Managing Mental Illness After COVID-19 Infection E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
A concise, practical guide to the mental health effects of COVID-19 and its treatments
Managing Mental Illness After COVID-19 Infection is a resource for people affected by COVID-19 and their loved ones. As the long-term effects, especially the psychiatric effects, evolve and become more common, people are increasingly searching for answers. This book reviews presentations and treatments for mental illnesses post-COVID-19. Readers will learn about the use of medications, supplements, and behavioral interventions to address these conditions.
This engaging and practical book includes numerous tables and other illustrations for easy reference. It provides enough medical detail for patients and their caregivers to better understand the symptoms they may experience, as well as the best ways to investigate and treat those symptoms. However, it is not too complex for the general reader, making it perfect as a standalone book for patients and their families.
- Learn how and why many people struggle with mental illness following COVID-19 infection
- Discover what your symptoms may indicate and get advice on how to pursue diagnosis and treatment
- Find a doctor who can understand and manage the mental and behavioral consequences of COVID-19
- Get up to speed on the psychiatric and psychosocial effects of COVID-19 infection
This is an excellent resource for the public, policymakers, clinicians, counselors, social workers, and behavioral health coaches that could benefit from the latest research on the psychiatric effects of COVID-19.
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Seitenzahl: 505
Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
List of Abbreviations
1 Introduction
What Are the Effects of COVID‐19 on Mental Health?
Navigating Community Resources
Purpose of this Book
References
2 Mental Illnesses Associated with COVID‐19 Infection
Introduction
Clinical Cases
Impact on Preexisting Conditions
Neurobiology of COVID‐19
Post‐COVID‐19 Psychiatric and Neuropsychiatric Disorders
Cognition
Situational Stress and Psychological Impact
Impact on Significant Others
Medical‐legal Aspects of COVID‐19
How to Talk with Clinicians About COVID‐19 and Mental Health
A Sample Dialogue
Augmenting a Person's Social Networks for Support
Conclusion
References
3 Management of Neuropsychiatric Symptoms Related to COVID‐19: An Integrative Approach
Introduction
Evidence for Brain Injury and Underlying Mechanisms of COVID‐19 Infection
Clinical Management of COVID‐19 Neuropsychiatric Symptoms: An Integrative Approach
Pharmacotherapy and Dietary Supplements
Mind‐body Therapies (MBTs)
Addressing COVID‐19‐Related Fatigue
Religion and Spirituality and Their Role in Neuropsychiatric Care
Biopsychosocial Model of Treatment
Psychotherapy: Acceptance and Commitment Therapy (ACT)
Telehealth and COVID‐19
Conclusion
References
4 Delirium Related to COVID‐19 Infection
Introduction
Recognizing Delirium
Prevention of Delirium
Acute Management of Delirium
Long‐term Management After Delirium
Conclusion
References
5 Mood Disorders as a Result of COVID‐19 Infection:
Introduction
Major Depressive Disorder (MDD)
Bipolar Disorder
Special Considerations: Treating Mood Disorders During COVID‐19
Conclusion
References
6 Anxiety and Trauma‐related Disorders due to the COVID‐19 Pandemic
Introduction
Neurobiology of Anxiety
Disproportionate Impact of COVID‐19 on Anxiety
Stress Responses to Trauma and Loss
Anxiety Disorders
Different Experiences of Anxiety
Anxiety With COVID‐19 and Other Chronic Health Conditions
Treatment of Anxiety Disorders
How to Assist a Loved One with Anxiety
Conclusion
References
7 Psychotic Disorders Related to COVID‐19 Infection
Introduction
What Is Psychosis?
How Can COVID‐19 Infection Lead to Psychosis?
Complications of COVID‐19 Psychosis
Treatment of COVID‐19‐associated Psychosis
Conclusion
References
8 Post COVID‐19 Condition
Introduction
Where Can You Go for Reliable Information on Long COVID?
What Is Long COVID?
Why Is this Happening?
Pathological Manifestations of Long COVID
How Is Long COVID Diagnosed?
When Should You See Your Doctor?
Who Is at Risk for Long COVID?
How Do I Prevent Getting Long COVID If or When I Get Infected with COVID‐19?
What Treatments Are Available for Long COVID?
Self‐management Strategies for Long COVID
Medical Treatments for Long COVID
What Does the Future of Long COVID Prevention, Diagnosis, and Treatment Look Like?
Conclusion
References
9 Mental Health Crisis
Introduction
Mental Health Crises as a Result of the COVID‐19 Pandemic
Brain Circuitry, Neurotransmitters, and Hormones Involved in Aggressive Behavior
Medical and Psychiatric Illnesses as Risk Factors for Violent Behavior
Delirium
Anticipating Agitation
How to Talk to an Agitated Person
De‐escalation Techniques
Medication and Restraint Use in Managing Agitation
Medications to Treat Agitation
The Use of Restraints in Hospitals
Self‐harm and Suicide
Conclusion
References
10 Maternal Mental Health After COVID‐19
Introduction
Overview of Maternal Mental Health
Perinatal Mood and Anxiety Disorders Before and After COVID‐19
Conclusion
References
11 The Impact of COVID‐19 Infection on Child and Adolescent Mental Health
Introduction
How Do Children and Teens Experience the COVID‐19 Infection Physiologically and Psychologically?
What Are the Neuropsychiatric Problems Related to COVID‐19, and How Can We Treat These Problems?
Treatment of Sadness, Grief, and Depression in Youth Related to COVID‐19 Infection
How Does COVID‐19 Affect the Treatment of Preexisting Psychiatric Problems?
How Do Social Determinants such as Race, Culture, Socioeconomic Status, and Climate Change Impact the Psychiatric Problems in Children and Teens Associated with COVID‐19 Infection?
How Do We Find Neuropsychiatric Problems in Children and Teens Associated with COVID‐19 Infection?
What Can We Say to Children and Teens About Neuropsychiatric Problems Associated with COVID‐19 Infection?
Conclusion
References
12 Reference Tables
References
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Clinical diagnoses and pearls for COVID‐19‐related mental disorde...
Chapter 3
Table 3.1 Core processes of Acceptance and Commitment Therapy (ACT).
Chapter 4
Table 4.1 Common predisposing and precipitating risk factors for delirium....
Table 4.2 Non‐pharmacological measures for delirium prevention and treatmen...
Chapter 7
Table 7.1 Symptoms of psychosis.
Table 7.2 Mechanisms leading to psychosis.
Table 7.3 Functional disorders linked to autonomic hypervigilance and dysre...
Chapter 8
Table 8.1 Long COVID treatments currently being used “off‐label” by Long CO...
Table 8.2 Upcoming placebo controlled Long COVID trials (from clinicaltrial...
Chapter 9
Table 9.1 Agitation due to general medical conditions.
Table 9.2 Medications associated with increased agitation.
Table 9.3 Medical workup for delirium.
