Complications from COVID: Diagnosis and Management of Medical and Psychological Issues
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Friday General Session
Complications from COVID: Diagnosis and
Management of Medical and Psychological Issues
Katherine Buck, PhD
Director of Behavioral Medicine
JPS Family Medicine Residency
Fort Worth, Texas
Grant Fowler, MD
Professor and Chair, Department of Family and Community Medicine
TCU and UNTHSC Medical School
Chair of Family and Community Medicine
Chief of the PC Service Line
JPS Health Network
Fort Worth, Texas
Educational Objectives
By completing this educational activity, the participant should be better able to:
1. Briefly summarize latest treatments for COVID.
2. Identify common short‐ and long‐term complications of COVID.
3. Describe likely presentation and prevalence of Long COVID.
4. Apply treatment recommendations to daily practice, including identification of
resources, management of psychological concerns, and medication management.
Speakers’ Disclosure
Dr. Buck has disclosed that neither she nor members of her immediate family have a
relevant financial relationship with an ineligible company.
Dr. Fowler has disclosed that he is a consultant for AstraZeneca.
7Complications from COVID: Disclosures
Diagnosis and Management of Medical and
Psychological Issues Dr. Buck has disclosed that neither she nor members
of her immediate family have a relevant financial
relationship with an ineligible company.
Grant Fowler, MD Dr. Fowler has disclosed that he is a consultant for
AstraZeneca.
Katherine Buck, PhD, LMFT
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Objectives Audience Polling Question #1
True or False? Hydroxychloroquine finally
received FDA indication for treatment of
• Briefly summarize the latest treatments for COVID
COVID and it is still recommended.
• Identify common short term and long‐term
complications of COVID
• Describe likely presentation and prevalence of long 1. True
COVID 2. False
• Apply treatment recommendations to daily
practice, including identification of resources,
management of psychological concerns, and
medication management
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Current Treatment Current Treatment
• Remdesevir (only FDA approved therapy)
• Dexamethasone (NIH recommends hospitalized requiring • NIH says all other therapies have insufficient data or
oxygen)
recommend against
• Tocilizumab (NIH recommends anti‐interleukin 6 [IL‐6] for
those requiring rapidly escalating oxygen)
• Anticoagulation (NIH recommends all non‐pregnant
hospitalized patients)
• Convalescent Plasma (hi‐titer, has FDA emergency use
authorization [EUA] for hospitalized patients)
• Bamlanivimab, bamlanivimab/etesevimab,
casirivimab/imdevimab (EUA, infusion for early Covid, not
requiring oxygen, although NIH says insufficient evidence)
MedPage Today updated 3/17/21
MedPage Today updated 3/17/21
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1Audience Polling Question #2 Short‐Term Severe Complications
Future Treatment: Which of the following is
showing promise in early treatment of Covid: • Pneumonia
• Adult Respiratory Distress Syndrome (ARDS)
1. Oseltamivir • Cerebrovascular Accident (CVA)
2. Ivermectin • Acute myocardial Infarction (MI)
3. Molnupiravir
• Pulmonary Thromboembolism (PE)
4. Baloxavir
• Multisystem Inflammatory Syndrome in Children (MIS‐
C, similar to Kawasaki Disease, about 2,600 cases
nationally, 33 deaths, can occur weeks after even
asymptomatic Covid)
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Short‐Term Severe Complications Leukoencephalopathy Associated
(MIS‐C) with Severe Covid
• Fever, abdominal pain, gastrointestinal distress,
rash, bloodshot eyes, swollen hands or feet,
and fatigue that can rapidly lead to severe
illness
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ARDS Normal Lung/ Covid Lung Needing
Transplant
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2Lung Transplant Most Common Long‐Term Symptoms
• First in 45 yo Covid patient in Vienna, Austria May 2020
• Fatigue
• First in Texas performed by UT Houston surgeons at
Memorial Hermann TMC August 2020 for Covid • Shortness of breath
pneumonia/ ARDs requiring 80 to 100% oxygen on • Cough
ventilator (resulting O2 sats down to 50s) in 70‐year‐old
retired construction worker with 9 children, 32 grand • Joint pain
children. He had failed remdesevir, convalescent plasma • Chest pain
and steroids. He was up and walking days after surgery and
discharged to rehab by early September
• First Covid recovered donor lung transplant performed for
Covid patient at Northwestern in Chicago February 2021 Long‐Term Effects of COVID‐19 | CDC accessed 3/21/21
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Other Reported Long‐Term Symptoms More Serious Long‐Term Complications
• Difficulty with thinking and concentration (brain fog) • Respiratory – pulmonary function abnormalities
• Depression • Cardiovascular – cardiomyopathy, CHF
• Myalgias • Renal – acute kidney injury (AKI)
• Headache • Dermatologic – rash, hair loss
• Intermittent fever
• Neurologic – smell and taste problems, insomnia,
• Palpitations difficulty concentration, memory issues
• Psychiatric – depression, anxiety, changes in mood
Long‐Term Effects of COVID‐19 | CDC accessed 3/21/21
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Long‐Term Symptoms (Long‐Haulers What’s the Impact?
