Multi‐disciplinary collaborative consensus guidance statement on the assessment and treatment of mental health symptoms in patients with post‐acute sequelae of SARS‐CoV‐2 infection (PASC)

PM&R, Journal Year: 2023, Volume and Issue: 15(12), P. 1588 - 1604

Published: Nov. 8, 2023

Post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC), also called Long COVID (coronavirus disease), is the experience new or worsened signs, symptoms, conditions that develop after resolution phase a COVID-19 infection. Although some people with recover well, others have persisting symptoms.1 PASC can manifest as wide-ranging constellation disabling sequelae, including mental health conditions.2 Anxiety and depression been reported second third most common symptoms PASC, respectively.3 Furthermore, in narrative review summarizing neuropsychiatric dimensions anxiety, post-traumatic stress disorder (PTSD), were among both ongoing symptomatic PASC. Pooled prevalence each was: anxiety 19.1% (95% confidence interval [CI], 13.3%–26.8%), PTSD 15.7% CI, 9.9%–24.1%), 12.9% 7.5%–21.5%).4 Despite high often impact PASC-related emerging data persist for months years,5 limited guidance currently exists regarding assessment treatment patients Addressing setting involves several unique complexities, addressing stigma may interfere appropriate diagnosis(es) treatment, insufficient availability professionals, differentiating physical diagnoses. Many described being questioned about their way feels dismissive and/or mistakenly attributed to an underlying condition.6 effects pandemic on individuals society exacerbate direct from SARS-CoV-2 infection, increasingly evidence supports be component caused by SARS- CoV-2 pre-existing exacerbated yet are not, themselves, overall cause PASC.7-9 Another challenge disorders national global shortage professionals.10 This further intensified because clinicians who not specialists express discomfort perception training discuss patients. Nevertheless, report they want broach topic acknowledge interplay between health.11-13 Finally, studies found due condition, but mimic disorder. These include fatigue, dysautonomia, disordered sleep, cognitive dysfunction,14, 15 which patient's ability fully participate first-line recommendations. The goal this consensus statement present practical treat Specifically, addresses initial depression, (including panic), PTSD. People worsening suicidal ideation, psychosis, obsessive compulsive (OCD), pandemic-related grief survivor's remorse8, 16-18; however, specific focus these outside scope statement. recommendations applicable all experiencing regardless time course. Of note, reflects current base related expert panel care professionals regularly should preclude clinical judgment must applied context patient, adjustments patient preferences, comorbidities, other factors. American Academy Physical Medicine Rehabilitation (AAPM&R) Multi-Disciplinary Collaborative (PASC Collaborative) was convened address pressing need members experts across variety disciplines specialties PM&R, neurology, neuropsychiatry, neuropsychology, rehabilitation psychology, primary care. following iterative, modified Delphi process achieve presented series statements symptoms. A full description methodology has published previously.19 informed established centers managing range symptoms.20-26 Whenever possible, existing specifically incorporated into statement, body somewhat evolving. As needed, guided applying general, well-established, approaches considerations intentional equity disparities critical factor contributing widespread outcomes, considered addressed. Collaborative's broaden understanding practices, only guide management, identify gaps opportunities future research. According original definition U.S. Centers Disease Control Prevention (CDC), "Long (PASC) broadly defined continue 4 weeks more infection; multisystemic; relapsing–remitting pattern progression over time, possibility life-threatening events even years CDC uses 4-week timeframe describing post-COVID emphasize importance evaluation supportive during 12 COVID-19.27 Based feedback our process, we advocate improving access beneficial interventions facilitating early evaluation, diagnosis, management experienced For purposes recommend if within 1 month symptom onset. Emotional mood fluctuations part normal everyday life, persistent, distressing disturbances emotional regulation, behavior, cognition indicative Diagnostic Statistical Manual Mental Disorders, Fifth Edition (DSM-5) depressive characterized primarily persistent sadness, emptiness, irritability, loss pleasure interest activities (anhedonia). They associated