When Glo Lindenmuth was sick with COVID-19 in December 2021, she was congested and exhausted for about a week; her sense of smell and taste were gone for two weeks. She knew about these symptoms before she caught the virus and wasn’t surprised by them. But the sadness and trouble sleeping that kicked in weeks after she recovered from COVID caught her off-guard.
“I had depression as a teenager, but this was much worse,” says Lindenmuth, 30, who works in corporate communications in New York City. In addition to suddenly feeling down, she had trouble sleeping and bad dreams. When she was awake, her brain was foggy and bleak thoughts—often about doing something harmful to herself—intruded. And though she was typically bubbly and extroverted, she was overwhelmed with social anxiety. “I’d cancel plans with friends, sleep all day on the weekends, and avoid the majority of calls and texts,” she says.
Her symptoms lasted for more than two months.
In the spring, Lindenmuth began feeling a bit better but then another intense wave of depression enveloped her from mid-June to mid-August. That’s when she went to see a behavioral psychiatrist who diagnosed her with depression.
It’s estimated that millions of people are discovering that even after they think they have bounced back from their COVID-19 illness, they continue to feel down, fatigued, apathetic, anxious, or otherwise emotionally out of sorts.
In a study based on millions of people who used the U.S. Department of Veterans Affairs health system, “we noticed that we had a nation in distress, due to the mayhem of the pandemic and lockdown,” says Ziyad Al-Aly, director of the clinical epidemiology center at Washington University in St. Louis, Missouri, and a coauthor of the report. Al-Aly and his colleagues wanted to know whether people who got COVID-19 had a higher risk of mental health problems after symptoms of the illness subsided. “The answer was absolutely yes. People with COVID had it much, much worse.”
According to research in the June 2022 issue of the journal CNS Drugs, 35 percent of people reported depressive symptoms after recovering from COVID. And it may not be simply because they lost days or weeks of their regularly scheduled lives to COVID. It may be because they have a little-known phenomenon called post-viral depression, which is likely triggered by inflammatory changes, psychological stress, and other factors.
These symptoms typically “kick in two to three months after the onset of COVID-19 and seem to last several months,” says Madhukar Trivedi, a psychiatrist and founding director of the Center for Depression Research and Clinical Care at the UT Southwestern Medical Center in Dallas. “There’s no way to predict who will have transient effects or who will have persistent ones.”
The scope of the phenomenon
The link between viral illnesses and depression isn’t new but has become more widely recognized and understood in recent decades. A study in a 2016 issue of the journal Brain, Behavior, and Immunity, for example, found that people who were sick with the flu in the previous 30 to 180 days had a 57 percent higher risk of new onset depression, compared to those who dodged the virus. Post-viral depression also can happen with the Epstein-Barr virus, which causes mononucleosis, and other non-specific viruses, experts say.
Al-Aly’s study, published in February 2022 in BMJ, found that people who’d been sick with COVID had a 35 percent higher risk of developing an anxiety disorder and a 39 percent higher risk of experiencing a bout of depression a month after their illness; these surges were accompanied by increased use of antidepressants and benzodiazepines.
This is far from an isolated finding. A study in the April 2022 issue of the Journal of Neurology found that elevated levels of apathy and anxiety were common among COVID survivors who had fatigue eight months after their illness. And in a study in the May 2022 issue of The Lancet, researchers followed the mental-health trajectory of people in six countries in Europe who had been sick with COVID—but weren’t hospitalized for it—and found that these individuals had a higher prevalence of depression in the subsequent months, especially if they had been bedridden with the illness.
Mechanisms behind the misery
Exactly how COVID-19 triggers depression isn’t fully understood but there are several hypotheses. The SARS-CoV-2 virus may cause more inflammation in the brain and activate microglial cells, immune cells in the central nervous system that produce inflammatory molecules, Al-Aly explains. “Inflammation can affect brain regions that regulate affect and emotions—it can turn them up or turn them down.”
Another theory is that the virus can attack the lining of blood vessels, which can compromise the blood and oxygen supply to the brain and disrupt areas that regulate emotion, Al-Aly adds.
A third hypothesis suggests that the virus can disrupt the diversity and equilibrium of the bacteria in the gut—the gut microbiome—which could in turn alter the levels of certain neurotransmitters, chemical messengers that transmit nerve signals throughout the body and brain and are involved in mood regulation, he says. “What’s really clear is that the virus’s effect on mental health is a biological phenomenon—it’s not imagined,” Al-Aly says.
That’s not to say there aren’t psychological elements at play. Prolonged isolation and feelings of loneliness during the illness may contribute to post-COVID depression, says Pravesh Sharma, a psychiatrist at the Mayo Clinic College of Medicine and Sciences in Eau Claire, Wisconsin. When it comes to post-COVID depression, “sometimes people think why me?” Sharma says. “That creates a lot of negative thought and affects how people function in everyday life.” These factors can trigger a vicious cycle that traps people in a depressive state.
