“A Lion Sleeping Next to Me”: Preliminary Considerations on the Psychological Consequences of Surviving COVID-19

Nine months have passed since the coronavirus disease 2019 (COVID-19) pandemic broke out in Italy, and psychologists and psychiatrists are beginning to observe the mental consequences in patients who were hospitalized with COVID-19 and survived. Many patients hospitalized with COVID-19 have developed psychiatric symptoms such as delirium, disturbance of consciousness, and neuropsychiatric disorders.¹ Mazza et al.² screened for psychiatric symptoms in 402 patients who had survived COVID-19, from 6 April to 9 June 2020, as part of an ongoing prospective cohort study at San Raffaele Hospital in Milan. A significant proportion of these patients self-rated their symptoms in the pathologic range: overall, 55.7% scored in the clinical range on at least 1 psychopathological dimension (posttraumatic stress disorder, depression, anxiety, or obsessive-compulsive symptoms), 36.8% on 2, 20.6% on 3 and 10% on all 4 dimensions. Women, patients with a positive previous psychiatric diagnosis, and patients who were managed at home had higher scores on most measures.

As one of the most important hospitals in Italy, Fondazione Policlinico “Agostino Gemelli”/Columbus COVID-19 Hospital was heavily involved in the management of Italian COVID-19 crisis. More than 2000 patients with COVID-19 have been hospitalized there from March to date, and most of these patients are still being followed up in dedicated day hospitals and outpatient clinics.

In July 2020, an integrated psychiatric/psychological service for COVID-19 survivors was instigated. Approximately 2 or 3 patients a week are visited by a psychiatrist and a psychologist and followed up pharmacologically and psychotherapeutically, when requested and indicated. To date, 31 patients have been taken in charge and 6 are undergoing psychotherapy. Anxiety, mood symptoms (mainly dysphoria), memory problems, and cognitive and/or emotional numbness have been frequently reported by patients during their hospitalization, and these symptoms persisted at home for many weeks. In about 70% of our sample, these symptoms and sleep disturbances required a psychopharmacological treatment. Pregabalin or gabapentin have been well tolerated for anxiety while, trazodone or mirtazapine have been preferred for sleep disturbances. More than half of our patients have been prescribed an selective serotonin reuptake inhibitor or an serotonin and norepinephrine reuptake inhibitor for a depressive disorder or a trauma- and stress-related disorder.

COVID-19 survivors shared many common issues with us in their first sessions of psychotherapy.

Guilt and Stigma

One of the most common emotions shared in the first interviews was the sense of guilt for having infected partners, children and elderly parents or in-laws. In the worst cases, COVID-19 survivors felt responsible for being the cause of the death of elderly relatives, and they still felt ashamed and terribly guilty.

“I knew that I had brought COVID-19 home, then I saw my in-laws get sick and my mother-in-law died after just two days of hospitalisation.”

“My sister also holds me responsible for our mother's death.”

The World Health Organization has acknowledged the social stigma of COVID-19, publishing A guide to preventing and addressing social stigma.³ Although the stereotype of the “Chinese virus” has been overcome, COVID-19 survivors still feel the stigma of having contracted this disease, which is still not fully understood, and are frightened that it will mark them for life.

Remaining Contagious/Getting Sick Again

Months after being declared healed from COVID-19, survivors still maintain distance from others, especially loved ones who are old or affected by chronic diseases. Some perceive themselves as dangerous or contagious and limit their social contact or adopt strict hygiene rules to protect others, sometimes seeking comfort in obsessive rituals of measuring body temperature and/or oxygen saturation.

“I don't go to dinner at my mother's nor my brother's home. They are old and sick. I keep my distance, and if I visit them, I still don't use the bathroom.”

The fresh outbreak of the pandemic in Italy is upsetting to survivors and the level of anxiety is rising day by day:

“Will my antibodies work or can I get sick again? I'm afraid the antibodies will go down.”

“I pass a lot of time searching for news on COVID-19 as in the early days of the pandemic. I try not to, but I do it anyway and so I panic.”

“Every now and then I take the oximeter and check: how am I breathing?”

Physical and Psychological Sequelae

Nobody knows the long-term physical sequelae of COVID-19, but survivors who were hospitalized receive many ongoing tests including radiological examinations to monitor lung function, liver function tests, and in some cases also central nervous system status. This exacerbates their worry about their health and makes them feel anxious about their health in the future, especially younger patients.

“We do not know the consequences of this disease. Due to COVID-19, my liver has been compromised and I have not yet recovered.”

“I had pneumonia twice after COVID-19: it's a true nightmare.”

“I have experienced dramatic hair loss in these months. I can deal with lung problems or neurological problems, but alopecia is too traumatic for me.”

Nightmares/Hallucinations/Sleep Disorders

Many patients spoke during their sessions of terrible nightmares/hallucinations that happened during hospitalization and also afterward, at home. The themes and characteristics of these nightmares are similar among hospitalized patients who received oxygen by mask or CPAP helmet or were intubated.

“I had the feeling that black buildings entered the window of my hospital room and came and crushed my chest and I did not know how to survive this.”

“I knew I had a lion sleeping next to me, in the other half of the bed and I did everything I could to react, to wake up before her, because otherwise she would have torn me apart.”

Previous Traumas

As observed by Mazza et al.,² patients with a positive previous psychiatric diagnosis had more psychiatric symptoms. In our initial interviews with patients, we found evidence of previous trauma: car accidents, previous psychopathologies, and problematic relationships (i.e., divorce) were all reported. However, the number of patients followed up is still limited, and any hypothesis about this relationship would be very premature.

Future Problems

Despite the difficulties, many patients have returned to work. In some case, the normality helps them not to think about their experience and to feel that “everything is okay.” For others, the workplace is where they became infected, so the fear of reinfection is huge.

For most survivors, normality is still a dream.

“I haven't visited my mother at the cemetery yet. It is still as if it hadn't happened.”

“I can't do the things I used to do anymore. I look at the guitar, but I haven't played since April.”

“I'm afraid to go back to work because it is the place where I got infected and I don't feel protected.”

Conclusions

The issues outlined previously are the most commonly reported in the first phase of our psychological treatment of patients with COVID-19. All of them deserve more specific elaboration in the context of COVID-19 survivors' lives.

The synergic commitment of psychiatrists and psychologists will help patients to process the stressful and/or traumatic experience of being hospitalized for COVID-19.

In this first analysis of the integrated psychological intervention in support of patients, we observed the symptoms prevalent in patients infected with SARS-CoV-2, paying attention to the stigma perceived by the patient but also to resources such as coping strategies to face the posttraumatic path. To achieve the objective of enhancing these resources to give meaning to and understand highly stressful events such as surviving COVID-19, an integrated approach is essential.