secondary poor concentration, psychomotor agitation retardation, fatigue energy, sleep difficulty (insomnia hypersomnia), feelings low self-worth excessive guilt, hopelessness future, changes appetite weight, thoughts dying suicide. fear, worry, apprehension, dread out proportion perceived threat. intrusive memories, dreams, dissociative reactions (flashbacks), prolonged psychological distress, physiological occur exposure actual threatened traumatic event.28 resulted 28% increase cases major (MDD) 26% worldwide 2020.29, 30 It estimated 137 additional disability-adjusted life (DALYs) per 100,000 MDD 116 DALYs disorders, incidence higher than influenza infections.15, 31, 32 Both women underrepresented race ethnic minority groups type(s) sequelae.33, 34 Women autoimmune diseases men, risk factors developing PASC35 conditions. at increased women, older adults, potentially Black/African socioeconomic strata.36, 37 In addition effect health, cumulative burden chronic (allostatic load) grown stressors concerns such fear death, short- long-term financial uncertainty, quarantine-associated social isolation, familial stress, guilt.38 surrounding disruptions system diminished services, frequent dismissal patients' community, particularly those without formal laboratory infection.39 Moreover, worse outcomes illness, hospitalization, PASC.39-44 pathophysiology still under investigation, it surmised cytokine storm created virus affect initiating central inflammatory response, reducing serotonin production attenuates downstream monoamine neurotransmission, increasing brain glutamate upregulation N-methyl-d-aspartate (NMDA) receptors.7, 8 aggregate, produce damaging neuronal excitotoxicity subsequent synaptic pruning loss. compounded cytokine-mediated reduction trophic induction new-onset re-exacerbation conditions.8, 9 role cytokines similar pro-inflammatory That is, appropriately generated response peripheral when cross brain, normal, evolutionarily conserved, protective illness allowing cope fever, lethargy, malaise.45 However, activation immune sustained beyond duration (e.g., disease, systemic cancer, PASC), resulting signaling lead exacerbation development vulnerable individuals.46 addition, biologic directly viral reservoirs, microvascular blood clots endothelial dysfunction, altered gut microbiome, autoimmunity.47-50 encountering stigmatization, disbelief, assumptions whole state,51 despite contrary.50 led fractured relationships patients, inherently degree able offer We encourage model approach based best practices myalgic encephalomyelitis/chronic (ME/CFS). take supportive, open, nonjudgmental stance; consider multifaceted biological aspects complex medical health–related treatments truly requires types interventions.52 especially challenging underreport clinician will attribute health. phenomenon contribute trend likely receiving significantly below-optimal level care.53 Therefore, helpful reassure let them know although one well-documented manifestations potential severe.53 Intentional effective challenging. Some delay accurate diagnosis dismissed purely psychosomatic manifestations.6 light context, suggest introduce validating PASC.50 by, mimic, worsen, coexisting why essential.2, 54 example, generalized post-exertional malaise another, result impairments function.55 developed fatigue.20, 22 Clinicians great driver(s) functional impairment treatment. When thorough facilitated collateral information close friends family members. Collateral history impaired memory, awareness how functioning long function impaired, otherwise would independently reporting sleep-related snoring, dozing off daytime, nighttime awakenings, etc.).22, 26 Loved ones important course severity observed mood, coping abilities, energy level, appetite, daily function, participation usual (Table 1). Patients screened signs using validated tools instruments, appropriate. Note: suicide screening screen positive plan place prior screening. questionnaires efficient implements questionnaires, understand whether questionnaire assesses somatic instance, Patient Health Questionnaire (PHQ-9) concentrating, disorders.56 autonomic dysfunction,20-26 so PHQ-9 overpredict presence multiple PASC.57 contrast, Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scale does inquire reduce confounding comorbidities (such PASC) health.58 Other measures used PHQ-2 (for screening), Generalized Disorder 7 (GAD-7) Hospital Scale (HADS) screening). Regardless tool(s) used, follow-up interview clarify settings versus select school/work, home, contexts), plans. Common PCL-5 (PTSD Checklist DSM-5) IES (Impact Events Scale). confirmation require referral