Washington University School of Medicine announced a new clinic specifically targeting patients who recovered from Covid-19 but continue to suffer from a wide range of symptoms. Covid Long Haulers in St. Louis and the surrounding area will have access to top-notch care in this multispecialty service line.

The Care and Recovery After COVID-19 (CARE) Clinic recognize people with long Covid presents with diverse issues and complications. Patients often complain about problems in the heart, lungs, kidneys, brain, blood, insomnia, sleep, and mood disorders. To facilitate care coordination, the CARE clinic has access to specialists in Cardiology, Endocrinology, Gastroenterology, Hematology, Infectious Disease, Nephrology, Neurology, Occupational Therapy, Physical Therapy, and Pulmonology.

The team of specialists addresses each patient’s needs by providing a comprehensive individual assessment. Referrals, testing, and recommendations are coordinate from the central hub of the CARE Clinic.

The St. Louis Washington University CARE Clinic will schedule patients with Long Covid symptoms who have had a confirmed positive case of COVID-19 by a nasal swab test, a saliva test, or a blood antibody test.

Washington University is not the only institute launching post-Covid care clinics. The National Institute of Health (NIH) announced a new initiative to study the causes of the post-Covid condition. The influx of a $1.15 billion investment in new medical research funding will hopefully open the doors to preventative steps and, ultimately, treatment options.

Scientists continue to learn more about persistent symptoms after a Covid-19 infection. Popular terms for the condition include “long Covid” or “Covid long haulers.” The CDC uses the more descriptive term post-COVID condition to cover the set of post-infection signs and symptoms experienced more than four weeks after infection with SARS-CoV-2.

We know that SARS-CoV-2 enters the brain and causes inflammation. Scientists in Bethesda, Maryland, published a paper in the New England Journal of Medicine evaluating the brains of people who died from Covid-19. They noted inflammation and evidence of leaky blood vessels in the postmortem brain tissue.

Despite these findings, we do not know the specific reasons the virus causes persistent symptoms in some patients. Long Covid symptoms appear in some patients with severe Covid disease and those with mild or asymptomatic infections.

The CDC lists common symptoms of post-Covid complaints.

• Tiredness or fatigue
• Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
• Headache
• Loss of smell or taste
• Dizziness on standing
• Fast-beating or pounding heart (also known as heart palpitations)
• Chest pain
• Difficulty breathing or shortness of breath
• Cough
• Joint or muscle pain
• Depression or anxiety
• Fever
• Symptoms that get worse after physical or mental activities

FIGURE. Self-reported symptoms at the time of positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) testing results and unresolved symptoms 14–21 days later among outpatients (N = 274)* — 14 academic health care systems,† United States, March–June 2020

A recent study published in the Lancet evaluated patients six months after hospital discharge. Approximately 75% of the 1,655 hospitalized COVID-19 patients in Wuhan, China, continued to have at least one symptom six months after discharge.

Another Lancet study evaluated the neurolgic and psychiatric outcomes in 236 379 Covid-19 survivors six months after infection. One third met criteria for a neurological or psychiatric diagnosis within six months of infection. Anxiety, depression, muscle pain, substance abuse and insomnia were the most common reported conditions.

Patients in St. Louis and the surrounding area with post-Covid condition symptoms can find more information here.

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Pediatric resident Dr. Poulami Saha suffered from depression. In May, She jumped off the 11th floor of her hospital in Calcutta. In March, Daniela Trezzi, an ICU nurse in the hard-hit Lombardy region of Italy, took her own life. Reports indicate she could not move on from the fear that she may have infected patients under her care.

As National Suicide Prevention Awareness Month comes to a close in the midst of a global pandemic, a focus on the health needs of medical professionals (often a taboo subject) feels overdue. As the leader of a large OB-GYN practice in Texas, I see the mental health impact on doctors, nurses, and other health care workers every day.

A crisis intensified

Suicide is the 10th leading cause of death in the United States. Health care providers are not immune. In fact, physicians take their own lives at twice the rate of the general population. One doctor per day dies by suicide in the United States. Long before the pandemic, stressful working conditions, excessively long hours, and sleep deprivation led to a surge in physician burnout. Pandemic stress puts health care providers at an even higher risk of despair.

Quarantines, school closings, social isolation, and shelter-in-place orders have changed the way we live. Frontline health workers in hard-hit areas are exhausted and often traumatized from treating Covid-19. But health care providers in all areas struggle to cope with the complicated politics that now surround the pandemic and the lack of a national, strategic plan to fight it.

While my city is not experiencing an overwhelmed hospital capacity, I understand what Breen, Saha, Trezzi, and other providers must have felt. With empathy, I recognize the feelings of hopelessness that can lead one to think the only way to make the pain stop is to die.

