On the long-term psychological consequences of COVID-19
While the number of new corona infections seem to have less and less relevance in the public discussion, another aspect of the pandemic is increasingly coming to the fore: long-COVID. But what exactly is meant by this? How is the diagnosis and treatment of mental and cognitive complaints in the context of long-COVID carried out?
Ms. H. fell ill with COVID-19 six months ago and reports cognitive deficits in addition to physical symptoms such as shortness of breath or muscle pain. She can only concentrate on something for a few minutes, reading texts is hardly possible anymore, when driving she has to be very alert and in group conversations she finds it difficult to focus. Especially in a family with three children, where there is often a high level of noise, these concentration problems are stressful. But also her memory performance has deteriorated. She has to write down all appointments in her mobile phone and check them several times a day so that she doesn't forget any of them. When shopping, she always has to use shopping lists. She finds her inability to remember numbers and billing procedures to be extraordinarily burdensome, as these are daily requirements of her job as a medical assistant. Until before she fell ill with COVID-19, she considered activities in this context to be one of her strengths. In addition to these cognitive problems, it sometimes happens that she cannot remember a certain word during a conversation, whereupon she falters in her flow of speech. In themselves, the cognitive deficits are stable in intensity, although the perceived complaints are also dependent on the time of day.
Unfortunately, Ms. H. is only one of many people who go to the "Long-COVID Outpatient Clinic for Mental and Cognitive Disorders" at the Department of General Psychiatry at Heidelberg University Hospital. We talked to the head of the outpatient clinic, Prof. Dr. Daniela Roesch-Ely, about long-COVID and her work with people affected by it.
What is long-COVID and how many people are affected by it?
Daniela Roesch-Ely (DR): The guidelines of the National Institute for Health and Care Excellence in the United Kingdom (NICE)1 define post-COVID-19 as a group of symptoms that occur during or after infection with COVID-19. They persist for more than 12 weeks and cannot be explained by an alternative diagnosis. The group of symptoms may fluctuate and be of various types. In addition to the clinical definitions, the terminology 'long COVID' is often used when the group of symptoms persists beyond the acute phase: This includes the phase with continuous COVID-19 symptoms (from 4 to 12 weeks) and the post-COVID-19 phase (more than 12 weeks). Symptoms can be physical, cognitive, and psychological.
A recently published review article2 shows an estimated prevalence of long-COVID ranging from 7.5% to 41% (in nonhospitalized adults). However, the figures are still heterogeneous and preliminary. Prospective studies with representative samples are still needed.
Are there certain risk factors for long-COVID?
DR: Preliminary evidence shows that female sex, older age, comorbidities (psychiatric and somatic), severity of acute illness (controversial), and obesity are associated with long-COVID.
Do we know anything yet about possible protective factors that prevent or at least mitigate long-COVID?
DR: Data on possible protective factors are scarce. There is discussion of good physical activity, which may reduce the risk of long-COVID. Evidence is generally still lacking regarding protective factors, the effectiveness of treatment approaches, and preventive measures including the effect of vaccination on the development of long-COVID syndrome.
What are the most common mental health complaints of people with long-COVID? Are there certain core symptoms?
DR: Individuals report fatigue (see Box 1), reduced quality of life, and ability to cope with everyday life, sleep disturbances, and various cognitive disturbances such as difficulty finding words, to concentrate, and/or remember things. In addition, there are affective symptoms such as increased anxiety, helplessness and/or depressed mood.
Which diagnostic methods and tests do you use?
DR: We perform a detailed medical and psychiatric history using structured interviews as well as neuropsychological testing. This includes subjective and objective assessment of cognition (e.g., processing speed, memory, attention, executive functions) using standardized tests in paper-pencil as well as computerized format (such as COGBAT). Furthermore, standardized questionnaires on quality of life, fatigue, performance and depression are used in addition to a screening procedure to detect dementia. If necessary, the patients are referred for further evaluation of the brain by means of MRI and EEG. This is done in a multidisciplinary team.
Box 1: Fatigue after COVID-19
Fatigue is a subjectively often severely limiting exhaustion at the somatic, cognitive, and/or psychological level that is disproportionate to the preceding efforts and cannot be sufficiently improved by sleep or rest. It also occurs after a variety of other viral illnesses. Self-report instruments are used to assess symptomatology. Since the causes of fatigue are unclear, only symptomatic therapy is currently used.
What are the treatment options?
DR: It is important to inform the person about long-COVID symptoms, their possible course, and to take the syndrome seriously. Facilitating the acceptance of symptoms and educating about their fluctuating nature is equally important. In case of diagnosed psychiatric diseases, we recommend psychiatric/psychotherapeutic support according to national guidelines. In addition, we recommend targeted treatment of sleep disorders, cognitive training, and other treatment options such as physical therapy, rehabilitation, and to connect with support groups. We also recommend maintaining a healthy lifestyle with a healthy diet and adequate physical activity. The important thing here is not to overdo it, and neither to demand too much nor too little from oneself.
What is your experience at the outpatient clinic so far regarding the course and prognosis of long-COVID?
DR: We are in the process of inviting individuals to a follow-up appointment after the initial contact. Data on course and prognosis are not available yet. From our point of view, it is important to include persons in a multidisciplinary treatment network, which allows to recognize the symptoms early and to treat them symptom-oriented. In our region, there is a long-Covid network (http://www.longcovidnetz.de/), through which those affected and those providing treatment can obtain information.
1National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General Practitioners (RCGP) (2022). COVID-19 rapid guideline: managing the long-term effects of COVID-19. https://www.nice.org.uk/guidance/ng188
2Nittas, V., Gao, M., West, E. A., Ballouz, T., Menges, D., Wulf Hanson, S., & Puhan, M. A. (2022). Long COVID through a public health lens: An umbrella review. Public Health Reviews, 43, Article 1604501. https://doi.org/10.3389/phrs.2022.1604501