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Even as we’ve learned how to manage COVID-19 in the last few years with vaccines, boosters, and antiviral treatments like Paxlovid, researchers are still exploring the somewhat mysterious effects of long COVID — and its link to mental health.

Nearly eight percent of adults in the United States have long COVID symptoms. These are symptoms that last three or more months after first contracting the virus and are symptoms patients didn’t have before COVID-19, per the U.S. Centers for Disease Control and Prevention.

Your chances of developing long COVID may be associated with your psychological state, according to new research. In a September 2022 study published in JAMA Psychiatry, researchers analyzed 3,193 participants who had reported COVID-19 infection and found that depression, anxiety, perceived stress, loneliness, and worry about COVID-19 were associated with a 1.3- to 1.5-fold increased risk of self-reported post–COVID-19 conditions.

These factors were also associated with an increased risk of daily life impairment related to post-COVID symptoms.

The associations were still significant even after researchers adjusted for health-related factors. What’s more, researchers found a dose-dependent association: Participants who experienced high levels of two or more types of distress had a nearly 50 percent higher risk of post-COVID-19 conditions than those who did not experience a high level of distress.

Keep in mind that these results shouldn’t be misinterpreted to mean long COVID symptoms are psychosomatic, or caused by a mental factor. The researchers say that’s because of four key things:

  1. Among respondents who developed post-COVID-19 conditions, more than 40 percent had no distress at baseline.
  2. Symptoms of post-COVID-19 conditions differ substantially from symptoms of mental health (although fatigue and brain fog may occur with depression, other symptoms like smell and taste problems, shortness of breath and difficulty breathing, and cough are not common mental illness symptoms).
  3. More than 50 percent of patients with post-COVID-19 conditions report relapses triggered by physical activity (on the other hand, physical activity actually prevents relapse of mental illness).
  4. Results were similar when excluding participants who reported only psychiatric, cognitive, or neurological symptoms.

Inflammation and immune dysregulation may be the link between psychological distress and post-COVID-19 symptoms, according to the study researchers. Distress is associated with chronic systemic inflammation, which can result in the production of pro-inflammatory cytokines over time. This may cause respiratory, neurological, cardiovascular, muscular, and gastrointestinal long-haul COVID-19 symptoms.

Factors like autoantibodies, chronic immunosuppression caused by stress, and hypometabolism in the brain’s frontal lobe and cerebellum (which is associated with major depression and has also been implicated in post-COVID-19 fatigue) may also play a role.

“Other studies have found that people with long COVID have higher levels of inflammatory biomarkers or the presence of autoimmune antibodies,” says Siwen Wang, MD, lead author of the study. “Some people with depression or anxiety also have increased levels of inflammatory biomarkers and autoimmune antibodies, so these overlapping mechanisms might explain the main hypothesis we have linking psychological distress and long COVID.”

The researchers used data from three large ongoing study populations: the Nurses’ Health Study II, Nurses’ Health Study 3, and the Growing Up Today Study. They followed up with participants with surveys between April 2020 and November 2021. Limitations of this study include that the study population was predominantly white and female and had a significant proportion of healthcare workers (limiting generalizability).

Further research is needed to determine whether interventions that reduce distress can help prevent or treat post-COVID-19 conditions. This might include typical interventions such as anti-depression or anti-anxiety medications, therapy, and regular follow-ups, says Dr. Wang.

What Research Says About Long COVID and Mental Health

Long COVID has been linked to conditions such as depression, anxiety, insomnia, and brain fog in other studies as well.

For instance, one study published in The Lancet Public Health found that COVID-19 survivors who were bedridden for more than a week had a 61 percent higher risk for depression and 43 percent higher risk of anxiety than uninfected participants throughout the study period.

Meanwhile, a 2021 study published in Cardiovascular Diabetology suggests that long COVID is primarily caused by microclots that starve cells of oxygen. These microclots form around trapped inflammatory markers, which can lead to inflammation in the brain. Some experts believe this could explain the pathology of long COVID and associated issues like anxiety.