Not only does the incidence of suicide signal unbearable conditions for doctors and health care workers, but when suicide happens in the industry, it creates a new layer of trauma and stress for everyone in medicine. Our colleagues’ suicide stories place us at increased risk of post-traumatic stress, anxiety, depression, and insomnia.

Physicians take their own lives at twice the rate of the general population.

In March, JAMA published a study evaluating the pandemic effects on health providers’ mental health in Wuhan, China. In this cross-sectional study of 1,257 health care workers, investigators demonstrated the high incidence of depression, anxiety, insomnia, and distress in frontline health care workers. Early in the pandemic, many health care workers around the world felt betrayed by the lack of PPE, ventilators, and ICU capacity. As Covid-19 drags on, physician workloads have increased, and general hospital morale has plummeted. Health providers worry about catching the coronavirus but also live in fear of infecting their families.

Health care workers and those who love them must be aware of the factors increasing the risk of suicide. Hopefully, improving our risk factor awareness will increase our capacity for recognition, early intervention, and prevention.

According to the National Alliance on Mental illness, risk factors for suicide include:

1. Mental health condition. Forty-six percent of suicide victims had a known mental health condition such as depression, anxiety, insomnia, or substance abuse.
2. Family history of suicide.
3. Substance use.
4. Intoxication. More than one in three people who die from suicide are under the influence of alcohol at the time of death.
5. Access to firearms.
6. A serious or chronic medical illness.
7. Gender. Women are more at risk of attempting suicide, while men are nearly four times more likely to succeed.
8. A history of trauma or abuse.
9. Prolonged stress.
10. A recent tragedy or loss.

The Covid-19 pandemic pushes health care workers to operate at peak performance levels. Patients are sicker, which requires a higher level of care. Covid-19 management guidelines are changing at a rapid pace. While the mortality rate is decreasing, physician workload is increasing.

The constant barrage of bad news, political turmoil, mask noncompliance, and social media toxicity strains our ability to get through each day.

I see firsthand how we are pushing ourselves to serve our patients better, and yet we are of no use to others if we do not first take care of ourselves. We all need a mental break, some moments of peace and tranquility — which can be challenging to come by in a time marked by paramount hardship.The National Alliance on Mental Illness offers the following five warning signs to look out for, as signals of the need for professional guidance and support:

1. Increased alcohol and drug use.
2. Aggressive behavior.
3. Withdrawal from friends, family, and community.
4. Dramatic mood swings.
5. Impulsive or reckless behavior.

The National Institute of Health offers a more extensive list of behavioral changes indicating someone may be thinking about suicide. Some people considering suicide may express their intent directly by talking about wanting to die or wanting to take their own lives. They may give away possessions, say goodbye to friends and family, or put affairs in order in the shape of a will.

Other at-risk individuals may express feelings of guilt, emptiness, or hopelessness. Some talk about feeling trapped or being a burden to loved ones. Anxiety and depression may lead to mood swings, agitation, and even rage.

Some people change their behavior by withdrawing from family and friends, drinking alcohol, using drugs or medications, or changing their eating and sleeping habits.

Not only does the incidence of suicide signal unbearable conditions for doctors and health care workers, but when suicide happens in the industry, it creates a new layer of trauma and stress for everyone in medicine.

Caring for health care workers

If you recognize any of these signs or symptoms in a friend, colleague, or family member, it is critical (and potentially life-saving) to reach out with compassion and empathy. Active listening techniques can help someone struggling with suicidal ideas to feel heard and not worry that their feelings are wrong.

If you recognize any of these signs or symptoms in yourself, please know it is safe to reach out and speak up. Schedule a telehealth visit. Reach out to a doctor, a colleague, or a friend.

If you are struggling with thoughts of self-harm or suicide, please do not hesitate to contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). This is a free 24/7 confidential service that can provide people in suicidal crisis or emotional distress, or those around them, with support, information, and local resources. For more information, call or visit SuicidePreventionHotline.org.

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The U.S. Centers for Disease Control and Prevention (CDC) provides updated guidance for public health information and recommendations through the weekly Morbidity and Mortality Weekly Report (MMWR). On November 2, the CDC released a report on pregnant women’s maternal outcomes who contract Covid-19.

The report, titled Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status, evaluated symptomatic women aged 15–44 with laboratory-confirmed infection with SARS-CoV-2.

This paper verifies the growing scientific consensus that women are at a higher risk of severe complications if they acquire Covid-19 during pregnancy compared with nonpregnant women. The analysis of approximately 400,000 women with symptomatic Covid-19 infections had a low overall risk of serious complications. Still, pregnancy increased the risk of intensive care unit admission, invasive ventilation, extracorporeal membrane oxygenation (ECMO), and death.