Compounding the problem, people with post-COVID depression often feel misunderstood. “Their families don’t understand why they’re not over it because they’re not sick anymore,” says Dawn Potter, a clinical psychologist who runs support groups for people with long COVID at the Cleveland Clinic. Plus, these “people don’t know when their symptoms are going to end or what’s going to help, and they’re scared. And it’s common for people to be afraid of getting COVID again.” Some people also worry about the potential long-term effects of COVID infection, which can contribute to their emotional turmoil after being sick, experts say.
Who’s vulnerable and why
While research on the issue is scarce because COVID-19 is still relatively new, experts believe that people who have a prior history of depression or anxiety are at higher risk of developing post-COVID depression. “What I’m seeing in my clinical practice is people getting depression after COVID or having it be exacerbated by COVID if they had depression before,” says Potter. “It may have been in remission or less severe.”
Others who are at higher risk for post-COVID depression, experts say, include people who had high levels of pre-infection stress, medical morbidities—obesity, asthma, hypertension, diabetes, and the like—and more severe illness with COVID-19.
In some instances, depression can occur as part of long COVID syndrome, which can include lingering problems with memory, thinking abilities and concentration, mood changes, fatigue, and organizational abilities such as difficulty managing medication or money. Dyani Lewis, 44, experienced this phenomenon firsthand after getting COVID in March of 2022. Despite having a mild case—“I’ve had colds worse than this,” she says—about a week after the infection passed, she had daily headaches, dizziness that felt like perpetual motion sickness, fatigue, and a lack of motivation. She had been taking a selective serotonin reuptake inhibitor (SSRI) for depression since 2019 and her mood symptoms had been well-controlled—until suddenly they weren’t.
“I was struggling to complete my work, and I didn’t have energy for my kids,” says Lewis, a freelance science journalist and mother of two daughters in Melbourne, Australia. “To what extent SARS-CoV-2 directly exacerbated my depression, or just created the circumstances that were ripe for me to feel like shit, I don’t know.” Lewis is in the process of switching to a new medication for her depression and has started resuming light exercise, to improve her mood and boost her energy.
Experts say they’re not seeing clear gender patterns with post-COVID depression. But a study in the January 2022 issue of the Journal of Psychiatric Research found that among COVID-19 survivors in Italy who experienced psychiatric symptoms, men had high levels of anxiety and depression at six months and even more severe symptoms at 12 months; women experienced the worst depression shortly after the infection, but by six months the symptoms were much less serious and continued to decline until 12 months. The researchers noted that this may be because men have a stronger pro-inflammatory immune response than women do, which could lead to sustained inflammation in their brains and bodies after COVID infection. Another explanation is that they’re less likely to seek professional help for mental health challenges.
Reclaiming a better state of mind
Although some cases of post-COVID depression will resolve naturally over time, there’s no reason to sit back and suffer in the meantime. “It’s important not to say this is due to COVID and therefore do nothing,” Trivedi says, “because it could last longer than you think.”
To feel better mentally and emotionally, it helps to engage in regular physical activity or exercise, which has anti-inflammatory properties as well as antidepressant effects, Trivedi says. Seek social support, by connecting with friends and family members and/or support groups in your community. And adopt healthy eating habits such as the Mediterranean diet—which is rich in fruits, vegetables, legumes, nuts, whole grains, fish, and olive oil—because research has found that it’s associated with a lower risk of developing depression. In addition, a study in a 2019 issue of the journal PLoS One found that a healthy dietary intervention can start to work in as little as three weeks, reducing symptoms of depression.
It's also important to set the stage for better sleep because “sleep problems and depression go hand in hand—it’s a bidirectional issue,” Potter says. Simply put, poor sleep can affect your mood, and depression can compromise your sleep quality. “If you can start sleeping better, it often helps mood,” she says. To that end, she recommends working on your pre-sleep habits, making a concerted effort to dim the lights, avoid digital screens in the evening, and go to bed and wake up at the same time, day after day, to maintain a consistent sleep-wake cycle.
There’s no need to stop your feel-better efforts with lifestyle modifications. Depending on the severity of your symptoms, you may benefit from therapy, particularly cognitive behavioral therapy (CBT)—which helps people shift detrimental thought patterns to more helpful ones. Another helpful approach is behavioral activation, a skill that’s often incorporated into CBT and involves setting goals that will help you get out and do things that can improve your mood, says Jed Magen, an osteopathic physician specializing in child and adolescent psychiatry at Michigan State University in East Lansing.
With the help of antidepressants, talk therapy, and sharing her experiences with her social network, Lindenmuth started to feel better. Gradually she began exercising more and rediscovered her love of cooking, dancing, and spending time with friends. “Now I’m feeling great, and I have the energy I used to,” she says. “I’ve also regained my creativity as well as a sense of clarity that I haven’t had in a long time,” Lindenmuth says. “I’m happy to be on the other side of the worst of it.”
When it comes to experiencing post-COVID depression and obtaining relief from it, Lindenmuth is in good company. “I would like people to know that post-COVID depression is very, very common and that there’s hope—the research is showing that there are ways to treat post-COVID depression, just like there are for other forms of depression,” Potter says. “Even though it’s not completely understood, we’re not reinventing the wheel.”