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

Abstract

Post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC), also called Long COVID (coronavirus disease), is the experience of new or worsened signs, symptoms, or conditions that develop after resolution of the acute phase of a COVID-19 infection. Although some people with COVID-19 recover well, others have persisting symptoms.1 PASC can manifest as a wide-ranging constellation of disabling sequelae, including mental health conditions.2 Anxiety and depression have been reported as the second and third most common symptoms of PASC, respectively.3 Furthermore, in a narrative review summarizing neuropsychiatric dimensions of PASC, anxiety, post-traumatic stress disorder (PTSD), and depression were among the most reported symptoms of both ongoing symptomatic COVID-19 and PASC. Pooled prevalence of each was: anxiety 19.1% (95% confidence interval [CI], 13.3%–26.8%), PTSD 15.7% (95% CI, 9.9%–24.1%), and depression 12.9% (95% CI, 7.5%–21.5%).4 Despite the high prevalence and often disabling impact of PASC and PASC-related mental health symptoms and the emerging data that PASC can persist for months or years,5 limited guidance currently exists regarding the assessment and treatment of mental health conditions in patients with PASC. Addressing mental health symptoms in the setting of PASC involves several unique complexities, including addressing stigma that may interfere with appropriate diagnosis(es) and treatment, insufficient availability of mental health professionals, and differentiating mental and physical health diagnoses. Many patients have described being questioned about their PASC-related symptoms in a way that feels dismissive of their experience and/or mistakenly attributed to an underlying mental health condition.6 Although the effects of the COVID-19 pandemic on individuals and society can exacerbate direct sequelae from SARS-CoV-2 infection, increasingly evidence supports that new mental health symptoms can also be a component of PASC or caused by SARS- CoV-2 infection, and pre-existing mental health conditions can be exacerbated by PASC, yet mental health conditions are not, in and of themselves, the overall cause of PASC.7-9 Another challenge in addressing mental health disorders is the national and global shortage of mental health professionals.10 This challenge is further intensified because clinicians who are not mental health specialists often express discomfort and a perception of insufficient training to discuss mental health with their patients. Nevertheless, most patients report that they want clinicians who are not mental health specialists to broach the topic and acknowledge the interplay between mental and physical health.11-13 Finally, studies have found that PASC can manifest as symptoms that are not due to a mental health condition, but that can mimic and/or be exacerbated by a mental health disorder. These symptoms include fatigue, dysautonomia, disordered sleep, and cognitive dysfunction,14, 15 which can also interfere with a patient's ability to fully participate in first-line treatment recommendations. The goal of this consensus statement is to present practical guidance for clinicians who treat patients with PASC. Specifically, this statement addresses the assessment and initial treatment of PASC-related mental health symptoms including depression, anxiety disorders (including panic), and PTSD. People with PASC have also reported new or worsening suicidal ideation, psychosis, obsessive compulsive disorder (OCD), and pandemic-related grief and survivor's remorse8, 16-18; however, specific focus on these conditions is outside the scope of this statement. The recommendations in this statement are applicable to all patients with PASC who are experiencing mental health symptoms, regardless of the time course. Of note, this guidance statement reflects the current evidence base and related recommendations from an expert panel of health care professionals who regularly care for people with PASC. The recommendations should not preclude clinical judgment and must be applied in the context of each specific patient, with adjustments for patient preferences, comorbidities, and other factors. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi-Disciplinary PASC Collaborative (PASC Collaborative) was convened to address the pressing need for guidance in the care of patients with PASC. PASC Collaborative members include experts across a variety of clinical disciplines and specialties including PM&R, neurology, neuropsychiatry, neuropsychology, rehabilitation psychology, and primary care. The PASC Collaborative is following an iterative, modified Delphi process to achieve consensus on assessment and treatment recommendations that have been presented as a series of consensus guidance statements regarding the most common PASC symptoms. A full description of the modified Delphi methodology has been published previously.19 These recommendations are informed by experts from established PASC centers who have experience managing patients with the full range of PASC-related symptoms.20-26 Whenever possible, existing evidence related to mental health assessment and treatment specifically for people with PASC has been incorporated into this guidance statement, and