Associations of Depression, Anxiety, Worry, Perceived Stress, and Loneliness Prior to Infection With Risk of Post–COVID-19 Conditions, 2022, Wang et a

[Wyva]

Key Points

Question Is psychological distress before SARS-CoV-2 infection associated with risk of COVID-19–related symptoms lasting 4 weeks or longer, known as post–COVID-19 conditions?

Findings This cohort study found that among participants who did not report SARS-CoV-2 infection at baseline (April 2020) and reported a positive SARS-CoV-2 test result over 1 year of follow-up (N = 3193), depression, anxiety, perceived stress, loneliness, and worry about COVID-19 were prospectively associated with a 1.3- to 1.5-fold increased risk of self-reported post–COVID-19 conditions, as well as increased risk of daily life impairment related to post–COVID-19 conditions.

Meaning In this study, preinfection psychological distress was associated with risk of post–COVID-19 conditions and daily life impairment in those with post–COVID-19 conditions.

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Abstract

Importance Few risk factors for long-lasting (≥4 weeks) COVID-19 symptoms have been identified.

Objective To determine whether high levels of psychological distress before SARS-CoV-2 infection, characterized by depression, anxiety, worry, perceived stress, and loneliness, are prospectively associated with increased risk of developing post–COVID-19 conditions (sometimes called long COVID).

Design, Setting, and Participants This prospective cohort study used data from 3 large ongoing, predominantly female cohorts: Nurses’ Health Study II, Nurses’ Health Study 3, and the Growing Up Today Study. Between April 2020 and November 2021, participants were followed up with periodic surveys. Participants were included if they reported no current or prior SARS-CoV-2 infection at the April 2020 baseline survey when distress was assessed and returned 1 or more follow-up questionnaires.

Exposures Depression, anxiety, worry about COVID-19, perceived stress, and loneliness were measured at study baseline early in the pandemic, before SARS-CoV-2 infection, using validated questionnaires.

Main Outcomes and Measures SARS-CoV-2 infection was self-reported during each of 6 monthly and then quarterly follow-up questionnaires. COVID-19–related symptoms lasting 4 weeks or longer and daily life impairment due to these symptoms were self-reported on the final questionnaire, 1 year after baseline.

Results Of 54 960 participants, 38.0% (n = 20 902) were active health care workers, and 96.6% (n = 53 107) were female; the mean (SD) age was 57.5 (13.8) years. Six percent (3193 participants) reported a positive SARS-CoV-2 test result during follow-up (1-47 weeks after baseline). Among these, probable depression (risk ratio [RR], 1.32; 95% CI = 1.12-1.55), probable anxiety (RR = 1.42; 95% CI, 1.23-1.65), worry about COVID-19 (RR, 1.37; 95% CI, 1.17-1.61), perceived stress (highest vs lowest quartile: RR, 1.46; 95% CI, 1.18-1.81), and loneliness (RR, 1.32; 95% CI, 1.08-1.61) were each associated with post–COVID-19 conditions (1403 cases) in generalized estimating equation models adjusted for sociodemographic factors, health behaviors, and comorbidities. Participants with 2 or more types of distress prior to infection were at 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).

Conclusions and Relevance The findings of this study suggest that preinfection psychological distress may be a risk factor for post–COVID-19 conditions in individuals with SARS-CoV-2 infection. Future work should examine the biobehavioral mechanism linking psychological distress with persistent postinfection symptoms.

Open access: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2796097

 

[John Mac]

Didn't take long for the usual suspects to chip in.

Is long Covid all in the mind?
What's the link between long Covid and mental health? A study just published in the Journal of the American Medical Association suggests it's a significant one. The paper looked at more than 3,000 people who tested positive for Covid in the US. Of those who went on to develop ‘long Covid’, it found many of them already experienced mental distress before catching the virus.

The study looked at 3,193 people – mostly women – who reported Covid symptoms continuing four weeks after first falling ill. They found that those reporting long Covid were more likely to have already experienced a range of symptoms including ‘depression, anxiety, worry about Covid, loneliness and stress’ before they tested positive. The risk increased between 1.3 and 1.5 fold. Scientists say this shows an association between prior mental health conditions and symptoms of Covid that last for more than four weeks. They were keen to stress that this only means mental health may be a risk factor, not that it is one.

