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Primary Care Clinicians Help Patients Manage Long COVID’s Mental Health Symptoms as Urged by HHS

COVID-19 may no longer be considered a public health emergency, but post–COVID-19 condition—also known as long COVID—remains a hurdle, according to the US Department of Health and Human Services (HHS).


Through the Substance Abuse and Mental Health Services Administration (SAMHSA), HHS issued a new advisory to help primary care clinicians identify and manage mental health symptoms associated with long COVID, which it defines as health issues that develop or persist for 4 or more weeks after an initial COVID-19 infection. The advisory discusses the epidemiology of symptoms such as anxiety, depression, fatigue, and cognitive impairment and provides resources for clinicians to assess and treat these issues.

Why This Is Important

The advisory states that at least 10% of people who develop COVID-19 experience long COVID symptoms, which may worsen over time and can continue in a pattern of relapse and recovery.

“We know that people living with Long COVID need help today, and providers need help understanding what Long COVID is and how to treat it,” HHS Assistant Secretary for Health Rachel Levine, MD, said in a statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”

The Range of Symptoms

According to the advisory, mental health symptoms linked with long COVID include

· Anxiety

· Cognitive impairment, such as brain fog

· Depression

· Fatigue

· Initial onset of substance use disorder

· Obsessive-compulsive disorder

· Posttraumatic stress disorder

· Psychosis

· Sleep disorders

In an interview with JAMA, Roy Perlis, MD, MSc, who was not involved with the advisory, said he was “very pleased that SAMHSA stepped forward to emphasize that mental health symptoms are common in people with long COVID.” Perlis is the associate chief for research in the Department of Psychiatry at Massachusetts General Hospital. “When we don’t talk about those symptoms,” he said, “we potentially deprive people of the opportunity to address some of the long COVID symptoms that may be really impacting their lives.”

Perlis underscored that it’s particularly important to screen patients with long COVID for anxiety and depression. “Those aren’t the only symptoms that people have, but they’re among the most common,” he explained.

Moreover, clinicians should watch out for other debilitating issues, according to Faith Gunning, PhD, a clinical neuropsychologist at Weill Cornell Medicine, who also did not contribute to the advisory. “Attention, processing speed, and higher-level executive functions are the most concerning cognitive effects of long COVID,” Gunning wrote in an email to JAMA. “These cognitive processes are necessary for efficient cognition in other areas, including learning and memory, [and] are important for daily functioning.”

Risk Factors and Inequities

The precise mechanisms by which long COVID affects mental health are unclear, the advisory notes. However, it also mentions that a history of anxiety, depression, loneliness, and stress correlates with more severe COVID-19 and a greater risk of long COVID. Other factors that increase the risk of mental health symptoms related to long COVID include preexisting and comorbid conditions, hospitalization from COVID-19, and severe COVID-19 illness.

Women are more likely to have long COVID–related mental health symptoms, as are American Indian and Alaska Native, Black, and Hispanic and Latino people, according to the advisory. People with disabilities have an 81% greater incidence of long COVID, which increases the likelihood of associated mental health symptoms. The rate of long COVID is also more than double among transgender people than cisgender males, the advisory points out.

The advisory acknowledges that the COVID-19 pandemic exacerbated health disparities. Contributing factors include financial instability, living and working in dense environments, and poor access to high-quality health care. Such chronic stressors can negatively affect mental health and COVID-19 outcomes, too.

“As was the case before the pandemic, there are big differences in people’s ability to access care,” said Perlis, who is also an associate editor of JAMA Network Open. “COVID made the cracks in our system that much more apparent.”

How to Assess the Symptoms

To help clinicians determine whether a patient has long COVID, the advisory suggests assessment recommendations developed by the American Academy of Physical Medicine and Rehabilitation (AAPM&R). The recommendations include a comprehensive evaluation of symptoms, lifestyle, medication use, and history of preexisting conditions. Clinicians should additionally provide laboratory tests to screen for treatable and reversible factors—such as a folate deficiency or thyroid disorder—that could contribute to cognitive symptoms.

Clinical interviews and self-report screeners can provide further insight into whether patients have mental health symptoms linked with long COVID. It may also be useful to check for factors known to exacerbate cognitive issues, such as autoimmune disorders and sleep impairment. Furthermore, the AAPM&R recommends detailed neurological examinations, especially for patients who report new or worsening cognitive symptoms.

Treatment Options

The advisory reiterates that long COVID is not a single disorder but rather a constellation of symptoms that requires a comprehensive treatment plan. An interdisciplinary approach integrating mental health with primary care is therefore optimal.

Because long COVID can become a life-altering chronic condition, the advisory suggests approaching patients as if they’re experiencing trauma. A trauma-informed approach emphasizes trustworthiness and individual empowerment.

Recommended interventions, which may call for referrals, include

· Peer support groups

· Physiatry

· Psychotherapy

· Occupational therapy

· Neurorehabilitation

· Prescription medication

· Speech therapy

· Substance use disorder referrals

“I think the advisory will help to inform clinical practice,” said Gunning, who is also the vice chair for research of Weill Cornell Medicine’s Department of Psychiatry and the director of the Weill Cornell Institute of Geriatric Psychiatry. “However, there are significant barriers to accessing interventions, including insufficient number of providers, stigma, and weak efficacy of many available cognitive interventions.”

The Upshot

Despite the recommendations, there are still many unknowns surrounding long COVID. Although it can be difficult to gauge whether someone’s mental health symptoms are because of long COVID or broader issues, the advisory highlights the importance of treating the symptoms as well as any comorbidities and monitoring patient progress.

To mitigate misdiagnoses, the advisory suggests that clinicians become familiar with the full range of long COVID symptoms. They should also be careful not to dismiss reported symptoms as exaggerated or psychosomatic, which may discourage patients from seeking further care. Instead, individual experiences should be validated. And while it’s important to acknowledge that a patient’s prognosis may be uncertain, clinicians should help set realistic goals for recovery and provide hope for improvement.

“As a society, there’s pressure to move on from talking about COVID, and I think even as physicians, there’s a desire to move to a post-COVID era,” Perlis said. “But this is a reminder that there are a lot of people who still have long-lasting effects of the illness and that some of those effects, unsurprisingly, are related to the brain.”


Article Information

Published Online: July 26, 2023. doi:10.1001/jama.2023.13605




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