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An interdisciplinary group of physicians has released the latest guidance in its series on long COVID, this time focusing on mental health symptoms.

The guidance, by the American Academy of Physical Medicine & Rehabilitation (AAPM&R), discusses how to assess mental health systems in patients with post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID, as well as options for treatment or referral.

Those symptoms commonly include anxiety, depression, and post-traumatic stress disorder, according to lead author Abby Cheng, MD, of the division of physical medicine and rehabilitation at Washington University in Saint Louis, Missouri, and colleagues.

"The COVID pandemic itself has contributed to new and worsened mental health symptoms in some people, but long COVID can also independently cause new or worsened mental health symptoms," Cheng told 番茄社区app. "Scientists have found biologic responses within the body related to cytokines and inflammation that occur in the context of acute COVID infection and can explain the new or worsening mental health symptoms that are a direct result of COVID-19 infection."

The first part of the guidance focuses on assessing mental health symptoms in long COVID patients, beginning with an acknowledgement that some patients' symptoms have previously been dismissed by other healthcare professionals as "purely psychosomatic."

"Long COVID is real and mental health conditions are not the cause of long COVID, so many of our patients have reported experiences in which their symptoms of long COVID have been dismissed either by loved ones in the community or also amongst healthcare providers," Cheng said.

The guidance recommends reducing stigma by listening to patients and validating their experiences with mental health symptoms, Cheng added.

In addition to screening patients for signs and symptoms of new or worsening mental health conditions, clinicians should also conduct a comprehensive patient history that includes understanding any changes in mental health symptoms before and after COVID infection; taking a medication history; and determining whether a referral to subspecialty care is needed.

Clinicians should also consider reviewing factors that may contribute to the patient's symptoms or exacerbations of those symptoms, the authors wrote.

As for treatment, the guidance notes that the clinical course of mental health symptoms in patients with long COVID varies widely, and that the "available evidence suggests that the general principles of treating mental health symptoms in the setting of PASC should generally mirror the treatment principles for those who do not have PASC."

Generally, clinicians should collaborate with the appropriate specialists or primary care in considering both pharmacologic and non-pharmacologic interventions; treating underlying medical conditions such as pain, sleep disorders, and neurologic issues; and reducing polypharmacy and medications that may worsen mental health symptoms.

Clinicians should refer out to mental health specialists for patients who score in the moderate-to-severe category for depression; have more significant psychiatric symptoms such as psychosis; have major functional impairment; and aren't improving over time, according to the guidance.

"We really rely on our mental health colleagues to ... support patients with long COVID," Cheng said. "This includes validating their experience and helping patients get through that stigma and have a supportive voice in their corner."

Guideline co-author Monica Verduzco-Gutierrez, MD, of the University of Texas Health Science Center at San Antonio, said collaborating with specialists or primary care physicians is important for consistent and effective care of long COVID patients.

"The presence of mental health issues in conjunction with long COVID can exacerbate the overall health journey to the individual, and so it's very crucial that we addressed both aspects comprehensively and equitably," Verduzco-Gutierrez told 番茄社区app.

The guidance was developed by AAPM&R's PASC Collaborative, a multidisciplinary group of physicians, clinicians, and patient advocates that has produced several other on long COVID, including fatigue, pediatric long COVID, , and cardiovascular issues.

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