Dr. Thida Thant, a leading psychiatrist in Long COVID care, joins Dr. Funmi Okunola to discuss mental health treatment approaches for long haulers. Dr. Thant emphasizes a comprehensive, symptom-focused approach, avoiding quick fixes, and prioritizing patient collaboration. She highlights group therapy’s powerful impact, especially for ICU survivors, and offers advice for primary care doctors managing post-COVID mental health. Watch for expert insights on treating Long COVID’s complex psychiatric challenges
Guest – Dr Thida Thant
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Podcast Overview:
Podcast: Mental Health in Long COVID with Dr. Thida Thant
- Introduction to Long COVID and Mental Health:
The episode begins by defining Long COVID and its psychological impacts, highlighting common symptoms like anxiety, depression, and cognitive challenges. Dr. Thant emphasizes the need for mental health support in recovery. - Comprehensive Care for Long COVID:
Dr. Thant discusses the importance of holistic care, integrating both mental and physical health management. She explains how comprehensive care models are essential to addressing the complexity of Long COVID. - Collaboration Between Patients and Healthcare Providers:
Fostering an open dialogue between patients and clinicians is crucial for effective treatment. Dr. Thant explores the benefits of patient collaboration, self-advocacy, and shared decision-making to achieve personalized care. - Mental Health Strategies for Long COVID Patients:
This section focuses on therapeutic approaches to managing the mental health symptoms of Long COVID. Dr. Thant outlines cognitive behavioral therapy, mindfulness practices, and other interventions that are proving successful. - Addressing Mental Health in ICU Survivors:
The episode delves into the specific mental health challenges faced by ICU survivors of COVID-19. Dr. Thant provides insights into managing PTSD, memory issues, and anxiety, emphasizing the critical role of post-ICU mental health care. - Future Outlook and Continuing Support:
Dr. Thant concludes by discussing the evolving understanding of Long COVID and the importance of ongoing research and patient support networks for long-term recovery.
Navigating Mental Health in Long COVID with Dr. Thida Thant
- Comprehensive, symptom-focused care for Long COVID patients.
- Avoiding quick fixes in mental health treatment.
- Importance of patient collaboration and group therapy, especially for ICU survivors.
- Guidance for primary care doctors handling Long COVID psychiatric cases.
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Podcast Transcript:
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Episode 15 – The Psychiatric Management of Mental Health in Long COVID ft. Dr Thida Thant
[00:00:00] Funmi Okunola: The information in this podcast is provided for informational purposes only. You should not use any information discussed in this podcast and related materials to make medical or healthcare related decisions. Always consult your physician or other qualified healthcare providers with regards to diagnosing and managing your medical condition. Any medications or treatments, including any discussed in this podcast, should be initiated and managed by a qualified healthcare professional
Funmi Okunola: [00:00:00] Welcome to Long Covid – the Answers. Today’s Episode is entitled “The Psychiatric Management of Mental Health in Long Covid”. This interview is part of our neurological Long Covid section of the series. I’d like to introduce you to Professor Thida Thant. Professor Thant is an award-winning consultation liaison psychiatrist and director of the University of Colorado Hospital Consultation Liaison Psychiatry Service on the Anschutz Medical Campus in Aurora, Colorado in the U.S.A.
She is also Assistant Chief of Service for Colorado University Medicine Psychiatry Community Practices and Director of the Psychiatric Consultation for the Medically Complex Clinic at the University of Colorado, where she provides rehabilitation for Long COVID survivors. Welcome Thida.
Thida Thant: Thanks for having me. I know my introductions are a mouthful, so I appreciate it.
Funmi Okunola: Thida, do you have any conflicts of interest to declare? [00:01:00]
Thida Thant: Yes. The main things I have received are for speaking honoraria’s from a few different hospital systems in the U. S. talking about this topic, and I do get some grant support for Long COVID research from NIH and from some private donors to the University.
Funmi Okunola: Great. Thank you. Thida, firstly, could you tell us the difference between a psychiatrist, particularly a liaison psychiatrist, psychologist, and neuropsychologist?
Thida Thant: Yes, I think that’s a great question because obviously a lot of COVID centers have some mix of the three. So, starting with myself, I’m a consultation liaison psychiatrist.
A psychiatrist is a physician who went through medical school and residency to focus on disorders of the brain and emotions and the psyche. Then within that there are some subspecialties. So, consultation liaison means I chose to pursue a fellowship in medically complex patients, basically, and that overlap and intersection between our mental and physical health.
