Long COVID is when a variety of symptoms (that may come in different clusters for different groups of people) persist beyond the initial infection stage of the COVID-19 illness. The infection will have gone, but the symptoms may remain and mostly clear up within 12 weeks (NHS, 2021); however, they can persist for much longer. Nabavi (2020) discussed the symptoms of long COVID, and one of the main ones noted was profound fatigue. A wide range of other symptoms were also noted by Nabavi (2020), including cough, breathlessness, muscle and body aches, chest heaviness or pressure, skin rashes, palpitations, fever, headache, diarrhoea and pins and needles, with a very common feature being the illness relapsing and remitting, where the patient may feel they have recovered but then suddenly feel unwell again.
The NHS (2021) updated their list of symptoms of long COVID, adding the symptoms of anxiety and depression. It is understandable why extreme fatigue with other symptoms of physical illness, which never seem to fully go, would affect someone's mood. However, there may be more of a neurological impact that also contributes to this state of mind, rather than just the depressing nature of the physical symptoms and the length of illness. This article explores the evidence available to shed light on the association between long COVID and mental health.
COVID-19 and neurological/psychological sequelae
Taquet et al (2021a) published the results of their study in the Lancet, which explored the neurological and psychological effect of the SARS-CoV-2 virus. They looked specifically into 6-month outcomes among survivors of the viral infection. The reason for the study was the alarming number of symptoms being reported as neurological and psychiatric sequelae of the virus. However, there was no evidence of a strong association between COVID-19 and brain health, so the researchers aimed to provide a robust series of estimates of incidence rates and relative risks of neurological and psychiatric diagnoses in patients in the 6 months following a COVID-19 diagnosis.
This was a retrospective cohort study and time-to-event analysis (Taquet et al, 2021a). The data were obtained from the TriNetX electronic health records network, which has the data of over 81 million patients. The primary cohort used for the study included patients who had a COVID-19 diagnosis; one matched control cohort included patients diagnosed with influenza, and the other matched control cohort included patients diagnosed with any respiratory tract infection, including influenza, in the same time period. Patients with a diagnosis of COVID-19 or a positive test for SARS-CoV-2 were excluded from the control cohorts, and all cohorts included patients over the age of 10 years who had an index event on or after 20 January 2020 and who were still alive on 13 December 2020.
The team estimated the incidence of 14 neurological and psychiatric outcomes in the 6 months after a confirmed diagnosis of COVID-19:
- Intracranial haemorrhage
- Ischaemic stroke
- Parkinsonism
- Guillain-Barré syndrome
- Nerve, nerve root, and plexus disorders
- Myoneural junction and muscle disease
- Encephalitis
- Dementia
- Psychotic, mood, and anxiety disorders (grouped and separately)
- Substance use disorder
- Insomnia.
Using a Cox model, Taquet et al (2021a) compared incidences with those in propensity score-matched cohorts of patients with influenza or other respiratory tract infections, and then they investigated how these estimates were affected by COVID-19 severity, as proxied by hospitalisation, intensive therapy unit (ITU) admission and encephalopathy (delirium and related disorders) (Taquet et al, 2021a).
The researchers ensured that their study was robust by repeating their analysis in different scenarios. They compared their primary cohort with four cohorts of patients diagnosed in the same period with additional index events: skin infection, urolithiasis, fracture of a large bone and pulmonary embolism. This was in order to provide benchmarking for the incidence and risk of neurological and psychiatric sequelae.
Some 236 379 patients who had experienced COVID-19 were studied. The estimated incidence of a neurological or psychiatric diagnosis in the following 6 months in these patients was 33.62%, with 12.84% (12.36–13.33) receiving their first such diagnosis. Taquet et al (2021a) found the approximate incidence of a neurological or psychiatric diagnosis for patients who had been admitted to an ITU, was 46.42%, and for a first diagnosis, it was 25.79%. The entire COVID-19 cohort had estimated incidences of 0.56% for intracranial haemorrhage, 2.10% for ischaemic stroke, 0.11% for parkinsonism, 0.67% for dementia, 17.39% for an anxiety disorder and 1.40% for psychotic disorder, among other diagnoses (Taquet et al, 2021a).
