While the pandemic era of masking and social distancing may seem a distant memory, for the estimated 15 million Americans dealing with long COVID — post-infection symptoms that linger for more than three months — life hasn’t returned to normal. This population has reported over 200 related ailments. Most common are fatigue, memory and concentration problems, and difficulty breathing. Unsurprisingly, the stress and discouragement of extended illness also cause anxiety and depression in many patients.
An editorial with long COVID guidance for family practice doctors appears in the April issue of the journal American Family Physician. It emphasizes the importance of a trauma-informed approach to care “that validates patients’ experiences, acknowledges uncertainty and avoids premature attribution of symptoms to a psychological cause,” said the essay’s lead author, Dr. Lindsey M. Knowles.
She is an attending psychologist in the UW Medicine Long COVID Clinic and assistant professor in the Department of Rehabilitation Medicine at the University of Washington School of Medicine.
“While many clinicians take the wide range of symptoms reported by patients with long COVID seriously, others may attribute them primarily to psychological causes. When symptoms are dismissed as ‘all in your head,’ this can be deeply invalidating and, in itself, harmful,” Knowles said.
She discussed approaches to managing anxiety and depression in patients with long COVID. This conversation was edited for clarity and length.
Q: If long COVID involves both physical and psychological factors, how might a patient navigate care to get both mind and body concerns addressed?
Knowles: Long COVID is a complex condition in which physical and psychological factors can interact. Depression and anxiety may emerge as part of the condition, but this should not lead to the assumption that symptoms are solely psychological.
To navigate care effectively, patients may benefit from tracking both physical and emotional symptoms over time and sharing this information with their care team. Clear communication about the full range of symptoms can help ensure that both medical and psychological needs are addressed. When possible, seeking care from clinicians or multidisciplinary teams familiar with long COVID may also support more integrated, whole-person care.
Q: Should patients with long COVID be screened for anxiety and depression?
Knowles: Yes, patients with long COVID should be routinely screened for anxiety and depression. These conditions are more common in people with long COVID than in the general population. They can have a real impact on daily life. Screening also helps identify more serious concerns, like thoughts of self-harm, so patients can get support as early as possible.
If a patient screens positive, that should open the door to a conversation about next steps. This might include medication, therapy such as cognitive behavioral therapy, or both. Just as important, mental healthcare should be part of a larger plan that also addresses the physical symptoms of long COVID — both matter and both deserve attention.
Q: Any caveats about patients with long COVID using antidepressants and anti-anxiety medicines?
Knowles: It’s important doctors choose medications carefully for these patients. Some medications, especially those that are more sedating or have anticholinergic effects, like certain sleep aids, older antihistamines, and some antidepressants and antipsychotics, can worsen fatigue or post-exertional symptom flares.
Q: Can cognitive behavioral therapy help long COVID sufferers?
Knowles: Yes, cognitive behavioral therapy can help people with long COVID. It is an evidence-based treatment for anxiety and depression, and it can also support day-to-day symptom management.
In long COVID, physical symptoms like fatigue or brain fog can trigger a chain reaction: How someone thinks about the symptom, how they feel emotionally, what they do and how their body responds can all interact and sometimes create a cycle that makes symptoms worse.
For example, someone might wake up feeling very fatigued. They could think, “I’m never going to get my energy back.” That can lead to feeling anxious or discouraged, which might lead them to avoid activity altogether. Over time, that can increase stress, muscle tension and deconditioning, which can make fatigue even worse.
Cognitive behavioral therapy seeks to gently interrupt this cycle. It teaches skills to shift unhelpful thoughts, manage stress and emotional responses, and find balanced ways to stay engaged in daily activities without overexertion. The goal isn’t to say symptoms are “in your head,” but to give people tools to reduce the impact of symptoms and improve their quality of life.
We know from other chronic conditions with similar symptoms, like multiple sclerosis, that cognitive behavioral therapy can help people manage fatigue, cognitive difficulties and other ongoing symptoms. Early research in people with long COVID shows similar benefits, especially for fatigue.
Q: What are other strategies for these patients?
Knowles: One simple and effective strategy is diaphragmatic breathing. This type of breathing helps activate the body’s relaxation response, which is the opposite of the stressful fight-or-flight response. When we’re stressed or not feeling well, our breathing often becomes shallow and fast, which can increase muscle tension, heart rate and feelings of anxiety.
Diaphragmatic breathing slows our breath and engages the diaphragm, which helps calm the nervous system. This can lower muscle tension, reduce stress hormones and promote a more relaxed, steady state in the body and mind.
For people with long COVID, this can be especially helpful, not only for anxiety, but also for symptoms like shortness of breath and fatigue. Over time, practicing this type of breathing can help the body spend more time in a rest-and-recover state, which may support overall symptom management.