With more than 24 million people in the U.S. having been infected with COVID-19 to date, it's an unfortunate truth that, for those lucky enough to have survived, this virus can have negative health effects that last long after recovery. Stories have emerged of people experiencing a lingering cough, fatigue, and pain, among other issues. Some former COVID-19 patients can even struggle with mental health issues.
"COVID-19 can also impact the brain," says Rajeev Fernando, M.D., an infectious disease doctor working in COVID-19 field hospitals around the country. "In my experience treating patients, the mental health issues after having COVID-19 are a pandemic in and of itself — we just haven't had time to focus on it."
This is not something that just impacts a tiny subset of people: Research published in The Lancet Psychiatry in November analyzed data from the electronic health records of 69.8 million people in the U.S. — including more than 62,000 diagnosed with COVID-19 — and found that nearly 20 percent of coronavirus patients developed a mental health issue such as anxiety or depression within three months of their diagnosis. And compared to those patients studied who struggled with other health issues (i.e. influenza, gallstones), those who contracted COVID-19 were twice as likely to be diagnosed with a mental health disorder.
But...why? And what can you do if you are infected with COVID-19 and experience mental health issues during or following recovery?
Why COVID-19 May Affect Mental Health
"With any physical illness or virus, there is always going to be some link with mental health," says infectious disease expert Amesh A. Adalja, M.D., senior scholar at the Johns Hopkins Center for Health Security. And COVID-19 is no different. And, as it's become increasingly more evident, COVID-19 is no different. Simply being diagnosed with such a novel virus can cause a deluge of stress and distress, nevermind having to isolate away from friends and family, which can also lead to anxiety and depression. (Related: How to Deal with Health Anxiety During COVID-19, and Beyond)
And, with SARS-CoV-2, the virus that causes COVID-19, "there may [also] be a direct effect of the virus on the brain," says Dr. Adalja. In fact, research published in the journal Nature Neuroscience in December 2020 found that SARS-CoV-2's spike protein can cross the blood-brain barrier (which essentially acts as a shield, allowing nutrients to reach the brain while keeping toxins or pathogens out) in mice. And, since the spike protein can enter the brain this way, it's likely the virus can, too, according to the researchers. That being said, more research is needed on human subjects before making any definitive links.
How the virus impacts the brain, though, is unclear at this point. "We don't quite understand all of the central nervous system effects of COVID-19, including on the brain," says Dr. Adalja. "With some mental health effects, we're also trying to understand if they're [directly] related to SARS-CoV-2 or just living through a pandemic in general."
Some people may also experience mental health issues as a result of having had a virus that's dominated headlines and completely altered society for the better part of a year, says Lily Brown, Ph.D., director of research at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine. So while, yes, recent findings suggest the virus might be able to enter the brain, it's also possible that simply having a virus that's so novel and destructive can impact your mental health more indirectly. (Related: What Are the Psychological Impacts of Social Distancing?)
Experts are still trying to figure out the why and how the coronavirus impacts mental health, but they've already established a shortlist of specific disorders that might arise post-COVID-19 infection.
Mental Health Concerns Linked to COVID-19
There is unfortunately a long list of mental health problems linked to having COVID-19. These are some of the most common as of now.
Delirium and Post-Intensive Care Syndrome
In general, several studies have found that patients who are in the intensive care unit are already at a higher risk than other ill people of developing delirium, which is an abnormal mental state that usually causes confusion. But research has found that those who are put on a mechanical ventilator are at a much higher risk of developing delirium — up to 80 percent, according to a study published in the journal Intensive Care Medicine. (It's likely due to a combination of the use of certain sedatives, disturbed sleep patterns, and other factors, according to the researchers.)
Typically, the delirium gets better as a patient improves physically, but there is also a higher-than-normal risk of developing what's known as post-intensive care syndrome, says Dr. Adalja.
PICS can encompass a range of physical, mental, and psychological health issues after a critical illness or time spent in intensive care, according to the Cleveland Clinic Journal of Medicine. And while the condition isn't unique to COVID-19, the major risk factors of developing PICS include delirium, prolonged mechanical ventilation, and acute respiratory distress syndrome — all of which can be brought on by severe cases of COVID-19. In fact, recent research suggests that those who had severe cases of COVID-19 are at a high risk of developing PICS, likely due in part to being on mechanical ventilation for longer time periods than patients who require ventilation for reasons other than coronavirus.
