from a psychologist or psychiatrist to get those all your symptoms under control.
Sources
1. COVID ‘Long Haulers’: Long-Term Effects of COVID-19. (2021, December 8). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/covid-long-haulers-long-term-effects-of-covid19
2. Delirium - Symptoms and causes. (2020, September 1). Mayo Clinic. Retrieved April 19, 2022, from https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386
3. Gore, T. A., MD. (2021, July 19). Posttraumatic Stress Disorder Medication: Selective serotonin reuptake inhibitors, Beta-blockers, Alpha-1 Receptor Antagonists, Alpha-2 Adrenergic Agonists. Medscape. Retrieved April 20, 2022, from https://emedicine.medscape.com/article/288154-medication#showall
4. Halverson, J. L., MD. (2021, November 29). Depression Medication: Antidepressants, SSRIs, Antidepressants, SNRIs, Antidepressants, TCAs, Antidepressants, MAO Inhibitors, Augmenting Agents, Serotonin-Dopamine Activity Modulators, Antidepressants, Other, Stimulants, Thyroid Products, Neurology & Psychiatry, Herbals, NMDA Antagonists. Medscape. Retrieved April 20, 2022, from https://emedicine.medscape.com/article/286759-medication#2
5. Post COVID-19 Interdisciplinary Clinical Care Network. Mental Health in “Long-COVID” – A Resource for GPs. Retrieved April 20, 2022, from http://www.phsa.ca/health-info-site/Documents/post_covid-19_Mental_Health_in_Long-COVID_for_GPs.pdf
6. Schreiber, M. (2021, July 1). Treating patients with long COVID. American Psychological Association. https://www.apa.org/monitor/2021/07/treating-long-covid
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