Zebra, Horse, or Zorse of Sorts? A Psychiatric Approach to Long COVID

By Luciana Giambarberi, M.D.

 

Long COVID, also known as chronic COVID -19 and long-haul COVID, is defined as COVID -related symptoms lasting longer than four weeks after infection not otherwise explained by another diagnosis.  Additionally, ICD-10 code “unspecified post- COVID conditions (U09.9)” was approved in October 2021.  The unavoidable lack of standardization that arises in situations of new, rapidly-changing information, has led to confusion about long COVID symptoms among providers and patients alike.  Naming a condition creates some structure for management and research, as well as context for our patients.  However, post-viral and post-hospitalization syndromes are not new [1-4].  There is still little known that is unique to long COVID, and long COVID symptoms can overlap or co-occur with other conditions.  This article provides a brief psychiatric approach to common long COVID symptoms.

Establishing rapport with long COVID patients is essential and includes emphasis on validation and empathy.  Long COVID patients may have experienced multiple forms of trauma, including healthcare-related, and some may still be uncertain about their diagnosis.  The psychiatric evaluation should always include a thorough review of medical history, medications, and plans for further workup.  This might consist of a complete blood count, comprehensive metabolic panel, electrolytes, hormone levels, medication levels, vitamin levels, urine analysis, urine drug screen, ECG, etc.

FATIGUE

Fatigue is one of the most common symptoms of long COVID, and it is associated with multiple etiologies [5-15].  Fatigue is often encountered by psychiatrists as it relates to mood, anxiety, and sleep disorders.  In the absence of a known psychiatric disorder, psychiatrists should communicate with the medical team for continued workup.      

TIPS

  • Avoid sedating medications.
  • Consider activating medications.
  • Refer to PCP/specialists as needed and keep an open dialogue.
  • Refer to/provide psychotherapy (ex. behavioral activation, cognitive behavioral therapy).
  • •Review pertinent lab work and testing.

NEUROPSYCHIATRIC SYMPTOMS

Cognitive change, sometimes referred to as “brain fog,” is another highly reported long COVID symptom [5, 6, 16, 7, 8, 10, 17, 12, 18-20, 2].  Patients have described examples of altered attention, executive function, and/or memory [21].  As with fatigue, cognitive changes are associated with a spectrum of etiologies [22].  In a psychiatric setting, subjective cognitive changes can often present as a result of untreated psychiatric disorders.     

   ADDITIONAL TIPS

  • Primary cognitive disorders are best evaluated when comorbid psychiatric conditions are controlled or in remission.
  • Consider a MoCA and/or neuropsychological testing.

Anxiety, depression, and PTSD are all symptoms of long COVID [6, 23] [7, 8, 22, 11, 12, 19, 15, 2]. These can present de novo or relative to other COVID stressors.  COVID patients who received treatment in the ICU may experience post-intensive care syndrome (PICS).  And some COVID courses are complicated by stroke, which itself can present with post-stroke psychosis, anxiety and depression.  Therefore, patients with a history of COVID and stroke may benefit from additional psychiatric monitoring. 

Secondary psychiatric symptoms can also manifest in long COVID patients.  For example, olfactory and gustatory abnormalities are not treated by psychiatrists, but it is worth mentioning that the loss of these functions can contribute to anxiety and depression [6, 7, 9, 12, 15].  Referral to sensory retraining therapy should be considered in long COVID patients[24].  

Of note, mental health patients often forgo general medical care.  Therefore, it is particularly important to ensure that long COVID patients have an established multidisciplinary team [22, 25].

OTHER SYMPTOMS

Chest pain, shortness of breath, and dysautonomia (ex. POTS)have been reported as long COVID symptoms [8] [22, 10, 11, 26, 27, 19].  While these symptoms may not be primarily psychiatric, they can correlate with anxiety or side effects of certain psychiatric medications.

Long COVID’s multisystem involvement has emphasized the need for more comprehensive psychiatric care.  Now, more than ever, long COVID has brought the collaboration of medical specialties into the spotlight [22].  As further information becomes available, we will continue to improve our approach to long COVID and gain confidence in its unique characterization. 


Reference List

1. Nersesjan V, Fonsmark L, Christensen RHB, Amiri M, Merie C, Lebech AM et al. Neuropsychiatric and Cognitive Outcomes in Patients 6 Months After COVID-19 Requiring Hospitalization Compared With Matched Control Patients Hospitalized for Non-COVID-19 Illness. JAMA psychiatry. 2022;79(5):486-97. doi:10.1001/jamapsychiatry.2022.0284.

2. Clift AK, Ranger TA, Patone M, Coupland CAC, Hatch R, Thomas K et al. Neuropsychiatric Ramifications of Severe COVID-19 and Other Severe Acute Respiratory Infections. JAMA psychiatry. 2022. doi:10.1001/jamapsychiatry.2022.1067.

3. Hatch R, Young D, Barber VS, Griffiths J, Harrison DA, Watkinson PJ. Anxiety, depression and post-traumatic stress disorder management after critical illness: a UK multi-centre prospective cohort study. Crit Care. 2020;24(1):633. doi:10.1186/s13054-020-03354-y.

4. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-16. doi:10.1056/NEJMoa1301372.

5. Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re'em Y et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine. 2021;38:101019. doi:10.1016/j.eclinm.2021.101019.

6. Sanyaolu A, Marinkovic A, Prakash S, Zhao A, Balendra V, Haider N et al. Post-acute Sequelae in COVID-19 Survivors: an Overview. SN comprehensive clinical medicine. 2022;4(1):91. doi:10.1007/s42399-022-01172-7.