Speak to doctors and they’ll tell you they knew this from the start. One says it was fairly obvious early on that long Covid patients were suffering from anxiety. But as a long Covid lobby grew, it became a taboo for GPs to say this.

That’s not to say there aren’t some who are suffering from a genuine physical condition. Post-viral fatigue (ME) is already a well-established disease, for example. The study's authors don’t rule out physical mechanisms at play. One possibility is that pre-existing mental distress makes people's bodies more susceptible to attack from the virus.

But they are adding to a growing pile of evidence. British researchers writing this June in the journal Nature found an increase in the odds of developing long Covid in people who already had anxiety and depression. That study of 6,907 Covid sufferers also found age, being female, white or obese were factors in longer-lasting virus symptoms. Women had a 50 per cent higher chance than men. It also found less-educated people were significantly less likely to have symptoms for more than three months. Interestingly though it found no link between long Covid and prior physical conditions such as diabetes, high blood pressure or high cholesterol.

In short, the most typical long Covid sufferer is a well-educated, obese white woman with a history of poor mental health. A less-educated non-white man is less likely to report having persistent symptoms. Other studies have found interesting associations too: in the US, a census study found 47 per cent of transgendered Covid sufferers reporting long Covid, compared with 39 per cent of women and 26 per cent of men. If you're a child of a long Covid patient, your odds of reporting the condition went up too.

According to the ONS, a million Brits might suffer from the condition. Another study, React, put the number as high as three million in England alone. Millions of pounds have been poured into treating and researching it. But if the cause of many cases is found in the mind, not the body, then doctors may have been approaching treatment in the wrong way.

https://www.spectator.co.uk/article/who-s-most-likely-to-report-long-covid-

"The study looked at 3,193 people – mostly women"

"In short, the most typical long Covid sufferer is a well-educated, obese white woman with a history of poor mental health. A less-educated non-white man is less likely to report having persistent symptoms."

Well if you look mostly at women then you are going to find more women with long Covid.
And I wonder how many "less-educated non-white men" they had in the study?

Study finds link between poor mental health and long Covid
High levels of distress before coronavirus infection raises risk of long Covid, say Harvard researchers

People who are highly stressed, anxious, lonely or depressed before catching coronavirus are more prone to long Covid than those in good mental health, according to a major study.

A Harvard analysis of health data from nearly 55,000 US volunteers, most of whom were women, found that high levels of psychological distress before Covid infection raised the risk of long-term illness by 32%-46%.

The results highlight the urgent need to support people with mental health conditions and the importance of building mental health resilience more widely in the population to reduce the impact of long Covid.

“Depression, stress and loneliness are very, very common, and the fact that they increase the risk of long Covid a fair amount is notable,” said Andrea Roberts, a senior research scientist at the Harvard TH Chan School of Public Health. “The associations were stronger with these risk factors than with other things we know to be associated with long Covid, such as obesity, hypertension and asthma.”

A sizeable minority of people who catch Covid develop long-term, often debilitating ailments such as fatigue, breathlessness, brain fog and heart problems. About one in six middle-aged people and one in 13 younger adults in the UK have symptoms that persist for more than three months. There are thought to be multiple causes, ranging from abnormal immune responses to damaged tissue and residual virus lurking in the body.

While the relationship between mental wellbeing and long Covid is unclear, psychological distress can drive chronic inflammation and disrupt the immune system, potentially making people more vulnerable to long Covid, the researchers note in JAMA Psychiatry.

The Harvard team used questionnaires to rank the mental wellbeing of 54,960 US volunteers drawn from the Nurses’ Health Studies and the Growing Up Today study. Most of the volunteers were white female nurses aged 40 to 70. In April 2020, none had tested positive for Covid, but over the following year more than 3,000 caught the virus and recorded their symptoms.

Those who scored higher on depression, stress, anxiety, loneliness and worry before catching Covid were more likely to report symptoms lasting more than one month. Such ongoing symptoms were 49% more likely in people with two or more forms of psychological distress compared with those who reported none. A similar finding was seen in people whose symptoms lasted at least two months.

All Covid symptoms apart from a cough and problems with smell or taste were more common in those who were distressed before they caught the virus. Depending on the type of distress, volunteers were 15% to 51% more likely to say long Covid impaired their daily lives compared with those with no mental health issues before testing positive.

