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Mr. Nacinovich:
Clinicians have identified a wide range of social and psychological factors that could not only be risk factors for long COVID but could also be a burden to our patients. What do these latest findings tell us, and how will they impact our clinicians' approach caring for patients with long COVID?

Welcome to COVID-19: On The Frontlines on ReachMD. I'm your host, Mario Nacinovich, and here with us to share insights on a recently published prospective study is the lead author of the publication, Dr. Siwen Wang, a researcher in the Department of Nutrition at Harvard T.H. Chan School of Public Health.

Dr. Wang, welcome to the program.

Dr. Wang:
Hi, Mario. Thank you for having me.

Mr. Nacinovich:
So, to start us off, Dr. Wang, Can you give us an overview of the manifestation of psychological distress before and during a COVID-19 infection? And what kind of impact can this distress have?

Dr. Wang:
So, what we study in this recent publication is psychological distress including depression, anxiety, worry, perceived stress and loneliness. And it is well established that mental health conditions are associated with greater severity and longer duration of acute respiratory tract infections, such as flu and common cold. Depression and other mental illness has been associated with greater risk of more severe COVID-19 including risk of hospitalization, so that's kind of the reason why we want to look into pre-infection psychological distress and risk of long COVID.

Mr. Nacinovich:
Now, let's talk about the prevalence of long COVID. How many patients typically develop this condition? And why are these patients developing it?

Dr. Wang:
Yeah. So, according to different definitions of long COVID, around 20 to 70 percent of people may have long COVID. The current definition we use are CDC definitions. That's longer than four weeks of COVID symptoms after the initial acute phase of disease. And in our current study, we found that more than 40 percent of people will have longer than four weeks of symptoms and around 30 percent then will have longer than 8 weeks of symptoms.

Mr. Nacinovich:
Now, some of the conditions have been linked with reduced quality of life and inability to work. Can you tell us a little bit about the burden of these symptoms on patients?

Dr. Wang:
Yeah, of course. So, long COVID could be very debilitating. People might complain about difficulty going back to work, having difficulty remaining active for an extended period of time, and it's also not uncommon to hear that people say that they cannot conduct any activities, such as brushing teeth, taking care of their children, and therefore, it caused great daily life functioning impairment among those who have long COVID. And also, it's estimated that in the United States there are around one million people who suffer from such extensive daily life impairment due to long COVID.

Mr. Nacinovich:
For those just tuning in, you're listening to COVID-19: On The Frontlines on ReachMD. I'm Mario Nacinovich, and I'm speaking with Dr. Siwen Wang about the link between social and psychological factors and long COVID.

Dr. Wang, let's shift our attention to your research. Can you give us an overview of your recent study on psychological distress and long COVID?

Dr. Wang:
Sure. From early in the pandemic, April 2020, we followed more than 54,000 people for a year. Over that year, more than 3,000 contracted COVID-19. We then asked them about their COVID symptoms and how long they lasted. We found that psychological distress before COVID infection, including depression, anxiety, worry, perceived stress and loneliness were associated with 32 to 46 percent risk of long COVID. This risk was not explained by health behaviors, such as smoking, or by physical health conditions like asthma. Participants with two or more types of distress prior to infection were at nearly 50 percent increased risk of long COVID. Among those who developed long COVID, people with higher psychological distress also had more symptoms of long COVID were up to 50 percent more likely to have daily life impairment due to long COVID.

Mr. Nacinovich:
Thanks for sharing that background with us. Now, what were some of your key findings?

Dr. Wang:
We found was that people with higher levels of psychological distress are at higher risk of developing long COVID, and more importantly, the psychological distress are more strongly associated with long COVID compared to other well-established risk factors for COVID severity, such as asthma, hypertension, and obesity.

Mr. Nacinovich:
Now, can you speak a little bit about your unique methodology in this prospective study and the various databases that you were able to look at from three large ongoing cohorts?

Dr. Wang:
Participants were drawn from three ongoing large cohort studies, the Nurses' Health Study II and Nurses' Health Study III, and the Growing Up Today Study. These studies are established back in the 1980s and has been actively followed ever since. During COVID-19, we also launched this COVID-19 substudy to actively follow them with regard to their COVID-19 pandemic exposure, infections, symptoms, as well as the adverse events they experienced during COVID-19 pandemic. Because these participants have been actively followed and they’re dedicated to our research, therefore, we were able to gather high-quality data from these participants, and we were able to prospectively identify pre-infection psychological distress with risk of subsequent development of long COVID as opposed to other studies were only able to look at post-infection psychological distress or they have to ask them to recall their pre-infection distress.

Mr. Nacinovich:
Now, there were some key points and insights gained from this study specifically about the inapplicability of psychosomatic illness here. Can you shed some light on your comments in the actual publication and the comments you've made also in the press about this?

Dr. Wang:
Yes, of course. We noticed that starting early in 2020 when people started to complain about having long COVID, there were a lot of skepticism saying that long COVID is all in patients' minds. It's kind of like blaming the victim thing, especially for those from disenfranchised communities. And what we found was that psychological distress was associated with increase of risk of long COVID, but that does not necessarily mean we support the statement that post-COVID-19 conditions are psychosomatic. First, among those who developed long COVID, more than 40 percent did not have any distress at baseline. More importantly, in a sensitivity analysis, when participants reported only psychiatric, cognitive or neurological symptoms, such as depression, anxiety, memory issues, headache, the results were almost identical to our primary findings. Therefore we do not support the hypothesis that long COVID are psychosomatic.

Mr. Nacinovich:
So all these findings help us pro-actively address patients with depression, anxiety, worried about COVID-19, perceived stress, loneliness. What does that say about the role and the need of mental health resources in the treatment of long COVID?

Dr. Wang:
So, definitely a lot of people, if not all of us, are heavily affected by the pandemic, and there are evidence suggesting that psychological distress is higher during a pandemic. Our findings suggested that the need to consider psychological health in addition to physical health as risk factors for long COVID and that mental health conditions and our physical health are so interconnected that we need to pay more attention to it. According to the World Health Organization, 75 percent of people with depression do not receive adequate treatment. We need to increase public awareness of the importance of mental health and focus on getting mental health care for people who need it and also increase the supply of mental health clinicians and improve access to care.

Mr. Nacinovich:
In a perfect world, Dr. Wang, how do these results help us increase access to mental health care prior to, during, and post-COVID in these patients?

Dr. Wang:
Yeah. The findings of our study suggest that pre-infection psychological distress probably will increase risk of long COVID, but we do not know whether reduced psychological distress will mitigate symptoms among those who have long COVID. I think that’s probably where future research should look into. And after all, we encourage people to stay healthy, stay in a healthy mental health state, and to reduce their psychological distress pre-infection, during infection, and post-infection, even though, as I just mentioned, there are some extrapolation of this disease that we cannot say for sure. But we encourage more researchers look into this field to help mitigate the symptoms of those with long COVID and also probably other post-infection disease to reduce public health burden.

Mr. Nacinovich:
Well, with these insights in mind, I want to thank my guest, Dr. Wang, for sharing her research and insights on long COVID and the psychological distress that could be linked to it. Dr. Wang, it was a pleasure speaking with you today.

Dr. Wang:
My pleasure. Thank you very much.

Mr. Nacinovich:
I'm Mario Nacinovich. To access this and other episodes in our series, visit ReachMD.com/COVID19 where you can be Part of the Knowledge. Thanks for listening.