Then you have psychologists who are experts in [00:02:00] evaluation and therapeutic management of Mental Health Disorders. They often focus on things like therapy, diagnostic evaluations, things like that, but don’t prescribe medications in most places and didn’t go through medical school.
Then the neuropsychologist is a specialized form of that. So those are therapists and psychologists that really specialize in the brain, how brain injury affects functioning, cognitive testing and how all those pieces go together and how to manage and rehabilitate brain disease. That’s how all three work together.
Funmi Okunola: That’s a fantastic answer. Thank you. Great clarity there. Could you tell us about the psychiatric consultation for the medically complex program or PCMPC that you direct? Why was it set up and how it provides rehabilitation for those suffering from Long COVID?
Thida Thant: Yes, so many psychiatrists like me often work in hospital-based settings. We tend to work on medical floors, and we work with all sorts of patients who [00:03:00] have (really again this is complex) intersections, so maybe they just got a transplant or need a transplant or maybe they have a Neurological Disease that causes psychiatric symptoms, or maybe they experience things like steroid-induced psychosis, whatever it may be. We have lots of specialists who see them on the in-patient side, and then when they get discharged back out to the community there aren’t as many places that feel comfortable managing those kinds of diseases.
That’s where the impetus for this clinic came from. It was made by a predecessor before me and really focused on helping these patients transition out of the hospital. When I joined the faculty back in 2018, I got to take over that clinic and worked on expanding it to take referrals from many specialists within our hospital system and many patients from the community. That’s how we ended up treating transplant patients, neurological patients, and all of that.
Funmi Okunola: How do you provide rehabilitation for Long COVID survivors?
Thida Thant: I got approached shortly before the pandemic by a pulmonologist who [00:04:00] already had interest in my clinic because she was getting ready to work with post ICU patients and there’s a lot of neuropsychiatric symptoms that come from that. We’d already been in discussion, then the pandemic hit, and she was pivoting her clinic because she started to realize there was going to be a lot of patients who needed higher levels of pulmonology and critical care things outside of the hospital. So, she asked if I would do that with her. We started to share patients and just tried to learn together in order to figure out how to support folks going through this.
My clinic really focuses on the mental health component. That’s like diagnostic evaluation. Treating neuropsychiatric symptoms through medications or psychotherapy and helping arrange referrals sometimes to other specialists as well. That can be referrals to sleep medicine, cardiology, or speech therapists to help with cognitive rehabilitation.
Funmi Okunola: Yes, you forget, as a physician, how a huge range of diseases when you’re [00:05:00] hospitalized can affect your mental health, whether directly or indirectly, whether it’s through the trauma of going through the disease, or whether having the disease affects how your brain functions, and therefore, leads you to develop Psychiatric Illness.
I’m amazed that we don’t have those types of clinics everywhere. Could you please tell us what proportion of your patients are Long Haulers?
Thida Thant: Yes. So, as you can imagine, my clinic is pretty small, and so I would say during the peak of the pandemic, probably half to two thirds of my clinic were Long Haulers. But I still had other patients as well who needed care. So, we’ve been refining our offerings, really trying to hone down what’s the part that really needs to happen with us, and what’s our specialty so to speak versus what care can happen in other parts of the system.
Now it’s probably a little closer to a quarter of my patients, at times still approaches half, it’s still a huge percentage of my clinic, but specifically we are medically complex clinics. I’m trying to provide care for everybody who needs it. [00:06:00]
Funmi Okunola: So how many patients do you have in the clinic as a whole?
Thida Thant: Oh, that’s a good question because it is a training-based clinic so there’s multiple caseloads going on. I think we often have at any given time maybe close to a hundred. I have problems quantifying because we are, as we’ve talked about before, a short-term model.
We have lots of new patients who come in and out to try to consistently stay open. So, it’s challenging. I work with two to three residents at a time for one half day. On any half day, we can really only see maybe eight to ten patients given their complexity, and then I have a psychologist who works with me as well.
She has a full-time caseload, and we run multiple groups. So, I think when you add all those numbers up, we get close to trying to evaluate a hundred plus patients per year, but it’s hard to say.
Funmi Okunola: So, what’s the wait time to get into your clinic for Long Haulers?
Thida Thant: Yes. It depends on the time of year. This time of year, as we get near the end of our academic year, we’re [00:07:00] pretty full. So, it can be several months to get in. Other times of year, I do try, that’s part of the short-term models, I really try to get people in within one to two months. But I think I do average two to three months to four, depending on what they’re coming in for, if it’s a group versus just evaluation versus therapy.