The findings do not mean that mental health issues cause long Covid: more than 40% of those who developed long Covid in the study had no signs of distress before infection.

Mental health is known to affect some diseases. Stress has been linked to a greater susceptibility to common colds and other respiratory tract infections. Last year, researchers in London reported that poor pre-pandemic mental health raised the risk of long Covid, as did being older, female, overweight, in poor general health, and having asthma. A separate study of people with multiple sclerosis found that those with anxiety or depression took longer to recover from Covid.

Siwen Wang, an epidemiologist at Harvard and first author on the study, said it was important for people in poor mental health to have good access to high-quality care. “Future research should investigate whether better management of psychological distress can prevent people from getting long Covid or improve their symptoms,” she said.

Claire Steves, a professor in ageing and health at King’s College London, who was part of a team that found a link between mental health and long Covid last year, said the Harvard study emphasised the need to build support for vulnerable people and to improve mental resilience in the population at large. “It’s important to state that this association does not mean that prior mental health issues cause long Covid, rather that mental health issues increase the vulnerability of individuals, due to decreased reserve so that physiological changes manifest in daily life.”

Adrian James, the president of the Royal College of Psychiatrists, said: “People with severe mental illness are at higher risk of developing a range of physical health problems, including long Covid. We are still learning about the impact of the virus on people’s physical and mental health but we know that long Covid can cause debilitating symptoms. People with long Covid must be able to access the healthcare they need, including appropriate specialist mental health provision.

“It’s also vital that research on the impacts of long Covid in people with pre-existing mental illness continues, if we are to ensure the best standard of care for patients down the line.”

https://www.theguardian.com/society...ink-between-poor-mental-health-and-long-covid

 

[Andy]

From the paper, the woeful questionnaires that they used to 'measure' levels of 'distress':

Types of Distress

Distress was measured at baseline. Frequency of depressive and anxiety symptoms in the past 2 weeks was assessed with the 4-item Patient Health Questionnaire (PHQ-4), which consists of a 2-item depression measure (PHQ-2) and a 2-item anxiety measure (2-item Generalized Anxiety Disorder scale [GAD-2]).30 Responses ranged from 0 (not at all) to 3 (nearly every day). Scores of 3 or higher on the PHQ-2 or GAD-2 indicated probable depression or probable anxiety.30-33 Worry about COVID-19 was assessed with the item, “How worried are you about COVID-19?” Response options were not at all, not very worried, somewhat worried, and very worried.34 The reference was not at all or not very worried.

Two additional types of distress were assessed only among participants who were not active health care workers. The 4-item Perceived Stress Scale (PSS-4) queries frequency of past-month feelings of stress (eg, “difficulties piling up so high that you could not overcome them”).35,36 Response options ranged from never to very often (0-4). The summed score was divided into quartiles for analysis.

The 3-item UCLA Loneliness Scale queried the frequency of feeling lack of companionship, left out, and isolated from others (hardly ever [1], some of the time [2], or often [3]).37 We divided the score into 3 levels for analysis: hardly ever lonely (3 points, reference), less than some of the time (4-5 points), and some of the time or often (≥6 points).

For each participant, we calculated the number of distress types experienced at a high level,30-37 including probable depression, probable anxiety, somewhat or very worried about COVID-19, the top quartile of perceived stress, and lonely some of the time or more often (coded as 0, 1, or 2 or more types of distress).

 

[Charles B.]

This is like injecting some otherworldly steroid into the veins of long Covid denIalists and paychologizers. The typical refrains will echo throughout the desolate wasteland that is social media. Ultimately, these pieces have a cumulative effect. They’ll reduce interest in genuine biomedical research and divert patients to the hinterlands where BPS functionaries stand at the ready.

Anyone who criticizes the quality of the research will be subjected to the usual litany of recriminations: stigmatizing mental illness; militant; activists; small vocal minority; etc. A major mistake was ceding the realm of public opinion and just hoping that facts would prevail. We need an incisive, adaptable media strategy that incorporates our scientific stalwarts to rebut harmful narratives. A benevolent Science Media Center if you would.

 

[rvallee]

Says everything about how all of this psychosomatic nonsense is pseudoscience. If people want to see something they'll find it, even if it's not there.

