The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus affects the mental health of many. Isolation, fear of infection, and social distancing may affect psychological functioning. Research continues to evolve and reveal the psychological symptoms reported by coronavirus disease 2019 (COVID-19) patients. Depression, anxiety, posttraumatic stress disorder (PTSD), and psychosis have been reported in the literature for COVID-19 patients. Potential preliminary treatment recommendations include various forms of psychotherapy, such as dialectical behavioral therapy, mindfulness-based cognitive therapy, and cognitive behavioral therapy. More research should be done regarding other additional treatment recommendations that may facilitate psychological healing in COVID-19 patients.
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has affected the mental health of many, regardless of whether an individual has been infected with the virus. In the past year, there has been an increase in alcohol use,1 domestic violence,2 and suicide.3 Social distancing, fear of infection, and chronic isolation may impact mental health. Those who have been diagnosed with coronavirus disease 2019 (COVID-19) may also face mental health issues. It is estimated that 1 in 3 patients diagnosed with COVID-19 may report lasting neurological or psychological symptoms.4
Psychological Effects of COVID-19
Assessing the psychological effects of COVID-19 is particularly complex because there is a significant difference between self-reported symptoms and an accurate psychiatric diagnosis. The diagnosis of psychological disorders is often complex owing to variable symptomatology, frequent comorbidity, possible (conscious or unconscious) exaggeration or malingering, and social or potentially confusing occupational factors.5
Fred Pelzman, MD, an internist in New York City, reported that his COVID-19 patients have described symptoms of depression, anxiety, and “COVID fog.” 4 Pelzman also pointed out that it can be challenging to disentangle psychological from physical symptoms when assessing and treating COVID-19 patients. While the literature on psychological symptoms post-COVID-19 continues to evolve, some have suggested that there may be a bidirectional relationship between COVID-19 and mental health.6 A recent meta-analysis examined 16 international studies on mental health and COVID-19,6 and prior psychiatric diagnosis was associated with increased mortality and disease severity in COVID-19 patients. There may be a genetic predisposition to experiencing persistent psychological problems post-COVID-19. There may also be preexisting psychological or personality factors that predispose someone to develop psychological adverse effects post-COVID-19. It is imperative that we continue to assess, monitor, and treat all symptoms of COVID-19, including neurological, neuro-cognitive, physical, and psychological.
Depression, Anxiety, and Post-traumatic Stress Disorder in COVID-19 Patients
In a recent study conducted in Italy, 402 patients recovering from COVID-19 were assessed approximately 1 month after hospital treatment.7 Psychiatrists conducted unstructured interviews with patients, and self-reported questionnaires were administered to patients to assess psychological symptoms. Approximately 56% scored in the clinical range in at least one psychopathological domain (eg, post-traumatic stress disorder [PTSD], depression, etc). Depression, PTSD, anxiety, obsessive compulsive symptoms, and insomnia were all reported. Self-reported instruments may be unreliable. Patients with a history of COVID-19 who reported more symptoms included females, patients with a previous psychiatric diagnosis, and patients who were being treated at home. Younger patients exhibited higher levels of depression and sleep disturbances.
