Mental Health Manifestations of PASC

Please Note: The information below is intended for healthcare professionals, specifically primary care providers. These are not meant to be guidelines or supplant individual provider discretion in the management of PASC, as evidence-based consensus guidelines for the diagnosis of management of this new disease do not exist currently. The following represents the expert opinions of an interprofessional group that is appraising emerging evidence and should be interpreted as recommendations and clinical guidance rather than the standard of care.

Mental Health Manifestations of PASC

Written May 12, 2021 by: Faith Noah, MS3, Donna Shanor, LCSW-S, LCDC, Matthew Seghers, MS3, and W. Michael Brode, MD

Survivors of COVID-19 have high rates of depression, anxiety, and PTSD. All patients with PASC should be screened for mood disorders using standardized assessments such as the PHQ-9, GAD-7, or PC-PTSD-5.

Treatment of mental health comorbidities is no different for PASC than for patients with other medical comorbidities. Medications like SSRIs/SNRIs should target patients’ symptoms and preferences, coupled with counseling using evidence-based therapies like cognitive behavioral therapy (CBT) with a psychologist or licensed clinical social worker (LCSW).

Since many of the physical manifestations of PASC lack evidence-based or curative therapies, establishing an empathetic and validating relationship is essential to help patients cope with the anxiety, stress, and hopelessness associated with the illness.

Preliminary research suggests COVID-19 survivors are at an increased risk for adverse psychiatric outcomes. For many patients this is a new diagnosis following the illness, but many have exacerbations of underlying conditions, all superimposed on a national mental health crisis from the psychological stress of the COVID-19 pandemic.

  • Among survivors without a prior psychiatric history, COVID-19 infection was associated with an increased incidence of a psychiatric diagnosis; 6% of COVID survivors had a first psychiatric diagnosis within 90 days of illness, double the rate of comparison groups. This increased incidence was seen most notably with anxiety disorders, insomnia, and dementia.
  • Receiving a psychiatric diagnosis in the past year was associated with a higher incidence of COVID-19 infection, this suggests that behavioral, socioeconomic, and lifestyle factors contribute to risk, although their association with PASC is not clear.1

Neurotoxic and immune-mediated effects have been demonstrated in COVID-192,3; thus, mental health manifestations could be the result of organic effects intersecting with psychological stress, heightened from chronic illness and anxiety/isolation of the pandemic.4

COVID patients who undergo ICU hospitalization have an increased risk for ICU-related psychiatric and cognitive effects.

  • Amid those who experience Post-ICU syndrome, non-COVID literature estimates that 40% experience depression and 30% experience PTSD in the first year after hospitalization.5,6
  • The trauma of a severe medical event coupled with long-term symptom persistence can exacerbate mental health problems.

Standardized assessments should be used to screen/diagnose psychological disorders associated with the post-infection state:

  • PHQ-9 for depression: used to screen for depression, quantify and monitor symptoms, and aid in clinical diagnosis
  • GAD-7 for anxiety: screens for clinically significant anxiety disorders
  • PC-PTSD-5 or IES-6 for post-traumatic stress disorder: used to screen and make an initial diagnosis of PTSD in primary care setting

Mental illness is strongly associated with the social determinants of health (e.g., poverty, discrimination, housing insecurity),7 so we also recommend evaluating whether patients’ basic needs are met with a detailed social history or standardized assessment like the PRAPARE tool.

Rule out substance use, alcohol misuse, and exacerbation of pre-existing psychological disorders.

Assess for the following:

  • Patient-identified most pressing concern
  • Severity of symptoms (using an objective measure like the tools above)
  • Current coping skills
  • Psychosocial factors contributing to mental health and current symptoms

Physicians, in consultation with a clinical social worker, should determine the need for:

  • Psychiatry consultation: although anxiety, depression, and PTSD are commonly managed in primary care, referral may be indicated for a newly diagnosed or uncontrolled psychiatric disorder requiring medication management, especially if there are severe, atypical, or psychotic symptoms.
  • Change in medications: mental health diagnoses should be treated with existing evidence-based therapies. There is no current evidence to support specific agents for PASC.
    • Medication selection should focus on side effects and patient preferences, we suggest using the Mayo Clinic Depression Medication Decision Aid. Some experts have also recommended using medications to target specific symptoms, for example using an SNRI like duloxetine for concomitant pain, or fluoxetine for fatigue or “brain fog” symptoms since it has a more energizing effect compared to other SSRIs.
    • The use of fluvoxamine is being studied in acute COVID-19 infection for its potential anti-viral properties, and some experts have argued there are theoretical benefits for it to be the preferred SSRI for longer term symptoms8,9 despite the lack of evidence.

Patients should be referred to psychotherapy with an LCSW or other mental health professional:

  • Therapy can augment medication management of psychiatric disorders and improve retention in care.
  • Independent of psychiatric diagnoses, evidence-based therapeutic techniques like CBT can improve coping skills, build resilience, and support overall mental well-being of patients amid COVID-19-related stressors.

In treating COVID-related mental health conditions, it is important to take a patient-centered approach, building therapeutic relationships and validating patients’ experience of symptoms.

  • Educate patients on the overlap in symptoms of PASC and mood disorders and how exacerbation of either can worsen symptoms.
  • Connect patients to PASC community (support groups, social media groups), such as the Survivor Corps website.

1. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry. 2021;8(2):130-140. doi:10.1016/S2215-0366(20)30462-4

2. Leung TYM, Chan AYL, Chan EW, et al. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 9(1):2190-2199. doi:10.1080/22221751.2020.1825914

3. Holmes EA, O’Connor RC, Perry VH, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry. 2020;7(6):547-560. doi:10.1016/S2215-0366(20)30168-1

4. Mukaetova-Ladinska EB, Kronenberg G. Psychological and neuropsychiatric implications of COVID-19. Eur Arch Psychiatry Clin Neurosci. 2021;271(2):235-248. doi:10.1007/s00406-020-01210-2

5. Hatch R, Young D, Barber V, Griffiths J, Harrison DA, Watkinson P. Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study. Crit Care. 2018;22(1):310. doi:10.1186/s13054-018-2223-6

6. Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293-1304. doi:10.1056/NEJMoa1011802

7. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020;370:m3026. doi:10.1136/bmj.m3026

8. Sukhatme VP, Reiersen AM, Vayttaden SJ, Sukhatme VV. Fluvoxamine: A Review of Its Mechanism of Action and Its Role in COVID-19. Front Pharmacol. 2021;12. doi:10.3389/fphar.2021.652688

9. Lenze EJ, Mattar C, Zorumski CF, et al. Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA. 2020;324(22):2292. doi:10.1001/jama.2020.22760