For those who had been admitted to intensive care, the estimated incidences were 2.66% for intracranial haemorrhage, 6.92% for ischaemic stroke, 0.26% for parkinsonism, 1.74% for dementia, 19.15% for anxiety disorder and 2.77% for psychotic disorder. Most diagnostic categories were found to be more common in patients who had COVID-19 when compared with those who had influenza, and also when compared to those who had other respiratory tract infections. As with incidences, people with COVID-19 compared with all other groups were found to have the highest number of diagnoses resulting from the condition and the highest number of ITU admissions. The data came from a large sample, and the results were robust to various sensitivity analyses and benchmarking against the four additional index health events (Taquet et al, 2021a).
The researchers stated that their study provides clear evidence of the substantial neurological and psychiatric morbidity in the 6 months following COVID-19 infection (whether the patient is officially diagnosed with ‘long Covid’ or not, these problems feature in the study within the 6-month period following a COVID-19 infection). Risks were found to be the highest in patients with a more severe diagnosis of COVID-19. Taquet et al (2021a) stated that their findings could assist in service planning and identification of research priorities. However, complementary study designs, including prospective cohorts, would be required to corroborate and explain these findings. It is essential that the underpinning physiology can be explored so as to explain how such effects occur following infection, in so many people. The findings regarding anxiety and mood disorders were found to be broadly consistent with 3-month outcome data from a previous study done in a smaller number of cases than this cohort (Taquet et al, 2021b), using the same network, which helped prove reliability of their findings (Taquet et al, 2021a).
Taquet et al (2021a) noted the marked increased risk of psychotic disorders, stating this may have reflected the larger sample size and longer duration of follow-up reported in comparison with previous studies. Substance use disorders and insomnia were found to be more common in COVID-19 survivors than in those who had influenza or other respiratory tract infections. Therefore, the authors concluded that, as with the neurological outcomes, the psychiatric sequelae of COVID-19 are widespread and persist up to, and likely beyond, 6 months. A longer study would be required to explore how long the after-effects can persist. The study concluded that services would need to be configured, and resourced, to deal with this anticipated need with regard to the neurological and psychological sequelae of COVID-19 infection, in the 6 months post-infection and beyond. Due to the nature of the longer term symptoms discussed in the study, it would be safe to consider such symptoms or clusters of symptoms to be defined within the ‘long Covid’ category.
Rogers et al (2020) carried out a systematic review, noting that previous severe coronavirus outbreaks had links to mental health. Prior to the current pandemic, other coronaviruses had also caused widespread disease, such as those responsible for severe acute respiratory syndrome (SARS) in 2002 and Middle East respiratory syndrome (MERS) in 2012. Rogers et al (2020) assessed the psychiatric and neuropsychiatric presentations of SARS, MERS and COVID-19. They determined that, if infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness, but SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage. As an outcome of the research, it is recommended by Rogers et al (2020) that clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder and rarer neuropsychiatric syndromes in the longer term following coronavirus infection.
Possible physiological effects of COVID-19 on the brain
Evidence is still limited as to how SARS-CoV-2 specifically affects the brain to produce such outcomes.
Weir (2020) noted that an explosive inflammatory response known as a ‘cytokine storm’ can occur in those with COVID-19, and this may damage the blood-brain barrier. In turn, this might allow inflammatory cells and molecules, as well as viral particles, to enter the brain. As a result, patients may develop seizures, confusion, coma or encephalopathy. The virus has been found in the cerebrospinal fluid of a few patients, which would increase the likelihood of the virus directly infect brain cells. However, the evidence that the virus can make its way into brain cells remains uncertain (Weir et al, 2020).
Those who have been in intensive care are more likely to experience long-term problems with cognition and have an increased risk of anxiety and depression. However, a study that was carried out prior to the pandemic found that 20%–40% of ICU patients experienced delirium, with rates going up to 60%–80% for patients on ventilators (Pandharipande et al, 2017), suggesting that intensive care itself can lead to psychological illness. Therefore, it is understandable that patients may experience such outcomes from being an intensive care patient rather than from the virus only.