Table 9.4 Helpful communication skills with an agitated person.
Table 9.5 De‐escalation techniques.
Table 9.6 Suicide risk factors and protective factors.
Chapter 10
Table 10.1 Signs and symptoms of depression during the perinatal period.
Table 10.2 Differentiating normal pregnancy changes, “baby blues”, and post...
Chapter 12
Table 12.1 Commonly prescribed psychotropic medication for children (<18 yea...
Table 12.2 Potential interactions between psychiatric medications and common...
Table 12.3 Common medications for the treatment of agitation.
Table 12.4 Commonly used benzodiazepines.
Table 12.5 Starting and stopping an antidepressant.
Table 12.6 Benzodiazepine prescribing information.
Table 12.7 Antipsychotic side effects.
Table 12.8 SSRI/SNRI side effects.
Table 12.9 Valproate side effects.
Table 12.10 Carbamazepine side effects.
Table 12.11 Lithium side effects.
Table 12.12 Common COVID‐19 medications and associated psychiatric side effe...
List of Illustrations
Chapter 3
Figure 3.1 The mechanisms by which mind‐body therapies enhance resilience to...
Chapter 4
Figure 4.1 Features of the confusion assessment method (CAM).
Chapter 5
Figure 5.1 Life chart showing progression of bipolar disorder.
Chapter 6
Figure 6.1 Important structures of the brain related to anxiety.
Figure 6.2 GAD symptoms.
Figure 6.3 Tips to relieve anxiety.
Figure 6.4 The sympathetic and parasympathetic nervous system.
Chapter 8
Figure 8.1 Pathophysiological Changes in Long COVID.
Chapter 9
Figure 9.1 Regions of the brain involved in agitation, impulsivity, and aggr...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
List of Abbreviations
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Managing Mental Illness After COVID‐19 Infection
Edited by Stephanie A. Collier, MD, MPH
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
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Library of Congress Cataloging‐in‐Publication Data Applied for:
Paperback: 9781394227594
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List of Contributors
Carmen BlackDepartment of PsychiatryYale School of MedicineNew HavenCT, USA
Mallory BryantDepartment of MedicineVanderbilt University Medical CenterNashvilleTN, USA
Stephanie A. CollierHarvard Medical SchoolBoston, MA, 02115 and McLean HospitalBelmontMA, 02478, USA
Drew CummingDepartment of PsychiatryMassachusetts General HospitalBostonMA, USA
Virmarie Diaz FernandezConcert HealthOrange ParkFL, USA
Maria C. DugganCritical Illness, Brain Dysfunction and Survivorship CenterVanderbilt University Medical CenterNashvilleTN, 37232, USA
Joshua D. FederDepartment of PsychiatryUniversity of California at San Diego School of MedicineLa JollaCA, USA
Gregory FricchioneDepartment of PsychiatryMassachusetts General HospitalBostonMA, USA
Susan Hatters FriedmanDepartment of PsychiatryCase Western Reserve UniversityClevelandOH, 44106, USA
Jacob HolzerDepartment of PsychiatryHarvard Medical SchoolBostonMA, USA
Jennifer HulmeDepartment of Family and Community MedicineUniversity of TorontoTorontoON, M5G 1V7 Canada
Mara KailinThe University of DenverCounseling Psychology ProgramMorgridge College of EducationDenverCO, USA
Chris KenediDuke University Medical CenterDurhamNC, USA
Helen LavretsyHope Therapy Center/UCLA Medical School Integrative PsychiatryBurbankCA, 91502, USA
Sarah NguyenDepartment of PsychiatryUniversity of California Los AngelesLos AngelesUSA
Hanadi A. OughliDepartment of PsychiatryUniversity of California Los AngelesLos AngelesUSA
Dale E. PanzerDepartment of PsychiatryDrexel University School of MedicinePhiladelphiaPA, USA
Cynthia PengDepartment of PsychiatryBrigham and Women's HospitalBostonMA, USA
Alison RembiszDepartment of PsychiatryHarvard South ShoreBrocktonMA, USA
Talya ShahalVeterans Administration Boston Healthcare SystemHarvard Medical SchoolBostonMA, 02132, USA
Megan SheddDepartment of PsychiatryUniversity Hospitals/Case Western Reserve UniversityClevelandOH, USA
Stacey SimmonsDepartment of PsychiatryUniversity of California Los AngelesLos Angeles, 90095, USA
Ryan L. TaDivision of Geriatric MedicineVanderbilt University Medical CenterNashvilleTN, USA
Ana TruebaDepartment of PsychologyMcLean HospitalHarvard Medical SchoolBelmontMA, USA
Department of PsychologyUniversidad San Francisco de QuitoQuito, Ecuador
List of Abbreviations
Chapter 1
post‐traumatic stress disorder (PTSD)
Inter‐Agency Standing Committee (IASC)
mental health and psychosocial support (MHPSS)
psychological first aid (PFA)
World Health Organization (WHO)
Chapter 2
Equal Employment Opportunity Commission (EEOC)
exposure and response prevention (ERP) [
Table 2.1
]
intensive care unit (ICU)
magnetic resonance imaging (MRI)
Montreal Cognitive Assessment (MoCA)
Occupational Safety and Health Administration (OSHA)
polymerase chain reaction (PCR)
positron emission tomography (PET)
post‐traumatic stress disorder (PTSD)
St. Louis University Mental Status Examination (SLUMS)
Chapter 3
acceptance and commitment therapy (ACT)
central nervous system (CNS)
cognitive behavioral therapy (CBT)
Emergency Use Authorizations (EUA)
Food and Drug Administration (FDA)
magnetic resonance imaging (MRI)
mind‐body therapies (MBT)
mindfulness‐based stress reduction (MBSR) [
Figure 3.1
]
mindfulness‐based cognitive therapy (MBCT) [
Figure 3.1
]
mindfulness‐based relapse prevention (MBRP) [
Figure 3.1
]
N‐Acetylcysteine (NAC)
National Institute of Health (NIH)
post‐traumatic stress disorder (PTSD)
problem solving therapy (PST)
religion and spirituality (R/S)
ribonucleic acid (RNA) viruses
severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)
Sudarshan Kriya Yoga (SKY)
transcranial magnetic stimulation (TMS)
Whole Health System Approach (HEALTH)
Chapter 4
acute respiratory distress syndrome (ARDS)
Age‐Friendly Health Systems (AFHS)
Confusion Assessment Method (CAM)
Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center
Differentiate Aging and Dementia (AD8)
Food and Drug Administration (FDA)
General Anxiety Disorder‐7 (GAD‐7)
Hospital Elder Life Program (HELP)
Institute for Healthcare Improvement (IHI)
intensive care unit (ICU)
Montreal Cognitive Assessment (MoCA)
Pain, Agitation, Delirium, Immobility, and Sleep (PADIS) guidelines
Patient Health Questionnaire‐9 (PHQ‐9)