this body of evidence is somewhat limited and evolving. As needed, recommendations have also been guided by applying general, yet well-established, mental health assessment and treatment approaches to unique considerations in people with PASC. The consensus guidance statements include an intentional focus on health equity because disparities in care are a critical factor in contributing to widespread disparities in clinical outcomes, and they must be considered and addressed. The PASC Collaborative's goal is to broaden the understanding of current patient care practices, not only to guide clinical management, but also to identify critical gaps and opportunities for future research. According to the original definition by the U.S. Centers for Disease Control and Prevention (CDC), “Long COVID (PASC) is broadly defined as signs, symptoms, and conditions that continue or develop after initial COVID-19 or SARS-CoV-2 infection. The signs, symptoms, and conditions are present 4 weeks or more after the initial phase of infection; may be multisystemic; and may present with a relapsing–remitting pattern and progression or worsening over time, with the possibility of severe and life-threatening events even months or years after infection. The CDC uses the 4-week timeframe in describing post-COVID conditions to emphasize the importance of initial clinical evaluation and supportive care during the initial 4 to 12 weeks after acute COVID-19.27 Based on patient feedback during our consensus process, we also advocate for improving access to beneficial interventions by facilitating early evaluation, diagnosis, and management of new or worsened symptoms that are experienced after COVID-19 infection. For the purposes of this guidance statement, we recommend assessment for PASC if symptoms are not improving within 1 month after acute symptom onset. Emotional and mood fluctuations are experienced as part of normal everyday life, but persistent, distressing disturbances in emotional regulation, behavior, and/or cognition can be indicative of a mental health disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) depressive disorders are characterized primarily by persistent sadness, emptiness, irritability, and/or a loss of pleasure or interest in activities (anhedonia). They are often associated with other secondary symptoms including poor concentration, psychomotor agitation or retardation, fatigue or loss of energy, sleep difficulty (insomnia or hypersomnia), of or about the in or and/or about or Anxiety disorders are characterized by or that is of to the PTSD is characterized by distressing and/or that after to an or The COVID-19 pandemic in a in of depressive disorder and a in of anxiety disorders in was also to have caused years people due to and people due to anxiety and the of new mental health symptoms experienced after SARS-CoV-2 infection has been after or other respiratory and people from and have been reported to have a of PASC, regardless of the of PASC also have a prevalence of pre-existing anxiety and and both conditions are for and new or worsening mental health People who are for specifically PASC-related mental health disorders include and American individuals and people from to the direct of SARS-CoV-2 infection on mental the of stress has due to widespread pandemic-related and as of COVID-19 infection and and and survivor's These have been further exacerbated by pre-existing stigma mental health in the health care which in access to mental health and of reported mental health symptoms by the health care early in the pandemic and for evidence of SARS-CoV-2 pre-existing mental health disorders have been associated with clinical related to SARS-CoV-2 infection, including an of severe acute PASC, and severe depression and anxiety symptoms in the setting of Although the of SARS-CoV-2 infection is is that the by the may mental health by a which and and of these with and This loss is by a in factors. The effects of these may be the of or of pre-existing neuropsychiatric This of in the context of PASC is to the of other are in to a infection or other process, and they into the they can cause symptoms of the body to with the infection, as and of the and is a normal in the setting of infection, and/or the to the can to an and the of depressive symptoms in mental health symptoms specifically in the setting of PASC may also be related to other that are caused by SARS-CoV-2 infection, including persistent due to an and Many patients with PASC have reported and that the of the PASC syndrome is due to their evidence to the This experience has often to between health professionals and their which has limited the to which clinicians have been to supportive interventions to these patients. clinicians who treat PASC to their on for the treatment of patients with fatigue syndrome Specifically, PASC clinicians should a they should the to the syndrome and recommend and mental a patient both of This can be because patients with PASC who are experiencing depression, anxiety, and/or suicidal may their mental health symptoms due to that their all their other PASC symptoms to their mental This may to the that these patients are more to report a of is for clinicians to patients and that not all patients with PASC experience mental health symptoms, they