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Experiencing Psychological Distress Before Infection Linked With Long COVID


Feeling depressed, anxious, worried, stressed, or lonely was linked with a higher risk of developing long COVID and hurting the ability to function in daily life, according to a study published this week.

Having psychological distress before SARS-CoV-2 infection was linked with a higher risk of developing long-lasting post–COVID-19 symptoms, but the authors cautioned against interpretations that would suggest long COVID is psychosomatic.

Little is known about why some individuals develop long COVID, which may include fatigue, brain fog, dyspnea, digestive issues, loss of taste and smell, and depression.

Post–COVID-19 conditions are linked with reduced quality of life and an inability to work; a report released last month from Brookings on the effect of long COVID on the labor market suggests that in the United States, as many as 4 million individuals may be out of the workforce due to ongoing symptoms. According to the CDC, about 20% of American adults who had COVID-19 have developed long COVID.

Some factors have been linked with long COVID, such as being female, having asthma or being immunocompromised, having obesity or high blood pressure, being older, or having a more severe case of infection.

Psychological distress, such as depression, is linked with having a negative impact on acute respiratory tract infections and other diseases, including chronic symptoms following Lyme disease and in chronic fatigue syndrome and fibromyalgia. However, only 3 prior studies have examined psychological factors as potential risk factors of post–COVID-19 conditions, according to the current study, which was published Wednesday in JAMA Psychiatry.

This prospective study used data from 3 large ongoing cohorts: Nurses’ Health Study II, Nurses’ Health Study 3, and the Growing Up Today Study. The majority of the 54,960 participants were female (n  =  53,107) and 38.0% (n  =  20,902) were active health care workers, with a mean (SD) age of 57.5 (13.8) years.

Participants were included in the analysis if, at the baseline survey in April 2020, they did not report being infected but did become sick during the study. They were followed until November 2021 with additional surveys. Each survey, taken monthly for the first 6 months and then quarterly, asked about depression, anxiety, worry about COVID-19, perceived stress, and loneliness.

On the last survey, answered 1 year after baseline, the researchers asked about COVID-19–related symptoms lasting 4 weeks or longer and their impact on daily life. Of 3193 individuals followed for more than 1 year, psychological issues were linked with a 1.3- to 1.5-fold increased risk—as much as 32% to 46% higher—of self-reported post–COVID-19 conditions and a 15% to 51% greater risk risk of daily life impairment.

The risk ratio (RR) for the specific, self-reported psychological issues were:

  • Depression, 1.32 (95% CI ,  1.12-1.55)
  • Anxiety, 1.42 (95% CI , 1.23-1.65)
  • Worry about COVID-19, 1.37 (95% CI , 1.17-1.61)
  • Perceived stress, highest vs lowest quartile, 1.46 (95% CI, 1.18-1.81)
  • Loneliness, 1.32 (95% CI, 1.08-1.61)

Moreover, those with 2 or more types of distress before becoming sick had a nearly 50% increased risk for post–COVID-19 conditions (RR, 1.49; 95% CI, 1.23-1.80). All types of distress were associated with increased risk of daily life impairment (783 cases) among individuals with post–COVID-19 conditions (RR range, 1.15-1.51).

The increased risk was independent of smoking, asthma, and other health behaviors or comorbidities.

The authors made several points in noting why their findings cannot be used to claim that post–COVID-19 conditions are psychosomatic:

  • More than 40% of participants who developed long COVID reported no psychological distress at the start of the study
  • Symptoms of long COVID-19, which may include smell and taste problems, shortness of breath, cough, and difficulty breathing, differ from mental illness symptoms
  • More than 50% of patients with post–COVID-19 conditions note relapses triggered by physical activity, but physical activity guards against mental illness relapse
  • Study findings were similar when excluding partients reporting only psychiatric, cognitive, or neurological symptoms

“We were surprised by how strongly psychological distress before a COVID-19 infection was associated with an increased risk of long COVID,” Siwen Wang, MD, a researcher in the Department of Nutrition at Harvard TH Chan School of Public Health, who led the study, said in a statement. “Distress was more strongly associated with developing long COVID than physical health risk factors such as obesity, asthma, and hypertension.”

“To the best of our knowledge, this is the first prospective study to show that a wide range of social and psychological factors are risk factors for long COVID and daily life impairment due to long COVID,” added Andrea Roberts, MD, MPH, senior research scientist in the Department of Environmental Health at Harvard TH Chan School of Public Health and a senior author. “We need to consider psychological health in addition to physical health as risk factors of long COVID-19. These results also reinforce the need to increase public awareness of the importance of mental health and to get mental health care for people who need it, including increasing the supply of mental health clinicians and improving access to care.”


Wang S, Quan L, Chavarro JE, et al. Associations of depression, anxiety, worry, perceived stress, and loneliness prior to infection with risk of post–COVID-19 conditions. JAMA Psychiatry. Published online September 7, 2022. doi:10.1001/jamapsychiatry.2022.2640

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