Continuing our series, Dr Peter Bagshaw discusses presentations of deteriorating mental health after Covid
Mental illness as a result of the pandemic
We know that the last year has had a huge impact on people’s mental health. Many studies show a similar picture: in one,1 over half of the adult UK population reported feeling anxious because of the pandemic. Just over one in five of the UK adult population reported feeling hopeless and almost a quarter (23%) reported feeling lonely. Another study showed a near-doubling of reported depression from 10% to 19%,2 and rates of eating disorder in young women have also soared. Disentangling the causes of new-onset mental illness can be very challenging. For most people, they will be the social implications of the pandemic, especially if affected by bereavement, loss of income, social isolation or any of the other well-publicised consequences of lockdown.
Mental illness as a long Covid symptom
Although the data are still emerging, there are early signs that Covid-19 has a direct effect on the brain, causing mental health effects. One study showed an overall incidence six months after Covid of 34% for mood disorders or anxiety, as well as rarer serious brain effects such as haemorrhage, stroke or dementia.3 It is becoming clear that Covid has many systemic effects, with inflammation and vascular damage likely to give long-term neurological sequelae. Again, this can be difficult to disentangle: is the anxiety a direct brain effect, or the result of long Covid and its physical and social consequences?
In addition, some people will develop PTSD from the acute effects of Covid – something I can personally attest to after oxygen levels of around 50% gave a feeling of drowning. For those admitted to ICU, all these after-effects are likely to be greater. Anxiety may also be the presenting symptom of a direct physical effect of Covid such as pulmonary embolism or heart failure. These are not rare complications: a JAMA study showed cardiac involvement in 78% of those recovering from Covid and ongoing cardiac inflammation in 60%.4 Oxygen saturations and a brain natriuretic protein (BNP) may help, but an urgent referral for a VQ scan or echocardiogram are sometimes the only way to be sure.
Differentiating between causes and effects
Given this very complex interplay of possible causations, when a patient presents to us with anxiety or depression following Covid, what can we ascribe to long Covid and what can we ascribe to pre-existing anxiety or depression that is aggravated by Covid? The answer is we cannot yet know. We can currently only treat the outcome, which will be the same regardless of the cause – though thinking about the causes may give insight into the different elements in play. However, it is crucial that we rule out physical causes arising from Covid, such as the cardiac and pulmonary conditions already described, and unrelated conditions such as anaemia or hyperthyroidism. We will all have seen patients whose apparent anxiety disappears once their low haemoglobin is corrected, and the reactive sympathetic overdrive resolves.
Treatment for long Covid-related mental illness
Psychological support is built into most long Covid clinics, which generally have access to the other investigations, although support varies from area to area. However, we can often treat our patients in the usual way without referral. If drug treatment is needed, an SSRI is the first line recommendation for both anxiety and depression;5,6 the same NICE advice states ‘do not offer a benzodiazepine…. except as a short-term measure during crises’.
Consider PTSD (see box). For those with PTSD, talking therapies are again the mainstay of treatments, whether trauma-focussed CBT or eye movement desensitisation and reprocessing (EMDR), a process in which the therapist aims to decouple memory and emotion by waving a finger from side to side. These should be available through the local talking therapies provider. The wording we use in such cases is crucial: we need to acknowledge the very real physical and social toll that Covid can take, while also offering help for the mental distress that arises from it. In general, distress arising from life events responds much better to talking therapies than medication, with CBT through your local provider being the first-line treatment with the strongest evidence base of benefit.8
|PTSD is a ‘memory filing error’ that can occur after any severely traumatic event. Although PTSD usually presents with anxiety it can also give rise to avoidance, hypervigilance, insomnia or emotional numbness.7 Consider PTSD in people reporting the following symptoms:|
• Re-experiencing a traumatic event, either through flashbacks or dreams and nightmares (the most common presentation)
• Negative self-perception
• Interpersonal difficulties
• Emotional dysregulation
• Dissociation — where a person feels disconnected from themselves or the world around them
• Emotional numbing — lacking ability to experience feelings, feeling detached from other people
• Negative alterations in mood and thinking
• Hyperarousal (including hypervigilance, anger and irritability)
• Avoidance of situations that trigger memories of the event
Source: NICE, When should I suspect post-traumatic stress disorder (PTSD)? October 2020 tinyurl.com/NICE-PTSD
Dr Peter Bagshaw is a GP partner in Minehead and Somerset CCG mental health and dementia clinical lead
1. Mental Health Foundation website mentalhealth.org.uk/
2. Covid’s mental-health toll: how scientists are tracking a surge in depression. Nature 2021;590:194-5 doi.org/10.1038/d41586-021-00175-z
3. Harrison P et al. Six-month neurological and psychiatric outcomes in 236,379 survivors of Covid-19: a retrospective cohort study using electronic health records. The Lancet Psychiatry 2021 doi.org/10.1016/S2215-0366(21)00084-5
4. Puntmann V, Carerj M, Wieters I et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (Covid-19). JAMA Cardiol 2020;5:1265-73 doi:10.1001/jamacardio.2020.3557
5. NICE. Generalised anxiety disorder and panic disorder in adults: management. 2011 (updated 2019) nice.org.uk/guidance/CG113
6. Covid-19 rapid guideline: managing the long-term effects of Covid-19 NICE guideline [NG188] Published: 18 December 2020
7. NICE. Post-traumatic stress disorder. 2018 nice.org.uk/guidance/NG116
8. Tolin D. Is cognitive behavioral therapy more effective than other therapies? A meta-analytic review, Clinical Psychology Review 2010; 30:710-20