Long Covid affects patients physically and mentally, requiring an integrated approach to care. This second article in the series looks at how to support patients’ holistic needs
Emerging understanding of long Covid shows it is a condition affecting both mind and body. Many post-Covid-19 sequelae present as undifferentiated symptoms not apparent on routine investigation, and it is important to listen actively to patients and not simply dismiss their physical symptoms as anxiety. At the same time, there is extensive evidence that anxiety is prevalent alongside physical symptoms and nurses must ensure this is assessed and that patients are offered appropriate help. This interrelationship between physical and psychological symptoms requires an integrated care approach.
Citation: Stucke J et al (2022) Long Covid 2: supporting the mental and physical needs of patients. Nursing Times [online]; 118: 7.
Authors: Jo Stucke is advanced nurse practitioner, Pennine Care NHS Foundation Trust; Elaine Maxwell is visiting professor at London South Bank University; Jo House is reader in environmental science and policy, Bristol University.
Long Covid is a multi-system condition affecting both the body and the mind that occurs in some people as a lingering consequence of a Covid-19 infection (Maxwell et al, 2022). As described in our first article in this series, symptoms are diverse and many post-Covid-19 sequelae present as undifferentiated symptoms not apparent on routine investigation (Maxwell et al, 2022). This can contribute to patients’ symptoms not always being taken seriously by health professionals. Lack of clarity over the mechanisms for long Covid means opinion can be polarised, with some practitioners believing all symptoms are physical and others that they are purely psychological. In truth, there is ample evidence that long Covid is a combination of physical and mental symptoms, many of which are undifferentiated and common in established physical and psychological conditions. Individual prognosis for individuals is hard to assess, with some people recovering within months but others still having problems after two years.
Mental health impact
Over the course of the Covid-19 pandemic, evidence has grown that people with a history of SARS-Cov-2 infection have a greater risk of mental health disorders. A large US study of health records by the Department of Veteran’s Affairs found those with a positive polymerase chain reaction (PCR) test were more likely to be diagnosed with anxiety, depression, adjustment disorders and cognitive decline and more likely to be prescribed antidepressants, benzodiazepines and opioids (Xie et al, 2022). The researchers found this risk was still increased when this group was compared with a pre-pandemic control group who had tested positive with seasonal influenza. Similarly, data from the US TriNetX electronic health records network showed nearly 34% of people testing positive for Covid-19 received a neurological or psychiatric diagnosis in the following six months (Taquet et al, 2021). These findings appear to be multifactorial and can be linked to both the sequalae of the virus itself and the psychological impacts of infection.
Long Covid and the brain
The effects of Covid-19 on the brain have been documented at post-mortem and through imaging. People who have died from acute Covid-19 infections have shown evidence of acute hypoxic injuries, haemorrhage, and inflammation (Mukerji and Solomon, 2021). Studies into the long-term effect of SARS-Cov-2 on the brain have been limited by the lack of pre-infection imaging, making it difficult to identify if findings are incidental and/ or as a result of pre-existing conditions. The UK Biobank had completed brain imaging studies before the start of the coronavirus pandemic, enabling them to rescan 401 participants who had been infected with SARS-Cov-2 and compare them with a previously scanned but non-infected control group (Douaud et al, 2022). Ninety-six percent of their sample had not been admitted to hospital with Covid-19, and there was no difference in the findings of hospitalised and non-hospitalised patients. Rescanning, an average of five months after the infection, showed reductions in grey matter thickness and brain volume, as well as tissue damage in the olfactory cortex. Cognitive function had also reduced, with an increase in time to complete Trail Making Tests in the Covid-19-positive group.
The researchers concluded that their results may be suggestive of degenerative spread of the disease by olfactory pathways, neuroinflammatory events due to the infection itself or even loss of sensory input due to anosmia. A systematic review of studies reporting neuroimaging abnormalities in SARS-CoV-2-infected individuals found a predominant involvement of the olfactory nerve, and that abnormalities extended to the corpus callosum, cingulate cortex and insula, jointly implicating the olfactory brain network (Najt et al, 2021). This is perhaps reflected in loss of smell, listed as one of the primary symptoms of Covid-19 in UK government guidance throughout 2020 and in recent updates (UK Health Security Agency, 2022).
“It is impossible to separate physical and psychological symptoms of long Covid and there is a need for an integrated approach to care”
Fallacy of a physical-psychological divide
Parallels can be drawn between long Covid and the experiences of people with other ‘invisible’ medium- and long-term conditions, such as myalgic encephalomyelitis/ chronic fatigue syndrome and fibromyalgia (Alwan, 2021). Because first-line diagnostics often fail to show any pathologies, health professionals may believe there is nothing physically wrong, leading to patients feeling dismissed with a false assumption that it must ‘all be in the mind’ (Ballering et al, 2021; Miyake and Martin, 2021).