post‐intensive care syndrome (PICS)
post‐traumatic stress disorder (PTSD)
Primary Care PTSD Screen for DSM‐5 (PC‐PTSD‐5)
Chapter 5
acceptance and commitment therapy (ACT)
cognitive behavioral therapy (CBT)
electroconvulsive therapy (ECT)
major depressive disorder (MDD)
mindfulness‐based cognitive therapy (MBCT)
Patient Health Questionnaire‐2 (PHQ‐2)
primary care physician (PCP)
serotonin‐norepinephrine reuptake inhibitors (SNRIs)
selective serotonin reuptake inhibitors (SSRIs)
severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)
transcranial magnetic stimulation (TMS)
Chapter 6
acceptance and commitment therapy (ACT)
cognitive behavioral therapy (CBT)
entromedial prefrontal cortex (VMPFc) [
Figure 6.1
]
exposure and response prevention (ERP)
generalized anxiety disorder (GAD)
obsessive‐compulsive disorder (OCD)
orbitofrontal cortex (OFC) [and
Figure 6.1
]
periaqueductal gray (PAG) [
Figure 6.1
]
post‐traumatic stress disorder (PTSD)
prefrontal cortex (PFC)
selective serotonin reuptake inhibitors (SSRI)
ventral tegmental area (VTA) [
Figure 6.1
]
Chapter 7
adverse childhood experiences (ACE)
neuroleptic malignant syndrome (NMS)
phencyclidine (PCP)
post‐traumatic stress disorder (PTSD)
Chapter 8
adenosine triphosphate (ATP)
angiotensin‐converting enzyme‐2 (ACE2)
aspirin (ASA)
beats per minute (bpm)
CC chemokine receptor 5 (CCR5)
chronic fatigue syndrome (CFS)
Centers for Disease Control and Prevention (CDC)
Coenzyme Q10 (CoQ10)
cognitive behavioral therapy (CBT)
Epstein‐Barr virus (EBV)
G‐protein coupled receptors (GPCRs)
graded exercise therapy (GET)
high‐efficiency particulate air (HEPA)
human herpes virus 6 (HHV‐6)
human herpes virus 7 (HHV‐7)
human immunodeficiency virus (HIV)
hyperbaric oxygen therapy (HBOT)
hyperbaric oxygen therapy for Long COVID syndrome (HOT‐LoCO)
Janus kinase (JAK) inhibitor
mast cell activation syndrome (MCAS)
minimum efficiency reporting value (MERV)
monoclonal antibodies (mABs)
multisystem inflammatory syndrome in children (MIS‐C)
myalgic encephalomyelitis (ME)
myalgic encephalomyelitis, or chronic fatigue syndrome (ME/CFS)
N‐acetylcysteine (NAC)
National Public Radio (NPR)
nicotinamide adenine dinucleotide (NAD+)
nicotinic acetylcholine receptors (nAChRs)
nitric oxide (NO)
obsessive‐compulsive disorder (OCD)
polymerase chain reaction (PCR) test
post‐exertional malaise (PEM)
postural orthostatic tachycardia syndrome (POTS)
randomized controlled trial (RCTs)
rheumatoid arthritis (RA)
ribonucleic acid (RNA)
selective serotonin reuptake inhibitors (SSRIs)
severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)
therapies for Long COVID (TLC)
transcranial direct current stimulation (tDCS)
transcutaneous vagus nerve stimulation (tVNS)
UHN Emergency Department (ED)
University Health Network (UHN) News
vascular endothelial growth factor (VEGF)
World Health Organization (WHO)
Chapter 9
5‐hydroxyindoleacetic acid (5‐HIAA)
acute respiratory distress syndrome (ARDS)
Centers for Disease Control and Prevention (CDC)
cerebrospinal fluid (CSF)
chronic obstructive pulmonary disease (COPD)
Diagnostic and Statistical Manual (DSM)
electrocardiogram (EKG or ECG)
Food and Drug Administration (FDA)
Edinburgh Postnatal Depression Scale (EPDS)
human chorionic gonadotropin (hCG)
intensive care unit (ICU)
intramuscular (IM)
intravenous (IV)
neonatal intensive care unit (NICU)
Patient Health Questionairre‐9 (PHQ‐9)
post‐traumatic stress disorder (PTSD)
selective serotonin reuptake inhibitors (SSRIs)
traumatic brain injury (TBI)
urinary tract infection (UTI)
World Health Organization (WHO)
Chapter 10
American Academy of Physical Medicine and Rehabilitation (AAPM&R)
American College of Obstetrics and Gynecologists (ACOG)
attention deficit hyperactivity disorder (ADHD)
Center for Disease Control and Prevention (CDC)
cognitive behavioral therapy (CBT)
Edinburgh Postnatal Depression Scale (EPDS)emergency room (ER)
gastrointestinal (GI)
human chorionic gonadotropin (hCG)
intensive care unit (ICU)
Maternal COVID‐19‐related Prenatal Exposure (MOM‐COPE)
messenger ribonucleic acid (mRNA)
neonatal intensive care unit (NICU)
Patient Health Questionairre‐9 (PHQ‐9)
postural orthostatic tachycardia syndrome (POTS)
respiratory syncytial virus (RSV)
selective serotonin reuptake inhibitors (SSRIs)
World Health Organization (WHO)
Chapter 11
American Academy of Physical Medicine and Rehabilitation (AAPM&R)
anorexia nervosa (AN)
attention deficit hyperactivity disorder (ADHD)
Centers for Disease Control (CDC)
central nervous system (CNS)
child‐parent psychotherapy (CPP)
cognitive behavioral therapy (CBT)
DIR‐Floortime (Developmental, Individual‐differences, and Relationship‐based model)
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM‐5TR)
electroconvulsive therapy (ECT)
gastrointestinal (GI)
generalized anxiety disorder (GAD)
Hungry, Angry, Lonely, Tired (HALT mnemonic)
irritable bowel syndrome (IBS)
obsessive‐compulsive disorder (OCD)
parent‐child interaction therapy (PCIT)
Patient‐Reported Outcomes Measurement Information System (PROMIS measures)
Pediatric Symptom Checklist‐17 (PSC‐17)
post‐traumatic stress disorder (PTSD)
postural orthostatic tachycardia syndrome (POTS)
respiratory syncytial virus (RSV)
serotonin‐specific reuptake inhibitor (SSRI)
trauma‐focused cognitive behavioral therapy (TF‐CBT)
Chapter 12
generalized anxiety disorder (GAD)
major depressive disorder (MDD)
obsessive‐compulsive disorder (OCD)
polycystic ovary syndrome (PCOS)
serotonin‐norepinephrine reuptake inhibitors (SNRIs)
selective serotonin reuptake inhibitors (SSRIs)
tricyclic antidepressants (TCAs)
1Introduction
Stephanie A. Collier
Harvard Medical School, Boston, MA, 02115 and McLean Hospital, Belmont, MA, 02478, USA
Every few years, our communities face trials that test our collective spirit and resilience. It could be dealing with the aftermath of a hurricane or flood, or the heartbreak of losing someone close to us. These situations push us to our limits. Lately, we have found ourselves in the grips of an entirely different beast – a pandemic that has changed how we live every day. As variants of COVID‐19 circulate across the globe, they challenge not only our physical health but also our mental well‐being. For some, the virus has been a direct catalyst for mental illness.
