Psychiatrists Uniquely Suited for Helping Patients With Long-Haul COVID-19

Treating patients with long-haul COVID-19 involves taking a comprehensive, multidisciplinary quality-of-life approach to this chronic illness, understanding that while patients can reach remission, it is not a quick fix, according to two experts.

“It’s essential for psychiatrists to become more comfortable in the evaluation and treatment of the neuropsychiatric sequelae of this illness,” explained Thida Miyo Thant, M.D., director of the Consultation-Liaison Psychiatry Service at the University of Colorado’s Anschutz Medical Campus. Patients are often sent to many other specialists before they finally arrive at the long-haul COVID mental health program she heads, she added. “Psychiatrists are uniquely well suited to provide the type of supportive and targeted treatment of the types of symptoms these patients are experiencing.”

The most common symptoms of the disorder are fatigue, headache, and neurocognitive deficits, such as attention-deficit problems, explained Abhisek Khandai, M.D., an assistant professor of psychiatry at UT Southwestern Medical Center. Various studies have shown that patients who were hospitalized for the disease are at the highest risk of developing long-haul COVID, particularly those who were in the intensive care unit and those with encephalopathy.

The development of neurocognitive and psychiatric illness is most likely within the first six months following acute COVID-19 illness, but risks stay elevated for as long as two years. Pre-existing conditions that leave patients at higher risk include prior psychiatric, hypertensive or chronic pulmonary disorders, or diabetes and other chronic illnesses. As for demographic factors, older patients, women, and people with higher body mass index are at increased risk. “There are also racial disparities in the diagnosis and treatment of the disorder, with Blacks and Latinos having high incidence of symptoms, but they just aren’t getting diagnosed or receiving care,” Khandai said.

Thant explained that neuro- and systemic inflammatory processes similar to those caused by other viruses are believed to play a key role. “Even those patients who don’t become very ill with COVID-19 infection may show some changes on head imaging and cognitive tests.”

Thant gave the following pointers for managing patients with long-haul COVID:

• Use formal screening: “Start by screening things you already know how to screen,” she said. Using validated screening tools that objectively assess depression, anxiety, trauma, and fatigue, as well as any somatic symptoms that allow clinicians to judge whether treatments are working.
  
  With regard to depression and anxiety screens, she finds that the Hospital and Anxiety Depression Scale provides a clearer view of patients than the PHQ-9. That’s because patients who are dealing with a new chronic illness tend to score overly high on the PHQ-9 because of the associated anhedonia, she added.
  
  “What you’ll find is that long COVID patients don’t necessarily meet the cutoffs on many screening tools, but they may still be troubled enough by their symptoms to warrant treatment,” Thant said.


• Address polypharmacy: Oftentimes, patients are already taking a slew of medications and supplements by the time they are seen in the long-haul COVID clinic. Thant starts by culling the list of what are likely to be duplicative or unhelpful treatments, such as Lyrica (pregabalin). For patients with fatigue, brain fog, and/or neurocognitive deficits, she ceases or limits the use of antihistamine or anticholinergenic medications, as well as benzodiazepines.


• Improve lifestyle factors: Patients with long-haul COVID often feel so ill that they stop pro-healthy habits in which they were engaging prior to contracting the infection, such as eating healthfully or working out.


• Assess insomnia and sleep problems: “If you’re not sleeping well, your memory is not going to be as good, and if you’re not sleeping well for months on end, you’re really not going to feel well,” Thant said. She uses validated screening tools to assess her patients’ sleep and also counsels them on avoiding caffeine. Other solutions include limiting screentime and water intake a few hours before bedtime. To address sleep problems in her patients, she utilizes sleep restriction, mindfulness exercises, melatonin, and CBT-i for insomnia.


• Take it slow: Patients who are just starting to feel better may rebound if they push too quickly to return to previous levels of functioning. “Then they come back feeling really distressed and depressed because all their symptoms flared again,” she said. “The challenging thing about long COVID is that the symptoms can wax and wane. Like many other chronic illnesses, you can be doing well until you’re not.”

Thant advises creating a structured return-to-activity program, including cognitive work. For example, instead of going on a five-mile hike, she encourages patients to take a walk around the block and see how they feel the next day. The idea is to build up activity levels in increments of 10% over a structured timeframe, she said. ■

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