Based on current data, there is no evidence at this time indicating pregnant women are more at risk for severe illness from Covid-19 than the general public. We know that viral infections in pregnancy and postpartum can lead to poor outcomes in mothers and newborns.

Pregnant women have a suppressed immune system and physiologic changes in their lung function. These changes put pregnant women at a higher risk for respiratory problems when they contract other similar viruses, such as MERS, SARS, influenza, or pneumonia.

On the plus side, data so far indicates that a Covid-19-positive pregnant woman has a low risk of passing the virus to her baby. The PRIORITY study(Pregnancy Coronavirus Outcomes Registry) showed babies born to Covid-19 positive women do well with no increase in important metrics such as low birth weight, difficulty breathing, apnea, or respiratory infections through the first eight weeks of life. The PRIORITY study showed that only 1.1% of infants contract the virus.

A November 6, a CDC paper titled Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancydemonstrated that pregnant women are at a higher risk of preterm labor if they acquire Covid-19 during pregnancy.

Although the increased risk of preterm labor is problematic, the low rate of infant transmission is encouraging. Yet obstetricians and pregnant women need more information revealing how moms do when they contract Covid-19.

This MMWR report sheds some light on this topic. Pregnancy data was collected through the National Notifiable Diseases Surveillance System (NNDSS) and reported to the CDC. Health history data was analyzed from 23,434 symptomatic pregnant patients from January to October. Asymptomatic carriers of SARS-CoV-2 were excluded from this analysis.

Most Covid-19-positive moms do well

The data showed symptomatic pregnant women with Covid-19 had a low overall risk of complications. This finding is important for health care providers, pregnant patients, and their families.

Most symptomatic Covid-19-positive moms do not experience severe disease. For example, ICU admission rates were 10.5/1,000 cases, invasive ventilation 2.9/1,000 cases, and death 1.5/1,000 cases.

Overall, most pregnant women experience mild symptoms and do not require hospitalization.

Covid-19-positive moms are at higher risk than nonpregnant women

Importantly, this study demonstrates pregnant women who contract SARS-CoV-2 do not fare as well as nonpregnant women of the same age group. Covid-19-positive pregnant women were more likely to be admitted to the intensive care unit, nearly four times more likely to need invasive ventilation, and twice as likely to die.

Even after adjusting for age, race, and preexisting medical conditions, the severe disease and respiratory compromise risk were present in all age groups.

ICU admission risk was higher among all pregnant women but highest among Asian and Native Hawaiian/Pacific Islander women. Among Latinas, Covid-19-positive pregnant women had 2.4 times the risk of death.

The study mentions an interesting and unexplained finding that pregnant women reported symptoms less often than nonpregnant women. The most common symptoms mentioned by pregnant and nonpregnant women were cough, headache, muscle aches, and fever.

Limitations of the study

The authors report limitations to this important publication. There is not a national standard for reporting data. National case surveillance data for Covid-19 is reported voluntarily by health care providers and public health agencies.

Case reporting varies by jurisdiction. Race and ethnicity were missing in 25% of reported cases. Symptoms and preexisting condition data were missing in approximately 50% of cases.

This study was limited to symptomatic patients with known pregnancy status, but in 64.5 % of reported Covid-19 cases, the pregnancy status was not reported.

How does this report help doctors manage pregnancy?

This CDC report adds essential information to the growing scientific literature to help health care providers manage pregnant women with Covid-19.

We can reassure women and families that the overall risk of severe complications from Covid-19 is low, but pregnant women should be counseled that their risk for severe Covid-19-associated illness is higher than that of nonpregnant women.

Health care providers should take extra caution, knowing that when a pregnant woman is symptomatic with Covid-19 she is more likely than nonpregnant women to experience respiratory distress and require ICU admission.

How do pregnant women protect themselves from Covid-19?

We all must do our part to prevent the spread of the virus. Pregnant women should follow the same global recommendations:

1. Wash your hands with soap and water for at least 20 seconds.
2. Use hand sanitizer containing at least 60% alcohol.
3. Avoid touching your face.
4. Practice social distancing.
5. Cover your mouth if you cough or sneeze.
6. Clean your cellphone and household surfaces.
7. Avoid travel.
8. Wear a mask when out in public.

CDC Morbidity and Mortality Weekly Report, “Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–October 3, 2020.”

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In my last article (Debunking 1 in 5 COVID-19 Patients Develop Mental Illness), I debunked a claim circulating around the world — that a Lancet Psychiatry study found 1 in 5 COVID-19 patients would become mentally ill in the first 3 months after diagnosis.