Funmi Okunola: Do you know the size of the population you’re serving?
Thida Thant: Oh gosh, I mean, it’s thousands when it comes to that because even if you just look at rates of COVID across the U.S., in Canada and other places, so much of the population has had COVID, right? Then we’re noticing that a significant portion of the population can go on to develop some form of Long COVID. It may not be debilitating, may not be multiple organs, but a lot of people experience something, whether that’s some brain fog, whether that’s feeling their mood just isn’t going back to where it is or feeling fatigued.
So, the population that needs and wants to get in to see me is thousands and thousands, and then our capability between the COVID clinic and myself is much, much less than that.
Funmi Okunola: [00:08:00] Yes. Thank you. That’s great. You talked about the time limit on attendance to the PCMPC program. Given that Long COVID is looking like a long-term Chronic Illness for a significant proportion of sufferers, what are the aims and objectives for attending your program?
Thida Thant: We really focus on the evaluation and brief initial treatment because what I started to discover was that many people in the community just didn’t even know where to start with patients coming in with these struggles, and given my background and our expertise and medical complexity, we’re able to sit down and really think about, okay, what are all the things that are happening?
Long COVID may be the main thing. It may only be a part, or maybe you have pre-existing conditions that are getting exacerbated by your Long COVID experience or Long COVID infection, and so that’s really the part we try to focus on. Then once we’ve developed what are the main diagnoses going on, what are the main needs, we will often initiate the first part of [00:09:00] treatment and say, you’re having this depression.
A part of it may be a Psychological Sequela of your illness, and sure, part of it may be Neuroinflammation. Regardless, we’ll start treatment for depression, right? We might start therapy. We may start medications, or it might be like, you have a sleep disorder, let’s get that referral going.
You need cognitive rehabilitation. Let’s do that. Or maybe I’m not sure we need some extra testing, and that part can take quite a while actually; it fits our short- term model. Usually once we’ve identified that and started to go down a treatment path, we can partner with either general mental health practitioners or family medicine or general practitioners or whatever it may be to continue on or maintain treatment.
That’s how we do that, and Long COVID is interesting because it straddles that line, I think, with acute and chronic Illness, where for some folks, it’s weeks to months, maybe six months before they are back to themselves. Other folks we are seeing in studies say a year or longer, and I have seen that in my clinic, but many of them do have improvement, whether it’s [00:10:00] resolution or not is different, but they often have improvement. We find that they can go back to their community, and then if they get a re-infection or something changes, they can come back for a re-evaluation, and we can see if something’s changed.
That’s how we handle the chronicity in my clinic, and then we do offer some longer-term aspects of our care. Our group therapy has historically been long term to give a place for people to continue to have support while their disease progresses.
Funmi Okunola: Right. So, what time period do you actually work on for Long Haulers in your clinics, sorting all of that out because that sounds great. It sounds like you really have your physician hat on as well as your psychiatric hat on when you’re managing them.
Thida Thant: Yes, we try. I have really good partners and other specialties as well, and our COVID clinic is very multi-disciplinary and that’s important. But I would say on my website we talk about one to six sessions. It’s somewhere in there because again, it depends on your needs, what the patient even wants.
Some folks just want to come in and have an expert look at them, and they’re like, okay, I feel better. I will work on rehabilitation. [00:11:00] I’ll work on my functioning, my goals of care. But I just wanted to make sure there wasn’t something else that was missing. So, some folks are happy with one or two sessions.
Others will do up to six sessions, and we try to have that span maybe up to six months. Oh, one session a month. Yes, about one session a month. Again, because we’re often adding other forms, and so psychotherapy will be with someone else in groups, so they may be getting more appointments than that.
But with me, it might be in my residence. It might be about once a month, and then some patients would keep closer to a year. Again, it just depends on what’s happening in their treatment plan.
Funmi Okunola: So, do they self refer or are they referred by their family physician or did you take some of them from the ICU or hospital? How does it work? How do they get into your clinic?
Thida Thant: Yes, it’s been a combination. My website doesn’t allow self referrals. We have started to because again of the demand for some of the self referrals we said, look, I can see you once and do a really good evaluation, and then we’ll talk about the next steps that may or may not be in my clinic.[00:12:00]
I do take the referrals from our multi-disciplinary COVID clinic. That’s where I prioritize it because that way, we can all work together, and those are usually even higher, complexity cases. Then we’ve been trying to train up other clinicians in the general larger clinic that I’m housed in.
