Post-COVID Syndrome in the Psychiatric Clinic

Addressing the Unique Challenges of the Post-COVID Patient

Late in the summer of 2020, I began to notice a pattern among my patients. Those patients who had become ill with COVID-19, the illness caused by the SARS-CoV-2 virus, were showing some similarities. None of them required hospitalization, but weeks or even months after their illness, they were complaining of new symptoms. Many patients noted new insomnia, difficulties with concentration, and a chronic fatigue, even patients who had been stable on their medications for years. Notably, these patients did not report increases in anxiety or depression. Around this same time, researchers began to elaborate on a “post-COVID syndrome.”

Many viral illnesses are associated with postviral sequelae, and unfortunately, COVID-19 is no exception. Some people diagnosed with COVID-19 report postviral symptoms that last only a few weeks, but many others report symptoms that have lasted months, and still others continue to report symptoms that have not resolved. Documented issues with vascular damage to tissues and hypoxia (“silent” or not) have been proposed to be the root of some of these issues. Others have documented the clinical course of COVID-19 patients who were hospitalized and suffering from “post-ICU syndrome,” including symptoms of weakness, cognitive issues, and balance problems.

In understanding post-COVID syndrome, we can look at those who suffered from another coronavirus illness, Severe Acute Respiratory Syndrome (SARS). One study revealed that patients who recovered from acute SARS, which is caused by SARS-CoV-1, reported fatigue, depression, sleep and cognitive issues up to almost 2 years after infection. Another study revealed that 40% of those recovered from SARS continued to experience chronic fatigue up to 4 years after illness and 27% met criteria for chronic fatigue syndrome (CFS).

The Presentation of Post-COVID Syndrome

What we are noticing with post-COVID syndrome is a constellation of symptoms that resemble CFS or myalgic encephalomyelitis (ME). “Long-haulers,” as some post-COVID syndrome patients have referred to themselves, have been reported to experience insomnia, sleep disturbance, “brain fog,” and fatigue that persist weeks or months from onset of viral illness. This post-COVID syndrome may sound suspiciously like what we see in our patients with autoimmune disorders such as Hashimoto’s thyroiditis or multiple sclerosis or lupus. Indeed, several researchers have begun to theorize that post-COVID complications, including the severity of disease after SARS-CoV-2 infection, could be mitigated by “rogue” auto-antibodies. 

This autoimmune-like presentation is what I have been seeing in my established patient population, and what I hypothesize will come to characterize many of our new patient evaluations in the coming months and years. We will start to see previously healthy individuals, with little to no previous psychiatric history, some in their 20s and 30s, some in their 40s or 50s, who will arrive in our offices with depression, anxiety, and perhaps post-traumatic stress disorder (PTSD) related to their illness or to their new symptoms of cognitive dysfunction, fatigue, and insomnia that occurred post-COVID infection. Some of these patients might have required hospitalization for their COVID illness and tell us that they believe their symptoms are related somehow to COVID-19. Others, and perhaps the vast majority, may not recognize their symptoms began after COVID (especially if their course of illness was mild or asymptomatic), and we will need to paint the clinical picture for them. I have started to ask all of my new patients about exposure to COVID, including timing and severity of disease course. I also do not exclude the possibility of a COVID infection in those who had a viral syndrome during the pandemic, but did not get tested for COVID, or whose COVID tests were negative (given the high false negative issues with our current testing). Patients with post-COVID syndrome generally notice that their symptoms have begun to interfere with their day-to-day functioning, to the point where they cannot return to work or complete activities of daily living due to severe fatigue, sleep issues, and inability to concentrate on or complete tasks. Some of these patients may be experiencing new onset depression and anxiety related to these symptoms, and they will be showing up in our clinics looking to us for help. In addition, new evidence suggests that those patients who already experience mental health issues are more at risk for COVID-19.

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Treatment Approaches

One of the challenges of practicing psychiatry with telemedicine, despite the advantages of being able to see my patients without face masks and the improved compliance with appointments, has been that many of my patients are not able to adequately provide their basic vital signs such as weight and waist circumference, and even fewer are able to provide information on their blood pressure and pulse. For those patients presenting with post-COVID syndrome, a medical workup with a primary care physician will be of the essence. I have encouraged my patients to invest in a blood pressure cuff if possible, or if this isn’t possible, to consider checking blood pressure at the grocery store or pharmacy at their next visit. Prior to engaging with any medication treatment, basic vital signs are necessary and become increasingly important as we follow treatment response and adverse effects. In the case of post-COVID syndrome, where multiple physical issues may complicate the clinical psychological presentation, I am even more adamant about my patients seeking a visit with their primary care physician.

