Thoughts on Long Covid

I read Dr. Ron Pies, MD’s essay today, “What Long COVID Can Teach Psychiatry—and Its Critics.” As usual, he made thought- provoking points about the disease concept in psychiatry. What I also found interesting was the connection he made with Long Covid, a debilitating illness. He cited someone else I know who was involved with a group assigned to create a working definition for it—Dr. E. Wes Ely, an intensive care unit physician at Vanderbilt University in Nashville, Tennessee.

I remember when I first encountered Dr. Ely, way back in 2011 when I was a consulting psychiatrist in the University of Iowa Health Care general hospital. I was blogging back then and mentioned a book he and Valerie Page and written, Delirium in Critical Care. Back then I sometimes read parts of it to trainees because I thought they were amusing:

“…there is a clearly expressed opinion about the role of psychiatrists. It’s in a section titled “Psychiatrists and delirium” in Chapter 9 and begins with the sentence, “Should we, or should we not, call the psychiatrist?” The authors ask the question “Can we replace them with a screening tool, and then use haloperidol freely?” The context for the following remarks is that Chapter 9 is about drug treatment of the symptoms and behaviors commonly associated with delirium.”

I would point out that the authors say, while acknowledging that the opinions of psychiatrists and intensivists might differ, “…we would advocate that a psychiatrist should be consulted for patients already under the care of a psychiatrist or on antipsychotic medications”. Usually, in most medical centers in the U.S.A. a general hospital consultation-liaison psychiatrist sees the delirious inpatient rather than the patient’s outpatient psychiatrist. And many delirious patients don’t have a previous formal history of psychiatric illness and so would not have been seeing an outpatient psychiatrist in the first place.” (Page, V. and E.W. Ely, Delirium in Critical Care: Core Critical Care. Core Critical Care, ed. A. Vuylsteke 2011, New York: Cambridge University Press).

I’m pretty sure I got an email from Wes shortly after I posted that, with his suggestion that I write more about the delirium research he was doing. He sent me several references. I met him in person at a meeting of the American Delirium Society later on and attended an internal medicine grand rounds he presented at UIHC in 2019, “A New Frontier in Critical Care Medicine: Saving the Injured Brain.” He’s also written a great book, “Every Deep-Drawn Breath.”

Anyway, Dr. Ely and others were tasked by the Administration for Strategic Preparedness and Response and the Office of the Assistant Secretary of Health in the Department of Health and Human Services tasked the National Academies of Sciences, Engineering, and Medicine (NASEM) with developing an improved definition for long Covid.

At first, I was puzzled by the creation of criteria that essentially defined Long Covid as a disease state which didn’t even necessitate a positive test for Covid in the history of patients who developed Long Covid. I then read the full essay by Family Medicine physician, Dr. Kirsti Malterud, MD, PhD, “Diagnosis—A Tool for Rational Action? A Critical View from Family Medicine.”

I was hung up on the dichotomy between physical illness and somatization and thought the Long Covid definition posed a dilemma because it purposely omits any need for an “objective” test to verify previous Covid infection, making the Long Covid diagnosis based completely on clinical grounds. The section on persistent oppositions (dichotomies) was helpful, especially the 2^nd point on the dichotomy of the question of whether an illness is physical or psychological (p.28).

The point on how to transcend the dichotomy was well made. I guess it’s easy to forget how the body and mind are related when a consultation-liaison psychiatrist is called to evaluate somebody for “somatization.” Often that was the default question before I ever got to see the patient.

Still, the person suffering from Long Covid often doesn’t seem to have a consistently effective treatment and may stay unwell or even disabled for months or years. Social Security criteria for disability look well-established.

I can imagine that many persons with Long Covid might object to have their care transferred to psychiatric services alone. I can see why there are Long Covid clinics in several states. It’s difficult to tell how many and which ones have psychiatrists on staff. The University of Iowa calls its service the Post Covid Clinic and can refer to mental health and neuropsychology services. On the other hand, a recent study of how many Long Covid clinics are available and what they do for people showed it was difficult to ascertain what services they actually offered, concluding:

“We find that services offered at long COVID clinics at top hospitals in the US often include meeting with a team member and referrals to a wide range of specialists. The diversity in long COVID services offered parallels the diversity in long COVID symptoms, suggesting a need for better consensus in developing and delivering treatment.” (Haslam A, Prasad V. Long COVID clinics and services offered by top US hospitals: an empirical analysis of clinical options as of May 2023. BMC Health Serv Res. 2024 May 30;24(1):684. doi: 10.1186/s12913-024-11071-3. PMID: 38816726; PMCID: PMC11138016.)

I’m interested in seeing how and whether the new Long Covid definition will be widely adopted.