A lot of them stay in that general clinic, but those clinicians can consult with me. So, we’re trying to improve and increase the kind of competency in the general mental health population, because again, the need is so high, and then I do take cases from my in-patient service. They message me and say, here’s why this case would really benefit from your clinic.
We try to get them in. So, over the years I’ve taken it from everyone. I definitely take referrals from other doctors and other specialties. Then we flex that based on how full I am. Honestly, and so some people will come back in three months. “I’m asking again”. I’m like, great. It’s great timing. I can get them in.
Funmi Okunola: Great. Okay. Could you please talk about the different Mental Health conditions that occur [00:13:00] with Long COVID, and what symptoms doctors and Long COVID sufferers should look out for?
Thida Thant: Yes. There’s a lot obviously, but I think things I most commonly see are depression, anxiety, symptoms of medical trauma or PTSD, and sleep disorders and cognitive issues.
Those are some of the top things that people tend to come in with, and it’s complicated because with the depression, it can be a couple of different things depending on how severe their illness was, depending on their medical co-morbidities. Their depression may be a combination of the physiologic impact of the illness combined with, as I mentioned before, the psychological sequelae.
So, what is it like to have gone from someone who’s super functional, super active, because I’m in Colorado, right? To someone who could barely get out of bed, and there’s a lot of obviously emotional toll of that. So, we can see that mix or anxiety about getting ill again. Or if they were someone who was very ill and was in the hospital in the ICU, fear of dying again, if they get sick, and then I [00:14:00] mentioned medical trauma.
That was very true, especially in the early waves when patients first started coming to me, just being in the hospital, and not knowing because seeing everything in the news, but how this new novel disease that no one knows how to treat, and people are dying from it. So many people were highly traumatized by that or just even if they were receiving excellent medical care, it’s really scary to be in the ICU or be in the ER.
Those are some of the big things, and obviously like brain fog, which is something that straddles multiple specialties, kind of neurologic, psychiatric, and so that one is, I’m lumping it in this question of mental health, but actually it’s arguably larger, more comprehensive than that.
But we know that many mental health symptoms and conditions can worsen cognitive functioning. Part of the evaluation I do as well is trying to figure out how do we optimize all parts of your care to try to improve some of the symptoms that are just going to take a while to get better.
Funmi Okunola: Okay. So, what symptoms should doctors and Long COVID sufferers look out for? Ninety-six percent of mental [00:15:00] health is managed in the community by family physicians, and I’m sure they’re managing a lot of sufferers. At what point would you say indicates that they need that extra help?
Thida Thant: Yes, and I think you’re right. GPs and family physicians handle so much in their clinic. My mom’s a primary care doctor, a family medicine doctor, and I see it right now. I think there are very many of them who are very comfortable initiating first steps. They can start an antidepressant.
They can refer for some forms of therapy. I think that it makes a lot of sense where you start to wonder if they need to come to my level of care is like, hey, these early steps are doing nothing. Yes. Or maybe I’m not even really sure how all these pieces fit together. My patient keeps coming back. They’re obviously suffering, they’re having significant impairment in multiple parts of their life from this, like they can’t work, their social relationships are suffering, their physical health is suffering, and I think those are ones where when you ruled out the things you feel comfortable with, and that can vary from doctor to doctor, but you’re making sure you’re not missing classic conditions.
I like to remind [00:16:00] people that besides Long COVID other things exist. common things exist with Long COVID. So, you can have Long COVID and addiction or Long COVID and COPD from your tobacco use. Or you can have all these things to try to work those parts up. But again, you’re scratching your head.
I treated all those other things the way I always do, but really, they’ve had this worsening since their COVID infection, it’s not getting better, and I think then it’s perfectly reasonable to try to seek consultation at minimum to make sure there isn’t something else that we’re not sure about.
Or I think another area is we’ve had some physicians are just well, “I’ve never heard of that”. So, there’s not really anything to do, and I think if that’s happening in the weight of a COVID infection and they meet the kind of time criteria for Long COVID, that would be another time to seek it out.
Because I think we have found that for those of us who have seen this in concentrated forms, we’re like actually that weird symptom can be seen in Long COVID. Again, even if we don’t know how to treat it, that itself is very validating to the patient to know yes, the symptom comes from somewhere. I’m not making [00:17:00] this up. So that’s what I tell family practitioners to look for. When it is exceeding the workup, you know how to do it for the symptom in front of you. When it exceeds the medications, you’re comfortable prescribing, that’s a good time.
