Psychiatry Patients With Long COVID-19 Need Team-Based, Coordinated Care

Since the onset of the COVID-19 pandemic, there has been a significant focus on the psychiatric and neurological complications of SARS-CoV-2 infection. Although recent data suggest that approximately 18% of patients who had a SARS-CoV-2 infection develop a psychiatric diagnosis between 14 and 90 days after infection, long-term data show that approximately 1 in 3 COVID-19 patients experience either a neurologic or psychiatric disorder six months after infection. The postacute sequelae of SARS-CoV-2 are increasingly recognized and include both physical and mental health symptoms, as well as the impact on quality of life and functioning, according to Ani Nalbandian and colleagues in an article posted March 22 in Nature Medicine. While those with more severe initial COVID-19 infection may be at higher risk of postacute sequelae, individuals with more mild to moderate initial presentations can also experience prolonged symptoms.

The increasing awareness of long COVID symptoms has significant implications for consultation-liaison psychiatrists working in integrated care models within primary care and specialty settings. The following case summarizes the complexity and the important role of psychiatrists in the assessment, support, and long-term management of long COVID symptoms.

Case Study

Ms R was a 30-year-old teacher with a history of major depressive disorder that had been in remission for the past three years. She was referred to outpatient psychiatry by a local COVID-19 recovery clinic. Ms R was infected with COVID-19 three months prior to the referral and had moderate flulike symptoms and did not require hospitalization. Ms R reported that she never fully recovered following her acute illness and continued to have lingering symptoms of extreme fatigue, muscle aches, palpitations, and shortness of breath on exertion. Because of her protracted symptoms, multiple referrals had been made including pulmonology, cardiology, neurology, physiatry, and behavioral health.

On evaluation via telemedicine, she described functioning poorly and being mostly homebound since her infection and unable to return to work. Her psychiatric symptoms of low mood, anhedonia, poor concentration, low motivation, psychomotor retardation, poor appetite, and sleep disturbances were consistent with a relapse of major depressive disorder. Ms R also described significant cognitive symptoms including inability to focus, forgetfulness, headaches, and feeling “out of it.” She did not report any drug or alcohol use and was not taking any psychotropic medications at the time of evaluation.

After initial evaluation, Ms R was started on a selective serotonin reuptake inhibitor to target her depressive symptoms, and this was titrated to a therapeutic dose. Psychotherapy and physical therapy were also recommended. She continued to follow up with the different specialists, and extensive workup by the cardiology, neurology, and pulmonology services was unremarkable. Over the next several months, Ms R showed slow but steady improvement in mood and overall functioning. With the help of intensive physical therapy, Ms R’s exercise tolerance improved, and she was able to resume most of her daily activities. She continued to follow up regularly with outpatient psychiatry for ongoing support.

Psychiatry’s Role in Long COVID Care

Recently published guidelines and literature highlight the importance of a patient-centered approach to care for those with long COVID, according to Robin Gorna and colleagues in the February 6 Lancet and Alice Norton and colleagues in the May 1 Lancet. This includes assessment of psychological and psychiatric symptoms, connection with appropriate community resources for mood and anxiety issues, and involvement of C-L psychiatric services for more complex presentations with co-occurrence of both mental and physical health symptoms.

Numerous mental health symptoms are associated with long COVID-19, and our understanding is evolving as we learn more about this condition. These include depression, heightened anxiety, fatigue, poor concentration, and insomnia. While some of these may be related to direct neurological impacts of the SARS-CoV-2 infection, others may be more related to the stress and isolation associated with the pandemic and having prolonged, severe illness. Attempting to parse which symptoms are “organic” and which are “psychiatric” risks further siloing and separation of physical and mental health. Instead, it is important to take an integrated and holistic approach to supporting patients with these issues, using our full repertoire of appropriate biopsychosocial interventions.

Because of the long-term functional impairment and complexity of long COVID-19 symptoms, patients with these persistent symptoms require a team-based approach with clear care coordination and planning, outlining interprofessional team members’ roles and responsibilities. Psychiatrists and mental health clinicians need to work collaboratively with patients, primary care professionals, specialists, and other health care professionals to ensure that care is integrated and focused on rehabilitation and functioning. ■