Mental health problems in Long Covid

Mental health in Long Covid
Photo by Nik Shuliahin on Unsplash

If you have been diagnosed with COVID-19 in the past four months and are experiencing feelings of being worried or restless most of the time, having low mood and/or an inability to enjoy your previous hobbies, it is possible that these are a part of the effect of the coronavirus infection. This alteration in mood is especially more likely if you are having other physical symptoms of the condition known as “Long Covid” (Covid-19 symptoms lasting longer than three months or occurring for the first time three months after initial diagnosis).

Recent studies demonstrate that mental health problems can be a symptom of Long Covid. A large cohort study from the USA has shown that new mental health diagnoses were higher in people who had had a COVID-19 infection within the last 14 to 90 days, compared to those having had non-Covid health events in the same time period.  Further, a more recent  study has shown that those with a previous COVID-19 infection had a 1.78 times increased risk of having new onset anxiety disorders, and a 1.79 times increased risk of mood disorders, compared to those who had an influenza infection. 

To underscore these findings for the medical community, a new infographic highlighting anxiety and depression as the main mental health problems in long Covid has been produced by the BMJ.

What explains the mental health symptoms in long Covid? 

The mental health problems in Long Covid may be attributed by many factors, and each Long Covid case is likely to be unique. However, many people with Long Covid have been shown to have multiple symptoms, both mental and physical. For example, a study in Milan observed that people who had physical symptoms at one to three months post COVID-19 infection were 4.5 times more likely to also have anxiety or depression. Whilst this relationship does not imply causation, it highlights the need for robust mental health assessments by clinicians of patients presenting with multiple physical symptoms of Long Covid, to ensure that this aspect is appropriately addressed.  

The link between physical and mental health problems is very likely due to physical and/or emotional stressors (e.g. Chronic illness or trauma).  Exposure to a severe or prolonged stressor (e.g. many viral infections) has long been shown to affect the body’s physiological system and increase cortisol release. Prolonged activation of this system causes impairment of glucocorticoid receptors in the body, reduces the body’s capacity to control inflammation and exacerbates the production of pro-inflammatory cytokines. The impact of inflammation on symptoms such as disturbed sleep and depression has been well documented. Indeed, individuals with depression have been found to have higher levels of cortisol and pro-inflammatory cytokines, depending on both the severity and stage of the depression.

Coronavirus infection is capable of invoking an inflammatory response which affects multiple organs in the body.  Indeed, systemic inflammation has been attributed to neuropsychological and mental health symptoms such as depression, anxiety and cognitive defects. This is supported by a prospective cohort study among adults where systemic inflammation scores predicted depression and cognitive impairment at three months post-COVID-19 diagnosis, thus indicating the importance of inflammation as a predisposing factor for depression and cognitive problems in Long Covid.

Direct infection of brain tissue with coronavirus is still being studied, with mixed results.  While there is not yet any compelling evidence of SARS-CoV-2 infecting neurons, it has been detected in the cerebrovascular fluid in patients with COVID-19, and pathological brain findings during autopsy of patients provided evidence of access of the virus to the nervous system and brain. This may represent another possible mechanism by which COVID-19 could affect mental health. 

What can we do if we are experiencing mental health problems?

The infographic produced by BMJ highlights the red flags which signify that immediate or urgent action is needed by the person experiencing the problem. These include thoughts of self-harm and worsening of anxiety and depressive symptoms. The attending clinician must acknowledge the urgency of the situation and manage it accordingly.

However, it is a good idea to have an assessment by your GP, even if you think you do not have these red flag symptoms. National Institute of Health and Care Excellence (NICE) recommends that General Practitioners should assess all the common symptoms (including mental health ones) for Long Covid to ensure that these problems are detected early and treated appropriately. 

Also available are online supports, including information on self-management and support groups. The NHS produces a generic online support, called ‘Your COVID Recovery’, which includes topics on mental health. Other potentially helpful online resources are ‘NHS every mind matters’ and  a leaflet by the World Health Organization (WHO), containing self-management advice for post-COVID-19 conditions. This leaflet includes a relaxation technique (Grounding Technique) and reference to a stress management guide for coping with adverse events.

NICE has emphasized the importance of a multi-disciplinary approach, including the signposting of patients to support groups and treating physicians in order to manage the physical and mental health problems of Long Covid. Indeed, previous qualitative studies have highlighted the advantages of online support groups for patients with Long Covid. These adults with Long Covid find that the support groups help by validating their experience of symptoms through the shared experience and increasing their knowledge of their condition. 

For those experiencing mental health symptoms of Long Covid, finding support and online self-management can be an initial step, prior to seeking help from the GP and other healthcare professionals. However, do initiate urgent consultation with your healthcare practitioner if the symptoms worsen, are impacting your life, or if there is any presence of thoughts of self-harm or suicide. 

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