Funmi Okunola: Okay. Your assessment is thorough and broad, and you take into account a lot of the other symptoms that Long Haulers are suffering from.
So, you don’t feel that every Long Hauler needs that type of assessment or do you, and there just isn’t the service?
Thida Thant: I think somewhere in the middle probably. I think there are a lot of folks with Long Haulers where it’s, I hate the word milder, but it’s milder. They’re kind of, you know, it’s getting better.
Yes, I had this for four months out, but I can feel every month that things are improving. Those folks really may not need us because I’ve actually had a number of those when they finally get in to see me, they’re “I’m good”, and I’m oh, they’re like, yes, I was really suffering when I got referred, but now it’s been this many months and actually I’m doing pretty well.
I don’t need it. I came because I wanted to see, but because they’re a conscientious person so that shows you that there is a self-limiting nature to this. At times it [00:18:00] can resolve. I don’t think those folks need to make it in, but there are folks who really are getting better despite optimizing their physical health, despite going to physical therapy, whatever their needs are, and I really think those are the ones. Again, this is becoming quite prevalent, and I do think every medical professional should be trying to figure out some base level of competency. That’s why I think things like this program, or there’s the ECHO series that we do. There are resource documents; we’ve put out the American Psychiatric Association Consensus Guideline.
It’s really important for everyone to read that because it is going to show the way we talk to primary care and said, depression’s going to show up, so, you have to find a way to develop some level of confidence with it. I do think Long COVID is reaching that point, and so everyone needs to be familiar with it, have some idea of how to approach it, and then that way use higher levels of care for when that fails. I do think we’re reaching that incidence rate.
Funmi Okunola: Oh, I think, yes, we reached it a long time ago. It’s just that the medical profession is just so slow, that’s why I’m doing this, but fantastic point. [00:19:00] Thank you. How do the Mental Health Disorders amongst Long Haulers differ from the increase in Mental Health Disorders amongst people during the pandemic as a whole?
Thida Thant: That’s a good question. I think that’s part of what everyone’s trying to figure out. So, we know rates of everything raised in both the pandemic, higher rates of depression, anxiety, substance use, all these things were happening. Higher rates of problems with concentration and focus, right?
ADHD requests, evaluation requests shot through the roof during the pandemic. It’s like some of the very same diseases or disorders or symptoms that you see in Long Haul. I think it’s just maybe all the factors feeding into it may be a little different. Not so much that the symptoms are different, but all the contributing factors are different.
So, in Long COVID, thinking that there might be a specific kind of neural inflammation from the disease process, there’s this hypothesis about serotonin depletion, all these kinds of things. That may not be why someone’s depressed in the general population, but it might be why depression is harder to treat in a Long Hauler.
How I think about it is that you’re going to see similar [00:20:00] things in both, but I think again, in Long Haulers, it’ll be part of a constellation. So, they will also have other physical, whether that’s clotting or breathing problems or cardiac issues, they’re going to have a constellation versus just a pure depression that you might see in someone who didn’t have COVID.
Funmi Okunola: Right. Again, another excellent answer. Thida, could you tell us about the pathophysiology; i. e. the disease-causing process behind the Mental Illness of Long Haulers?
Thida Thant: Yes, sorry to touch on that in my last answer, but it’s pretty complicated, and I think there’s a lot of things still being looked at.
Again, a big one was, is and has been from the beginning is inflammation. Before COVID came along, this was already getting looked at in the field of psychiatry because, again, some of these things are actually not new. I know it feels novel, this idea of a post viral illness or inflammatory illness leading to depression, but we had seen that well before COVID.
We’ve seen it with other diseases. viruses, we’d seen it like in autoimmune disorders, endocrine [00:21:00] disorders, folks with Chronic Fatigue Syndrome existed before this. So, we’d already started to be like, what’s going on there? I think there’s this idea that COVID itself really triggers this inflammatory pathway and that can cause damage on a neuronal level.
That’s definitely one of the big hypotheses in Long COVID. I mentioned the serotonin depletion because they started to find, and there’s recent studies looking at serotonin reservoirs in the gut and it’s hanging out there.
What does that mean? This idea that COVID triggers deficiencies and tryptophan and then downstream from there. So that’s why there started to be increased interest in antidepressants early in COVID. There’s already this idea that folks who are on SSRIs were maybe less likely to get Long COVID or had better outcomes in some ways in their COVID disease process.
