SARS-CoV-2 infection resulting in COVID-19 increases the risk of developing psychiatric disorders [1]. Severe COVID-19 illness, long ICU admissions and hospitalization, deconditioning, and long-term cognitive deficits are associated with high psychiatric morbidity among the general population, with common presentations including depression, anxiety and post-traumatic stress disorder (PTSD) [2]. Depression and anxiety specifically are related to higher risk of medical care delays and avoidance [3].
Behavioral health interventions can reduce psychiatric symptoms in medically ill populations, especially in the post-acute period [[4], [5], [6]]. A growing body of evidence supports the efficacy of telepsychotherapy in psychiatric symptom management [[7], [8], [9]]. However, there has been limited research on behavioral treatment options for the growing population of COVID survivors. Thus, the purpose of this study is to characterize the outcomes of psychiatrically acute COVID-19 patients referred for outpatient telepsychotherapy in the first wave of the pandemic.
Medical records were reviewed for 28 COVID-19 survivors referred to a free outpatient telepsychotherapy program from a COVID-19 recovery clinic, post-ICU recovery clinic, and the community betweenMay 2020 and March 2021 within a large hospital system in New York City. Twenty-six patients met criteria for treatment; 69% (18/26) began therapy, while 31% (8/26) declined to participate (Supplementary Fig. 1).
Clinical staff consisting of clinical psychologists and psychology postdoctoral fellows delivered a course of up to 14 virtual, evidence-based psychotherapy sessions to patients who met criteria for clinically significant anxiety or depression. This cognitive-behavioral treatment (CBT) program integrated psychoeducation, cognitive restructuring, mindfulness, acceptance and exposure-based techniques described in detail elsewhere [10].
Participants were on average 55 (σ = 16.3) years old and were diverse in race/ethnicity, insurance status, and medical comorbidities (Table 1 ). Prior to COVID-19 infection, approximately 58% (15/26) had no prior history of psychiatric disorders, 15% (4/26) had pre-existing depression, and 27% (7/26) had pre-existing anxiety disorder. There were no statistically significant differences between patients who completed (n = 14) and those who declined or only partially completed (n = 12) treatment in age, pre-existing psychiatric disorders, or pre-existing medical illnesses (Table 1).
Table 1.
Demographic and clinical characteristics of 26 patients enrolled in treatment at a telepsychotherapy clinic following COVID infection.
| Demographic and Clinical Characteristics | Overall (n = 26) | Completed Tx (n = 14) | Partial or declined treatment (n = 12) | P-value |
|---|---|---|---|---|
| Age in years (σ) | 55.2 (16.3) | 54.2 (18.0) | 56.3 (14.8) | 0.58 |
| Gender | ||||
| Male | 16 (61.5%) | 6 (42.9%) | 4 (33.3%) | 0.70 |
| Female | 10 (38.5%) | 8 (57.1%) | 8 (66.7%) | |
| Race/Ethnicity | ||||
| White | 8 (30.8%) | 6 (42.9%) | 2 (16.7%) | 0.22 |
| Non-White | 18 (69.2%) | 8 (57.1%) | 10 (83.3%) | |
| Primary Language | ||||
| English | 16 (61.5%) | 9 (64.3%) | 7 (58.3%) | 1.00 |
| Non-English | 10 (38.5%) | 5 (35.7%) | 5 (41.7%) | |
| Insurance Coverage | ||||
| Public | 16 (61.5%) | 9 (64.3%) | 7 (58.3%) | 1.00 |
| Commercial | 10 (38.5%) | 5 (35.7%) | 5 (41.7%) | |
| Pre-existing psychiatric conditions; n (%) | ||||
| Yes | 11 (42.3%) | 7 (50%) | 4 (33.3%) | 0.45 |
| No | 15 (57.7%) | 7 (50%) | 8 (66.7%) | |
| Pre-existing medical conditions; n (%) | ||||
| None or one | 14 (53.8%) | 7 (50%) | 3 (25%) | 0.25 |