Understanding the link between an infection and its mental health effects is tricky. The brain is a complex organ with approximately 100 billion nerve cells (neurons) weaving a network of 100 trillion connections. It is within this dense network that we are beginning to understand many of the factors affecting the presentation of disease. How does an infection that leads to fever, cough, and difficulty breathing cause mental disorders? More importantly, how can we harness the latest body of research to improve mental health outcomes?
Year after year, healthcare professionals across disciplines – doctors, nurses, and therapists – are expanding our toolkit for treating the mental health consequences of this virus. Treating mental illness requires more than just a pill. Healthcare professionals are listening to your experiences to find the best treatments for you.
What Are the Effects of COVID‐19 on Mental Health?
The reach of COVID‐19 extends far beyond its immediate physical toll, touching various aspects of mental health. You have likely seen how infection can lead to drastically different physical symptoms in people around you. In terms of mental health, COVID‐19 infection can cause or contribute to virtually every psychiatric disorder. Some people may experience anxiety or depression as a result of infection. Others develop post‐traumatic stress disorder (PTSD) following a traumatic experience, like a stay in the intensive care unit. Others struggle with the physical effects of the virus, such as fatigue and ongoing difficulties breathing, which affect their mood and motivation.
The line between a “normal” response to stress and a “pathological” one is often blurred. Diagnostic criteria, or how we make a diagnosis based on a person's symptoms, also change over time. What classifies as a mental disorder varies across cultures. This is important, as clinicians can cause harm when applying a diagnostic label that does not fit a person's explanatory model of their symptoms. While this book organizes chapters around common psychiatric diagnoses, we acknowledge the diverse experiences of our readers. Symptoms do not always fit neatly into diagnostic categories.
The downstream effects of COVID‐19 infection on a person's mental health can be life‐changing, even if they do not culminate in a full‐blown psychiatric illness. Yet, interventions can significantly alleviate distress. Recall the early pandemic days: the paradox of social isolation at a time when connection was most needed led to a spike in loneliness, particularly among older adults and people living with disabilities. While not “sick” in the traditional sense, their distress was sky‐high – and certain actions may have reduced their distress.
Many of us have experienced grief and loss, often multiple losses, as the virus devastated our communities. Grief is the most natural response to a significant loss, and it does not require treatment. However, we can still bear witness and support those in the throes of mourning – this book aims to guide you in that process.
Addressing mental illness in the era of COVID‐19 requires us to consider both psychological and social dimensions. The pandemic's disruption has ushered in economic turmoil for countless individuals, who may now be facing job insecurity and financial hardships. We cannot think about interventions and treatment without recognizing barriers of care around the globe.
In spite of numerous efforts and campaigns, mental illness remains feared and stigmatized. Discrimination in the face of the pandemic prevented those struggling with mental distress from receiving the help and support they needed. Psychiatric complications from COVID‐19 have left many people shunned, shackled, and struggling to regain functioning.
Navigating Community Resources
Patients frequently ask me where to find support. This book aims to be practical, with chapters providing additional resources. In addition to trying out different interventions and treatments, I encourage readers to connect with mental health professionals. I understand that navigating community resources can be daunting, and it is influenced by geographical and logistical factors. Here is a primer on finding the right level of care:
Outpatient clinics
Provide medical care and monitoring following COVID‐19 infection
Appointments are usually in‐person but may be remote
Telemedicine and telepsychiatry
Deliver clinical and mental healthcare from a patient's home
Are often more practical for the patient
Integrated care
A team approach involving primary care clinicians, behavioral health clinicians, and oftentimes social workers
Rehabilitation centers
Improve both cognitive and physical effects of the virus
Include physical therapy, occupational therapy, and other rehabilitative services
Home health services
Provide rehabilitation and care in a person's home
Community support groups
Allow people to connect with others to share experiences
Helpful for learning about coping strategies
Key Messages in Managing Mental Illnesses Due to COVID‐19
In the maze of today's information overload, pinpointing trustworthy information can be challenging. Thankfully, for medicine and public health, there are a number of organizations that you can trust. For people interested in addressing the mental health effects of COVID‐19 infection, the World Health Organization (WHO) is a good starting point. The WHO provides key messages on the management of mental illnesses, including guides for specific groups, such as children and older adults.
The Inter‐Agency Standing Committee (IASC), which is composed of United Nations agencies and other humanitarian organizations, also provides excellent briefings on key mental health and psychosocial support (MHPSS) to prevent and treat mental illnesses in the wake of COVID‐19 (IASC 2020, pp. 2–7). The IASC bases their guidance on a pyramid of interventions that starts with the essentials – access to food, shelter, and healthcare – and builds up to specialized support by mental health specialists. For those involved in prioritizing mental health resources, this multilayered COVID‐19 response strategy includes:
Securing the basics
: Ensuring everyone has access to essential needs such as food, shelter, and healthcare, and feels safe in their environment.
Building support systems
: Strengthening the networks that bind us, be it through family and community supports.
Cultivating community resilience
: Empowering community members to support each other's well‐being, essentially training them to be the first line of psychological support.
Providing specialized care
: Recognizing and addressing the needs of those with more complex mental health challenges, ensuring they have access to the expert care they require.
Psychological First Aid (PFA)
While psychological first aid (PFA) is not a new concept, its application has never been more critical. The World Health Organization, and many other organizations, champion PFA as a frontline psychosocial support – one simple enough that anyone can learn, yet robust enough to make a difference in the immediate aftermath of trauma (World Health Organization, World Trauma Foundation and World Vision International 2011). The essence of PFA is active listening, but it is more than just hearing the accounts and distress of someone in crisis. It is about validating experiences without judgment, offering a stabilizing presence during upheaval.
PFA's utility has expanded amid COVID‐19, requiring innovative delivery methods. You can deliver it via telehealth platforms, ensuring continuity of care while adhering to infection control protocols. It is also able to address the unique stressors of the pandemic head‐on, such as the challenges of living in lockdown and quarantine, the effects of prolonged isolation, anxiety about viral exposure, and the sorrow of losing loved ones.
One of PFA's core functions is informational: demystifying COVID‐19 to reduce fear and counteract misinformation. Moreover, PFA empowers individuals by tapping into their strengths and local support systems for better coping. It also connects them with essential services, ranging from medical and mental health services to financial and food assistance.