Generally, my approach to the post-COVID syndrome patient is similar to my approach to any patient complaining of fatigue, insomnia, and cognitive issues. My first line of treatment is to encourage engagement with wellness practices including improving sleep, exercise, and diet. Because this can be an overwhelming task, I often ask if they can consider engaging with a month of wellness (eg, an approach similar to WILD 5 Wellness) including working with a therapist or counselor, reaching out to friends and family for support, and engaging with mindfulness or relaxation exercises. I also ask about substance use, and especially try to gather information on alcohol and caffeine, two primary culprits in sleep (and cognitive) issues. We have seen a large increase in substance use during the pandemic, and some of my patients, especially those working from home, have reported consuming alcohol throughout the day. Other patients, trying to overcome fatigue and brain fog, will increase caffeine consumption, consuming caffeine throughout the day and into the evening and then wonder why they cannot sleep. Many patients have never been educated about the effects of alcohol and caffeine on anxiety and sleep. Another nonmedication intervention that I have found helpful is to ask patients to move exercise to the mornings and encourage at least an hour without screen time prior to bed.

Some patients, however, may require (or request) pharmaceutical intervention for their post-COVID syndrome symptoms. In informal discussion with my colleagues in other fields of medicine on the topic of treatment for the post-COVID syndrome, several have suggested modafinil, bupropion, dextroamphetamine or other stimulating medications to help with fatigue and “brain fog.” While these are not bad strategies, the cardiovascular and neurologic risks of these and other stimulants and stimulating agents will need to be weighed in a population of patients who may have new onset cardiovascular and neurologic risks given COVID-19 infection. Keep in mind that even previously healthy individuals with mild COVID illness can be at risk for new-onset stroke, pulmonary embolism, kidney failure, myocardial infarction, arrhythmias, and hypertension and it is unclear if or when these risks resolve.

Overall, we will be managing our post-COVID syndrome patients who complain of depression or anxiety with a pharmaceutical algorithm, similar to how we approach any of our patients diagnosed with depression or anxiety. However, I am also exploring repetitive transcranial magnetic stimulation (rTMS) as a potential treatment avenue, especially in my post-COVID patients who also meet criteria for treatment-resistant depression. Given the possible autoimmune implications and presentation of the post-COVID syndrome, it is interesting to note that off-label explorations of rTMS have shown promise and benefit in the area of cognitive improvement for patients with MS, as well as improvement in fatigue in patients with CFS and ME. Difficulty obtaining insurance coverage for rTMS treatment for the post-COVID syndrome patient who does not meet criteria for treatment-resistant depression may, however, be an obstacle to this route of care.

Screening and treating new and existing patients, including post-COVID patients, for depression, PTSD, panic, and suicidal ideation is a routine part of our job as psychiatric providers, and we must continue to be attentive to the increase in these issues across the population since the beginning of the COVID-19 pandemic. In many ways, the post-COVID syndrome patient may appear indistinguishable at first glance from other new patients, and because of this, we will need to be more vigilant in our screening process to assess who has and has not yet been exposed to the SARS-CoV-2 virus. The hospital where I am an outpatient provider is creating a multidisciplinary team to identify and provide care for the post-COVID population of patients. Especially important to consider in this regard is access-to-care issues facing populations of individuals most likely to affected by COVID-19, including especially the BIPOC patient populations that have been particularly hard hit by the pandemic. As the pandemic continues to ravage all aspects of human life, we mental health care providers must become alert to and prepared to treat the mental health issues that are created not just by the psychological aspects of the pandemic, but by the disease itself.

Holly Hendin, PhD, MD, is a faculty physician in the psychiatry department at Dignity Health St. Joseph Medical Group, Phoenix, Arizona, and assistant professor, Health Sciences Associated Faculty in the department of psychiatry at Creighton Medical School, Omaha, Nebraska. She received her PhD from the University of California, Davis and her MD from the University of Arizona, Tucson. Her PhD is in personality psychology, and her graduate research was on narcissism, shyness, and self-esteem. She believes that all forms of therapeutic interventions from yoga and mindfulness-based CBT to eye movement desensitization and reprocessing (EMDR) and psychedelic-assisted therapy can be useful in building a touchstone community of wellness both within the self and outside of the self.