are of the of PASC and have the to be and assessment of mental health symptoms in patients with PASC can be patients have experienced a in and appropriate management because their PASC-related symptoms have been by health care professionals as of this we that clinicians the topic of mental health by that mental health conditions are not, in and of themselves, the cause of mental health symptoms can be worsened can and can PASC symptoms, which is assessment of mental health symptoms is For fatigue and as symptoms of depression can both mimic and exacerbate and they can in to a patient's Although the scope of this statement, the PASC Collaborative and published guidance on cognitive and physical should care to identify the underlying of to guide appropriate possible, a assessment of a patient's mental symptoms can also be by from or more or may be a patient has poor regarding they are and/or their of has been or have difficulty symptoms for symptoms as during the can regarding the time and of to the patient's sleep, and in activities should be for and symptoms of new or worsening depression, anxiety, or PTSD and as should for patients who for mental health conditions and should have an established in to Although can be for evaluation, if a or more mental health is for the to the symptoms. For the symptoms as sleep fatigue, difficulty and because they can be of depressive Nevertheless, these symptoms can also be present due to other PASC-related conditions as the can the or of depressive symptoms in patients with of the not about symptoms to in patients who have as that physical that may be include the depression Anxiety anxiety and Anxiety and depression and anxiety of the a is to the reported mental health symptoms present across only manifest in which may guide and treatment for PTSD include the for and of of the may a to a for more for PTSD should be in patients who are of critical experienced care in an care a SARS-CoV-2 infection, are health care and/or were PTSD can manifest as to and/or persistent cognition and and symptoms of as anxiety, sleep and The context of a mental health can Although are often to patients to a clinical and clinical context is some patients report mental more and a clinical the and of the as is to and the the patient's on the and the impact treatment Of note, some clinicians express discomfort in and mood due to a of of if a patient The American on and with patients of and the training and the as the need to their be for patients who A may include with an mental health as a or in an or a or on Mental or mental health for more with the patient and treatment or to and care of the a patient suicidal ideation, they should not be is to the patient of the importance of their of and which may also include or to a and/or care of is as as other physical health and should be with appropriate and is to a patient's and For in patients with a the in which the is being may need to be these patients may be more to the of their reported symptoms, which may into the of the who patients with disorders should an to assessment and of people with and/or disorders may that are on and possible, should be to the patient's clinical symptom Nevertheless, to the on the patient's and both and should be incorporated into the regarding people with has in and across with for reported health for physical and is also to as and and and clinicians should a to their related must also be that in mental health symptoms are and/or described that patients from may be to mental health symptoms due to a for As should be and/or to for conditions that can as symptoms of a mental health disorder. For a patient's and can be attributed mistakenly to anxiety they are of and/or A of a that or mental health symptoms has been reported in people with pre-existing people with a and people from is in the symptoms of and disorders that manifest in PASC. symptoms include disordered sleep, fatigue, cognitive and mood of that can mimic conditions and to mental health symptoms include disorders disease), and primary sleep care syndrome can also manifest as neuropsychiatric symptoms and can with PASC, disorders are more common in in that may an underlying disorder as to an disorder for the an of symptom symptom normal to symptom to and/or symptoms that are or to The that of a mental health disorder a clinical to for these factors. emotional is related to a ability to in is also to the effects of mental health symptoms on a and A should the patient's and current ability to in activities and activities of with or of to and for PASC-related physical and mental health symptoms can also a patient's ability to and fully participate in and and these in impact and with in these activities can in and a of and patients may to in these activities even if their other PASC-related symptoms as this interplay is an to a treatment that addresses physical mood symptoms, and regardless of symptoms were with PASC. should also about that exacerbate a patient's mental health symptoms. symptom but are not limited pre-existing and and or physical or and as being or being or being limited people to with or other and regarding and These are more in people with Furthermore, mental health assessment should also the impact of the COVID-19 pandemic stress from and/or in and/or or stress due