As the pandemic drags on, ripples and waves, very few brave hearts may still be standing whose spirits remain unscathed over the course of the last year-and-a-half.
FIT has spoken at length about the mental health crisis that the pandemic has stirred.
However, ‘pandemic fatigue’ and ‘COVID anxiety’ may be a lot more tangible than just a feeling, especially in those who have got COVID.
For the relatively young and healthy who caught and fought COVID, the struggle may not have been all that.
“It was like having a slight cold, nothing more,” I've heard friends say.
But little did they know, for a lot of them, their woes were only beginning with the end.
And sometimes these symptoms start showing up so late – weeks and even months – after recovery that patients aren't able to join the dots right away.
How Deep Does This Causal Link Run?
FIT speaks with Dr Avindra Nath, intramural clinical director of the National Institute of Neurological Disorders and Stroke (NINDS) and the Chief of the Section of Infections of the Nervous System, at the National Institutes of Health (NIH) in the US.
The neurological effects of long COVID have been on the radar of experts for a while now, Dr Avindra Nath being perhaps one of the first to ring the alarm bells back in May 2020.
And now, a recent study published in The Lancet has further bolstered what these experts have been speculating from the very beginning – that COVID is far more than just a pulmonary illness.
The study, conducted by Oxford University researchers, found that 1 in 3 COVID-recovered patients developed neurological or neuropsychiatric disorders within six months of recovery.
These include a range of manifestations such as anxiety, mood disorder, psychosis, dementia, stroke, and even some muscle disorders.
“Among the 2,36,379 patients diagnosed with COVID-19, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 33.62 percent,” the study says.
Commenting on the study, Dr Avindra Nath says, “It's an important study. And though it does have certain drawbacks—it is conducted retrospectively using healthcare records by physicians that weren't collected for research purposes, it confirms what others (scientists) are saying too, that several months after the acute infections, there are a wide variety of neurological and psychiatric manifestations that persist.”
Though people who were hospitalised and were admitted to ICUs had the highest hazard risk of developing them, the study found that those who only experienced mild symptoms, too, were found to be at serious risk.
COVID and the Brain
Considering one of the defining symptoms of COVID is the loss, and even alteration of smell and taste, there is some connection between COVID and the brain, of this we know.
Dr Avindra Nath speaks of the three major categories of neurological symptoms that manifest in people with long covid “with significant overlap”.
“One is that they complain of neurocognitive problems. They have word-finding difficulties, difficulty remembering things, and they may have depression or anxiety.”
“The second group is what we call dysautonomia. This means that they have problems with their autonomous nervous system. They experience a racing heart, dizziness when they stand up, they could also have diarrhoea, constipation or urinary problems,” he explains.
“There is also a third category of people who develop exercise intolerance. This means they get extremely fatigued doing any little bit of exercise and it can take them the whole day to recover.”Dr Avindra Nath, Director, NINDS the US National Institutes of Health (NIH)
“Then there are some who experience pain, and even persisting low-grade fever,” he adds.
But how exactly does COVID affect the brain? Experts have some theories.
An Inflammatory Response
Dr Sumit Ray, critical care medicine, Holy Family Hospital, Delhi tells FIT, “any critical illness triggers certain pathways of our immune system which causes the release of certain cytokines (toxins produced by our body to fight the invaders).”
“The virus leaves our body within 7-10 days but in those who have severe illness, the symptoms persist because of our immune response, which is what causes the more severe damage to our organs, including the nervous system.”Dr Sumit Ray, critical care medicine, Holy Family Hospital, Delhi
Dr Avindra Nath also speaks of this possible explanation.
“One of the major possibilities is that it is an ongoing inflammation, that is driving these symptoms,” he says.
“Sometimes you can have antibodies that can attack various parts of the body and cause symptoms called autoimmune reactions, and it has been shown that this does occur in the COVID patient population,” he explains.
“We looked at autopsy brain tissues of patients who had died of COVID and we found that the blood vessels in the brain were quite abnormal. They were leaky blood vessels.”Dr Avindra Nath, Director, NINDS the US National Institutes of Health (NIH)
“The small blood vessels in the brain were leaking blood substances into the brain, and in multifocal areas scattered across the brain,” he adds.
Virus in the Brain?
Could this inflammation just be a result of a disarrayed immune system or could it be because of persistent viruses that the patient never got rid of, like in the case of some other viruses? Could the SARS-CoV virus be escaping into the brain?
While viral encephalitis—encephalitis caused due to viruses escaping into the brain, is something that occurs in some viral infections like Herpes, Dr Nath and Dr Ray are both of the opinion that it is very unlikely in the case of COVID, as the evidence is very weak.
In the autopsy examinations conducted by Dr Nath and his team, he explains that they tried detecting viruses but couldn't find any, although they did find inflammation in the brain.
But he also adds that though the chances are very slim, “it is possible that they may have missed them or that the virus had been present at some point and wasn't anymore.”
The study published in the Lancet, interestingly, also found that around 17 percent of these patients developed anxiety disorders, followed by mood disorders, substance abuse, and other types of psychosis.
Dr Nath speaks of his personal experience dealing with such cases.
“We’ve seen patients develop acute psychosis after COVID, sometimes weeks after their recovery. And a fair bit of anxiety and depression in patients as well.”Dr Avindra Nath, Director, NINDS the US National Institutes of Health (NIH)
One hypothesis for this that Dr Ray presents is that it could be because of the subliminal anxiety of catching COVID, and the fear of possible death, and of course, the forced isolation.
“Humans are social beings and prolonged isolation—whether hospitalised or not, we don't realise how much of a toll it can take on our psyche,” says Dr Sumit Ray.
This is why Dr Ray is of the opinion that these neuropsychiatric symptoms have a great deal to do with post intensive care stress (PICS).
Not Just in COVID, But Now More Than Ever
“ICU delirium is a very common phenomenon in all severe illnesses, particularly in elderly patients, but in COVID patients, it's been especially common,” he explains.
“We have had to use more antipsychotic medication in the (patients admitted to the) ICU than I’ve ever had to use in my 25 years of experience in critical care.”Dr Sumit Ray, critical care medicine, Holy Family Hospital, Delhi
But Dr Ray also goes on to emphasis that these manifestations aren't unique to COVID, rather it's their volume that has increases during the pandemic.
So in that sense, these persistent symptoms aren't any more cause for alarm than similar symptoms that develop in the case of other severe viral infections.
‘Long Haul’ Isn't Forever
“I think it’s important to convey to the public that most of these symptoms are treatable. You don’t have to suffer in silence. If you notice any of these symptoms, you should seek help.”Dr Avindra Nath, Director, NINDS the US National Institutes of Health (NIH)
Dr Sumit Ray speaks about psychosomatic symptoms and how it is often trivialised by the doctors, and the patients as being ‘just in their heads.’
“Psychosomatic doesn't mean the symptoms aren't real. It just means that the way we approach and treat it needs to be more complex,” he says.
“There is a tendency to blame the patient and say ‘there's nothing really wrong with you,’ when you can't find any reason for it (the symptoms). It is important for people to know that it is not their fault, and that they can get help,” says Dr Nath.
(This story was first published on FIT.)