(062) A Case Series: Psychiatric Comorbidity in Long Covid

Abstract:

Background: Long Covid, or Post-Acute Sequelae of COVID-19 (PASC), affects multiple organ systems and has clinical and pathophysiologic parallels with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and dysautonomias. Neuropsychiatric symptoms include anxiety, depression, and PTSD. We present two PASC psychiatric cases. Guided by these, we outline suggestions for evaluation and management of comorbid anxiety and depressive disorders in PASC, based on clinical experience and a review of psychiatric comorbidity in ME/CFS and dysautonomias.

Cases: 1) A 31 year old woman with no prior psychiatric or medical history experienced palpitations and tachycardia at rest, and fatigue worsened by exertion following acute SARS-CoV-2 infection. She developed panic attacks, compulsively checking her pulse oximeter with every episode of tachycardia and palpitations. Fluoxetine worsened her palpitations, while clonazepam 0.25 mg TID significantly improved her anxiety. 2) A 54 year old man with a history of MDD and no prior medical history experienced profound fatigue worsened by exertion and numbness/tingling in his legs following acute SARS-CoV-2 infection. Psychiatric symptoms included low mood, hopelessness, and irritability, exacerbated by intense physical or mental exertion.

Observations: Medical workup of PASC and specialist referral is crucial to ensure sufficient medical treatment. Detailed evaluation and characterization of symptoms is required to diagnose anxiety and depressive disorders, as PASC symptoms overlap with DSM-V criteria. Psychotropics should be started at low doses and titrated slowly, as intolerance is common. Psychotropics may benefit PASC symptoms or be intolerable based on common side effects and overlapping PASC symptoms. SSRI, SNRI, and low dose TCA, shown to improve depression in ME/CFS1, are potentially useful in PASC. However, SNRI and TCA may worsen existing dysautonomia.2 Bupropion1, aripiprazole3, or methylphenidate may be considered for augmentation and potentially improve PASC fatigue and brain fog. Benzodiazepines may treat acute anxiety, but carry risks of dependence and potentiating PTSD if administered chronically. Gabapentin or buspirone may be utilized alternatively for anxiety.

Conclusion: This case series highlights the considerations in evaluation and management of psychiatric comorbidity in PASC. Evidence is currently limited. Data in ME/CFS and dysautonomias may serve as early guidance.

References:

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3. Crosby LD, Kalanidhi S, Bonilla A, Subramanian A, Ballon JS, Bonilla H. Off label use of Aripiprazole shows promise as a treatment for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): a retrospective study of 101 patients treated with a low dose of Aripiprazole. J Transl Med. 2021;19:50. doi:10.1186/s12967-021-02721-9