In the end, almost all psychological research can be ignored on the basis that correlation is not causation. People are doing the rest, finding crooked noses or beady criminal-looking eyes or whatever if they feel like it. It's simply not a legitimate discipline, I've seen enough of this nonsense.

 

[Sid]

Pretty funny study if not for the fact that it will be used as a weapon against ME/CFS patients. These marginal associations don’t exceed the ambient noise / crud factor that afflicts this sort of questionnaire research and can easily be explained by the common method bias. They measured exposures and outcome using self-report questionnaires. People tend to have a response style so what you typically find in studies of this type is that every construct is correlated to one another to some extent.

 

[Arnie Pye]

depression, anxiety, perceived stress, loneliness, and worry about COVID-19 were prospectively associated with a 1.3- to 1.5-fold increased risk of self-reported post–COVID-19 conditions

A problem I have with doctors is that if I tell them I'm not depressed, anxious, stressed or worried about something they never believe me.

 

[rvallee]

A problem I have with doctors is that if I tell them I'm not depressed, anxious, stressed or worried about something they never believe me.

That's why atypical depression, depression without depression, and generalized anxiety, anxiety without anxiety, were invented.

Heads you're anxious. Tails you're also anxious. Refuse to toss the coin? Clearly anxious about the outcome. The magic of circular evidence.

 

[Hutan]

54 960 participants
Six percent (3193 participants) reported a positive SARS-CoV-2 test result during follow-up (1-47 weeks after baseline)
post–COVID-19 conditions (1403 cases)

So many holes in this one, based on the abstract.

1403/3193 is 44%. Nearly 50% of participants who were infected reported "Covid-19 related symptoms" lasting four weeks or longer. That to me suggests a problem with the definition of Covid-19 related symptoms.

Respondent bias

From April 2020 to May 2020, 105 662 participants who returned the most recent main questionnaire of each cohort were invited to complete an online COVID-19 questionnaire. A total of 58 612 invited participants (55%) responded to this questionnaire

Participants were included if they reported no current or prior SARS-CoV-2 infection at the April 2020 baseline survey when distress was assessed and returned 1 or more follow-up questionnaires.

People are going to be far more likely to return a survey if they have a symptom. They are also going to be far more likely to return a survey if they don't have much else going on in their life - so retired people, people who are lonely. The busy nurse and mother or father of three is much less likely to bother. There were three layers of selection - first, participants had to complete the cohort survey, and then they had to complete the baseline survey, and then they had to complete a followup survey.

Circularity e.g. depression and anxiety are both symptoms and correlations

Post–COVID-19 conditions were assessed on the final questionnaire, administered 336 days after baseline. Participants were asked, “Have you experienced any long-term COVID-19 symptoms (lasting for more than 4 weeks)?”1 If yes, participants were asked to endorse any COVID-19–related symptoms they experienced, including fatigue, shortness of breath or difficulty breathing, persistent cough, muscle/joint/chest pain, smell/taste problems, confusion/disorientation/brain fog, memory issues, depression/anxiety/changes in mood, headache, intermittent fever, heart palpitations, rash/blisters/welts, mouth or tongue ulcers, or other symptoms.

This is just plain ridiculous. Consider the title of the paper:
"Associations of Depression, Anxiety, Worry, Perceived Stress, and Loneliness Prior to Infection With Risk of Post–COVID-19 Conditions"
Given that "post-covid-19 conditions" includes depression and anxiety, the title could be "Associations of depression, anxiety, worry, perceived stress and loneliness prior to infection with depression and anxiety after a Covid-19 infection". It's hardly surprising that someone with depressive feelings at baseline would be somewhat more likely to have depressive feelings 12 months later.


Inadequate discounting of pre-existing conditions
I haven't read the full paper, but the fact that they are counting depression and anxiety at baseline and also counting it at followup suggests that there wasn't much effort to remove the effect of pre-existing conditions. People with various symptoms (e.g. memory issues, confusion, pain) prior to infection would be more likely to feel isolated and sad at baseline, and would be more likely to still be feeling isolated and sad at followup.


As Sid said:

These marginal associations don’t exceed the ambient noise / crud factor that afflicts this sort of questionnaire research and can easily be explained by the common method bias. They measured exposures and outcome using self-report questionnaires.

the associations aren't enormous. The biases evident from the abstract surely account for most of the associations. These authors found what they wanted to find.