Long COVID and Its Psychiatric Aspects.

Dear editor,

We recently read with interest the article by Cabrera et al entitled “Coronavirus and Its Implications for Psychiatry: A Rapid Review of the Early Literature.” Although they provide a comprehensive review of psychiatric disorders associated with coronavirus disease 2019 (COVID-19), we would like to highlight a clinical condition that we are concerned about being overlooked by the recent literature. “Long COVID” can be defined as the continuation of symptoms much longer than usually expected or persistence of symptoms despite the recovery from the acute infection. Although fatigue is the most common symptom, symptoms such as cough, shortness of breath, headache, diarrhea, stinging and burning sensations, and palpitations can be seen. A common feature of long COVID is a course characterized by remissions and relapses.

A study investigating ongoing symptoms after recovery from the acute infection showed that 3 or more symptoms persisted even after 2 months in 55% of patients. It was observed that 44.1% of these patients had deterioration in quality of life. A study with more striking results found that 99% of patients in the low-risk group had 4 or more symptoms and 42% had 10 or more symptoms, even after 140 days. It has been suggested to use the term chronic COVID syndrome to describe this clinical condition, which has recently attracted more attention.

While research on long COVID continues, psychiatrists should be involved in this process. We often see that people with symptoms such as fatigue, insomnia, shortness of breath, or palpitations are referred to psychiatry because no underlying cause can be found. Referral of these patients who experience repetitive physical symptoms to psychiatry often leads them to feel that they are not believed or are inventing symptoms. Interestingly, in the psychiatric outpatient setting, it is not uncommon to discover that the symptoms of patients with similar thoughts are due to overlooked organic causes. In this respect, it is necessary to be curious and open-minded about the chronic effects of a disease such as COVID-19 that can only be fully understood with time.

We think that psychiatrists have 2 critical duties here. First, because we are facing a disease whose etiology and long-term symptomatology are not yet fully defined, prematurely diagnosing potential long COVID symptoms as psychiatric disorders may harm the patient by delaying the appropriate treatment. For example, frequent complaints such as shortness of breath, palpitations, and fatigue should not be immediately considered to reflect “anxiety”. This attitude may cause an inaccurate diagnosis overlooking the underlying disease, affecting the treatment and the patient's compliance. Therefore a very detailed psychiatric history and examination, inclusive of premorbid characteristics and generating a careful differential diagnosis is essential.

Second, it should not be forgotten that psychiatric symptoms may accompany long COVID. Health anxiety and depressive complaints associated with the feeling of hopelessness can be seen. Insomnia and concentration problems are also common psychiatric findings. Long COVID is a condition that may seriously affect the functioning of patients. Diagnosis and treatment of psychiatric symptoms can significantly improve patients' quality of life. Thus, a careful psychiatric examination and effective treatment of psychiatric comorbidities are crucial in patients with COVID-19. There is no information in the literature that psychotropic medicines that are routinely used in the treatment of the previously mentioned psychiatric conditions cause worsening of physical symptoms. Psychotherapy options should be evaluated in cases where there is hesitation about psychopharmacology. In particular, cognitive behavioral therapy is considered to be effective on postviral fatigue and may be useful in long COVID.

Since the early stages of the pandemic, consultation-liaison psychiatrists have played a critical role in the evaluation of patients with COVID-19. Being in close contact with other specialties and working in general medical settings, they encounter these patients more than other psychiatrists. In addition, they are more experienced in the physical and neurological examination and differential diagnosis with physical illnesses. Therefore, we would like to emphasize the important role of consultation-liaison psychiatrists in the diagnosis and management of long COVID.