Purpose of this Book
This book explores how COVID‐19 impacts mental health, moving beyond the neurological effects to consider the full scope of mental illness. It examines the complex mix of environment, genetics, social support, existing medical conditions, and pandemic‐induced stress affecting mental health and resilience.
A person's mental state can influence all body systems. For example, social isolation can weaken the immune system and reduce resistance to infections. Enhancing social connections, even during isolation, can mitigate loneliness while lowering the risk of anxiety and depression.
Interventions are easier said than done. Coming up with creative solutions takes time and effort, and most people in the depths of sickness do not want a list of to‐dos (or should‐dos). This book acknowledges that the path to wellness is not one‐size‐fits‐all. What we offer are evidence‐based strategies that can work consistently. We provide tips on how to manage challenging emotions, avoid maladaptive coping, and promote healthy lifestyles.
How to Use this Book
Assembled here is knowledge gathered from various medical specialties – psychiatry, psychology, emergency medicine, and geriatric medicine. Our authors have expertise in integrative therapies, forensics, mind‐body medicine, and working with special populations (children, adolescents, older adults, and women in the peripartum period). Each chapter is based on the most up‐to‐date knowledge at the time of writing. Whether you are dealing with mood swings or anxiety, this book distills research into actionable advice, with the goal of transforming suffering into manageable states.
There is no right way to use this book. You can read it from beginning to end, or you can skip to the chapter that is most relevant to your symptoms. Each chapter can act as a stand‐alone chapter to guide you and your loved ones through one of the mental illnesses caused by, or exacerbated by, COVID‐19 infection.
We've studied the virus and its aftermath for a few years. We now have a better sense of what works, and what does not work, to improve mental illness and psychological distress. In this book we explore common symptoms during and after infection, medication treatments and alternative therapies, psychotherapy, and social interventions. The authors understand that most people do not receive treatment in specialized clinics for post‐COVID‐19 symptoms, and treatments for mental illnesses are not always available due to cost, stigma, and access. Where possible, we highlight low‐cost and easily available interventions proven to make a difference. We want to use our experiences and knowledge to help you find meaningful improvement in your post‐COVID‐19 journey.
References
Inter‐Agency Standing Committee (2020). Addressing Mental Health and Psychosocial Aspects of COVID‐19 Outbreak. Version 1.5.
IASC Reference Group on MHPSS in Emergency Settings
.
World Health Organization, War Trauma Foundation and World Vision International (2011).
Psychological First Aid: Guide for Field Workers
. Geneva: World Health Organization.
https://iris.who.int/bitstream/handle/10665/44615/9789241548205_eng.pdf?sequence=1
(accessed 13 Aug 2024).
2Mental Illnesses Associated with COVID‐19 Infection
Jacob Holzer1, Dale E. Panzer2, and Ana Trueba3,4
1 Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA
2 Department of Psychiatry, Drexel University School of Medicine, Philadelphia, PA, 19102, USA
3 Department of Psychology, McLean Hospital, Harvard Medical School, Belmont, MA, 02478, USA
4 Department of Psychology, Universidad San Francisco de Quito, Quito, 170901, Ecuador
Introduction
COVID‐19, or coronavirus disease 2019, is the disease caused by the virus SARS‐CoV‐2. It can be highly contagious, spreads rapidly, and causes respiratory and other symptoms. The clinical picture of COVID‐19 varies widely. Patients can experience an array of symptoms, ranging from none to severe multisystem impairment, potentially leading to death. Some individuals may develop a chronic post‐COVID‐19 condition called Long COVID.
The virus is spread through droplets and particles through the air, primarily by breathing. It lands on the eyes, nose, or mouth, and lingers on surfaces. Certain patient groups are at higher risk for severe infections, including the elderly, people who are immunocompromised, and those with underlying medical conditions.
Antibodies, proteins that are part of the immune system to fight infections, can be detected through a test, indicating a positive infection, a history of an infection, or prior vaccination. However, antibody levels may diminish over time. It is known that the virus causing COVID‐19 undergoes modifications, resulting in variants with changing levels of contagiousness and severity of illness (Centers for Disease Control and Prevention. 2023).
The onset of COVID‐19 started in December 2019 when a cluster of patients in China developed an atypical pneumonia‐like illness. By January 2020, the virus appeared in the northwest part of the US and then spread across the country (Centers for Disease Control and Prevention. 2023). Since the introduction of COVID‐19 into the US and around the world, extensive research has been conducted. This research has significantly enhanced our understanding of the virus, its clinical impact, and interventions for preventing infection and reducing illness severity. There are two key interventions widely available in the US. One is the vaccine and booster series produced by various pharmaceutical companies. Vaccines have undergone modifications over time to match variations in the virus. Additionally, antiviral medications, such as nirmatrelvir/ritonavir (brand name Paxlovid), are taken once symptomatic infection has started.
COVID‐19 infection is associated with psychiatric and neurological symptoms in some patients, and the COVID‐19 infection can directly impact the brain due to inflammation (Siow et al. 2021). Brain tissue inflammation, called encephalitis, can cause cognitive symptoms – confusion, problems focusing attention, and memory difficulties (Komaroff 2023). An encephalopathy (general term for altered brain function) can develop due to various factors, including inflammation, low oxygen, effect of drugs and toxins, or metabolic (body chemistry) problems (Ellul et al. 2020). COVID‐19 can also affect the brain autonomic system, which can cause problems with a person's blood pressure and heart rate. In addition, the COVID‐19 virus can cause damage to the linings of blood vessels and increase the risk of blood clotting, which can lead to strokes (Nannoni et al. 2021) and heart attacks. Psychiatric disorders can occur as part of the COVID‐19 infection including depression, anxiety, and psychosis. Patients with more severe COVID‐19 infections have an increased risk of cognitive decline later. COVID‐19‐related ongoing low‐grade brain inflammation can lead to chronic symptoms, including pain, fatigue, and cognitive difficulty including difficulty concentrating and recalling information.
This chapter will review the different facets of COVID‐19 infection on an individual's mental health. We will describe how COVID‐19 infection may worsen preexisting psychiatric conditions and discuss the neurobiology of COVID‐19. We will consider its impact on the brain and how it results in problems with mood, thinking, behavior, cognition, and memory. We will review the psychological impact of COVID‐19 including stress on affected individuals and their family members. Finally, we will provide examples on how patients and families can interact with physicians and healthcare clinicians around their mental health issues related to COVID‐19 infection. We will first present three cases based on our clinical experience working with COVID‐19 patients. The first two cases are of patients seen early in the pandemic before the availability of vaccines and antiviral treatment. The third case involves a patient seen more recently. We changed all patient identifiers to protect patient privacy.