So now can you treat Long COVID with antidepressants? Those are some of the hypotheses there. Then there’s the ones that come from how sick were you? I know we’re saying you can develop Long COVID regardless of the severity of your COVID infection. I think we’ll start to understand that in a more nuanced way because [00:22:00] there are some differences.
So, if you’re in the ICU to where you’re hypoxic and you really couldn’t breathe, your oxygen levels are really low, you needed to be intubated and on a ventilator, we know that inherent in and of itself can cause problems, right? There is injury in the brain and they’re physiologic changes from not having oxygen that can make you look depressed. That can make you confused or have cognitive impairment. Or if you were in the ICU and you got that hospital acquired delirium or ICU delirium, we know that has residual cognitive and emotional impact and the medications you get. So, there’s that.
Again, it depends on your treatment setting, your co-morbidities, all of that. But I do think it’s going to end up somewhere in that realm of inflammation and some of these neurotransmitters. That just makes sense.
Funmi Okunola: Great, thank you. Which group of people with Long COVID are more susceptible to mental illness?
Thida Thant: Yes, there’s been a lot of things looking at that too, and right now it’s a pretty wide bucket. Here are all the things associated with Long [00:23:00] COVID. We see a high prevalence, and female sex versus male. We see a higher prevalence in folks who had a lot of like chronic medical conditions ahead of time.
So, if they again are inflammatory based, if they have things like diabetes or something causing high blood pressure, those sorts of things, pre-existing seems to make people more vulnerable. Pre-existing mental illness too. If you already had a history of depression and anxiety and trauma, that seems to predispose as well. I’ve definitely had folks all over this spectrum. I have folks with none of that who had Long COVID, and I had folks with all of that. Anecdotally, I have seen that the more of those things you have, and the more mental health issues you’ve had, it does seem to take longer for the symptoms to resolve versus someone who really didn’t have any of that and then developed new onset depression, anxiety, other physical symptoms after their COVID infection. I think the jury’s out, but that seems to be what we’re seeing clinically.
Funmi Okunola: Yes. Well, very interesting. So, what psychiatric [00:24:00] medications do you prefer and why?
Thida Thant: That’s a tough question because people come in, they come to see me, they’re you must have something, right? You’re the Long COVID psychiatrist, and I treat things similarly to how I treat other mental health conditions. I’ve talked about my evaluation stance and focus. I try to be really thoughtful about how all the symptoms fit together. So, you’re not going to see me throwing medications at symptoms that often.
That doesn’t mean I won’t use medications to target sleep or anxiety, but I try to be like, okay, what is the quality of the sleep disruption? Why are you having it? What is the quality of your depression or your anxiety? Where is it coming from? How do these pieces fit together? Then I try to target that sort of formulation as we call it in psychiatry with medications.
Someone will come in and say, “I have brain fog”. I won’t go straight to a stimulant. For example, I get asked about that a lot and maybe eventually I’ll be outed as being overly conservative. That’s being actively studied right now, but I’m just finding that it doesn’t really do anyone service to throw a med for every symptom.
So, I try to be, okay, you’re having depression. Let’s take a look at that. When we score [00:25:00] you, does it seem to meet criteria for Major Depressive Disorder? Is it more of a psychological depression from trauma? Is it depression because you’re not eating well, you’re on oxygen, your sleep’s disrupted.
Maybe you have sleep apnea, and then I try to target the underlying condition. So, if I do think it fits a major depression or a generalized anxiety or PTSD, I will use conventional antidepressants that I would use anyway. Sometimes I will lean more towards the activating ones. If the patient also comes in saying, “I really was so exhausted. I’m experiencing extreme fatigue”, then I might reach more for fluoxetine, bupropion, activating ones like that. But in general, I try to figure out what the side effect profiles, what are the medical comorbidities. What is the patient also targeted, and how can we collaboratively make a decision together. So, lots of antidepressants happening in my clinics.
I’ll be curious to see what the SSRI studies say because people are messaging me. Hard to say if they’re progressing any faster than the folks I don’t have on that team. I will, like I said, use some sleep medications, trazodone, [00:26:00] melatonin, things like that. If they’re having trauma symptoms, I’ll use prazosin like we do for trauma related nightmares, and then occasionally I’ll use stimulants. I’ve had a lot of patients where it turns out that they probably had ADHD all along. It just was mild enough that they could deal with it or compensate and then COVID tipped them over. So, I’ve used some stimulants in those, or if they have a sleep disorder, I might use modafinil or things like that.