As our knowledge of the pathophysiological mechanisms of long Covid develops, it provides a growing body of evidence showing it is impossible to separate physical and psychological symptoms of long Covid (Maxwell et al, 2022) and that there is a need for an integrated approach to care.
A closer look at several symptoms associated with long Covid shows this interplay in action. People with long Covid may develop new-onset postural tachycardia syndrome (PoTS), possibly due to the virus, inflammation, or the autoimmune response (Crook et al, 2021). Symptoms of PoTS, such as racing heart rate, sweating and shaking, can mimic those of anxiety and may be misattributed to this. Conversely, the frightening nature of such symptoms may cause thoughts such as “I am going to die”, leading to anxiety, which in turn exacerbates the experience. People with PoTS also report difficulties with attention, concentration, memory, and brain fog, and PoTS is associated with chronic fatigue and sleep disturbances (Raj et al, 2018), all of which are also symptoms of depression.
Similarly, we know people with long Covid have an increased risk of developing diabetes mellitus (Maxwell, 2021). Several potential mechanisms have been proposed, including stress-related factors such as insulin resistance – ultimately leading to increased glucose production and cell dysfunction – due to the SARS-COV-2 virus binding at ACE2 receptors in pancreatic islet cells. Previous studies have shown disrupted blood glucose is associated with reduced cognitive function and poor mood in adults with type 2 diabetes (Cox et al, 2007; Cox et al, 2002).
PoTS and diabetes are just two conditions associated with long Covid that highlight the need for comprehensive integrated services to ensure that the mind and body are treated holistically.
Mental health needs
People with long Covid present with a wide spectrum of mental health as well as physical health needs. A systematic review of psychiatric symptoms associated with long Covid identified 20 articles reporting a prevalence of post-traumatic stress disorder (PTSD) type symptoms of between 6.5% and 42.8% (Schou et al, 2021). The Veteran’s Affair’s study found an increase in diagnosis of acute stress/adjustment disorders and PTSD after one year, with a hazard ratio of 1.38 (95% confidence interval 1.34 to 1.43) (Xie et al, 2022). There is conflicting evidence about whether hospital admission increases the risk of developing PTSD (Vrettou et al, 2022). Many people had distressing experiences of their acute infection and their anxiety in hospital being compounded by the inability of friends and family to visit and disorientation caused by staff wearing personal protective equipment, or by the fear of being left at home uncertain of how their infection would progress.
People living with long Covid can experience significant changes in their lives. Some may have lost roles within their families, other relationships and employment, all contributing to a loss of identity (Van de Vyver et al, 2021). Good mental wellbeing is associated with the ability to connect with others, be physically active and learn new skills, all which are challenging for people with long Covid. Many patients face the stigma of having an ‘unexplained’ condition, including ‘gaslighting’ from some health and social care professionals, colleagues, friends and family, who minimise the symptoms (Ireson et al, 2021). We propose that these social factors, combined with the uncertainty of a novel, poorly understood, and potentially long-term illness, can contribute to poor psychological wellbeing and increased rates of clinical depression, independent from neurological causes.
“All nurses must consider the mental wellbeing of people in their care living with Long Covid”
Mental health interventions
As with any nursing intervention, mental health interventions should be informed by assessment as the first stage of the nursing process. Painter (2021) argues that mental health nurses are biopsychosocial specialists, and assessing physical, psychological and social context together allows clinicians to understand how long Covid is affecting a person’s life.
The biopsychosocial model underpins and informs person-centred care and is widely used in physical and mental health services, including physical rehabilitation services (Wade and Halligan, 2017). A biopsychosocial assessment provides a framework to explore how people’s past experiences affect their current situation, and to better appreciate their understanding and beliefs about their own health. Some people with long Covid may have had negative experiences navigating the healthcare system with a new condition that may have been ignored, dismissed, or not recognised and this may be their first assessment that considers their mind, body, and spirit. Simply being heard may be a therapeutic intervention in itself.
The assessment should include an assessment of risk, including suicide. The National Confidential Inquiry into Suicide and Safety in Mental Health (2022) highlighted that 25% of suicides had a comorbid physical illness, and people were more likely to be older, living alone or on long-term sick leave – factors which may apply to people with long Covid. People with physical illness were more likely to die by self-poisoning, often using prescribed opiates/opioids. A diagnosis of an affective disorder was more common than in people without long-term conditions. However, factors usually associated with an increased risk of suicide, such as alcohol and drug use, were less prevalent.