Clinical Cases
Mr. Johnson is a 38‐year‐old man working full‐time in law enforcement. He was seen for psychiatric consultation following a complex lengthy hospital course in the intensive care unit (ICU) after COVID‐19 infection. Before his infection, he was in excellent physical health, athletic, and physically active. Although he had experienced a few periods of mild depression throughout his life, his depression had responded well to individual supportive therapy without medications. His infection happened early in the pandemic and pre‐dated the availability of vaccines and antiviral medication. His early hospital course was marked by complications, including severe lung problems. This resulted in low blood oxygen levels that required sedation and placement on a ventilator. During his hospitalization, he developed organ failure, blood clots, and blood bacterial infections (known as sepsis). He slowly improved physically, and when his breathing ability had improved, he was removed from the ventilator. When I first saw him, he was in the ICU, awake but in a severely confused state (called delirium). Over a lengthy hospital course of approximately two to three months, he steadily improved. However, he continued to have muscle weakness, residual mild confusion, and complaints of difficulty concentrating and remembering. He was also severely depressed. He was able to discuss aspects of his hospital course (although much of it was a blur due to the sedation and confusion), and it became clear that he felt very traumatized by his experience. He told me he felt severely depressed and anxious, had difficulty sleeping, and intermittently felt hopeless. He would misinterpret things he saw and heard in his room, although he denied experiencing formed hallucinations. He had passive thoughts about whether life was worth living, but he denied active suicidal thoughts or plans. He was fully oriented when I saw him, but he had difficulty with bedside tests of more complex attention tasks (such as sustained attention and the ability to shift between competing tasks) and recall. He was treated with a combination of a serotonin‐reuptake inhibitor antidepressant, a low dose of sedating antipsychotic medication as needed, used for acute anxiety and confusion, and a low dose of a sedative‐hypnotic medication for sleep. He also received bedside supportive counseling. When I saw him after a few weeks, he reported about a 50% improvement in his level of depression and anxiety and told me that he believed he was able to cope better. Additionally, his sleep had improved, and he no longer experienced confusion. However, he shared significant worries with me that included worries about his ability to work at his previous job, his home life and relationships, and his ability to engage in athletic activities.
Mr. Brown is an 81‐year‐old man who was admitted to rehabilitation following a complex course at a general hospital. He was generally in good health, but he had a history of mild cognitive difficulties and mild depression. He was initially admitted to the hospital in acute respiratory distress, sleepy, and confused. Evaluation in the emergency room showed a low blood oxygen level, numerous abnormalities on laboratory testing, and acute confusion. He was close to respiratory arrest. He was diagnosed with severe COVID‐19 infection. He was intubated and admitted to the ICU. Following a lengthy hospital course with several complications including kidney failure, infections, and skin breakdown, he was felt to be stabilizing and sent to a rehabilitation setting for continued medical care and rehab. When evaluated psychiatrically, he had a tracheostomy (surgically placed airway in front of the base of the neck to help with breathing) and was on a ventilator. When I saw him, he was awake, but not in any distress. He was unable to talk but could nod/gesture and would “mouth” responses. He was also able to write out answers. His writing was illegible and nonsensical – he replied to questions with lines and squiggles. Based on his responses, he was clearly confused and unable to provide any meaningful history. He was distracted, and at times he would not respond to questions. He made errors when tested with basic yes/no questions testing comprehension. The nurses noted that he would get frustrated and agitated at times. He was treated with a low dose of a second‐generation antipsychotic medication, which can sometimes help with acute confusion and agitation. Over his hospital course, he appeared to settle down in terms of frustration and agitation, but he remained in a confused state during his three‐month stay in the hospital.
Mrs. Cooper is a 52‐year‐old woman who came to my psychiatry clinic with concerns about her thinking. She told me she had a long history of depression. She had previously been treated with antidepressant medications and individual therapy. Based on her history and symptoms, she appeared to have “double depression.” This involves a long history of persistent low‐level depression, along with periods of more severe depression, the latter responding to antidepressant medications. She identified that she had always felt somewhat depressed. When I saw her, she reported mild depression and a number of stressful issues in her life that could be contributing to her depression. She also mentioned to me that she was struggling with thinking, concentration, and focusing her attention. She thought her symptoms may be consistent with “brain fog.” She told me these symptoms were not new, especially during times when she felt stressed, such as after a breakup and when work became stressful. She also reported sensitivity to noisy and busy environments, struggling more with her memory and attention in certain settings. She was up to date with her COVID‐19 vaccinations and boosters. Last year, she was infected with COVID‐19 and had a cough. She took a home test that was faintly positive, and a confirmation polymerase chain reaction (PCR) test was positive. She thinks she had a low‐grade fever during that time but did not have other symptoms. She completed a course of nirmatrelvir/ritonavir. She reported no change in her mood symptoms since the infection, although she felt she had more difficulty with concentration and focusing her attention since the COVID‐19 infection. Despite her symptoms, she continued to work, and functioned well (although she told me she felt a bit slower at work and struggled more with complex tasks).
Impact on Preexisting Conditions
The limited medical research on the impact of COVID‐19 on people with preexisting mental health conditions highlights the diverse ways the infection can affect people. Many find it scary, given the potential for severe illness or death, with numerous unknowns – from asymptomatic cases to critical illness requiring life support. Additionally, there is the added stress of loneliness, isolation, and uncertainty related to home testing, as negative test results aren't always 100% accurate.
In Canada, a research study revealed a higher risk of anxiety, depression, and poor family functioning during the initial quarantine for the COVID‐19 pandemic, especially among young parents with limited household income or preexisting psychiatric conditions (Hwang et al. 2022). Early pandemic data indicated a negative impact on mental health, with variables such as preexisting psychiatric conditions, female gender, and prior trauma exposure associated with increased psychological symptoms that, in some cases, persisted as restrictions lessened (Plomecka et al. 2021). In a study of military veterans, preexisting psychiatric conditions, being single, pandemic‐related social restrictions, and financial stress were all linked to persistent loneliness (Na et al. 2022).
In the UK, a large study examining preexisting psychiatric conditions found a negative impact on mental health during the pandemic. Individuals with psychiatric conditions noted a transition to the highest levels of symptoms, with anxiety being the most affected mental health condition. Women and older adults were more affected compared to their baseline (Hampshire et al. 2022). Another large study addressing preexisting mental health conditions suggested that people with such conditions were more vulnerable and were likely to suffer greater psychological effects due to the pandemic. In general, people with preexisting psychiatric conditions experienced more psychological distress and anxiety during the early phase of the pandemic, with adverse impacts on specific conditions like eating disorders and obsessive‐compulsive disorders. External factors such as unemployment, work stress, and financial stress were related to higher levels of distress in people with mood disorders (Carvalho et al. 2022). In another large Canadian study of the pandemic's impact, patients without a psychiatric history showed positive anxiety and depression symptoms when surveyed, while those with preexisting psychiatric conditions reported worsening anxiety, depression, and suicidal ideation. More severe psychological impact was associated with several variables, including female gender, younger age, low income, poor coping skills, multiple psychiatric conditions, previous trauma exposure, worsening physical health, and poor family relationships (Robillard et al. 2021).
