Stress, Depression, and Anxiety Linked to Higher Risk of Developing Long Covid, Study Shows

People who felt stressed, anxious, lonely, depressed or worried about COVID-19 before getting infected were at higher risk of developing long-term symptoms from their illness, according to a new study.

"We were surprised by how strongly psychological distress before COVID infection was associated with increased risk of long COVID," said Dr. Siwen Wang, MD, an author of the study and research fellow at the Harvard T.H. Chan School of Public Health. "Distress was more strongly associated than physical health risk factors such as obesity, asthma, and hypertension."

Link Between Psychological Distress and Long COVID

The study found that people who reported psychological distress before they got infected had a 32% to 46% increased risk of long COVID, compared to people who did not report such distress. They also experienced an increased risk of daily life impairment related to post–COVID-19 conditions.

Researcher's drew participants from three ongoing longitudinal studies: Nurses' Health Study II (NHSII), Nurses' Health Study 3 (NHS3), and the Growing Up Today Study (GUTS). They analyzed questionnaire responses from 54,960 participants who responded from April 2020 to September 1, 2020. After that, respondents were given monthly surveys. Participants who actively worked at healthcare facilities were given additional weekly questionnaires, and in August 2020, the surveys were administered quarterly.

Although some of the participants were healthcare workers, Wang says only 1 in 3 were actively working in a healthcare setting by the start of the pandemic. "Second, if we are talking about responses to the questionnaires, they have higher accuracy in self-reporting health-related information compared to the general public," she said.

However, Wang noted that because the study participants were not a random sample of the U.S. population, more studies are needed to confirm the findings.

Symptoms Are Real, Not Imagined

The findings indicate that mental health can have an effect on physical COVID symptoms. However, the researchers stressed that long COVID symptoms among the people studied were real and arose as a result of their infection.

In fact, in their analysis, they separated overlapping symptoms, such as fatigue, brain fog, and memory issues to look at symptoms like persistent cough, shortness of breath, or trouble smelling or tasting "because we want to address that we are not simply measuring distress symptoms among those who were already distressed," said Wang.

In other words, the researchers note that the results should not be misinterpreted to mean that post–COVID-19 conditions are psychosomatic. To support this notion, in their results, researchers pointed out the following:

• Among respondents who developed post–COVID-19 conditions, more than 40% had no distress at baseline.
• Symptoms of post–COVID-19 conditions differ substantially from symptoms of mental illness. Although fatigue and brain fog may occur with depression, smell and taste problems, shortness of breath and difficulty breathing, and cough are not common symptoms of mental illness.
• More than 50% of patients with post-COVID-19 conditions report relapses triggered by physical activity. In contrast, physical activity is protective against relapse of mental illness.
• Results were similar when excluding participants reporting only psychiatric, cognitive, or neurological symptoms.

Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center in Nashville, Tennessee, said infectious disease doctors are increasingly appreciating the number and variety of impairments and symptoms that continue after COVID, including the psychological and mental aspects.

"We've heard a lot about fuzzy thinking, but this is different. This is people feeling low, depressed, not as in touch with their world, not as energetic, or withdrawn and it might indeed add onto those senses of depression and withdrawal that already exist," Schaffner said.

He said the study findings are not surprising, but are important to note so that healthcare providers can better care for patients with mental health conditions. "They can be particularly attentive to patients who were struggling with anxiety or depression before getting COVID, and be aware that they may be more predisposed to long-term psychological effects of the virus," Schaffner said.

Can Stress and Distress Make You Prone to Illness?

Wang pointed out that previous research showed mental health conditions are associated with greater severity and longer duration of acute respiratory tract infections, such as flu or the common cold.

"Depression and other mental illness have been associated with greater risk of more severe COVID-19, including risk of hospitalization," she said. "Previous studies have suggested that distress is associated with chronic symptoms following Lyme disease and in chronic fatigue syndrome and fibromyalgia, which have symptoms similar to those of long COVID (such as fatigue, headache, and muscle pain)."

However, her current study did not investigate the potential biological pathways. She said based on prior research, psychological distress is associated with chronic systemic inflammation and immune dysregulation, and both have been associated with increased risk of persistent COVID-19 symptoms.

"There is also evidence showing that some people with mental health conditions sometimes develop autoantibodies that have also been associated with increased risk of long COVID. In addition, depression affects the brain in ways that may explain certain cognitive symptoms in long COVID. More studies are needed to understand how psychological distress increases the risk of long COVID," Wang said.

It's important to note that viruses don't seek people out and don't have an advantage in making people ill who happen to be in psychological distress, explained Schaffner.

"But if you happen to be in that low state and you get the viral infection, it's more difficult for you to recover to get back to where you were," he said.

Additionally, many people adhere to the recommendations to isolate themselves when they have COVID, and if they are fatigued may even avoid interacting on social media or via email or the telephone.

"Doing that would accentuate the whole sense of loneliness that already was there in some people," said Schaffner. "So, it's not just the virus, it's what we do when we get sick."

A Call for Mental Health Awareness

Wang said the findings suggest the need to consider psychological health in addition to physical health as risk factors of long COVID-19 and points to the World Health Organization statistic that 75% of people with depression in low or middle income countries 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, increasing the supply of mental health clinicians and improving access to care," said Wang.

Schaffner agreed.

"Depression, anxiety, feelings of loneliness and remoteness, and not being connected, those are real things and we're way beyond the notion that mental illness is somehow fake or not real unless you're psychotic. Mental illness is illness," he said.

For those with mental health conditions, he added that this study shouldn't make them more fearful of COVID, but rather empower them to advocate for themselves.

"If you have these feelings after getting COVID, reach out to the healthcare professional with whom you were working with before and let them know you might need some additional help," said Schaffner.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.