Kaseda and Levine8 hypothesized that, based on previous data on coronavirus outbreaks, COVID-19 patients may demonstrate a similar prevalence of PTSD. The authors reviewed previous literature on patient outcomes after severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). They also reviewed literature on various neurological outcomes in COVID-19 patients, along with literature on PTSD associated with procedures that are occasionally required while treating COVID-19. For example, literature suggests that invasive ventilation, which is sometimes used to treat patients who have COVID-19, can result in PTSD symptoms.9,10 Gosselin et al 11 found that 14% to 51% of intubated and mechanically ventilated patients reported experiences consistent with PTSD. Kaseda and Levine 8 found in their literature review that PTSD risk was elevated in MERS and SARS survivors, and PTSD has also been reported in COVID-19 patients. The authors warn that it may be challenging when assessing COVID-19 patients to disentangle the potential numerous causes of cognitive impairment and self-reported cognitive symptoms. The authors provide several recommendations for neuropsychologists to consider when treating COVID-19 patients with possible comorbid PTSD. Trauma-focused psychotherapies have also been successful in improving cognition.12
In a recent cohort study, Taquet et al13 examined 62354 COVID-19 patients in which they assessed whether a COVID-19 diagnosis predicted subsequent psychiatric diagnoses. They examined anonymized electronic health record data from 54 healthcare organizations in the United States. The results revealed that a COVID-19 diagnosis was correlated with a new psychiatric diagnosis within 14 to 90 days. Anxiety disorders, insomnia, and dementia were commonly found in patients recovering from COVID-19. In addition, COVID-19 was associated with patients' psychiatric diagnosis in the previous year, suggesting that previous psychiatric diagnosis is independently associated with a greater risk of a COVID-19 diagnosis. More research needs to be done on the correlation between psychiatric history and the incidence of COVID-19.
Researchers in the United Kingdom (UK) developed an online network for compiling case reports throughout UK neuroscience organizations.14 COVID-19 cases were submitted by clinicians, and the median age was 71 years. Of 153 cases, 59% presented with altered mental status and were felt to meet the criteria for a psychiatric diagnosis, with most of these being new psychiatric diagnoses. Of 23 patients with neuropsychiatric disorders, 43% were reported to exhibit new-onset psychosis; approximately 25%, a neurocognitive syndrome; and 17%, an affective disorder. Of 37 patients with altered mental status, 49% were younger than 60 years. In summary, altered mental status was the second most common presentation, and primary psychiatric diagnoses often occurred in younger patients.
Ferrario and colleagues15 examined 181 hospitalized COVID-19 patients. Of these, 47% underwent psychological assessment, and acute stress disorder was the most common psychological issue (19%). Additional psychological issues included anxious and demoralization symptoms (27%), depression (10%), and grief (8%). Some patients were discharged home (38%) after recovering, and some patients received further rehabilitation in various other medical departments (42%). Patients who exhibited more severe psychological difficulties (36%) required further structured psychological treatment. Cognitive behavioral therapy (CBT) was used, and specific interventions included cognitive restructuring, psychoeducation, relaxation techniques, grounding techniques, and in some cases, family meetings to focus on communication. Data were not collected on caregivers, but 60 participated in psychological support over the telephone. Caregivers reported a variety of psychological symptoms, such as anxiety, mood swings, and sleep disturbances.
While there has not been a sufficient number of large studies on psychosis post-COVID-19, there have been several isolated case reports. One study discussed the case of a 49-year-old man with no prior psychiatric history who presented with psychosis and mania.16 He was brought to the psychiatric emergency department (ED) with bizarre behavior and altered mental status. While hospitalized, he reported auditory hallucinations, delusions of grandiosity, insomnia, and paranoia. He apparently also displayed passive suicidal ideation while hospitalized. In another case report,16 a 34-year-old woman with no psychiatric history presented to the ED with altered mental status and psychosis. While hospitalized, she displayed bizarre behavior such as disrobing, verbosity, insomnia, and persecutory thoughts. The authors posit that the immune system may become activated when infected with SARS-CoV-2 virus, which may cause inflammation in the central nervous system. Specifically, they noted that activation of the kynurenine pathway has been identified in other psychiatric presentations (eg, psychosis, bipolar disorder, depression, suicide).16 Ferrando and colleagues17 also discuss three case studies of new-onset psychosis in young patients diagnosed with COVID-19 (aged 30, 34, and 33 years). International reports of new-onset psychosis in COVID-19 patients have also been published.18,19
Unfortunately, there have been several reports of suicide and suicide attempts in patients with post-COVID-19 symptoms. Kent Taylor, the founder and chief executive officer of the Texas Roadhouse restaurant chain, died by suicide after struggling with lingering COVID-19 symptoms after his diagnosis.20 One case report21 in the United States discussed a 38-year-old man who attempted suicide and was later found to have been infected with SARS-CoV-2 virus. The young man had a previous history of anxiety and depression, including a history of psychiatric hospitalizations. He apparently reported neck pain, worsening headache, and nausea, along with an increase in depression and suicidal ideation leading up to the attempt. He denied any previous suicide attempts. The authors state that this case does not necessarily imply causation, but they warn of the potential bidirectional effect that physical illness and psychological disorders share. Research is needed on the risk of suicide in COVID-19 patients, and identification of risk factors has the potential to save many lives.