When we explore the impact of COVID‐19 on individuals with more severe psychiatric conditions, those requiring in‐patient psychiatric hospitalizations face heightened risks of illness and death. The research sheds light on a significant need for transfers to medical units, bringing with it an associated upswing in the risk of acute confusion and delirium. Factors such as advanced age, the presence of an organic mental disorder, acute confusion, and severe respiratory illness stand out as contributors to an increased risk of death (Dobre et al. 2023). Furthermore, the medical literature underscores an alarming surge in suicidal ideation and attempts during the course of the COVID‐19 pandemic (Yan et al. 2023).
No one would find it shocking that the pandemic took a toll on the mental well‐being of healthcare workers. A survey looking at the experiences of healthcare workers highlighted that those with psychiatric diagnoses reported a heightened perception of negative impacts on their symptoms. This, in turn, correlated with more severe psychiatric outcomes and increased stress stemming from the need to avoid physical contact with others (MacKenzie et al. 2021). Throughout the pandemic, the research spotlight also turned toward the pervasive issue of burnout among practicing physicians and surgeons (Alkhamees et al. 2023).
Neurobiology of COVID‐19
COVID‐19 can infect the brain. This can lead to many symptoms ranging from headaches, a loss of sense of smell and taste (Najt et al. 2021), or brain fog. It can also lead to more serious (but less frequent) neurological complications like strokes and seizures. COVID‐19 infection can also affect your thinking, which we will review in more detail below. In general, following infection people can be slower in their thinking and less accurate in reporting details. They can also struggle with complex tasks involving planning and reasoning.
There are several ways that COVID‐19 can affect the brain. It can impact blood vessels, disrupting blood flow and potentially reducing the delivery of oxygen to the brain, which may lead to blockages and increase the risk of stroke. Additionally, COVID‐19 can cause inflammation, which damages both blood vessels and brain tissue, further compromising brain health (Marshall 2023). Autopsy studies have shown that the COVID‐19 virus can penetrate the brain, although we are still learning about the consequences of viral infection on the brain (Stein et al. 2022). We do know that combining anti‐inflammatory drugs (like steroids) with antiviral drugs (like remdesivir) is more effective at reducing neurological complications than using either medication alone.
COVID‐19 infection can alter brain functioning, resulting in symptoms such as depression, anxiety, brain fog, memory difficulties, and fatigue. The virus is thought to enter the brain by different routes, including the nasal passages, the respiratory tract, and to a lesser extent, through the eyes. Brain fog is thought to result from the immune response and inflammation. People experiencing brain fog may have difficulty with memory, attention, concentration, or decision‐making. They may feel confused at times or struggle with their usual activities. Research has shown that, although it is not common for the virus to invade the brain, even mild COVID19 cases can negatively impact the brain (Kumar et al. 2023). As outlined above, inflammation appears to be a common pathway. We think that chronic inflammation also leads to the symptoms associated with Long COVID. Reports suggest that the immune system can go into overdrive (Ricks 2020), attacking the body's own organs, tissues, and blood vessels rather than targeting foreign invaders. Studies have shown changes in brain size (volume atrophy) and brain cell connections in Long COVID (Van Beusekom 2023). Long COVID can result in both neurological and neuropsychiatric symptoms, including cognitive decline, mood symptoms, tremors, and even seizures (Ducharme 2023).
COVID‐19 infection can also damage the brain indirectly through its effects on other parts of the body. High fevers, low oxygen levels, and organ failure–which can lead to toxin buildup–can all contribute to the inflammation's impact on the brain. Additionally, reduced blood flow and an increased risk of clotting can result in serious complications like delirium, coma, and even death. Research from the U.K. has shown that COVID‐19 infection can lead to a decrease in brain volume, particularly in regions related to taste, smell, and memory (Douaud et al. 2022).
Post‐COVID‐19 Psychiatric and Neuropsychiatric Disorders
There are important variables to consider in the association of mental health issues and COVID‐19 (Vindegaard and Benros 2020). One key factor is the impact of stress, including social isolation, loneliness, disruption of daily routines, and uncertainty about the future. Another significant concern is the potential worsening of preexisting mental health conditions. In addition, there is a risk of developing new post‐COVID psychiatric and neuropsychiatric conditions.
The incidence of specific symptoms varies greatly, although studies have shown that neuropsychiatric symptoms are more common in patients after the resolution of early COVID‐19 medical symptoms (Efstathiou et al. 2022). There is also a growing belief that the severity of the initial infection may be linked to a higher likelihood of developing long‐term neuropsychiatric symptoms, particularly if the initial phase of the illness involved reduced oxygen or blood flow to the brain. While the introduction of vaccines and antiviral treatment has decreased the frequency and severity of these conditions in many patients, many others remain at risk. Psychiatric symptoms can occur during the active, acute phase of COVID‐19 infection or persist long‐term. We describe the most common ones below. Table 2.1 highlights key clinical concepts or “pearls” related to specific conditions.
Table 2.1 Clinical diagnoses and pearls for COVID‐19‐related mental disorders.
Diagnosis/Condition
Clinical Pearls
Anxiety
Various types (generalized anxiety, panic disorder, social anxiety)
Treatment includes therapy and medications.
Limit caffeine and alcohol.
Relaxation techniques
Identify triggers, coping skills, and supports.
Bipolar disorder
Can include intense excitement or happiness, irritability, aggression, increased activity, elated or expansive mood, and increased energy
Characterized by episodes of depression and mania (or hypomania, a milder form of mania without significant impact on functioning)
Treatment includes mood stabilizers and therapy.
Brain fog
Treated with cognitive rehabilitation, focus on physical activity/exercise, good nutrition, and sleep hygiene.
Medications may be indicated.
Depression
Common symptoms include low mood, fatigue, and changes in sleep and appetite.
Ask about suicidal thoughts and develop a safety plan.
Treatment includes therapy, medications, increasing physical activity, optimizing nutrition, and improving sleep.
Insomnia
Causes of disrupted sleep include medical, neurological, and psychiatric conditions, poor sleep hygiene, and substances including caffeine.
Treated with CBT and medication.
Exercise and relaxation techniques are helpful.
Obsessive‐compulsive disorder (OCD)
Characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions)
Exposure and response prevention (ERP) is a primary form of therapy.
Medications are often used in conjunction with therapy.
Post‐traumatic stress disorder (PTSD)
Characterized by trauma‐related intrusive thoughts, flashbacks, hypersensitivity to sounds, and symptoms triggered by a stimulus
Treated with trauma‐focused therapy and medications
Schizophrenia, psychosis
Can experience hallucinations, delusions, and disorganized thinking
Treatment includes antipsychotic medications.
