Large study reveals clearer links between COVID-19, mental health risks

In a large US study that tracked people for as long as a year, COVID-19 patients had a 60% higher risk of mental disorders such as anxiety, depression, or substance abuse compared with those who weren't sickened by the virus.

Given the large number of people infected with COVID-19, the findings suggest that nations should take more steps to tackle the growing challenge of managing mental health conditions in survivors. Researchers based at the Veterans Administration (VA) and Washington University in St. Louis published their findings yesterday in The BMJ.

Senior author Ziyad Al-Aly, MD, clinical epidemiologist at Washington University in St. Louis, said in a news release from the school, "But while we've all suffered during the pandemic, people who have had COVID-19 fare far worse mentally. We need to acknowledge this reality and address these conditions now before they balloon into a much larger mental health crisis."

Probing a range of mental health impacts

Earlier studies have drawn links between COVID-19 illness and mental health conditions, but the new study is the largest known to date, harnessing information from 153,848 patients who tested positive for COVID-19 from Mar 1, 2020, to Jan 15, 2021, in a database from the Department of Veterans Affairs, which is the nation's largest integrated health delivery system.

For comparison, the researchers assessed mental health conditions in two control groups: 5.6 million who weren't sick with COVID-19 during the same period, and more than 5.6 million patients who were in the VA system before the pandemic began.

The authors emphasized that the study period they focused on came before vaccines were widely available and before the Delta and Omicron variant waves took place. And though most of the patients in the dataset are older white men, its large size included more than 1.3 million women, more than 2.1 million Blacks, and large numbers of people of different age-groups.

When the team drilled down into specific mental health issues, they found a 35% higher risk of anxiety in the COVID-19 group, a 39% higher risk of depression, and a 41% higher risk of sleep disorders. People who recovered from COVID-19 were 80% more likely to experience neurocognitive decline—a constellation of symptoms known as "brain fog."

And for treatment for mental health conditions, the investigators found a 55% increase in the use of antidepressants and a 65% jump in benzodiazepines for treating anxiety. They also found a 76% higher risk of opioid use, 34% higher risk of opioid use disorder, and a 20% higher risk for the use of other substances.

Unique to COVID? Typical after hospitalization?

To assess patterns that they found were unique to COVID-19, the researchers compared the COVID-19 patients with those in the database who had flu, including hospitalization for the condition, in the three flu seasons leading up to start of the pandemic.

The risk of mental health conditions was still significantly higher in COVID-19 patients: 27% in those with mild infection and 45% in those who were hospitalized.

Al-Aly said, "My hope is that this dispels the notion that COVID-19 is like the flu. It's so much more serious."

Because hospital stays are known to provoke anxiety, depression, and other conditions, the team compared those hospitalized for COVID-19 during the first 30 days of infection with those hospitalized for any other cause. Mental health conditions were 86% more likely in those who were hospitalized for COVID-19.

Though the findings suggest a link between COVID-19 and mental health disorders, Al-Aly said a leading hypothesis is that the virus can enter the brain and disrupt cellular and neuron pathways, leading to mental disorders.

Take-home messages from the study are that the best defense against long COVID is to avoid contracting COVID-19 in the first place by getting vaccinated and wearing quality masks, the authors said. First author Yan Xie, PhD, an epidemiologist with the VA St Louis Epidemiology Center, said she hopes the study's findings will raise awareness to make the conditions easier for health providers to identify and treat.

Prioritizing mental health with COVID-19

In a related editorial in the same issue, Scott Weich, MD, professor of mental health at the University of Sheffield in England, said the study paints a clearer picture of COVID-19's mental health impacts.

For the general population, the pandemic setting and lockdown caused transient distress related to the threat. But those who contracted the virus had a moderately increased risk of anxiety and depression, mainly for the first 6 months but greatest in the first month.

He said the bulk of the research on the mental health impact of COVID-19 represents more hindsight than insight and that, moving forward, investigations need to focus on understanding the causes and evaluating treatments for mental health conditions more generally.

"We do not yet know the true incidence and consequences of long covid, and we are still witnessing the unfolding toll of the pandemic on healthcare staff," he wrote. "And while epidemiological research has flourished—at least in terms of scientific publications—we are guilty of failing to prioritise evaluations of mental healthcare interventions, including clinical trials, just when these are most needed."

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