Sleep disturbances are also estimated to affect up to 50 to 75 percent of COVID-19 patients, per a 2021 review in the Journal of Personalized Medicine. Meanwhile, brain fog — the feeling of slow or sluggish thinking — occurs in an estimated 22 to 32 percent of patients who recover from COVID-19, per Harvard Medical School.

“Based on the available data and the patients with whom I’ve worked, the biggest mental health challenge for individuals, particularly those suffering from long COVID, has been the brain fog and mental fatigue,” says Samoon Ahmad, MD, clinical professor of psychiatry at NYU Grossman School of Medicine. “These symptoms can be crippling. Patients who are dealing with these challenges tend to feel overwhelmed and depressed, which only adds to the overall psychological burden of dealing with long COVID, as well as contributing to inflammation.”

In a study in the journal Nature, researchers looked at brain changes in 785 participants ages 51-81 whose brains were scanned twice (including 401 people who contracted COVID-19 between their two scans). They found evidence that COVID-19 can reduce gray matter in regions that control emotion and memory, causing the brain to shrink.

What’s more, a January 2022 study published in Brain Communications suggests that some people might not even realize they have problems with memory and attention after recovering from a mild case of COVID-19. In this study, performance on attention and memory tasks were poorer in participants who had COVID-19 compared to those that didn’t. However, these effects seemed to improve within six to nine months.

“Being in a distressed state — whether it’s due to anxiety, depression, loneliness, or just an extreme amount of stress — can lead to persistent inflammation throughout the body and in the brain and lead to improper digestion, disrupted sleep, higher levels of stress hormones, and imbalances in proteins known as cytokines, which are key players in our immune system,” says Dr. Ahmad.

This stress-induced, pro-inflammatory state can also lead to a dysfunctional immune system, which can make you more susceptible to long-term symptoms of respiratory tract infections like COVID-19 or even the flu, adds Dr. Ahmad.

Maintaining a Good Baseline of Mental Health

The experts we spoke to agree that, theoretically speaking, tending to your psychological health and practicing good mental hygiene could potentially lower your risk of developing long COVID. Taking steps to reduce stress means making healthy lifestyle choices, even if they may not seem closely connected to mental health. Just one example: Eating a well-balanced diet.

“Avoiding a diet composed of highly refined and processed foods and instead choosing fruits, vegetables, lean meats, and whole grains will help reduce inflammation — and there is evidence indicating that such a diet can reduce anxiety and depression, as well,” says Dr. Ahmad.

Other ways to reduce stress include getting restful sleep, exercising, and avoiding loneliness by being in the company of friends and family, adds Dr. Ahmad.

Loneliness is a major contributor to poor mental health. In fact, patients who struggle the most with their mental health after COVID-19 tend to be those who rarely leave home, says Serenity Serseción, PhD, a licensed psychologist based in Sunnyvale, Calif.

“Any way that people can go outside and interact with others in a safe way is best,” says Dr. Serseción. “The people who stay at home 24/7 tend to be more depressed and have lower energy. They’re not getting vitamin D from going outside and they tend to be more isolated.”

You can still be part of your community without putting yourself at risk for COVID-19. If you don’t feel comfortable gathering with others, start by chatting with friends on a video call, attending a drive-in movie (and staying in your car), or simply talking on the phone during a walk outside in your backyard or an uncrowded park.

“For some reason, just the act of not going outside seems to lead people to not reach out to others, even when they can use tools for interacting online or on the phone,” says Dr. Serseción.

There are also several popular apps that can help you keep your mental health at a healthy baseline. The UCSF Weill Institute for Neurosciences recommends the following apps:

“I think the experiences of the last two years have really driven home the point that you can’t separate the mind from the body when you’re treating a patient, because the two are constantly influencing each other in profound ways and have a reciprocal relationship,” says Dr. Ahmad.