7. Kim Y, Bitna H, Kim SW, Chang HH, Kwon KT, Bae S et al. Post-acute COVID-19 syndrome in patients after 12 months from COVID-19 infection in Korea. BMC Infect Dis. 2022;22(1):93. doi:10.1186/s12879-022-07062-6.

8. Rivera-Izquierdo M, Láinez-Ramos-Bossini AJ, de Alba IG, Ortiz-González-Serna R, Serrano-Ortiz Á, Fernández-Martínez NF et al. Long COVID 12 months after discharge: persistent symptoms in patients hospitalised due to COVID-19 and patients hospitalised due to other causes-a multicentre cohort study. BMC Med. 2022;20(1):92. doi:10.1186/s12916-022-02292-6.

9. Strahm C, Seneghini M, Güsewell S, Egger T, Leal O, Brucher A et al. Symptoms compatible with long-COVID in healthcare workers with and without SARS-CoV-2 infection - results of a prospective multicenter cohort. Clin Infect Dis. 2022. doi:10.1093/cid/ciac054.

10. Garrigues E, Janvier P, Kherabi Y, Le Bot A, Hamon A, Gouze H et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020;81(6):e4-e6. doi:10.1016/j.jinf.2020.08.029.

11. Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. J Med Virol. 2021;93(2):1013-22. doi:10.1002/jmv.26368.

12. Rass V, Beer R, Schiefecker AJ, Lindner A, Kofler M, Ianosi BA et al. Neurological outcomes 1 year after COVID-19 diagnosis: A prospective longitudinal cohort study. Eur J Neurol. 2022. doi:10.1111/ene.15307.

13. Goërtz YMJ, Van Herck M, Delbressine JM, Vaes AW, Meys R, Machado FVC et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the post-COVID-19 syndrome? ERJ open research. 2020;6(4). doi:10.1183/23120541.00542-2020.

14. Carfì A, Bernabei R, Landi F. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603-5. doi:10.1001/jama.2020.12603.

15. Premraj L, Kannapadi NV, Briggs J, Seal SM, Battaglini D, Fanning J et al. Mid and long-term neurological and neuropsychiatric manifestations of post-COVID-19 syndrome: A meta-analysis. J Neurol Sci. 2022;434:120162. doi:10.1016/j.jns.2022.120162.

16. Fernández-Castañeda A, Lu P, Geraghty AC, Song E, Lee MH, Wood J et al. Mild respiratory SARS-CoV-2 infection can cause multi-lineage cellular dysregulation and myelin loss in the brain. bioRxiv : the preprint server for biology. 2022. doi:10.1101/2022.01.07.475453.

17. Zhou H, Lu S, Chen J, Wei N, Wang D, Lyu H et al. The landscape of cognitive function in recovered COVID-19 patients. J Psychiatr Res. 2020;129:98-102. doi:10.1016/j.jpsychires.2020.06.022.

18. Cecchetti G, Agosta F, Canu E, Basaia S, Barbieri A, Cardamone R et al. Cognitive, EEG, and MRI features of COVID-19 survivors: a 10-month study. J Neurol. 2022:1-13. doi:10.1007/s00415-022-11047-5.

19. Graham EL, Clark JR, Orban ZS, Lim PH, Szymanski AL, Taylor C et al. Persistent neurologic symptoms and cognitive dysfunction in non-hospitalized Covid-19 "long haulers". Annals of clinical and translational neurology. 2021;8(5):1073-85. doi:10.1002/acn3.51350.

20. Widmann CN, Wieberneit M, Bieler L, Bernsen S, Gräfenkämper R, Brosseron F et al. Longitudinal Neurocognitive and Pulmonological Profile of Long COVID-19: Protocol for the COVIMMUNE-Clin Study. JMIR research protocols. 2021;10(11):e30259. doi:10.2196/30259.

21. Zhao S, Shibata K, Hellyer PJ, Trender W, Manohar S, Hampshire A et al. Rapid vigilance and episodic memory decrements in COVID-19 survivors. Brain communications. 2022;4(1):fcab295. doi:10.1093/braincomms/fcab295.

22. Vance H, Maslach A, Stoneman E, Harmes K, Ransom A, Seagly K et al. Addressing Post-COVID Symptoms: A Guide for Primary Care Physicians. J Am Board Fam Med. 2021;34(6):1229-42. doi:10.3122/jabfm.2021.06.210254.

23. Stephenson T, Shafran R, De Stavola B, Rojas N, Aiano F, Amin-Chowdhury Z et al. Long COVID and the mental and physical health of children and young people: national matched cohort study protocol (the CLoCk study). BMJ open. 2021;11(8):e052838. doi:10.1136/bmjopen-2021-052838.

24. Whitcroft KL, Hummel T. Olfactory Dysfunction in COVID-19: Diagnosis and Management. JAMA. 2020;323(24):2512-4. doi:10.1001/jama.2020.8391.

25. Crook H, Raza S, Nowell J, Young M, Edison P. Long covid-mechanisms, risk factors, and management. BMJ. 2021;374:n1648. doi:10.1136/bmj.n1648.

26. Raj SR, Arnold AC, Barboi A, Claydon VE, Limberg JK, Lucci VM et al. Long-COVID postural tachycardia syndrome: an American Autonomic Society statement. Clin Auton Res. 2021;31(3):365-8. doi:10.1007/s10286-021-00798-2.

27. Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R et al. Autonomic dysfunction in 'long COVID': rationale, physiology and management strategies. Clin Med (Lond). 2021;21(1):e63-e7. doi:10.7861/clinmed.2020-0896.