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Infectious Diseases

Updated 26 May 2020

Depression, anxiety, PTSD may plague many Covid-19 survivors

In a number of pandemics, there have been associated behavioural health issues, not only short-term but also long-term.

The ordeal faced by critically ill Covid-19 patients likely won't end even if they pull through and survive their life-threatening infection, experts fear.

Some of these survivors will be emotionally scarred by their time spent in an intensive care unit (ICU), and they are at increased risk of psychological problems, such as anxiety, depression and post-traumatic stress disorder (PTSD).

"Unfortunately, I do think this is one of the expected unintended consequences of a pandemic," said Dr David Shulkin, a former secretary of Veterans Affairs and former president and CEO of Beth Israel Medical Center in New York City.

"In almost every other pandemic that's been studied, there have been associated behavioural health issues that have been not only short-term but long-term in standing, and this one is no different," Shulkin said during a HealthDay Live Stream interview.

Shulkin noted one study from Wuhan, China, in which more than 700 Covid-19 patients were given a standardised test for symptoms of PTSD.

"Over 96% of those respondents indicated they were suffering from post-traumatic stress," Shulkin said. "I do think this is something we have to give serious evaluation to and make sure we are addressing these issues."

Severely ill Covid-19 patients often require mechanical ventilation to maintain their breathing as the virus ravages their lungs. The procedure keeps them alive, but ventilation is a nightmarish experience.

Lingering trauma

A ventilated patient cannot talk or eat. The tube down their throat causes coughing or gagging. Many are heavily sedated to keep them comfortable and prevent them from "fighting" the ventilator by trying to breathe on their own, according to the American Thoracic Society.

About one-quarter of patients on a mechanical ventilator end up developing PTSD, said Dr Udit Chaddha, an interventional pulmonologist with Mount Sinai Hospital in New York City. As many as half suffer symptoms of depression afterwards.

"It is not a benign thing," Chaddha said. "There are a lot of side effects."

The numbers Chaddha cited are similar to the results from a 2018 British study of nearly 5 000 ICU patients.

About 46% of patients developed symptoms of anxiety, 40% reported depression and 22% had problems related to PTSD within a year of their discharge from the ICU, according to the findings published in the journal Critical Care. Nearly one in five patients appeared to suffer from all three psychological conditions.

The British study also found that former ICU patients with depression were 47% more likely to die within two years of leaving the hospital, compared to those without.

There's also some concern that the Covid-19 coronavirus itself might cause neurological or psychiatric problems, said Dr Joshua Morganstein, chair of the American Psychiatric Association's Committee on the Psychiatric Dimensions of Disasters.

Neurological symptoms

"There certainly are many infectious illnesses that have associated with them the development of temporary or permanent neuropsychiatric symptoms that can range from things like mood changes to confusion or cognitive impairment to pain or fatigue," Morganstein said.

One example is Lyme disease, a tick-borne bacterial infection that can cause mental fogginess, anxiety, depression, sleep disorders and mood swings, according to the International Lyme and Associated Diseases Society.

"Because this [Covid-19] is a novel infectious disease, it will be important for us to be open to investigate and to better identify the degree to which people who recover from this infectious disease may also experience some of those symptoms," Morganstein said.

Further, Covid-19's high degree of infectiousness hampers the sort of close emotional support that can help people avoid mood disorders after traumas, Morganstein added.

Family members are barred from visiting seriously ill Covid-19 patients, lest they contract the virus themselves. Even during recovery, they are asked to isolate themselves from others.

"We know that social connectedness is one of the most protective things people can have against the effects of trauma," Morganstein said.

Nurses, doctors help ease the trauma

Some hospitals are trying to help patients stay connected with family through technology, using apps like Skype and FaceTime, "so people can see and hear their loved ones – not necessarily in the way that is most ideal, but that for many people can diminish their sense of feeling isolated," Morganstein said.

ICU workers decked out in full personal protective gear – mask, gown, gloves – can be intimidating and hard to understand for patients confused by Covid-19 symptoms like fever, headache and cough, Morganstein added.

"When a person's body and mind are trying to respond to and manage a severe infection, this can be disorienting and fatiguing," Morganstein said. "Healthcare workers should take their time when they are talking to articulate clearly and speak in a gentle but audible manner to patients, to help ensure the patients understand what is happening."

Health care workers and family members should keep an eye on recovering Covid-19 patients for any signs of depression, anxiety or PTSD, Shulkin said.

Former patients "certainly deserve evaluation by a professional, should those symptoms continue to be present," Shulkin said.

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