specialist extensive testing. Suspicion raised survivors intensive unit (ICU),59 had confirmed frontline workers, quarantined. flashback-like reactions; efforts avoid trauma-related thoughts, feelings, places, people; negative mood; hyperarousal, difficulties, irritability.60-63 delivering tool responses. given encounter before any provided, answering questions thoughtfully honestly when: (1) team member describes relevance purpose introduced them, (2) acknowledges responses explains results recommendations.11 assessing ideation depressed lack familiarity immediate next steps expresses active ideation. Psychological Association provides continuing education intervening (https://www.apa.org/monitor/2022/06/continuing-education-intervene-suicide), Columbia University, through Lighthouse Project, disseminates Protocol—also known Columbia-Suicide Severity Rating (C-SSRS) https://cssrs.columbia.edu/. establish what endorse consultation in-clinic worker psychologist interdisciplinary setting, contacting crisis worker, hotline (988 National Alliance Illness [NAMI] hotline), center detailed inquiry necessary intervention maintain safety patient. If left unsupervised. assure acknowledging distress providing care, transfer hospital emergency department psychiatric hospital. Urgent equally situations managed equal immediacy. selecting tools, administration approaches, informants, essential chronological/mental age, educational history, environments. reading (in language administered), read aloud rather self-administered. cases, sensitive acceptability bias tool. manage neurodevelopmental judicious measurements informants. Assessment sensorimotor proxy inventories focused largely behaviors subjective experiences, informants characterize onset, changes). extent possible comprehension self caregiver, teacher, etc.) assessments diagnostic evaluation. Literature intellectual disabilities suggested mixed agreement self- caregiver-report health-related factors, better correlation activity engagement, support.64 identity race, ethnicity sexual orientation gender identity, make conscious effort own implicit (unconscious) biases. aware cultural differences exist expressed certain cultures hesitant concern acceptability.65 appropriate, tests reviewed obtained evaluate masquerade tachycardia palpitations cardiovascular dysfunction.23, 24 having condition presents as, contributes to, conditions, lower strata.66 There considerable overlap neurologic commonly Commonly overlapping pain, apathy, changes, changes. Major categories disease neurodegenerative Parkinson Huntington's Alzheimer's vascular inflammatory/infectious/autoimmune trauma, metabolic/endocrine disturbances, nutritional deficiencies, structural disorders. Post-intensive (PICS) coexist movement PICS PASC.67 Factors (or coexisting) opposed isolated include: features atypical disorder, unusual age paroxysmal recent substance abuse/intoxication leading encephalopathy, prescription medicine overuse, resistant respond unusually conventional treatment.66 DSM-5 considers careful assess Because wellness bidirectionally person's engage tasks, vice versa. explore baseline self-care instrumental living bathing, dressing, grooming, ambulating use adaptive equipment, cooking, cleaning, shopping, attending household chores, paying needs/bills). limit attend work, school, social, activities, limitations can, turn, coping, satisfaction life.68 Decreased engagement added strain, feeling feel pressured worsens malaise. Understanding patient-specific prerequisite patient-centered interrelated impairments, skills, premorbid triggers Reported include, foods, menstrual cycles,69 conditions,70 prescribed over-the-counter medications, alcohol drug misuse,71 psychosocial uninsured underinsured, unemployed underemployed, socially isolated, support assist transportation, translation, needs), personal safety, food insecurity, stable housing.72-74 prevalent PASC.72,73 itself, as: distancing, childcare, media coverage infection.75 varies widely Symptoms COVID-19.76, 77 Available suggests general principles treating generally mirror do (see Table 2).78, 79 Patients' constellations, impairment, quality impacted approach. impacting life/function practice clinician, (examples therapist, counselor, neuropsychologist, psychologist, psychiatrist) expertise psychological/psychiatric (and worsen) note provided recognizes typically cluster systems, might co-existing always suggesting test rehabilitation. plan, encouraged unknowns prognosis, well benefits risks screens aforementioned interview, adequate comfort psychopharmacologic provide in-office means offering intervention. referrals psychiatrist,