Researchers drew on the electronic health records (EHRs) from a US managed health care system to match 62,354 patients COVID-19 with patients with 6 other medical diagnoses.

Claims about mental illness were based on recording in the electronic health records of mental health diagnoses 14–90 days after diagnosis of COVID-19 or the comparison health conditions. These diagnoses of mental illness were originally made for administrative purposes — billing and documentation — and would be considered poor quality for scientific purposes.

I pointed out that the excess of mental health diagnoses associated with COVID-19 was almost entirely due to more adjustment disorders.

Patients diagnosed with COVID-19 were likely to be experiencing some anxiety (worried) or depressive symptoms (sad, pessimistic) that were not serious enough to justify a diagnosis of major depression or a serious anxiety disorder. So, a diagnosis of adjustment disorder was entered into their EHRs.

These do not seem like abnormal reactions to me. In fact, adjustment disorders were formerly called adjustment reactions and clinicians could not be reimbursed for treating them.

Dissenting from the portrayal of the study in the media

Why was my interpretation of the Lancet Psychiatry article at odds with almost all of the media coverage I could find, which proved to be remarkably similar?

I arrived at my conclusions by looking at the study design and closely examining the tables of numbers.

I applied knowledge that any journalist should have in writing about a topic that has great importance to readers facing a profound public health crisis like COVID-19.

America is facing a profound crisis of faith in democracy and in science. It desperately needs media filled with articles by journalists who think for themselves and consult experts when they need to.

In an ideal world, journalists should have called up their own independent experts and asked them about their impression of the study. Were these experts expecting a tsunami of mental health problems or did they think these authors might have overstated the importance of their findings a bit?

Journalists should have had the curiosity to ask how serious a mental illness an adjustment disorder and why there was not more depression associated with COVID-19.

In a bygone era, journalists were better able to play an important function in society. At their best, journalists buffered laypersons and policymakers from the self-promotion, conflicts of interest, and sheer overenthusiasm of researchers for their own work. Journalists provided independent assessments of science to satisfy readers’ curiosity, but also to guide their personal and collective decision making.

But journalists face different challenges than only a few years ago.

Most newspapers and magazines have laid off their full-time staff and depend on freelance journalists. Journalists can no longer assume researching articles will be reimbursed.

Often, journalists will not have the time to look at a scientific paper carefully or to consult their trusted sources. Few will have the courage or the recklessness to say that the authors of the Lancet Psychiatry study (from Oxford University, after all) are exaggerating the significance of their findings.

Editors will also not be pleased with a story on which they cannot slap a clickbait, screaming headline like “1 in 9 mentally ill!!”

Media have gone online, some abandoning print editions altogether. They need clickbait to attract and retain readers’ interest. Traffic to a media website and readers’ time spent there are tracked as altmetrics, which determine the advertisements the media get and what they can charge for ads.

This consideration matters for which articles from which journalists are published.

Science Media Centre of London (SMC_L)

Media coverage of the Lancet Psychiatry article was almost identical worldwide. If articles quoted an expert, it would likely be identical quotes from the same experts. A lot of the articles credited Reuters News Service. The articles that did not credit Reuters but named a journalist in the byline were generally quite similar, even having the same quotes.

Noting that some authors of the Lancet Psychiatry article were at Oxford University, I immediately suspected the Science Media Centre of London (SMC_L) was involved.

The SMC_L website welcomes journalists.

When science hits the news agenda, it’s our job to pass on to journalists as much accurate information as we can, as quickly as possible. In order to do this, we send out quotes from experts and statistical analyses of scientific studies, in addition to running regular press briefings on the latest hot topics. Find our most recent Roundups and Rapid Reactions, briefings and ‘Before the Headlines’ analyses below…

Who are the experts that SMC_L consults? Can anyone submit their credentials and expect to be called?

We are always on the lookout for top experts, but it’s important that each scientist knows us before we call them. So, we generally don’t add scientists before we’ve worked with them at least once.

It sounds like British English for “Don’t call us, we will call you.”

SMC_L warns of storms around science stories in the media.

When science hits the headlines, it’s not only journalists and scientists who find themselves in the eye of the storm, but also press, media and communications officers, working to support their scientists and engineers whilst also providing journalists with what they need.

I expect that bad science will get into the media and even good science will get misrepresented. Such occurrences are inevitable. When it happens, controversy and criticism are healthy and necessary parts of fixing things.

You might get a sense that SMC_L disagrees. They seem to be offering shelter from such “storms.”

