The effects of Covid-19 are here to stay, including in the brain, at least according to a new study by Mario Mazza and colleagues in the journal Brain, Behavior, and Immunity. Patients in the study had their mental health assessed using clinical interviews and commonly used self-assessment screening tools. One month after they presented to the emergency room with Covid-19 and then were either treated in the hospital or at home, out of 402 patients, 55% were found to have at least one psychiatric disorder. These included: Post-Traumatic Stress Disorder (PTSD) in 28%, Depression in 31%, Anxiety in 42%, Insomnia in 40%, and Obsessive-Compulsive Disorder in 20%.
Dr. Charles Nemeroff, The Matthew P. Nemeroff Professor and Chair of the Department of Psychiatry and Behavioral Sciences at The University of Texas at Austin, Dell Medical School explained he was not at all surprised by the findings. He noted that there has been emerging research that the virus has “direct effects on the central nervous system” and that if someone had preexisting psychiatric conditions, a new Covid-19 infection might be able to trigger a mood or anxiety episode. On the other hand, he says, if someone had genetic vulnerability and was previously asymptomatic for psychiatric symptoms, it is possible the stress of the infection or the infection itself would be enough to bring them to the threshold to then develop a psychiatric condition. Either way, the disease becomes the precipitating factor. He adds that overall, “These data fit with the notion that we are in the midst of and will see in the aftermath of Covid-19 a mental health pandemic [with] marked increases in mood and anxiety disorders and we need to be on the lookout for neuropsychiatric [symptoms].”
While the article looks at whether inflammation and the immune response from the virus itself could be a cause of the psychiatric symptoms, the data are not convincing, with large standard errors and deviations. Dr. Nemeroff calls the correlations “weak” as they are missing many needed measurements typically used in inflammation studies (e.g. cytokines), as well as a healthy comparison group. The question then becomes, what might be another reason for such high psychological burden in Covid-19 survivors?
Dr. E.Wesley Ely, Co-director of the CIBS center at Vanderbilt University Medical Center, explains that is likely multifactorial. He notes when you compare Covid-19 to something like sepsis where you know it affects the brain and has psychological aftermath, Covid-19 is 2-3 times longer of an illness and has more periods of low oxygen that require interventions like mechanical ventilation. With each of these interventions, he points out, a person will require medications that can make you have delirium, which has its own psychological risks to it. The illness itself also affects the brain through what he calls “macro and micro clots” that can cause strokes. He explains, “It doesn’t seem like the virus is directly affecting the brain much. Most of this is an indirect effect from hypoxemia (low oxygen) and the clotting problems and bleeding problems...and then the effect of isolation and sleep/wake and absence of human touch and loved ones not being around them..it’s like a perfect setup-like a bombshell for psychiatric illness.”
Among the more interesting findings of the study, the duration of hospitalization was inversely correlated to psychiatric symptoms. In other words, the longer someone was outpatient and home, the worse their symptoms became. The authors believed this could be attributed to “less healthcare support” leading to “increased..social isolation and loneliness.” Dr. Lakshman Swamy, a pulmonary & critical care physician in Boston, adds that “maybe the social factor plays a bigger role than the disease itself for some patients —being sick and frail and alone at home may be worse for your mental wellbeing than being hospitalized, with regular (albeit limited and professional) social contact. Isolation and quarantine are brutal for many, and certainly worse if you're sick.” Dr. Yelizaveta Sher, Clinical Associate Professor of Psychiatry at Stanford University School of Medicine adds that hospitalization might also include in house mental health services or processing of what is going on from nursing, respiratory, or medical teams which, though not mentioned explicitly in the study, could have all “made a difference.”
At-risk groups noted in the study included females, who had higher rates in all psychiatric conditions, and those with previous psychiatric diagnoses. Since these populations are inherently more at risk from psychiatric conditions due to the pandemic and are also more at risk in frontline work and healthcare, this is particularly important if a frontline, female, worker, with a past psychiatric history becomes infected. This might perhaps be something to consider for screening, follow-up, and checking in on employees. Additionally, younger patients had higher levels of depression and sleep disturbances, suggesting a worsened psychological impact of the pandemic on younger survivors, who even without infection, already experience more loneliness and worsened mental health outcomes. This may be yet another reason Covid-19 is not “completely harmless” in them, after all.
So, what do we do about it?
First, we have to acknowledge that mental health issues are going to be a part of the aftermath of Covid-19 survivorship. We might not yet know if they will last for 6 months, a year, or 5 years, or what long-term truly means, but that does not really matter as Dr. Ely says they are “debilitating for people...are a major trajectory changer for people’s lives and they cannot be brushed under the rug.”
We need to be vigilant about screening patients, looking for signs and symptoms in our loved ones and friends, and even ourselves if we are survivors. Dr. Sher says, “Just inquiring about emotional well-being can go a long way.”
Second, we should consider building holistic, integrated care for Covid-19 survivors. Dr. Swamy says, “I'm a big supporter of the post-ICU syndrome clinics that address this directly. This kind of holistic approach will look directly at mental health and offer treatment, referral, [and] support as necessary.” Dr. Ely’s CIBS Center is one such example.
Overall, this paper highlights that Covid-19 is not just an illness that you get, and either die from or survive and are cured— long-term effects on mental health exist and might be chronic. Dr. Dara Kass, Associate Professor of Emergency Medicine at Columbia University Medical Center explains, “Just because you don't die, it doesn't mean that your life isn't completely affected, and/or you don’t have new chronic disease. We are looking now at lung disease and heart disease and we also need to look at brain disease, and remember these are new chronic diseases that are accumulating as a result of the virus spraying. unrelenting, affecting people who are young and have lives ahead of them.”
In other words, we need to talk about survivors and we need to start talking about them now-so that we can build the infrastructure that they need to get and stay well physically and mentally. Because, as Dr. Kass adds, “the compounded effects of the social, psychosocial, and medical consequences of the virus will be the defining issue of our generation.”