Behavioral Health Management in Long COVID | Unraveling Long COVID Care

Behavioral Health Management in Long COVID | Unraveling Long COVID Care

um so I’m going to be talking about behavioral health management and longcoid care um my name is Tyler Preswood i’m an MD PhD i completed my MD and PhD here at Stanford um from a research angle I have had experience working on deni virus about 20 years ago i started in the lab working on that um and looking at imunopathogenesis there and then during my PhD worked on cancer imunotherapy and helped develop some new treatments that we’re hoping will make it to the clinic one day um and then through my clinical rotations got very interested in psychiatry and unanswered immune questions in psychiatry and how that connects with um psychiatric disease uh how the immune system plays into that um so I’ll be kind of touching on some of the areas I’m particularly interested in but um I do have this talk pretty predominantly focused on the psychiatric experience of patients and what it’s been like for me in helping manage um the psychiatric um ramifications of of having long CO um so I have no disclosures to mention um but so I I work as both um a clinician and then as an immunologist researcher uh I work with PJ UTS and um study generally the like post-infectious consequences um and impact on psychiatric illness as well as general immune um dysfunction that happens after viral infections um and then also attach that to primary psych psychiatric illnesses as well um so for today’s talk uh I’ll be focused on what the psychiatric spectrum is in long co and how to how to recognize those features and then what um what kind of plays into that biologically as far as what we understand um and then as I mentioned before understanding the psychologic impact of long co the way that it plays out in people’s lives um and then what what the barriers are to obtaining mental health care and then last I’ll I’ll review the evidence um based or the evidence-based approaches is to treating the psychiatric complications of long co um so for for me um just generally I’ve I’ve only seen really maybe a handful of patients long term with longcoid but have done some short evaluations with people when there’s a concern for um psychiatric pathology um so looking broadly uh this is a study from 2023 published in frontiers that shows the overall prevalence of psychiatric diseases and symptoms um comparing longcoid to overall world prevalence so on the right hand side uh it lists the the world prevalence uh median p value here um of depression anxiety you know sleep disturbances PTSD and cognitive impairment and as you can see this is relatively low um incidence but the criteria used to to report these were were quite stringent um but about 4% for most of these illnesses at any given time is the prevalence um and then down to 1% with cognitive impairment however when you compare to people with long COVID in general it’s closer to 20% for all of these different um pathologies which is I think very very important in thinking about the the patient experience of having long co and it’s important to note that a lot of these illnesses are are quite non-specific and they have overlapping symptoms with longcoid including fatigue cognitive dysfunction attention issues memory deficits and then sleep disturbances um whether whether that’s not being able to sleep or or sleeping excessively um so to a word about the path the pathogenesis in general of of what’s understood about anxiety and depression and how that compares to longco um the there are a lot of diseases um that I’m very interested in that have this low-grade inflammatory signature which often includes CNF alpha lowgrade TNF alpha elevations in the periphery as well as IL is 6 and CRP we don’t really know what causes this and it’s it shows up in a lot of different diseases um but it’s not the same thing as when somebody is in septic shock and has really high elevation of these parameters it it is a chronic lowgrade level that just tends to be on the higher side um and we know that shows up in longcoid patients shows up in people with depression shows up in people with severe mental illness as well as many other um metabolic diseases as well um and then in terms of what’s known from big biological studies uh one of the one of the best predictors of whether or not somebody or one of the best differentiators between people who have long COVID and people who get SARS COV2 infections and recover are the levels of cortisol um and those are reduced typically in people with long COVID in depression and anxiety those are fluctuating and and distinct from healthy controls but um it’s it doesn’t it doesn’t show the exact same correlation there uh and then in terms of the more skep or speculative side of this slide um there are mechanisms of neuroinflammation and microgle activation that are thought to maybe result in pathogenesis and it’s known that hippocample neurogenesis is a problem in depression and it’s been speculated that too is an issue in longcoid um and that the results of this inflammation drive these differences in synaptic plasticity the maintenance of synapsis particularly in hippocampus which is a very active area in the brain for neurogenesis in adults um and then the downstream effect of that is believed to be working through neurotransmitter differences um the changes in levels of dopamine epinephrine norepinephrine result in in this pathogenesis and and exist in a cycle um and then in terms of the screening tools that are important probably most people are familiar with these but just to review um using a PHQ9 is a good way um for general providers to identify if somebody has psychiatric needs related to depression if somebody has for like reference if somebody has a score over a 12 or 15 that range it it might be a good reason to talk about um getting psychiatric referrals or getting psychiatric care if somebody’s open to it and then similarly doing suicide assessments is always very helpful um GAD 7 is an analogous tool it’s used for anxiety and same with PCL5 with PTSD and then Promise 10 looks more globally at how people are kind of coping with and perceiving um the the impacts on quality of life that they may be dealing with um but important considerations here again a lot of psychiatry is very non-specific um and so just thinking about the physical symptom overlap of all these conditions with the um longcoid pathogenesis the fatigue brain fog sleep disturbances headaches muscle aches all um can go with basically any of these illnesses depending on how they’re affecting an individual and then a word about um kind of how patients experience in seeking um diagnoses and and being kind of referred to mental health care and the way that that is done um there’s a study showing that people with POTS who later received a diagnosis of POTS prior to getting that diagnosis were told um you know almost four out of five were told that they had a primary psychiatric issue when we know that POTS does have this major biological component too and also affects people’s um psychological health um but then after they have a diagnosis of POTS that they aren’t told this as much so I think it’s an important thing to think about as as a provider um like as people