Expert reaction to study looking at psychiatric diagnoses after COVID-19

I don’t like authorities telling me how to think or what to write, even if, like Ringo Starr, they can call themselves Sir or Dame or wear medals at breakfast.

Searching for the Lancet Psychiatry study, I found a past Briefing and an Expert Reaction with seven of SMC_L’s usual suspects as experts.

Six of the seven mostly sounded like experts, but really did not get into the nitty-gritty of the study, content enough to demonstrate expertise.

One expert had “Sir” between “Prof” and his name. Another had “Dame” between “Prof” and her name.

I cannot understand why Brits bring up knighthood and damehood in these contexts. When Ringo Starr got to call himself Sir, it did not improve my appreciation of the Beatles.

There was not very much reference in this Expert Reaction to crucial methodological details of the study and the limitations of EHRs as scientific data.

It would seem that a grasp of these details should temper any recommendations for clinic or public health policy based on the study.

No expert conveyed any sense of the messiness of big data from an American health care system, especially if one is intent on making policy recommendations for organizing a response to mental illness associated with COVID.

Six of the Expert Reactions sounded like a string sextet accustomed to playing together, mostly without creating a fuss. The seventh, however, arrived like a tuba player, oblivious to not contributing to the harmony.

Prof David Curtis politely alluded to a lot of problems with the Lancet Psychiatry study. He seemed to wonder aloud why such a fuss is being made about it. He injects some uncommon common sense into the discussion

“It may be unsurprising that this happens a bit more often in people with COVID-19, who may understandably have been worried that they might become seriously unwell and who will also have had to endure a period of isolation.”

If there is any doubt about where he stands, he clarifies at the end:

“Overall, the results reported seem broadly plausible but I’m not sure that they have specific implications for patients or health services.”

My kind of expert. I hope Prof Curtis gets invited back by SMC_L.

Getting personal

I think my humility is still intact after decades of writing hundreds of scientific papers, some that deserve more criticism than they received. I welcome criticism from experts. I welcome peer-review by academics, but also feedback from patients who are experts on their experience and who have had to live with the modest clinical and public health implications of what I have written.

Yet, I think there is a vital distinction to be drawn between expertise and authorities. The good experts have the credibility to gain our attention by showing things we might not know, but that we would agree we should. The not-always-good authorities believe they have the power to enforce rules and tell us how to think and what to write.

I think that is what SMC-London is doing here. I am biased by my experience with them, but that bias is valuable because it is grounded in experience. I have seen their ways too often for my liking.

• One of the experts being cited in this Expert Reaction — the Dame — also endorsed an awful study that she claimed showed cognitive therapy for psychosis was effective for psychosis in the absence of medication. The study did not show that, but such claims encouraged some patients to refuse medication. The Cochrane Collaboration showed twice in systematic reviews that cognitive behavior therapy was ineffective.

• One of the experts who was cited — the Sir — advocated cognitive behavior therapy and graded exercise for chronic fatigue syndrome, which patients insisted was ineffective and harmful. Fiona Fox, Director of SMC_L organized a campaign that media that condemned the patients as militant terrorists. The press releases were picked up in British media. The patients were subject to considerable abuse and harassment as a result.

Whiskey, tango, foxtrot! The patients were often bedbound or confined to wheelchairs. I do not think anyone would recruit them as suicide bombers or even assassins.

• I decided to look into the matter. I requested data from the PACE clinical trial for reanalysis. I believed the PACE investigators were legally bound to make these data available. Fiona Fox, Director of SMC_L organized a letter-writing campaign to Parliament calling for researchers to be exempt from such requests.

As promised, SMC_L tried to provide shelter from the storm.

• More recently, patients with chronic fatigue syndrome and professionals from around the world convinced the UK National Institute for Clinical Excellence to issue draft recommendations that no longer endorsed GET as a safe and effective treatment. SMC_L has organized resistance from academics strongly invested in this treatment, including the Sir.

I am exceptionally lucky. I came out of public housing on a shitty mudflat in Chelsea, MA, and spent my high school years on welfare. By many accidents of circumstances, I somehow ended up an emeritus Ivy League med school professor.

I am painfully aware of my deficiencies in preparation and seek my corrective expertise where I can find it. But I don’t like authorities telling me how to think, even if, like Ringo Starr, they can call themselves Sir or Dame or wear medals at breakfast.

America is facing a profound crisis in its faith in democracy and in science. It desperately needs media filled with articles by journalists who think for themselves and consult whatever independent expertise they feel they need.

I don’t care that SMC_L gives lots of stuff away free and does not mind if journalists plagiarize them.

Journos, please find your own experts and write your own articles on which you can proudly stick your byline.

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