or Long Covid) June 24‐30, 2020 Survey
• Patients with symptoms that linger or may develop months • 40% of U.S. adults struggling with mental
after initial infection health or substance abuse
• Is this unique to Covid? Or a variation of syndromes that can
occur after other infections? Chronic fatigue syndrome?
• Is this a physical reaction related to upheaval of pandemic
year? (e.g., lockdowns, quarantines, isolation, job losses or
insecurity, racial unrest, political and economic turmoil,
overwhelming illnesses or deaths)
Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the
COVID‐19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–
1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1
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3Long‐Term Symptoms Long‐Covid
(Long‐Haulers or Long Covid) (From review of 300 scientific papers worldwide)
• In hospitalized patients, 50% to 89% have at least one lingering
• Is the virus still active? symptom 2 months later
• Has an autoimmune response been provoked? • Of those with milder bout, 20% to 30% endure one or more
symptoms 4 weeks later, while 10% have long Covid 3 months
• Are damaged blood vessels causing minute, later
undetectable blood clots and wreaking havoc • Long Covid more common in women, with females 28 days
• 15% of children age 12‐16 had at least one symptom 5 • 189 (4.5%) symptoms >=8 weeks
weeks later • 95 (2.3%) symptoms >=12 weeks
• Fatigue is most common symptom, but also
respiratory symptoms, insomnia and others • Fatigue, headache, dyspnea and anosmia are most common
symptoms; more common with increasing age, body mass and
female sex
Office for National Statistics
• Experiencing 5 symptoms in first week was associated with Long
(https://www.ons.gov.uk/peoplepoulationandcommunity/healthandsocialcare/healthandlife
Covid (odds ratio 3.53)
expectancies/adhocs/12788updatedestimateoftheprevalanceoflongcovidsymptoms) released
Jan 21, 2021
Attributes and Predictors of Long Covid; Sudre CH, et al Nature Medicine, March 10, 2021
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Management of Long Covid Return to Sport
• Consortium of all professional sports (MLS, MLB, NHA, NFL, NBA,
• Rehab WNBA) cardiac screened athletes with Covid from May to October 2020
• 789 athletes with Covid (74.4% by PCR, 58.3% moderate symptoms)
• Physical Activity • Initial cardiac screening tests (mean 19 days after positive test) were
• Psychological Care ECG (1.3% abnormal), troponins (0.8% abnormal) and resting echo
(2.5% abnormal) performed a mean of 19 days after positive test
• 30 (3.8%) had abnormal screening and underwent cardiac MRI and/ or
stress echo and 5 (0.6%) had abnormal cardiac MRI (2 pericarditis, 3
myocarditis) and were restricted from sport
• No adverse cardiac events occurred in those that returned to play
NIHR (https://evidence.nihr.ac.uk/themedreview/living‐with‐covid19‐second‐review)
published March 16, 2021 JAMA Cardiol 2021;Mar 4:[Epub ahead of print].
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4Return to Sport after Covid
Return to Sport after Covid
(AAP Guidance)
(AAP Guidance)
• Children or adolescents asymptomatic or with mild symptoms (100.4, < 1 week chills, myalgias, lethargy) warrant 10 days
resting period and must be completely asymptomatic for 24 hours off intubation or MIS‐C) must be treated as though they
meds before gradually returning to exercise or competition have myocarditis and restricted from exercise and
• Those with moderate symptoms (>4 days fever >100.4, > 1 week chills, participation for three to six months and obtain
myalgias, lethargy, non‐ICU hospital stay, no multisystem inflammatory cardiology clearance
syndrome in children [MIS‐C]) may return if 10 days have passed and
asymptomatic for 10 days off fever‐reducing medication
• All should be cleared for competition by PCP (use 14 element American
Heart Screening Evaluation and perform complete physical exam)
AAP Covid Interim Guidance: Return to Sport and Physical Activity, 3/1/21 AAP Covid Interim Guidance: Return to Sport and Physical Activity, 3/1/21
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Audience Polling Question #3
Recommended Resources
How much is NIH spending to study
Long Covid?
