COVID-19 has infected nearly 5 million people globally and killed almost 323,000. It can devastate a range of organ systems, including the lungs, the kidneys and the cardiovascular system.
But for those who get very sick and are lucky enough to recover, the virus carries another potential danger — to mental health. Hundreds of thousands of COVID-19 survivors could be at risk for symptoms of post-traumatic stress disorder. As the number of infections continues to rise steadily, this potential hazard will also grow.
We have long known that being critically ill can lead to symptoms of PTSD, including chronic fear, arousal and avoidance. The reasons for this are complex. Having a life-threatening illness that requires intensive care can be terrifying. These patients are facing the possibility of their own death in a situation in which they have ceded control of their own bodies to strangers, often in painful or unpleasant ways. They often can’t move, they are intubated, and they receive medications that make them feel sick or cause them to drift in and out of consciousness.
This nightmarish experience is often the everyday reality of being hospitalized with serious illness. These patients can also fall into a delirium and, after they recover, they are disturbed by vivid memories of these hallucinations and misperceptions.
Brains primed to remember trauma
It also appears that being critically ill, particularly with severe infections that cause inflammation, can prime the brain to remember traumatic experiences. The brains of many of these patients are deluged with adrenaline, the fight-or-flight neurotransmitter. After all, what is more urgent than trying to stay alive? Adrenaline activates the amygdala, the fear center of the brain. When this happens, a person’s memories tend to be strongly encoded. This is a key reason that people tend to remember so much about traumatic experiences.
Many seriously ill patients can also experience a burst of inflammatory chemicals that triggers an additional adrenaline spike. On top of that, many of these patients suffer a dangerous drop in blood pressure, which is often treated with, you guessed it, a shot of adrenaline. As a result, many seriously ill people, including those with COVID-19, have very high levels of adrenaline, which likely affects how they experience the already distressing ordeal of being sick in the hospital.
As a psychiatrist who often sees survivors of critical illness, I am very familiar with these problems. In some ways, being seriously ill can resemble combat, another common cause of PTSD: In both cases, people feel extreme fear, intense arousal and a sense — often quite accurate — that they have little control over their own fate.
Given these circumstances, it makes sense that many hospitalized COVID-19 patients could be at risk for PTSD symptoms once they recover. The problem may be exacerbated because most hospitals are not allowing any visitors for these patients, so most of them must suffer alone, without family or friends.
Research suggests that PTSD symptoms are particularly common in people who survive acute respiratory distress syndrome, or ARDS, in which the lungs fill with fluid and breathing becomes difficult. Oxygen is central to life, and we have evolved to prize it intensely. Anyone who has gotten something caught in their throat knows how terrifying this feeling is. Now imagine that sensation lasting for days or weeks.
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Of course, ARDS is a hallmark of severe COVID-19. Many such patients must be attached to ventilators in order to breathe. A tube is inserted deep into their throats, which can give them the sensation of being choked. Often, these patients must be sedated and restrained to keep them from pulling the tube out in a panic.
The problem may extend beyond the hospital. The health care system has been stretched so thin that many COVID-19 patients with serious symptoms don’t go to the hospital at all. Some describe struggling over days to breathe freely. This group could also be at risk for persistent emotional effects.
Don't overlook PTSD after COVID-19
Because COVID-19 is so new, there is little research on its mental health consequences. A study of over 700 COVID-19 patients by Chinese researchers, published in March in the journal Psychological Medicine, found that an astounding 96% of them had significant PTSD symptoms during quarantine. This rate is much higher than what researchers typically find for non-COVID critical illness survivors. Most researchers agree that 20% to 25% of such patients end up with PTSD symptoms.
The high rate found in the Chinese study could be due in part to the fact that these patients were quarantined for weeks in hospitals, apart from family and friends. The United States has not used this strict approach. Nevertheless, not all of these patients had a serious illness. In that region of China, anyone who tested positive for COVID-19, whatever their symptoms, was quarantined.
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PTSD after critical illness is treatable, with strategies similar to those used for PTSD triggered by other circumstances. For many patients, a combination of medication and psychotherapy can, over time, ease or eliminate symptoms. But because the problem remains unfamiliar to many doctors, including most psychiatrists, many of these patients don’t receive the help they need.
It is impossible to know how many Americans will ultimately be infected with COVID. But as the partial reopening continues, the number will likely stretch into the millions. Not all of these people will become seriously ill, of course, but many will. One recent paper from the Annals of Internal Medicine estimated that about 9% of patients infected with COVID-19 require intensive care. Of those, tens or perhaps hundreds of thousands could end up with symptoms of PTSD.
Over the coming months and years, we will need to make sure that we focus on the mental health of these patients, providing the support they need to recover, not only physically but emotionally as well.
Dr. Joseph Bienvenu, a psychiatrist at the Johns Hopkins University School of Medicine, studies mental health in survivors of critical illness.