to the of life-threatening and/or direct to other people who severe SARS-CoV-2 The clinical for mental health symptoms in the setting of PASC from patient to may be more severe and in patients who a pre-existing mental health and/or a more severe acute of evidence that the of mental health symptoms in the setting of PASC should the treatment for who not have PASC symptom pre-existing and/or PASC-related comorbidities, of and the to which their of is should guide the treatment For patients with symptoms that are everyday and are outside the scope of of the to an appropriate clinical and/or with in assessment and should discuss with the patient that mental health symptoms can be worsened by can other PASC symptoms. is to that the treatment recommendations in this guidance statement should not preclude clinical judgment and must be applied in the context of each specific patient, with adjustments for patient preferences, comorbidities, and other factors. the PASC Collaborative that patients with PASC present with a of symptoms that body as fatigue and dysautonomia, which their ability to fully participate in some of these assessment and treatment recommendations. These conditions must be considered a or treatment as physical As with treatment clinicians patients with PASC are to discuss the of PASC and as as the and of treatment a patient for a disorder of the or in clinical clinicians with training and with management may care as a of to a mental health mental health for further evaluation and management should be considered for patients in the to severe on depression and anxiety but more symptoms psychosis, suicidal and/or to post-traumatic stress symptoms, conditions as anxiety disorder and are and/or related to their mental health symptoms, and are not over time, initial treatment within the possible, to mental health specialists who have experience patients with however, access may be limited in some general, to an appropriate that has access is to to a who has PASC but the of and other that may in patients to appropriate mental health clinicians are to to within their and national of mental health specialists Many are with for mental health treatment not related to PASC and are to to their and and to if are mental health professionals who are in PASC-related mental health mental health symptoms may with other PASC-related symptoms cognitive to mental health should be in with to other For a a patient with severe fatigue and to both a sleep and a mental health a patient with mood and cognitive symptoms in PASC may from for a assessment to the by to persisting symptoms. The of to mental health also and has during the COVID-19 the was to patients a of and this mental may be and appropriate for the of and health care also over treatment for patients with PASC who have fatigue, and/or Nevertheless, equity for patients who are often for patients who not have access and/or not or not to with in this For patients in clinicians may appropriate to address specific mental symptoms. should be guided patient a of that to and with effects that may exacerbate PASC symptoms as fatigue and treatment of conditions in PASC is guided by approaches to with the of several considerations for this a of in depression, anxiety, and PTSD in the should be that specific recommendations on and are limited with to is in patients with PASC. effects to of of energy, The of management of PASC should from the between the and the A is the patient feels both and of the most a can this is the of the patient's and that they are being is to patients a of over treatment which to have in their is also to with the patient that the goal of mental health treatment is to the to which mental health symptoms are the for specific for mental health symptoms in the setting of PASC has not been in the current the which health has been found to be in mood symptoms and physical symptoms for conditions with as PASC fatigue and approaches for include a of supportive and cognitive have evidence for in to patient and the of A (including and may be beneficial for patients who or have evidence stress and clinical depression and anxiety, and a high of about These are not in people who develop patients with should be considered and with because is to participate in this and is in this The and Mental for PASC other and to and by may also be beneficial for patients with PASC because can of and is a setting for that are to and of Of note, both and during the COVID-19 people who identify as a of a with and have experienced disparities in access to mental health and of the care and clinical should be to gaps in these health disparities and care for this health should to these of the for PASC patient and other for people with PASC and their members and of these are specifically for people who to specific Of note, some patients may be in because of or because they not yet to discuss their mental health symptoms with a and/or because they to the mental health care they are can these patients with from as the and Mental and mental also stress guided and should patients who are a mental health to the and and may want to the as a to to their in their and and the of these should be in in treatment with a mental health The U.S. of an health with to with stress and as as on depression, and PTSD. These