Social impact of COVID-19
Alongside the physiological impact being hypothesised, there is the ongoing social impact of the virus, which undoubtedly affects mental health, especially in those who are already vulnerable. It is important to be aware of the effects of loss in many ways-many have not only lost loved ones to the virus, but have experienced loss of routine, social connection and employment, as well as financial losses, all of which can affect a person's mental health (Torales et al, 2020). Paying attention to what the individual for their specific situation might have lost in their own life to this pandemic is important when looking for solutions in tackling the profound effect on their mental health that the pandemic has had.
The loss of some of our freedom is something we can probably all universally relate to, with lockdowns making us realise that anything can happen. It is through gaining an understanding of the individual circumstances of a person that we can gauge how to go about helping them with their mental health. The new pandemic could be the mental health side effect of COVID that we must prioritise in our treatment, where possible, for the vulnerable people in our care.
What can be done?
Torales et al (2020) noted that the emerging mental health problems relating to such a global event may eventually become long-lasting health problems, involving isolation and stigma. Therefore, they recommended that global health measures should be employed to address psychosocial stressors, especially related to the use of isolation/quarantine, fear and vulnerability among the general population. Torales et al (2020) stated that there should be a worldwide inclusive response that involves a focus on that mental health impact on patients and the general population. Community supportive psychological interventions should be globally promoted (Torales et al, 2020).
One patient personally told of her story of her own long-COVID experience, and her story is published on the Mind (2020) website. She joined group therapy on Zoom and found 7000 other people experiencing the same mental health challenges but to varying extents, who also were suffering from the longer term effects of the virus. Mind (2020) recommends that patients speak with their GP and refer themselves or request the GP to refer them for therapy, psychiatric medication following medical consultation and self-help, such as learning to strengthen coping mechanisms and engaging in good self-care while managing fatigue. The patient should be encouraged to participate in all of these, where appropriate or possible. Group therapy may be one of the easier options for accessibility while unwell with mental health symptoms and severe fatigue. Further, motivational interviewing can be a tool for health practitioners to encourage the patient to continue with, for example, their routine but to a manageable extent, rather than succumb entirely to the effects of their depression and fatigue.
Long COVID clinics are being set up all over the country with the aim of dealing with the range of symptoms brought about by the virus, and it is hoped that the mental health aspect can be dealt with appropriately in these settings also. The British Lung Foundation (2021) noted that, if a person has symptoms of a mental health condition, such as depression or anxiety, they may be referred under treatment guidelines for psychological therapies, such as cognitive behavioural therapy. This may be through the GP or a long COVID service. Services are still in development, and it is looking hopeful that long-COVID patients can get a holistic service tailored to treating their physical and their mental health symptoms, because both are equally important.
KEY POINTS
- Long COVID involves a continuation or development of symptoms or clusters of symptoms following the initial infection stage of COVID-19. Typically, long COVID can last for up to 12 weeks, but it may persist for longer
- Increasingly, mental health issues such as anxiety and depression, as well as psychosis have been linked to the condition
- Neurological consequences linked to long COVID include confusion and dementia symptoms. These may be linked to a cytokine ‘storm’ from the immune response to the infection, which affects the blood brain barrier
- Psychological therapies, self-help strategies for coping and self-care, alongside medication, may help treat the mental health symptoms of long COVID
- Long COVID services are in development, and primary care will play a role in assessment of the patient for symptoms and risk factors
- It must be kept in mind that every care plan is individualised to the patient, as people can experience different symptoms, physically and mentally
CPD REFLECTIVE QUESTIONS
- What would be involved in your assessment of someone who has had COVID-19, bearing in mind the possibility that they could have long COVID?
- What symptoms are you looking out for with specific reference to the mental and neurological effects they may be experiencing?
- How would you deal with a patient who confides in you that they are experiencing depressive symptoms relating to their condition?