Really, I use a wide range. Also, yes, I’ve started using a low dose naltrexone that a lot of people have looked into for things like Chronic Fatigue inflammation, and we use like tiny, tiny doses to try to target that holistically. Some patients have really liked that, and some have said, “I don’t know if it’s doing anything”. So, we try to do a combination of things.
Funmi Okunola: Yes, you’re such a good psychiatrist. You really look at the whole person. It’s just so refreshing.
Thida Thant: I try. I try hard.
Funmi Okunola: No, it’s great, and you’ve got such a sunny personality. You know, I think just being around you, it [00:27:00] is uplifting in itself. Could you please tell us about your group therapy services for Long Haulers?
Thida Thant: We’re really proud of our group therapy. That’s one of our longer standing offerings and really some of our most popular with our patients. They’re like, this is the thing, yes, all the doctors, you all were great, but this group is really what’s changed my life. We love that.
So, right now we have two different Long COVID groups, and those are the only long-term portions of our clinic. We allow folks to stay in those as long as they want to and are actively engaged. Naturally over time, some people get better, they get busy, and then we add new group members.
We call them ‘emotion focused processing’. The idea there is to have a safe space where we have therapists and psychiatry facilitators. They’re there to make sure the group stays on track and is a safe space to talk about how you are feeling. What is happening in your life in the context of Long COVID. What’s changed, not changed and be able to talk to other people that get it really and, share frustrations like here I am dealing with Long COVID, and there’s my family member going out, not [00:28:00] masking and partying and doing all these things. Or really, what was fascinating was that some of the early things we learned about Long COVID came from that group.
I remember really early some of my women patients being like, I’m losing my hair, and we hadn’t yet written about that in the literature, that that was a thing that could happen. So that’s the sort of space happening there. We introduced some skills, ways to cope with things, things like that, and then we have a chronic illness group that we had created pre-COVID, but lots of our Long COVID folks do rotate through that while they’re waiting for a space in our other group because as you can imagine, we have wait lists for that as well. We’re so full that we are working on creating a third Long COVID group that’ll be more time limited and more skill and knowledge base to give people a foundation to work with while they’re getting connected with other forms of therapy.
Funmi Okunola: Wow. Fantastic service! Could you tell us about the two different Post COVID groups, and why there are two different groups? I noticed looking on your website that one is for people who have come up from ICU, and the other is for people [00:29:00] who have been hospitalized or non-hospitalized so that you separated them. Is there any reason for that?
Thida Thant: Yes. So early on when no one knew anything, that’s when we were starting these groups, and we were at first experiencing the wave of folks who have been in the hospital for quite a long time. Then we started to see more patients who hadn’t been hospitalized, and that’s where we started with the ICU hospital level group, because that was the patient population at the time, but we kept it going for a few reasons.
I talked earlier about things like medical trauma, ICU delirium, and so we wanted everyone to feel their experiences were valid. We wanted them to feel other people in the group understood them, and as you can imagine, these are very different experiences. So, for our folks in the ICU, they’re talking about near death experiences, they’re talking about intubation, they’re talking about being months in a hospital. We’ve had some patients who required lung transplant afterwards, and we wanted them to share that freely and not be…. But also to have patients who didn’t have any of that, but are still suffering, not feeling like “Oh, I can’t say anything. I wasn’t as sick as them”. So, we felt they just [00:30:00] had actually different experiences, different rates of recovery, different goals early on. That’s why we keep it separate, and we felt that was the right way to go.
Funmi Okunola: Great. Thank you. I could talk for hours and get into more detail, but we don’t have that much time. Given the access to programs like yours is low, do you have any advice for how someone with Long COVID should approach their family physician for treatment of their mental illness?
Thida Thant: This is maybe for both sides, for the medical practitioner, as well as the patients, really from a place of collaboration and the mindset that everyone’s doing the best they can.
I’ve seen a lot of frustration and tension because everyone’s just overwhelmed, and no one knows what to do. Patients come in because they’re scared. They read about this, they’re hoping for care, and then they feel disappointed; disappointed if their doctor doesn’t know what to do, and then the doctors on the flip side want to help. They’re healers by nature, and then they get stressed and maybe distant, even if they don’t know what to do. This isn’t a thing I’ve heard of.