Language: Английский

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Resonant breathing improves self-reported symptoms and wellbeing in people with Long COVID

Frontiers in Rehabilitation Sciences, Journal Year: 2024, Volume and Issue: 5

Published: July 12, 2024

Introduction Long COVID involves debilitating symptoms, many of which mirror those observed with dysautonomia, and care must be taken rehabilitation for autonomic dysfunction to avoid post-exertional malaise/post-exertional symptom exacerbation. Resonant breathing (breathing slowly at a defined rate breaths per minute) requires less exertion can potentially improve function. The objective this work was report on the impact resonant program self-reported symptoms wellbeing in people COVID. Methods A retrospective analysis de-identified data completed convenience sample COVID, who participated Meo Health (formerly known as Stasis HP) program. Participants baseline follow up surveys. Results Data were available 99 participants. Most measures improved up, largest differences participant seen sense wellness (47.3%, p < 0.0001), ability focus (57.5%, breathe (47.5%, control stress (61.8%, 0.0001) sleep quality (34.9%, = 0.0002). (92%) participants reported improvement Patient Global Impression Change Scale. Conclusion Self-reported completing breathing. considered an option within broader treatment plan

Language: Английский

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Management of patients with neurological diseases considering post‐pandemic coronavirus disease 2019 (COVID‐19) related risks and dangers — An updated European Academy of Neurology consensus statement

European Journal of Neurology, Journal Year: 2024, Volume and Issue: 31(10)

Published: Aug. 1, 2024

In October 2020, the European Academy of Neurology (EAN) consensus statement for management patients with neurological diseases during coronavirus disease 2019 (COVID-19) pandemic was published. Due to important changes and developments that have happened since then, need has arisen critically reassess original recommendations address new challenges.

Language: Английский

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The impact of gut microbiome and diet on post-acute sequelae of SARS-CoV-2 infection

Journal of the Neurological Sciences, Journal Year: 2024, Volume and Issue: 467, P. 123295 - 123295

Published: Nov. 10, 2024

Language: Английский

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A review of intravenous immunoglobulin in the treatment of neuroimmune conditions, acute COVID-19 infection, and post-acute sequelae of COVID-19 Syndrome

Brain Behavior and Immunity, Journal Year: 2024, Volume and Issue: 123, P. 725 - 738

Published: Oct. 9, 2024

Language: Английский

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A Practical Framework for Long COVID Treatment in Primary Care

Published: June 10, 2024

Long COVID, also known as Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), is a complex, multisystem illness with poorly understood pathophysiology, absence specific diagnostic tests or criteria, evidence-based treatments. With over 200 identified symptoms and approximately 10% COVID-19 cases resulting in PASC, it challenge to provide comprehensive treatment at scale commensurate the burden. The diverse manifestations encompassing numerous medical specialties, typically place primary care providers (PCPs) forefront management, navigating an evolving landscape research lack guidelines. This paper presents pragmatic, structured framework for PASC management care, integrating current knowledge best practices. approach individualized, addressing PASC's broad symptomatology through four-step framework. first step focuses on energy strategies, emphasizing prevention post-exertional malaise, cardinal feature PASC. second step, intentional rehabilitation, employs carefully titrated multidisciplinary modalities address physical, cognitive, emotional domains. third utilizes symptomatic both pharmacological non-pharmacological interventions, targeting debilitating like fatigue, insomnia, chronic pain. fourth outlines trialing experimental, targeted therapies that may impact underlying pathophysiology. These treatments, while experimental lacking quality evidence be available off-label individual basis following thorough risk-benefit discussion. stepwise can equip PCPs effectively most common disabling individualize remain attuned scientific understanding condition.