| Two or more | 12 (46.1%) | 7 (50%) | 9 (75%) | |
| COVID-Related Variables | Overall (n = 26) | Completed Tx (n = 14) | Partial or declined treatment (n = 12) | P-value |
| Cardiovascular symptoms (venous thromboembolism, arterial thrombosis, myocardial injury, ACS) during acute stage of COVID | 12 (46.1%) | 7 (50%) | 5 (41.7%) | 0.71 |
| Pulmonary symptoms (dyspnea, ARDS, pneumonia, respiratory failure) during acute stage of COVID | 26 (100%) | 14 (100%) | 12 (100%) | NA |
| Hospitalization | ||||
| Patients hospitalized; n (%) | 24 (92.3%) | 12 (85.7%) | 12 (100%) | 0.48 |
| Duration of hospitalization in days (σ) | 42.7 (55.4) | 32.2 (37.7) | 55.0 (70.6) | 0.48 |
| Inpatient medicine | 9.4 (11.4) | 7.1 (10.3) | 12.2 (12.6) | 0.40 |
| Acute rehab Total |
52.2 (59.3) | 39.3 (41.5) | 67.2 (74.2) | 0.29 |
| Intubation/Mechanical ventilation | ||||
| Yes; n (%) | 16 (61.5%) | 9 (64.3%) | 7 (58.3%) | 1.00 |
| No; n (%) | 10 (38.5%) | 5 (35.7%) | 5 (41.7%) | 0.91 |
| Duration of mechanical ventilation among ventilated patients in days (σ) | 64.5 (106) | 22.7 (35.4) | 59.5 (124) | |
| Rehospitalization for COVID-related complications | 4 (15.4%) | 1 (7.1%) | 3 (25%) | 0.31 |
Of participants, all 26 experienced pulmonary symptoms during their acute stage of COVID, with 12 having additional cardiovascular symptoms (Table 1). Our sample was largely medically compromised due to COVID infection. 24 patients (92.3%) were hospitalized due to COVID sequelae. The average duration of inpatient hospitalization was 52 days (σ = 59.3). Moreover, 16 patients required intubation or mechanical ventilation during the course of their COVID-19 infection. Of patients requiring breathing support, the average duration of mechanical ventilation/intubation was 64.5 days (σ = 106). Among hospitalized patients, the most common complications were respiratory (100%), cardiovascular (46%), and gastrointestinal (46%), with lower rates of neurological (34.6%) and renal (15.4%) complications. Four patients were re-hospitalized for COVID-related complications during a one-year follow-up period.
Baseline PHQ-9 (n = 10) and GAD-7 (n = 9) scores were collected for approximately half of the sample (N = 26) prior to the start of therapy. For these patients, the average PHQ-9 score was 11.9 (σ = 5.4) while the average GAD-7 score was 12.8 (σ = 4.7) consistent with clinically significant anxiety and depression. In our sample, a total of 6 patients (23%) met clinical cutoffs for mild cognitive impairment (Supplementary Table 1).
Among the 18 who enrolled, 14 patients completed treatment (≥7 sessions of psychotherapy or remitting prior to seven sessions). Four patients had partial treatment, discontinuing during the acute course (1 could not continue due to rehospitalization, and 3 were lost to follow-up). Though not statistically significant, patients who declined treatment or had incomplete treatment tended to be non-English speaking, had no pre-existing psychiatric history, had more medical comorbidities, and were sicker with longer durations of mechanical intubation and hospitalization.
Of patients who completed psychotherapy (n = 14), clinical consensus diagnoses of anxiety and depression by clinicians indicated that all patients (100%) met criteria for anxiety at treatment entry while 78.6% of patients met criteria for depression. At treatment end, 42.9% (6/14) met clinical criteria for anxiety while only 21.4% (3/14) remained depressed. Comparison of pre- and post- treatment psychiatric diagnoses indicated a significant resolution of both clinical depression (McNemar's test p = 0.005) and anxiety (McNemar's test p = 0.005) (Supplementary Fig. 2).
