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 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.      


  • 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.


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.     


  • 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].


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

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