Addressing the Unique Challenges of the Post-COVID Patient
Late in the summer of 2020, I began to notice a pattern among my patients. Those patients who had become ill with COVID-19, the illness caused by the SARS-CoV-2 virus, were showing some similarities. None of them required hospitalization, but weeks or even months after their illness, they were complaining of new symptoms. Many patients noted new insomnia, difficulties with concentration, and a chronic fatigue, even patients who had been stable on their medications for years. Notably, these patients did not report increases in anxiety or depression. Around this same time, researchers began to elaborate on a “post-COVID syndrome.”
Many viral illnesses are associated with postviral sequelae, and unfortunately, COVID-19 is no exception. Some people diagnosed with COVID-19 report postviral symptoms that last only a few weeks, but many others report symptoms that have lasted months, and still others continue to report symptoms that have not resolved. Documented issues with vascular damage to tissues and hypoxia (“silent” or not) have been proposed to be the root of some of these issues. Others have documented the clinical course of COVID-19 patients who were hospitalized and suffering from “post-ICU syndrome,” including symptoms of weakness, cognitive issues, and balance problems.
In understanding post-COVID syndrome, we can look at those who suffered from another coronavirus illness, Severe Acute Respiratory Syndrome (SARS). One study revealed that patients who recovered from acute SARS, which is caused by SARS-CoV-1, reported fatigue, depression, sleep and cognitive issues up to almost 2 years after infection. Another study revealed that 40% of those recovered from SARS continued to experience chronic fatigue up to 4 years after illness and 27% met criteria for chronic fatigue syndrome (CFS).
The Presentation of Post-COVID Syndrome
What we are noticing with post-COVID syndrome is a constellation of symptoms that resemble CFS or myalgic encephalomyelitis (ME). “Long-haulers,” as some post-COVID syndrome patients have referred to themselves, have been reported to experience insomnia, sleep disturbance, “brain fog,” and fatigue that persist weeks or months from onset of viral illness. This post-COVID syndrome may sound suspiciously like what we see in our patients with autoimmune disorders such as Hashimoto’s thyroiditis or multiple sclerosis or lupus. Indeed, several researchers have begun to theorize that post-COVID complications, including the severity of disease after SARS-CoV-2 infection, could be mitigated by “rogue” auto-antibodies.
This autoimmune-like presentation is what I have been seeing in my established patient population, and what I hypothesize will come to characterize many of our new patient evaluations in the coming months and years. We will start to see previously healthy individuals, with little to no previous psychiatric history, some in their 20s and 30s, some in their 40s or 50s, who will arrive in our offices with depression, anxiety, and perhaps post-traumatic stress disorder (PTSD) related to their illness or to their new symptoms of cognitive dysfunction, fatigue, and insomnia that occurred post-COVID infection. Some of these patients might have required hospitalization for their COVID illness and tell us that they believe their symptoms are related somehow to COVID-19. Others, and perhaps the vast majority, may not recognize their symptoms began after COVID (especially if their course of illness was mild or asymptomatic), and we will need to paint the clinical picture for them. I have started to ask all of my new patients about exposure to COVID, including timing and severity of disease course. I also do not exclude the possibility of a COVID infection in those who had a viral syndrome during the pandemic, but did not get tested for COVID, or whose COVID tests were negative (given the high false negative issues with our current testing). Patients with post-COVID syndrome generally notice that their symptoms have begun to interfere with their day-to-day functioning, to the point where they cannot return to work or complete activities of daily living due to severe fatigue, sleep issues, and inability to concentrate on or complete tasks. Some of these patients may be experiencing new onset depression and anxiety related to these symptoms, and they will be showing up in our clinics looking to us for help. In addition, new evidence suggests that those patients who already experience mental health issues are more at risk for COVID-19.