While delirium is often short-term — ending within a few days, says Dr. Adalja — there's no hard and fast timeline for how long PICS can last. For some, it can be months; for others, years. And the odds of developing long-term cognitive difficulties are high. In fact, anywhere from 8 to 57 percent of PICS patients experience mental health impairments such as anxiety, depression, and post-traumatic stress disorder long after being discharged, according to the Cleveland Clinic.
Difficulty focusing can actually be a clue that a COVID-19 survivor is struggling with an anxiety or depressive disorder, says Brown. "We know, across the board, that people are at an elevated risk right now of anxiety and depression — having lived through a COVID-19 infection can increase that," she says.
But even if a survivor isn't struggling with anxiety or depression, Brown says the financial fallout of having the virus can lead to trouble focusing. "People who have contracted the virus are out of work for weeks and may struggle with an increased risk of job loss and trouble paying bills," she explains. "The stress from that can lead to problems concentrating."
As for how long brain fog can last, there's no real data on this, but Dr. Fernando says that, in his experience, it usually continues for about three weeks.
Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder is a mental health condition that can occur in people who have experienced a shocking, scary, or dangerous event, according to the National Institute of Mental Health (NIMH). "Having COVID-19 qualifies [as all of these]," according to Brown. Coronavirus survivors are thought to be at a high risk of developing PTSD, according to an article published in the journal, Global Health Research and Policy.
Research on PTSD and coronavirus is ongoing, but one study of more than 700 COVID-19 survivors in Wuhan, China, found that more than 96 percent of those patients had "significant" symptoms of PTSD. Their situation may have been slightly different than those many Americans experience — in Wuhan, for example, people with the virus were separated from their families and sent to quarantine centers — but plenty of Americans may still struggle with PTSD tied to COVID-19, explains Brown. The disorder can manifest in many different ways, including fear of doctors or hospitals, avoiding leaving the house, and nightmares, she says. Symptoms typically appear within three months of the traumatic event but can show up later. Without proper treatment, symptoms can linger indefinitely, adds Brown. (Related: How Trauma-Informed Yoga Can Help Survivors Heal)
Depression and Anxiety
Going through a serious illness and the stress that comes with it, can spark depression and anxiety, explains Brown. Studies have repeatedly linked anxiety and depression to having COVID-19. Case in point? A recent survey of more than 759 Ecuadorian men and women between ages 27 and 49 found that those who eventually had confirmed COVID infections were more likely to develop mild, moderate, and severe symptoms of both anxiety and depression than those who tested negative. In another study, 402 COVID-19 survivors with a mean age of 58 filled out questionnaires about their mental health one month following hospital treatment: Thirty-one percent reported symptoms of depression, 42 percent of anxiety, 28 percent of PTSD, 40 percent of insomnia, and 20 percent of obsessive-compulsive [tendencies]. (Some patients self-reported experiencing more than one psychological difficulty.)
The same study of previously hospitalized COVID-19 survivors found that 40 percent reported struggling with insomnia a month after returning home.
"We know that when people have problems with structure in their life, sleep can have a major decline," says Brown. And, even on a very basic level, some of the physical symptoms of COVID-19 can impact sleep — coughing, trouble breathing, and shortness of breath, all of which can last long after recovering from COVID-19.
"People that experience those sleep problems are also at a higher risk for developing depression and anxiety," notes Brown, suggesting this lingering effect can be part of a vicious cycle of COVID-19 recovery.
How to Treat Mental Health Problems Following a COVID-19 Infection
First, check in with your primary care physician, recommends Dr. Adalja. "Talk about what's going on and see if they think you need to see a psychiatrist or psychologist," he says. Another option is to seek out a mental health professional directly via online resources such as practitioner directories on Psychology Today, Therapy for Black Girls, and American Psychological Association. (Need a little more guidance: Here's how to find affordable mental health care based on your insurance situation.)
The treatment around mental health issues related to having COVID-19 is more about treating that specific issue vs. an overarching post-COVID treatment, explains Brown. Meaning, your doctor will likely recommend standard methods of psychotherapy such as talk therapy, cognitive-behavioral therapy, and perhaps medication.
Keep in mind that it might take time to find the right mental health provider, cautions Brown. "There's such a need for mental health services right now that it can be hard to get through the door," she says. But don't let that deter you from getting help. Brown's advice? "The more people you can connect with to explore your options, the better."