Our findings suggest that telepsychotherapy delivered post-acute medical illness can reduce anxiety and depression among COVID-19 survivors. Our preliminary data highlight the capacity of patients recovering from moderate to severe illness to successfully engage with virtual platforms and benefit from short-term, remotely delivered psychotherapy. Limitations include the unavailability of a standardized primary outcome measure and the naturalistic nature of our study, making our sample underpowered to detect statistical significance in trends among patients who engaged versus did not engage in treatment. Nonetheless, we hope that these findings provide insight into improving psychiatric outcomes among medically acute patients and increasing the accessibly of high-quality mental health care to diverse populations.
Statement of ethics
This study protocol was approved by the Weill Cornell Medicine Institutional Review Board (IRB) as an exempt study: IRB approval #21-01023251. Written consent was not required, and thus this study has been granted an exemption from requiring written informed consent by the Weill Cornell Medicine IRB.
Funding sources
There are no funding sources to report.
Author contributions
Nana Park collected data, performed statistical analyses, and wrote initial drafts and final revisions of the manuscript. Dora Kanellopoulos conceptualized the intervention, developed the methodology of the study, collected data, performed formal statistical analysis, wrote initial drafts, supervised execution of the manuscript and edited final revisions. Katarzyna E Wyka provided valuable input on statistical analyses and the manuscript. Lauren Oberlin, Monika Dargis, Stephanie Cherestal and Christina Bueno Castellano delivered the intervention, participated in data collection, and provided critical comments on the manuscript. Abhishek Jaywant provided input on methods and statistical analysis as well as valuable edits to the manuscript. All authors approved the final version for submission.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Acknowledgements
We would like to acknowledge the administration of Weill Cornell Medicine, Department of Psychiatry and New York Presbyterian Hospital for their support in our volunteer efforts to treat first-wave COVID survivors. We would also like to acknowledge the clinicians of the Intensive Care and Physical Medicine Departments, including Drs. Lindsay Lief and Elyse Lafondwho recognized the need for mental health treatment of COVID-survivors and acted quickly to obtain psychological care for their patients.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.genhosppsych.2023.01.010.
Appendix A. Supplementary data
Supplementary Figure 1: Flow diagram of study design
Supplementary Figure 2: Symptoms of depression and anxiety among patients who received treatment. PHQ-9 (a) and GAD-7 (b) scores at baseline, as well as mid- and end of treatment when available. Line graphs indicate trajectory of scores for 5 patients with available data over time. Isolated data points reflect patients who had scores measured at intake but were lost to follow-up. (c) Presence of clinical depression symptoms at beginning versus end of treatment, as determined based on clinical assessments, therapy notes and provider consensus. (d) Presence of clinical anxiety symptoms at beginning versus end of treatment.
Supplementary Table 1: Baseline neuropsychiatric characteristics of patients that engaged in treatment
Data availability statement
The data that support the findings of this study are not publicly available due to the containing of information that could compromise the privacy of research participants, but are available from Dora Kanellopoulos (D.K.) upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Figure 1: Flow diagram of study design
Supplementary Figure 2: Symptoms of depression and anxiety among patients who received treatment. PHQ-9 (a) and GAD-7 (b) scores at baseline, as well as mid- and end of treatment when available. Line graphs indicate trajectory of scores for 5 patients with available data over time. Isolated data points reflect patients who had scores measured at intake but were lost to follow-up. (c) Presence of clinical depression symptoms at beginning versus end of treatment, as determined based on clinical assessments, therapy notes and provider consensus. (d) Presence of clinical anxiety symptoms at beginning versus end of treatment.
Supplementary Table 1: Baseline neuropsychiatric characteristics of patients that engaged in treatment
Data Availability Statement
The data that support the findings of this study are not publicly available due to the containing of information that could compromise the privacy of research participants, but are available from Dora Kanellopoulos (D.K.) upon reasonable request.