NICE’s rapid guideline, published last December, says the term ‘long Covid’ is ‘commonly used to describe signs and symptoms that continue or develop after acute Covid‑19’. It defines acute Covid as signs and symptoms up to four weeks after onset. The latest figures from the Office of National Statistics (ONS) underline the seriousness of the issue, estimating that one million people in the UK are living with ongoing symptoms, with two-thirds of these saying their day-to-day activities are limited. As well as the common symptoms of fatigue, breathlessness and muscle ache, significant numbers of people are reporting worry/anxiety, low mood and confusion. For patients who were admitted to ICU, all these effects are more common.
We know that the past year has had a huge impact on the mental health of the wider population, with many studies showing a similar picture. The Mental Health Foundation’s ongoing UK-wide study has reported that more than half the adult UK population have experienced anxiety because of the pandemic, and the figure is much higher for those with a pre-existing metal health diagnosis. Fear and isolation have been significant problems: more than one in five of the UK adult population has reported feeling hopelessness and almost a quarter have reported loneliness. Another study showed a doubling of depression, while rates of eating disorders in young people have soared, with longer waits for referral adding to the problems.
Understanding a complex picture
Despite the growing association of Covid with mental health problems, it is important to keep an open mind when a patient presents with anxiety or depression. Other unrelated conditions can be involved, as can psychosocial factors and pre-existing pyschiatric illness that may have been worsened by the stress of the pandemic.
Physical conditions experienced by those living with ongoing physical symptoms, such as the respiratory, cardiovascular and neurological conditions described by NICE, can lead to psychiatric symptoms. One study pointed to an association between mental health problems and persistent physical symptoms, and also suggested an increased mental health burden could present as physical symptoms. The study said Covid-19 could also directly cause psychiatric symptoms through cerebral infection or inflammation. Another study found almost a quarter of all Covid patients developed a mood, anxiety or psychotic disorder. Where there is uncertainty, patients should be referred to their GP for assessment.
In those living with pandemic-related mental health problems, disentangling the precise causes can be difficult. As well as the possible physical causes, social isolation, domestic pressures and concerns about employment, finances, housing and family are all potential contributing factors that need to be explored. Of course, bereavement will also be an important cause of distress in those who have lost loved ones.
The right approach
When the physical symptoms of a person’s long Covid are being appropriately investigated, the approach we take to addressing their mental health symptoms is critical: some patients report feeling ‘gaslighted’ by their healthcare practitioners, with psychiatric symptoms not taken seriously by staff dealing with a condition they do not fully understand. The language we use is crucial: we need to acknowledge the very real physical and social toll that Covid, long Covid and lockdown can take, while also offering help for the mental distress that results. In general, talking therapies can play an important role in distress arising from life events; in most cases patients can self-refer to talking therapies rather than going through the GP, so it is worth familiarising yourself with the local services as these will vary from place to place. In our local area, for instance, we have set up a 24-hour Mindline telephone service that is proving popular. Specialist support is improving but the promised network of long Covid clinics is taking longer to establish than expected, while the numbers of patients in need is growing and referrals can be hard to secure. The coming months should see an increase in practice-based mental health workers but these will be shared across primary care networks and demand is likely to be high.
The pandemic has taken a major toll on the mental health of young people, with school closures and isolation having serious effects. In a recent survey of more than 500 children with long Covid symptoms, significant prevalence of mental health symptoms was reported.
In the case of children, it is very important to listen to and take seriously the concerns of parents, especially as there can be periods of recovery followed by a return of symptoms. The advocacy group Long Covid Kids is a useful hub for resources for nurses and parents.
For adolescents, the affect of limitations placed on their lives by long Covid will be particularly acute, and providing emotional support and reassurance will be crucial. The explosion in cases of eating disorders and body image is likely to relate to young people relying increasingly on social media, so offering simple advice to limit screen time and block anyone making negative comments can be effective. Of course, the best way to prevent long Covid is to avoid the virus in the first place, so support and advice as vaccines become available for younger people will be important.
Try to keep it simple
In many cases, the best way for us to help is to point our patients to simple things we know help our mental health. Exercise, particularly in nature, is useful, although it must be remembered that exercise is not beneficial to all those living with long Covid. Mindfulness and staying in the moment could also help people manage their anxiety and fears for the future – the way people achieve this is unique to that individual, and I find asking people what makes them lose themselves in the moment is helpful.
Some people will need medication, and this simple three-question depression screen can help identify those who may need to be assessed for clinical depression: Do you feel depressed? Have you lost enjoyment in the things that usually give you pleasure? and Have you had any thoughts of self-harm?
For those with post-traumatic stress disorder (PTSD), defined as ‘an anxiety disorder caused by very stressful, frightening or distressing events’, talking therapies are again the mainstay of treatment. Again, this should be available through the local talking therapies provider. Psychological support should be available at long Covid clinics, alongside other investigations, although provision remains patchy and varies from area to area.
Look after your own mental health
The National Audit Office has warned that the pandemic’s affect on the mental health of healthcare staff will be ‘long lasting’. The pressures of helping patients manage ongoing and unpredictable symptoms is likely to add to the burden, so it will become increasingly important to take steps to protect your own wellbeing and that of colleagues.
Covid is likely to cast a long shadow on the mental health of those living with long Covid as well as their physical health. Health Education England has called for the development of specialist Long Covid nurses and the National Institute of Health Research is calling for specific training for nurses. Until that happens, people are likely to continue presenting in general practice and other community settings, and the core skills nurses possess will be vital in helping patients deal with the distress and uncertainty of their symptoms. As ever, listening sympathetically, and offering appropriate treatment will be the cornerstones of care.