1. $10 million
2. $150 million
3. $1.15 billion
4. $100 billion
5. $1 trillion
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Treatment – Treatment –
Generalized Anxiety Disorder Generalized Anxiety Disorder
Level of Evidence
• Physical activity B • Buspirone better than placebo
• SSRIs/ SNRIs first line B • Bupropion can worsen anxiety in some patients,
• Continue meds for 1 year C so monitor closely
• Short‐term benzos B
• Psychotherapy (esp. CBT) A
• Combination C
Locke AB, et American Family Physician 91(9), May 1, 2015 Locke AB, et American Family Physician 91(9), May 1, 2015
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5Treatment – Depression Treatment – Depression
• Meta‐analyses of controlled studies of venlafaxine, • Meta‐analyses of 117 randomized trials with 25,928
duloxetine and mirtazapine may show small increased subjects found the greatest degree of overall
likelihood of response or remission compared with acceptability with escitalopram and sertraline with
SSRIs greatest efficacy for mirtazapine, escitalopram,
• Meta‐analyses of controlled studies of bupropion sertraline and venlafaxine compared with duloxetine,
show in general comparable in efficacy to SSRIs fluoxetine, fluvoxamine, paroxetine and reboxetine
McIntyre JS et al, Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, Cipriani A, et al, Comparative efficacy and acceptability of 12 new‐generation antidepressants, Lancet,
3rd ed, APA, 2010. 2009;373:746‐758.
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COVID & Mental Health Typical Complaints
• COVID Perfect storm of anxiety
• Difficulty breathing
• Anxiety
• Fatigue
• Brain Fog • Depression
• Non‐linear course • Insomnia
• Grief
• JPS Post Discharge Clinic
• Psychology, Family Medicine, Pulmonology, Physical • Social concerns/disruptions
Therapy, Nutrition
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Anxiety Diaphragmatic Breathing
• Baseline anxiety vs. “new” anxiety
• Two keys:
• Hypervigilance • Mechanics
• Rate
• Recommendations:
• Ask pt to demonstrate
• Normalizing • Shoulder breathing
• Use of diaphragmatic breathing exercises
• Incorporation of pulse‐oximetry • Laying down may help
• Word of caution!
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6Depression Exercise
• Exacerbation of pre‐existing conditions
• Perceived rate of recovery
• Almost any exercise sees benefit
• Fatigue
• Disengagement from ADLs, previous life
• Social Support/Interaction
• 30 min 3‐5 times per week
• Break into bits
• Recommendations
• Start small
• Behavioral Activation
• Plan contingent vs Mood contingent
• Increasing activity tolerance/new valued activities • Online classes
• Connection to values prior to COVID
• Martial Social Support
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Insomnia Grief
• Dysfunctional Cycle Vs Anxiety Mediated Vs Residual Sx • COVID tends to run in families
• Dysfunctional Cycle: Fatigued, but not sleepy Resting
Unable to sleep • Loss of friends/family as they are recovering
• Slowly build activity into day
• Inability to say goodbye
• Engage in basic sleep hygiene
• Anxiety Mediated: Nervousness about illness course, PTSD‐
like sx • Recommendations:
• Teach Diaphragmatic Breathing • Normalizing
• Encourage social support
• Daily activities – re‐engage
• Healthy space to talk about loved one
• Provide factual information regarding course • Letter writing
• Residual sx • Connection to valued activities of loved one
• Target sx reduction
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Social Disruption Taking Care of Ourselves
• All previous recommendations apply
• Loss of income • Waxes and Wanes
New data from JAMA Psych (7.2.20)
• Change from caregiver to recipient of care • Resilience is inversely related to burnout
• Loss of social role • BUT, physicians had higher levels of resilience that normal population, and
still burnout exhibited in 29% of those in highest resilience group
• Takeaway – focus on systems … resilience is necessary but not sufficient
• Targets for change:
• Recommendations:
• “inefficient workplace processes, excessive workloads, and negative
• Reinforce activity/engagement as possible leadership behaviors”
• Normalize • FM showed lower resilience
• Higher – neurosurgery, prev/occ, EM, ortho, ophthalmology, rad
• Connect to values (if not actual activity)
onc, ENT
• Advocate for pt where possible • My hypothesis front line continuous work, burden of primary
• Ex, CDC guidance on contagiousness care
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7Notes
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