Preliminary Treatment Recommendations
As evolving literature continues to demonstrate, psychological symptoms are being reported and observed in patients recovering from COVID-19. While literature on the cognitive and psychological symptoms reported in COVID-19 patients is limited, literature on psychological treatment interventions in patients with COVID-19 is even more limited.
A recent study by Li et al22 examined the effectiveness of CBT in patients diagnosed with COVID-19 in which a sample of 93 COVID-19 patients with no prior diagnosis of depression were included. Patients were broken into a control group (46 participants) that consisted of participants who received routine medical care, and a separate intervention group (47 participants) whose participants received routine medical care in addition to CBT. The average age was 48 years, and the mean hospital length of stay was 14 days. At baseline, 54% of participants had depression symptoms, 90% had anxiety symptoms, and 73% had stress symptoms. The mean values of depression, anxiety, and stress decreased significantly in both groups after the completion of the study. It is important to clarify that statistically, there was a significant decrease in symptoms for both the intervention and control groups. CBT did not result in a statically significant decline in symptoms when compared to routine medical care. However, the authors posit that participants in the intervention group had a larger mean reduction for depression and anxiety, which suggests that CBT may improve the psychological health of COVID-19 patients. Further research must be undertaken in this area. Patients with longer hospital stays were less likely to improve their anxiety level in the intervention group. The authors suggest that CBT should be focused on patients who have long hospital stays and a chronic disease history.
Some researchers have proposed the use of mindfulness-based therapy to reduce psychological symptoms during the global pandemic. While literature on the use of mindfulness-based therapy with recovering COVID-19 patients is limited, we can reflect on the existing literature on the benefits of mindfulness. Behan23 explains that mindfulness-based cognitive therapy24 (MBCT) incorporates mindfulness practices and cognitive interventions, which are easy to learn and practice at home. MBCT typically includes an 8-week, group-based therapy in which mindfulness skills are taught.25 MBCT has been shown to be beneficial in treating PTSD,26 anxiety,27 and depression.26
Dialectical behavior therapy28 (DBT) is another potentially useful treatment for those with psychological symptoms post-COVID-19. DBT places more of an emphasis on the role of emotions in dysfunctional behavior compared to other cognitive and behavioral therapies.29,30 DBT incorporates some of the core principles of CBT, but dialectical and mindfulness components distinguish it from traditional CBT. DBT was originally developed for the treatment of borderline personality disorder, but numerous studies have revealed its' usefulness in treating other psychological disorders. Although there is no known research at this time on the benefits of DBT for patients diagnosed with COVID-19, there is extensive research supporting the benefits of DBT in patients diagnosed with anxiety, depression, PTSD, and suicidal ideation. One study showed that DBT has a significant effect on anxiety, depression, stress, and problem-solving skills in students with depression.31 Another study found that DBT was effective in treating depression, anxiety, and emotion dysregulation in patients diagnosed with generalized anxiety disorder.32 This study compared DBT with CBT in patients diagnosed with generalized anxiety disorder and found that CBT was more effective in reducing symptoms of depression and anxiety and DBT was more effective in establishing emotion regulation and mindfulness.
Further research on effective treatment interventions for lingering psychological effects in COVID-19 patients is critical. One potential area of future research should focus on family interaction and communication within families affected by a COVID-19 diagnosis.