are coming through do do we believe that this person is suffering from a primary biologic illness um and if so how do we frame that for them um and then to touch on specific quotes I’ve had from patients that have left me um kind of you know thinking a lot about these things that have stayed in my memory that have affected the way I’ve perceived people’s experience with longco um one patient was telling me that uh I’ll just read the quote directly this thing has eaten into my mind i have this sense that either I’ve lost the plot or everyone else has and this is a person who was otherwise very healthy until they got co 19 and then had this huge change in their life and it it really took away a lot of their agency to be free in their life and to um exist socially the way that they wanted to divided relationships for them um and then another quote long co is like being hunted by a monster um which again is from an adult who had had gotten this kind of after living a very healthy life then this comes in and now it’s factored into a lot of their social decisions work decisions um their relationships um then another one just the touching on the issues of identity and um agency in general to have control over one’s life um I was asking you know what what’s your understanding of what long co is and I was thinking about it very biologically as I do um they said it’s more of a political or societal idea i was victimized lied to and stolen from and I’ve been kicked down into a prison um which which really spoke to me as you know this is this is this is his life um and then the last was from a female patient um when we were talking about her seeking disability she says “I worry that other people don’t think my symptoms are real and then I worry that my symptoms aren’t real.” And I think all of these speak to that psychological impact that and a lot of this is secondary right and I’ve also touched on the primary um biologic impact but I think it’s really important to remember this is this is where people are often coming from um and then as I mentioned before there are both direct and indirect impacts on um mental health of of long COVID and just to touch on the things that are believed to be the the major determinants of happiness for people economic security social relationships physical health freedom to make life choices uh generosity social cohesion and then trust in institutions and society and I’d argue that for a lot of people with long co all of these can be compromised depending on the person and how this has affected their life um so it makes a lot of sense that there would be you know both direct and indirect impacts on uh mental health um so this slide kind of follows from all that why do people have trouble getting into psychiatric care one of those things is is the stigma about mental illness this is generally an issue in psychiatry but um particularly with an an invisible illness that is suddenly come in and taken away somebody’s quality of life this is a big factor um and and often um for people this this gets reinforced by their experiences in the medical system um and I think in general you know as doctors we tend to focus more on physical symptoms more things that are measurable so we can look at treatment responses and that’s I think very fair but at the same time I think sometimes the the mental health component can be a bit um not not a major focus of things and then as I mentioned before invalidation of people’s experience trying to navigate the health care system and then the resultant distrust in the medical establishment um when people feel like their symptoms aren’t taken seriously or um you know their mental health considerations aren’t really an important consideration um so then to go through the evidence-based treatments um we know from from various trials that for treating depression anxiety primarily um SSRIs and SSRIs work very well um and generally are very well tolerated in longco specifically uh personally have seen benefits beyond mood and anxiety with SSRIs and SNRIs um where people do have a pretty big improvement in quality of life and even physical symptoms um and then uh using medafanil can be very helpful for some people with fatigue other people I’ve had no response um and then melatonin is also really helpful in sleep regulation uh and then center column are um different treatments that are more psychological based therapy based um kind of CBT adapted treatments for fatigue with graded activity and scheduling and pacing and then mindfulness-based stress reduction very important in general in physi uh in mental health well-being uh and then some kind of more exciting treatments over on the right that are novel and um active sources of investigation and I know used by the um clinic here at Stanford as well both the lowdose nrexone and lowdose ailify but also um starting to use TMS to treat brain fog which has some promising early results um and then wanted to touch on this study I found very interesting um this was uh done a couple of years ago uh it was given where people were given people with longcoid were given SSRIs so one of these four so fluoxamines or or fluoxitine all of which have a high higher index of sigma 1 agonism with the idea being that the anti-inflammatory elements of that sigma 1 agonism could be important in reversing some of the inflammatory components of longco um in this study I thought it was very interesting how they framed with patients that they were not giving these medications to treat depression but instead trying to treat the brain fog over stimulation or cognitive issues that come up in people with long co and what they saw was about a twothirds of the people had a pretty strong response to SSRIs um and in general I’d say I see a quite good response um with SSRIs in my patients as well um and then just to to wrap up I think the the mental health component of long COVID is really complex that there’s a fundamental biological basis for it and I think that’s an important thing to remind patients of um and then it’s really important in our job as providers to validate patients experiences and how how their disease impacts various aspects of their lives and then just want to end with like a hopeful message that for patients um we still really don’t understand the neuroscychiatric effects of COVID and and the long-term consequences of that but there are treatments that help and more advances are coming and getting mental health care is not an admission of of failure or neglecting physical symptoms but something to support people through really challenging experiences and with that I’ll pass it on to Dr lazaro thanks for your attention

Tyler Prestwood, MD, PhD
In this session, clinicians will learn about the psychiatric aspects of long COVID, including the significantly higher prevalence of conditions like depression, anxiety, and PTSD in affected patients. They will gain insights into the biological mechanisms linking long COVID and psychiatric disorders, as well as effective screening tools and evidence-based treatment options.

Additionally, the session will address barriers to mental health care and emphasize the importance of validating patients’ experiences while framing mental health support as an integral part of long COVID management.