July 25, 2022 – There’s little doubt that long COVID is real. Even as doctors and federal agencies struggle to define the syndrome, hospitals and health care systems are opening long COVID specialty treatment programs. Today, there’s at least one long COVID center in almost every state – 48 out of 50, according to the patient advocacy group Survivor Corps.
Among the biggest challenges will be treating the mental health effects of long COVID. Well after people recover from acute COVID infections, they can still have a wide range of lingering symptoms, including depression, anxiety, brain fog, and posttraumatic stress disorder.
Specialized centers will be tackling these problems even as the U.S. struggles to deal with mental health needs.
One study of COVID patients found more than one-third of them had symptoms of depression, anxiety, or posttraumatic stress disorder 3 to 6 months after their initial infection. Another analysis of 30 previous studies of long COVID patients found roughly one in eight of them had severe depression – and that the risk was similar regardless of whether people were hospitalized for COVID-19.
“Many of these symptoms can emerge months into the course of long COVID illness,” says Jordan Anderson, DO, a neuropsychiatrist who sees patients at the Long COVID-19 Program at Oregon Health and Science University in Portland. Psychological symptoms are often made worse by physical setbacks like extreme fatigue and by challenges of working, caring for children, and keeping up with daily routines, he says.
“This impact is not only severe, but also chronic for many,” he says.
Like dozens of hospitals around the country, Oregon Health and Science opened its center for long COVID as it became clear that more patients would need help for ongoing physical and mental health symptoms. Today, there’s at least one long COVID center – sometimes called post-COVID care centers or clinics – in every state but Kansas and South Dakota, Survivor Corps says.
Many long COVID care centers aim to tackle both physical and mental health symptoms, says Tracy Vannorsdall, PhD, a neuropsychologist with the Johns Hopkins Post-Acute COVID-19 Team program. One goal at Hopkins is to identify patients with psychological issues that might otherwise get overlooked, she says.
A sizable minority of patients at the Johns Hopkins center – up to about 35% – report mental health problems that they didn’t have until after they got COVID-19, Vannorsdall says. The most common mental health issues providers see are depression, anxiety, and trauma-related distress, she says.
“Routine assessment is key,” Vannorsdall says. “If patients are not asked about their mental health symptoms, they may not spontaneously report them to their provider due to fear of stigma or simply not appreciating that there are effective treatments available for these issues.”
Fear that doctors won’t take symptoms seriously is common, says Heather Murray MD, a senior instructor in psychiatry at the University of Colorado School of Medicine.
“Many patients worry their physicians, loved ones, and society will not believe them or will minimize their symptoms and suffering,” says Murray, who treats patients at the UCHealth Post-COVID Clinic.
Diagnostic tests in long COVID patients often don’t have conclusive results, which can lead doctors and patients themselves to question whether symptoms are truly “physical versus psychosomatic,” she says. “It is important that providers believe their patients and treat their symptoms, even when diagnostic tests are unrevealing.”
Patients often find their way to academic treatment centers after surviving severe COVID-19 infections. But a growing number of long COVID patients show up at these centers after milder cases. These patients were never hospitalized for COVID-19 but still have persistent symptoms like fatigue, thinking problems, and mood disorders.
Among the major challenges is a shortage of mental health care providers to meet the surging need for care since the start of the pandemic. Around the world, anxiety and depression surged 25% during the first year of the pandemic, according to the World Health Organization.
In the U.S., 40% of adults report feelings of anxiety and depression, and one in three high school students have feelings of sadness and hopelessness, according to a March 2022 statement from the White House.
Despite this surging need for care, almost half of Americans live in areas with a severe shortage of mental health care providers, according to the Health Resources and Services Administration. As of 2019, the U.S. had a shortage of about 6,790 mental health providers, the agency says. Since then, the shortage has worsened; it’s now about 7,500 providers.
“One of the biggest challenges for hospitals and clinics in treating mental health disorders in long COVID is the limited resources and long wait times to get in for evaluations and treatment,” says Nyaz Didehbani, PhD, a neuropsychologist who treats long COVID patients at the COVID Recover program at the University of Texas Southwestern Medical Center in Dallas.
These delays can lead to worse outcomes, Didehbani says. “Additionally, patients do not feel that they are being heard, as many providers are not aware of the mental health impact and relationship with physical and cognitive symptoms,” she says.
Even when doctors recognize that psychological challenges are common with long COVID, they still have to think creatively to come up with treatments that meet the unique needs of these patients, says Thida Thant, MD, an assistant professor of psychiatry at the University of Colorado School of Medicine who treats patients at the UCHealth Post-COVID Clinic.
“There are at least two major factors that make treating psychological issues in long COVID more complex: The fact that the pandemic is still ongoing and still so divisive throughout society, and the fact that we don't know a single best way to treat all symptoms of long COVID,” she says.
Some common treatments for anxiety and depression, like psychotherapy and medication, can be used for long COVID patients with these conditions. But another intervention that can work wonders for many people with mood disorders – exercise – doesn’t always work for long COVID patients. That’s because many of them struggle with physical challenges like chronic fatigue and what’s known as post-exertional malaise, or a worsening of symptoms after even limited physical effort.
“While we normally encourage patients to be active, have a daily routine, and to engage in physical activity as part of their mental health treatment, some long COVID patients find that their symptoms worsen after increased activity,” Vannorsdall says.
Patients who are able to reach long COVID care centers are much more apt to get mental health problems diagnosed and treated, doctors at many programs around the country agree. But many patients hardest hit by the pandemic – the poor and racial and ethnic minorities – are also less likely to have ready access to hospitals that offer these programs, says Anderson, from Oregon Health and Science.
“Affluent, predominantly white populations are showing up in these clinics, while we know that non-white populations have disproportionally high rates of acute infection, hospitalization, and death related to the virus,” he says.
Clinics are also concentrated in academic medical centers and in urban areas, limiting options for people in rural communities who may have to drive for hours to access care, Anderson says.
“Even before long COVID, we already knew that many people live in areas where there simply aren’t enough mental health services available,” says John Zulueta, MD, an assistant professor of clinical psychiatry at the University of Illinois at Chicago who provides mental health evaluations at the UI Health Post-COVID Clinic.
“As more patients develop mental health issues associated with long COVID, it’s going to put more stress on an already stressed system,” he says.