key: cord-0940839-0sd1pdpn
authors: Liyanage-Don, Nadia A.; Winawer, Melodie R.; Hamberger, Marla J.; Agarwal, Sachin; Trainor, Alison R.; Quispe, Kristal A.; Kronish, Ian M.
title: Association of depression and COVID-induced PTSD with cognitive symptoms after COVID-19 illness
date: 2022-03-02
journal: Gen Hosp Psychiatry
DOI: 10.1016/j.genhosppsych.2022.02.006
sha: 51f038429ae3f3d9435e74fe0021bd6954da824a
doc_id: 940839
cord_uid: 0sd1pdpn

OBJECTIVE: Many patients recovering from COVID-19 report persistent psychological and cognitive symptoms months after viral clearance. We examined the association of depression and COVID-induced PTSD with cognitive symptoms following COVID-19 illness. METHODS: Patients treated for COVID-19 between March 26 and May 27, 2020 were surveyed three months later. Cognitive symptoms were assessed by asking “Since your COVID-19 illness, do you now have more difficulty: 1) Remembering conversations a few days later? 2) Remembering where you placed familiar objects? 3) Finding the right words while speaking?” Patients endorsing at least one such complaint were coded positive for cognitive symptoms. Logistic regression was used to estimate the association of depression (PHQ-8 ≥ 10) and COVID-induced PTSD (PCL-5 ≥ 30) with cognitive symptoms, adjusting for demographic and clinical factors. RESULTS: Among 153 participants, 44.4% reported at least one cognitive symptom, 18.3% were depressed, and 23.5% had COVID-induced PTSD. Adjusting for covariates, depression (OR 5.15, 95% CI 1.30–20.35, p = 0.02) and COVID-induced PTSD (OR 3.67, 95% CI 1.13–11.89, p = 0.03) were significantly associated with cognitive symptoms; self-reported history of mental illness was also associated (OR 4.90, 95% CI 1.24–19.41, p = 0.02). CONCLUSIONS: Depression, COVID-induced PTSD, and prior mental illness were strongly associated with cognitive symptoms three months after acute COVID-19 illness.

The survey included three questions based on the Cognitive Change Index: 11 "Since your COVID-19 illness, do you now have more difficulty: 1) Remembering conversations a few days later? 2) Remembering where you placed familiar objects? 3) Finding the right words while speaking?" Patients endorsing at least one such complaint were coded positive for cognitive symptoms. COVID-induced PTSD was assessed using the PTSD Checklist for DSM-5 cued to the COVID-19 illness (PCL-5, ≥30 positive). 12 Current depression was assessed using the 8-item Patient Health Questionnaire (PHQ-8, ≥10 positive). 13 Table 2 ). In a sensitivity analysis excluding ICU patients, these associations became modestly attenuated but the overall pattern remained unchanged.

Nearly half of patients discharged home after COVID-19 illness reported cognitive deficits three months later. Psychological factors (i.e., current depression, COVID-induced PTSD, prior mental illness) were robustly associated with cognitive symptoms. Cognitive symptoms were highly prevalent, even among patients who did not require critical care. Our results are consistent with other studies describing cognitive deficits in young, otherwise healthy patients with brief COVID-19 hospitalizations. 4,6-9 We extend these findings by demonstrating that such cognitive symptoms are closely correlated with psychological distress.

The odds of persistent cognitive symptoms were five-fold greater in patients with concurrent depression and nearly four-fold greater in patients with COVID-induced PTSD. Since cognitive impairment is a common feature of both depression and PTSD, 14 it is possible that these cognitive symptoms were manifestations of underlying depression and/or PTSD, further exacerbated by the experience of COVID-19 and its sequelae. Alternatively, cognitive symptoms may have been a primary consequence of COVID-19, via direct neuropathogenic effects [15] [16] [17] [18] [19] or indirect systemic derangements (e.g., hypoxia, inflammation, coagulopathy, cytokine storm). [19] [20] [21] [22] Neuropsychiatric and neurocognitive symptoms of COVID-19 are thought to develop via similar mechanisms, 23-25 which may at least partially explain the robust associations observed here.

Additionally, the experience of COVID-19 hospitalizationoften involving invasive procedures, prolonged sedation, social isolation, and real or perceived threat of mortalitymay contribute to immediate or delayed neuropsychiatric repercussions via sympathetic system activation, stress hormone release, formation of traumatic memories, or other unrecognized factors. 19,23-25 A deeper understanding of the mechanistic relationship between the psychological and cognitive sequelae of COVID-19 will require detailed neuropsychological assessments to confirm selfreported symptoms, as well as neuroimaging for clinical correlation, neither of which is routinely performed post-COVID. 3 

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