are to and mood and anxiety disorders may be secondary exacerbated and/or a contributing factor to other is to address conditions to a patient's overall mental health symptom Although the and treatment of conditions is in some in other is The clinical of PASC has and symptom that are to other after infection with or and clinical a and syndrome is that the common symptom constellation including fatigue, disordered sleep, cognitive symptoms, and/or mood disorders may be a of a common across all these conditions that in a of and of the underlying that is contributing to these symptoms, management can include supportive care and interventions sleep and of the most reported PASC symptoms, including that can be of a mental health fatigue, cognitive can also be exacerbated due to and/or (including and/or is a for events in other as and patients with and/or other As a as the have been and can a for a in of to include or with with and have and Many to treat mental health symptoms also have this is of in the setting of PASC. Another in this is that that are to treat mental health symptoms can impact underlying include that have effects effects and effects on or in the setting of PASC may exacerbate a patient's underlying fatigue and/or and cause people with PASC-related may also have an of associated with of in this is that patients may experience worsened if the to more and of activities but they their may also be considerations for on can be found can be guided by symptom symptom to treatment, and as their health and and ability to advocate for with more and/or mental health symptoms and related should and more for most patients who present with severe symptoms, of mental health symptoms can in the context of new mental health symptoms can be caused by PASC, worsening of pre-existing mental health symptoms can be caused by PASC, and mental health conditions are not, in and of themselves, the overall cause of PASC. Although may be PASC or mental health symptoms to assessment and management of existing symptoms. the with a that the patient's experience and this management is an to and for and mental health symptoms. This can also and be the to the patient mental health of mental health symptoms in the setting of PASC must also the patient's of symptoms because other PASC-related symptoms as fatigue and ability to fully participate in treatment recommendations that be considered Although evidence is to be a regarding PASC-related mental health symptoms patients from on or health or regarding PASC-related of mental health disorders is also for including and people with considerations as and For PASC-related mental health interventions to the of patients with the we advocate that that to and their access to care also be addressed. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) the need to access to rehabilitation care for individuals with of CoV-2 infection The that access to care and patient access to addressing in the health that in access to care because of or and including evaluation and of the PASC guidance statements were by a and of experts with patient Although an of health equity is the scope of the PASC guidance each health equity and to other and The has and they focus on that is to achieve the of health and For the Centers for Disease Control and Prevention health equity as the for people to their full health and that people should not be from their because of or other The Centers for uses the definition established in on which that equity is and and treatment of all including individuals who to who have been treatment, as and and American and and other of members of and with who in and by persistent or are for health some of which the within of health of include but are not limited to availability and access to and access to a to for access to rehabilitation care for all with PASC, the supports of and which is more of and may be as a of a to of and a for and and for opportunities that of of and are incorporated and to that an and among and of the PASC guidance statements are to the recommendations the of health equity in to access to rehabilitation care for all individuals with PASC. The of this Multi-Disciplinary was in with the PASC Multi-Disciplinary PASC or As members of the PASC individuals in their or from their unique in the assessment and treatment of PASC to the of a series of consensus guidance The and by Collaborative are their and not the of This consensus guidance statement reflects a the clinical are in the and the members This consensus guidance statement reflects from patient and the the following and individuals for their during the Collaborative the Long and and Long and The to specifically acknowledge the of the PASC Collaborative and also to acknowledge and a to and for their in the of the PASC Collaborative and the of this The of the is by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) were to with and other are to of for review and during the The are to that are not in with the of this consensus guidance statement. The following and have or from some to their and some for activities related to PASC, and of and but for the of this The only for this specific report is who is to to the and of each PASC Collaborative consensus guidance statement.

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