Supportive therapy and community integration are important.
Suicidality
A psychiatric emergency
Treatment may include developing a safety plan, therapy and medications.
Treatment often involves family
May require psychiatric hospitalization
Mood and Anxiety Symptoms
COVID‐19 infection may trigger a mood episode through a combination of psychosocial factors, such as social isolation and disrupted sleep patterns, as well as biological factors, including the direct effects of the viral infection on the brain and the indirect effects of inflammation. People with mood disorders may experience symptoms such as dysphoria, irritability, or severe depression. They may struggle with sleep, appetite, and energy. Others may have racing thoughts. While less common than depression, the onset of mania may also occur in the context of COVID‐19 infection. Mania is characterized by irritability, aggression, increased activity, elated or expansive mood, and increased energy. There does not appear to be a direct correlation between the severity of the COVID‐19 illness and the onset of mania (Del Casale et al. 2022). However, studies have shown a small but significant increase in the prevalence of depression and anxiety associated with COVID‐19 compared to rates observed before the pandemic (Klaser et al. 2021).
Post‐traumatic Stress Disorder (PTSD)
Survivors of severe COVID‐19, in particular those who required intubation or ICU care, may develop symptoms of post‐traumatic stress disorder (PTSD). People with PTSD may experience unwanted or intrusive memories, avoiding situations that trigger those memories – places like hospitals or clinical environments. They may also startle easily and battle bouts of depressed mood and anxiety. These changes in mood, thinking, sleep, and functioning can overlap with COVID‐19 symptoms that are not directly related to PTSD.
Insomnia and Sleep Disruption
Sleep problems commonly occur in people infected with COVID‐19. Numerous factors contribute to difficulty sleeping, including stress, pain and discomfort, changes in routine, and worries. Depression, confusion, hallucinations, and suspiciousness and paranoia can also disrupt sleep.
Psychosis
Psychosis is characterized by a loss of contact with reality, with symptoms including delusions, hallucinations, incoherent speech, and agitation. While instances of psychosis due to COVID‐19 infection are rare compared to anxiety and mood changes, when psychosis does occur, it may be related to direct effects of the virus on the brain.
Neuropsychiatric Symptoms
Neuropsychiatric symptoms may also result from the direct brain effects of the infection. These include difficulties with thinking including experiencing “brain fog,” fatigue, mood and sleep changes, headaches, dizziness, balance problems, vertigo, psychosis (as described above), and nerve pain (called neuropathy). Neuropsychiatric symptoms are common and can persist after infection. It appears individuals experience a particularly high rate of insomnia, fatigue, cognitive symptoms and anxiety in the months after COVID‐19 infection (Badenoch et al. 2022).
Suicide
There is an association between a higher risk of suicide and Long COVID (Yan et al. 2023). As reviewed, Long COVID can encompass a number of symptoms, including depression, anxiety, PTSD, sleep disruption, fatigue, pain, and difficulties with thinking and memory. Some research reports have specifically found an association between Long COVID, cognitive symptoms, and suicide risk (Sher 2023).
Cognition
Brain fog is not a medical condition, but rather a general term used to describe various difficulties with thinking and memory in the setting of a number of medical conditions and situations (Benisek and Ratini 2023). This term includes problems with concentration, attention, memory, and organization. As described in the clinical case above, a person may experience sensitivity or increased difficulty concentrating and functioning in a noisy, busy environment. They may experience slowed thinking, or they might feel fuzzy or confused. They may struggle to find the right word, or they might have difficulty with decision‐making and multitasking. Brain fog can occur in a number of conditions and situations, such as pregnancy, neurological conditions such as multiple sclerosis, as a result of certain medications, in some cancers and cancer treatments, in menopause, in chronic fatigue syndrome, in depression, and when people experience sleep disruptions (Sheikh 2023). In addition, brain fog can develop in association with COVID‐19 infection. Symptoms of brain fog can occur early in the course of the infection, or they may persist for a longer period in Long COVID.
If you are concerned about Long COVID cognitive changes, your clinician may consider using simple screening tools, which take about 15 minutes. The Montreal Cognitive Assessment (MoCA) and St. Louis University Mental Status Examination (SLUMS) are the most commonly used screens for cognitive impairment, although they may not pick up many people with Long COVID, who have slowed reaction times, for example. However, if these screening tests show impairment, at least the clinician is alerted to investigate your complaints further. Screening tests are important in that cognitive impairments related to COVID‐19 can persist beyond the “acute” infectious period and persist for months after, and these tests can monitor impairment over time (Vasile et al. 2023).
The American Medical Association wrote an excellent review of practical approaches to understanding brain fog and cognitive difficulties in COVID‐19 (Berg 2023). A few highlights from this review:
Formal neurocognitive evaluation is important.
Vaccines and antiviral treatment can lower the risk of Long COVID and brain fog.
Identify areas you are struggling with and come up with a plan to manage those areas. This may include avoiding multitasking or taking notes and writing out plans.
Get a good night's sleep, eat a healthy diet, stay hydrated, and avoid alcohol.
Exercise your body and mind, and reduce stress levels.
Try to avoid getting COVID‐19 again.
How does infection lead to changes in thinking? There are both direct and indirect mechanisms at play here. The virus directly infects brain tissue, but it is also the indirect effects, including brain tissue inflammation and various neurochemicals, proteins, etc. released in this process that affect thinking and memory. Low oxygen levels (hypoxemia) also affect brain tissue, as do infection‐induced changes in the tiny blood vessels of the brain. There is also a “revving up” of the central nervous system (called sympathetic excitation). Finally, metabolic problems (such as problems regulating blood sugar, the production of “free radicals,” and neurotransmitter changes in specific regions of the brain) can result in injury and affect thinking. Unfortunately, brain imaging (such as magnetic resonance imaging [MRI] and positron emission tomography [PET] scans) does not add much in terms of diagnostic value. COVID‐19 infection can be associated with persistent imaging findings, but these are not specific to COVID‐19 and are often not clinically useful. Research has shown that COVID‐19 contributes to cognitive decline by damaging important brain regions associated with cognition and emotional regulation (Li et al. 2023).
Situational Stress and Psychological Impact
A common experience during the COVID‐19 pandemic involved situational stress and adjustment, particularly during the earlier part of the pandemic before vaccines and treatments. People struggled with the increasing rate of sickness and death throughout the nation, quarantines and social distancing, concerns about the spread of infection, and restrictions and closures involving work and schools. Many people experienced isolation and loneliness as a result. In our clinics, we commonly treated patients who experienced these added stressors in addition to the clinical issues they were already dealing with. Although the pandemic no longer fits the definition of a public health emergency, and the associated situational stress and adjustments have lessened, they have not resolved (World Health Organization 2024).
There were a number of situational stressors during the pandemic, many of which still exist to some extent (Pfefferbaum and North 2020
