Researchers have long understood that people with chronic health conditions, such as heart disease, are at increased risk for depression. The same may be true for people with COVID-19 symptoms that linger for months and sometimes years.
An estimated 28% of U.S. adults who have had acute COVID-19 infections say they have experienced long COVID at some point, according to the latest survey data from the U.S. Census Bureau. Long COVID occurs when a constellation of symptoms persist following the initial illness. It's more prevalent among people who are older, female, hospitalized and unvaccinated. Symptoms vary but may include fatigue, brain fog, dizziness, gut problems, heart palpitations, sexual problems, change in smell or taste, thirst, chronic cough, chest pain, muscle twitching and the worsening of symptoms after any type of physical or mental exertion.
The U.S. Department of Health and Human Services in June issued an advisory warning that long COVID can have "devastating effects on the mental health of those who experience it, as well as their families," stemming from the illness itself, social isolation, financial insecurity, caregiver burnout and grief. It has been linked to fatigue, sleep disturbances, depression, anxiety, cognitive impairment and post-traumatic stress disorder, among other conditions.
"Depression is the most prominent symptom we see," said Dr. Jordan Anderson, a neuropsychiatrist and assistant professor in the department of psychiatry and neurology at Oregon Health and Science University in Portland.
Diagnosing depression in someone with long COVID takes a more nuanced approach than diagnosing the condition in the general population, Anderson said. That's because symptoms often associated with depression – such as sleep disturbances, fatigue, changes in appetite and concentration – also are associated with long COVID.
These symptoms alone "might not truly reflect how depressed someone is," he said. Instead, he looks for signs a person is no longer deriving joy from things they used to enjoy and are still capable of enjoying. He also asks about feelings of hopelessness or suicidal thoughts.
Dr. Anna Dickerman, chief of consultation-liaison psychiatry and associate professor of clinical psychiatry at New York-Presbyterian Hospital/Weill Cornell Medicine in New York City, said rates of depression and anxiety in people with long COVID appear to be higher than in the general population, just as they are among people with other chronic illnesses.
The virus that causes COVID-19 may be contributing to a person's mental state in a variety of ways, she said. The person may have experienced prolonged isolation or they may be dealing with physical limitations directly related to their illness, such as being easily fatigued and unable to function normally. Such limitations may have even led them to lose their jobs.
"That can affect you in your day-to-day existence," Dickerman said. "If a person has low energy, they may want to stay in bed all day. But doing that might make you feel even more depressed."
Anderson said suicidal ideation is present in about half the long COVID patients he sees at his clinic. "I'm very specific in the questions I ask," he said, which include whether the thoughts began after getting COVID or if they happened before.
Anderson said he sees two potential explanations for the high rate of suicidal thinking.
"On the one hand, it's intuitive to think having a chronic illness that limits your capacity so greatly for such a long time – and also causes stigmatization from family and others – would be demoralizing. That is perhaps the most common explanation I get from my patients," he said.
But some studies suggest COVID may affect the brain directly. This raises the question, Anderson said, that "if it's getting into the brain, is it affecting the parts of the brain responsible for mood? We just don't have those answers."
People with additional stressors from social determinants of health – such as discrimination, lower incomes, limited access to health care and other resources – may experience even higher rates of depression, Dickerman said.
"If you have greater stress in general, if you have fewer social supports, all of these things will negatively impact you," she said.
In addition to depression, Anderson said he sees a lot of anxiety, panic attacks and PTSD in the long COVID patients he treats.
PTSD occurs in patients who have had near-death experiences or hospitalizations related to their COVID infections, and in those who have lost loved ones to the virus and may have survivor's guilt, Anderson said.
"Having long COVID itself is a prolonged trauma that occurs over a period of many months. Someone might be triggered by anything invalidating or by any indication they might be sick again, even if it's a common cold. It's a terrible feeling that they are going to get worse again or have a life-threatening experience again."
Other long COVID symptoms, such as heart palpitations, can be confused with panic attacks, he said.
"A person's heart rate will drastically increase randomly without any provoking factors," he said. "That itself can be very unsettling and may be confused with or lead to a panic attack."
When that happens, someone may be treated with an antidepressant when what they really need is medication to control their heart rate, or a referral to a cardiologist, Anderson said.
There's no standardized treatment for mental health issues related to long COVID, Anderson said. Treatment could include medication or psychotherapy or both, based on an individual's symptoms. Group therapy can help people who need validation for their illness from others going through a similar experience. "When people feel like they have a community, that's worth its weight in gold," he said.
Dickerman said that in addition to medication and psychotherapy, helpful techniques for anxiety include meditation, relaxation and breathing exercises, along with graded physical activity tailored to the person's capabilities.
"Do exercise in a way that's tolerable and gradual," she said.
For those needing immediate help, a national mental health crisis line launched in July 2022. People can call or text 988 to talk with suicide prevention and mental health counselors. Chat is available on the 988 Suicide & Crisis Lifeline website. Text and chat also are available in Spanish.