Comprehensive assessment allows diagnosis of needs and potential interventions to be identified. While it is important to follow evidence-based guidelines, skilled nursing is required to adapt this to the specific needs of people with long Covid. For example, people with comorbid mild to moderate symptoms of anxiety and/ or depression may benefit from cognitive behavioural therapy (CBT). However, given the combined physical-psychological nature of long Covid, and that anxiety is typically induced by its physical symptoms rather than vice versa, it may be more appropriate to consider the long-term conditions pathway of the Improving Access to Psychological Therapies (IAPT) programme (NHS England and NHS Improvement, 2018). This can include acceptance and commitment therapy and mindfulness strategies. People experiencing PTSD symptoms may benefit from trauma-focused CBT or eye movement desensitisation and reprocessing therapy. Again this can be accessed by local IAPT services. Psychotropic medication may also be considered dependent on a person’s presentation and wishes.
People with long Covid may benefit from psychoeducation, goal-setting and self-management strategies to help them better understand and manage their concurrent mental health difficulties. Poor sleep may be caused by pain, breathing difficulties, unwanted intrusive images, and worries exacerbated by a fear of being unable to get to sleep.
Conversely, poor sleep may worsen pain and other physical symptoms, and this may increase anxiety. Full physical assessment can be complemented by giving advice on a good sleep routine and helping with skills in progressive muscle relaxation; avoiding alcohol and caffeine may also be helpful, as well as education on medications that can affect sleep.
People with cognitive impairment may benefit from help in using memory aids and identifying exacerbating factors and ways to manage them. Some people may gain benefit from referral to neuropsychology, speech and language therapy or occupational therapy for further assessment and intervention.
Supporting mental wellbeing
All nurses must consider the mental wellbeing of people in their care living with long Covid. Nurses should assess mental health without prior assumptions about the causation of long Covid symptoms, recognising they may have a physical or a psychological component, or both.
It is important to acknowledge the impact language can have on people’s wellbeing. Long Covid is a complex, multisystem condition and health professionals should use language that shows people they are believed when they describe their symptoms. They also need to find a nuanced balance between acknowledging the uncertainty of the condition and giving people hope of recovery.
The principles of mental health first aid (Box 1), widely adopted in the NHS to support people during the pandemic – for example, the advice from NHS Employers (2021) for children and young people can be used by non-mental health nurses for people living with Long Covid.
Box 1. Principles of mental health first aid
- Listen non-judgmentally
- Give reassurance and information
- Encourage self-help and other support strategies
- Assess for risk (including suicide)
- Encourage appropriate professional help
Source: Kitchener and Jorm (2006)
A number of validated screening tools are available to assess anxiety and depression after a Covid-19 infection. These include the Patient Health Questionnaire (PHQ-9) (Staudt, et al, 2022) and Generalised Anxiety Disorder Assessment 7 (GAD-7) (Ismael et al, 2021). Both are self-administered questionnaires, which can form the basis of a therapeutic conversation with a health professional.
While most people with long Covid can be supported in primary care, nurses need to be aware of specialist mental health services in their communities that can provide more tailored support, including mental health nurses, and how to make referrals to them. Currently care pathways for people with long Covid vary across the UK, with different services provided.
Some services include mental health nurses working as part of multiprofessional teams, others refer patients to online psychological support, including the Your Covid Recovery programme School nurses and health visitors have a role to play in supporting children (Fanner and Maxwell, 2021). Nurses also need to be mindful of the needs of family and carers of adults and children with long Covid and provide them with information on any local support services available.
As with many long-term conditions, peer-to-peer support networks can be invaluable and a number of support groups exist in the UK (Box 2).
Box 2. Peer support resources
Long Covid as a result of a Covid-19 infection covers a broad range of symptoms. It is becoming clear that these symptoms can have multiple, and interactive, causal mechanisms, including neurological and psychological processes. Maintaining people’s mental wellbeing alongside investigation and treatment of physical symptoms is a key intervention that all health professionals must adopt.
- Long Covid is a multisystem disease involving both physiological and psychological processes
- Evidence is growing that people with a history of Covid-19 infection have a greater risk of mental health disorders
- The physical and mental symptoms of long Covid are interrelated, requiring an integrated care approach
- Not all symptoms are apparent in routine investigations and it is important to listen to patients to ensure they get the right support
- While most people with long Covid can be supported in primary care, more tailored mental health support may be needed
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Article From: Nursing Times