Language: Английский

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The Impact of COVID‐19 Infection on Child and Adolescent Mental Health

Published: Nov. 15, 2024

This chapter covers how COVID-19 infection can affect the mental health of children and teens at different ages. It begins by describing lives four people ages who are affected COVID-19. They are: Audra – an 18-month-old girl was cared for her grandmother; Emiliano a 9-year-old boy with asthma; Raven autistic 12-year-old chose their own name; Maeve 17-year-old young woman. Due to impact on brain, bring wide range neuropsychiatric conditions first time. As other forms sadness, sadness that occurs may respond non-pharmacological treatments and, times, also medications. There no data link beginning new substance use disorders in teens.

Language: Английский

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Dissecting Clinical Features of COVID-19 in a Cohort of 21,312 Acute Care Patients

medRxiv (Cold Spring Harbor Laboratory), Journal Year: 2023, Volume and Issue: unknown

Published: Nov. 27, 2023

Abstract COVID-19 has resulted in over 645 million hospitalization and 7 deaths globally. However, many questions still remain about clinical complications if these changed with different circulating SARS-CoV-2 strains. We analyzed a 2.5-year retrospective cohort of 47,063 encounters for 21,312 acute care patients at five Central Texas hospitals define distinct trajectory groups (TGs) latent class mixed modeling, based on the World Health Organization Ordinal Scale. Using this TG framework, we evaluated association demographics, diagnoses, vitals, labs, imaging, consultations, medications severity broad outcomes. Patients within 6 TGs differed manifestations multi-organ disease multiple factors. The proportion mild increased time, particularly during Omicron waves. Age separated fatal patients, though did not distinguish severe versus critical disease. Male Hispanic/Latino demographics were associated more severe/critical TGs. More had higher rate neuropsychiatric brain which change significantly across variant severely affected also demonstrated an immunological signature high neutrophils immature granulocytes, low lymphocytes monocytes. Interestingly, albumin was one best lab predictors malnutrition raising concern nutritional insufficiency influencing Despite this, only small fraction labs checked (pre-albumin, thiamine, Vitamin D, B vitamins) or received targeted interventions to address deficiencies such as vitamin replacement. Our findings underscore significant link between severity, complications, key risk factors outcomes raise question need widespread early assessment patients’ neurological, psychiatric, status settings help identify those

Language: Английский

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Persistent Chest Pain Following COVID‐19 Infection – A Scoping Review

PM&R, Journal Year: 2023, Volume and Issue: 16(6), P. 605 - 625

Published: Oct. 31, 2023

Persistent chest pain (PCP) following acute COVID-19 infection is a commonly reported symptom with an unclear etiology, making its management challenging. This scoping review aims to address the knowledge gap surrounding characteristics of PCP COVID-19, causes, and potential treatments. 64 studies, including observational (prospective, retrospective, cross-sectional, case series, case-control) one quasi-experimental study, from databases Embase, PubMed/MEDLINE, Cochrane CENTRAL, Google Scholar, Database Systematic Reviews, Scopus. Studies on patients mild, moderate, severe were included. any age, that persisted disease, irrespective etiology or duration A total 35 studies symptoms (0.24%-76.6%) at average follow-up 3 months longer, 12 1-3 17 less than 1-month not specified. was common mild-severe infection, mostly reported. Fourteen proposed etiologies endothelial dysfunction, cardiac ischemia, vasospasm, myocarditis, arrhythmia, pneumonia, pulmonary embolism, postural tachycardia syndrome, noted MRI (cMRI) changes. Evaluation methods included cardiopulmonary tests, as well tests such flow-mediated dilatation, cMRI, single-photon emission computed tomography myocardial perfusion imaging, exercise testing. Only study specific treatment (sulodexide). prevalent various etiologies. Further research needed establish better understanding causes develop targeted treatments for COVID-19.

Language: Английский

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