So, everyone’s struggling. I always say approach in this place of ‘I’m experiencing these things’. “Can you help [00:31:00] me figure out what’s going on?” Or “if there’s any parts of this that we can do something about?” Because I think the part that’s really hard is the chronicity and the complexity of this is that we may identify things, and there still may be a long road to recovery.
It’s not really about finding the fast answer, unfortunately, it’s about let’s rule out big scary things, let’s identify, rule in or rule out things we can intervene on. Have you developed a new lung condition or heart condition? Or do you need physical rehabilitation? Then we have to really be comprehensive. So, for the patient too, knowing that their treatment plan to get back may be pretty comprehensive and very rehabilitation focused as opposed to cure-focused, and then knowing that it’s a process. You could ask your GP or family doctor, do you know of any place where I can get a second opinion or a consultation, and then we can continue working together on how to manage this.
Funmi Okunola: Do you have any advice for family physicians on how to manage mental health [00:32:00] amongst Long Haulers in the community, and when and when not to initiate medication?
Thida Thant: Yes. So, the flip of what I was saying earlier, but I think it’s really again there, you have a lot of training in mental health and don’t be – I don’t want you to feel like you don’t have what it takes to treat Long COVID. But I think again, it’s really about figuring out impairment. If you’re unsure of the level of impairment, are there objective ways to test for that? So, you don’t want to jump straight to like neuropsychological testing, that’s a very limited resource. But if you have someone who was maybe previously a doctor doing ER shifts, and now they can barely manage their bills, and you’re trying to figure out can they go back to work, or figure out why, why is their impairment so significant? They had Long COVID for one week, then that might be a time to seek out additional ones. Again, but if someone’s on the road to recovery, I think that’s okay. You can just be there in the journey with them.
You don’t have to seek specialty care. So, I really think that’s kind of a thing. What is the trajectory of recovery? What is their level of impairment? The same thing for initiating mental health treatment. What is their level of impairment? Are they getting better? Are they not? [00:33:00] Is their mental health contributing to other parts of their care, which we know it does.
So, if they have brain fog and depression and anxiety, you want to optimize treatment of the depression, anxiety. Not because you expect that to fully cure the brain fog, but it’s going to help, right? So that kind of thing is the mental health symptoms or conditions feeding into other parts of that whole picture.
I think again, lean heavily on resources like this to try to make sure you’re doing this level of work-up. Then once you’ve exhausted it, then you’d be, okay, I need someone else with new ideas to come help us out.
Funmi Okunola: That’s an excellent answer. So, you talked briefly about an ECHO project. Are you going out into the community now and training GPs in your area on how to manage Long COVID, how to diagnose it? Is that what you’re doing?
Thida Thant: Yes. So, the ECHO programs existed well before me and is managed by a lot of people, but the whole goal there is community outreach, education. So, whether that’s community, whether that’s primary care, all of that, and it’s these sessions people can sign up for, they’re free, they’re bite sized, and trying to target really high yield things, and how do you do this in [00:34:00] primary care? So yes, there have been COVID related ones. There have been ones in connection with the CDC.
We’re working on some new modules now actually with our Colorado local program to offer this virtually, and so I think that’s what there’s a lot of it’s going to be coming out there now. I mentioned that with the American Psychiatric Association we put out a guidance document as well just last month to help guide psychiatrists in general with how to do this. So again, just trying to make this something so where every kind of doctor you encounter has some level of comfort and knowledge, even if it’s not super in depth.
Funmi Okunola: If that guidance is in the public domain, I will include it in the show notes as a link, and, yes, please keep us informed of anything that we can include on the website for people to get access to. Well, thank you, Professor Thant for such a wonderful interview, and for taking the time to educate us and to share your experience of working with and for Long Haulers today.[00:35:00]
Thida Thant: Thank you so much for having me. It was great.
Funmi Okunola: Please join us for next week’s Episode of Long Covid – the Answers.
Funmi Okunola: Some questions for listeners to consider.
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SHOW NOTES:
This interview is part of our neurological Long COVID section of the series.
Professor Thida Thant MD is an award-winning consultation liaison psychiatrist and Director of the Psychiatric Consultation for the Medically Complex Clinic at the University of Colorado, where she provides rehabilitation for Long COVID survivors. She is one of the few psychiatrists we have found who is taking a lead in the rehabilitation of people with complex chronic disease.
References
1 Psychiatric Consultation for the Medically Complex Program at the University of Colorado
2 APA Resource Document on Neuropsychiatric Symptoms of Subacute & Chronic Long COVID