What This Means for You

The link between mental health and long COVID is particularly important if you’re immunocompromised, because you may be more susceptible to severe COVID-19 and long COVID.

“If someone is in good mental health and taking care of themselves mentally and physically, even if they have a chronic health issue, they don’t tend to have as poor of a prognosis as someone who isn’t doing those things,” says Dr. Sercesión.

Of course, if you’re high-risk for severe COVID-19, the past few years have likely been particularly challenging for you. It may feel like everyone is “returning to normal,” while you continue to take every mitigation effort you can to avoid contracting COVID-19 — even if it means declining holiday parties or family gatherings.

You may be told to “just think positive!” or find yourself in a cyclone of negative thoughts. Neither is helpful: The key is to keep your mindset neutral.

“Even in mental health, thinking positively usually is not the solution,” says Dr. Serseción. “It’s best to think in a neutral way. Toxic positivity can be as harmful as being overly negative, so think about things realistically and have balanced thoughts.”

For example, you might think: “If I go outside, I might have a negative run-in with someone — but I also might not.” Keep in mind that staying balanced may involve spending more time with people who support you and spending less time with those who spread negativity or toxic positivity.

And, importantly, trust in yourself and the symptoms you’re experiencing. Just like with an underlying condition, even invisible symptoms of long COVID are very much real. “I think that sometimes people think, ‘Maybe I’m imagining all of this, maybe it’s not real,’” says Serseción. “But they are having real symptoms. There are things they can do to improve it, but not if they deny that something’s happening.”

The key takeaway: Keep in touch with your doctor about your symptoms, work to keep your mental health at a good baseline, and know that you deserve to address the symptoms you’re experiencing. 

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Brain fog: Memory and attention after COVID-19. Harvard Medical School. March 17, 2022. https://www.health.harvard.edu/blog/brain-fog-memory-and-attention-after-covid-19-202203172707

Douaud G, et al. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature. March 7, 2022. doi: https://doi.org/10.1038/s41586-022-04569-5.

Interview with Samoon Ahmad, MD, clinical professor of psychiatry at NYU Grossman School of Medicine.

Interview with Serenity Serseción, PhD, a licensed psychologist based in Sunnyvale, California.

Interview with Siwen Wang, MD, lead author of the JAMA Psychiatry study.

Magnúsdóttir I, et al. Acute COVID-19 severity and mental health morbidity trajectories in patient populations of six nations: an observational study. The Lancet Public Health. March 14, 2022. doi: https://doi.org/10.1016/S2468-2667(22)00042-1.

Nearly One in Five American Adults Who Have Had COVID-19 Still Have “Long COVID”. National Center for Health Statistics. U.S. Centers for Disease Control and Prevention. June 22, 2022. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220622.htm.

Pataka A, et al. Sleep Dysfunction in COVID-19 Patients: Prevalence, Risk Factors, Mechanisms, and Management. Journal of Personalized Medicine. November 14, 2021. doi: https://doi.org/10.3390/jpm11111203.

Pretorius E, et al. Persistent clotting protein pathology in Long COVID/Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin. Cardiovascular Diabetology. August 23, 2021. doi: https://doi.org/10.1186/s12933-021-01359-7.

Zhao S, et al. Rapid vigilance and episodic memory decrements in COVID-19 survivors. Brain Communications. January 19, 2022. doi: https://doi.org/10.1093/braincomms/fcab295.

Useful Wellness and Mental Health Apps. UCSF Weill Institute for Neurosciences. Accessed October 6, 2022. https://psychiatry.ucsf.edu/copingresources/apps.

Wang S, et al. Associations of Depression, Anxiety, Worry, Perceived Stress, and Loneliness Prior to Infection With Risk of Post–COVID-19 Conditions. JAMA Psychiatry. September 7, 2022. doi: https://www.doi.org/10.1001/jamapsychiatry.2022.2640.

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