BACKGROUND

Conceptualization of long COVID

There are several reviews comparing the long-term effects suffered by people in past pandemics such as the Russian flu (1889-1892), the Spanish flu (1918-1919), and even comparing the sequelae of previous coronaviruses such as MERS-CoV and SARS-CoV-1, where some side effects of the infection became chronic conditions (Ashton, 2020; Higgins, Sohaei, Diamandis, & Prassas, 2020; Stefano, 2021).

In this sense, the concept of long COVID is used to describe the secondary ‒or persistent‒ aftereffects that people recovered from COVID-19 present for a longer period than expected, approximately ≥ 12 weeks (Mahase, 2020). It has been argued that those who had mild and moderate COVID-19 symptoms, and were even asymptomatic, could present this type of effects, becoming so severe that they would entail an inability to return to their normal pre-COVID life due to the need for constant medical attention (Yelin, Margalit, Yahav, Runold, & Bruchfeld, 2021).

Another feature of long COVID has been the development of new symptoms, even weeks or months after the disease (Raveendran, 2021a). The authors argue that this is because, although microbiological recovery is present upon negative PCR testing, clinical recovery would be far from being achieved. Reasons for this are the extent of organ damage suffered during the disease, persistent inflammation, or aspects related to the generation of the immune response (Raveendran, Jayadevan, & Sashidharan, 2021b, p. 871).

Due to this, it has been argued that part of the conceptualization of long COVID should address more than microbiological criteria (such as obtaining negative results for COVID-19) and focus on clinical improvement by emphasizing the disease experience of patients (Long COVID, 2020). This aspect is relevant since it would prevent the severity of the conditions present in people with long COVID from being minimized, and they would be able to access the corresponding health services (Callard & Perego, 2021). An example of this is the work of Nabavi (2020) in which he presents the experiences of people with long COVID regarding the different symptoms they have experienced, but also the changes and modifications they have made to better cope with these conditions, an aspect that will be discussed in more detail in the psychological strategies proposed below.

Impact of long COVID

More than 50 long-term effects have been reported to be related to long COVID, where it is estimated that 80% of the people infected with SARS-CoV-2 would develop one or more effects between 14 and 110 days after infection, the most common being fatigue, headaches, attention disorders, hair loss, and dyspnea (Lopez-Leon et al., 2021). Among the wide variety of long-term effects, shortness of breath, palpitations and chest pains may be observed, which are thought to be mediated by impairments in the autonomic nervous system during infection (Dani et al., 2021). More specifically, it has been observed that different body systems are affected, such as the immune system ‒arthritis or pediatric multisystemic inflammatory syndromes‒, the hematological system ‒vascular hemostasis, blood coagulation‒, the pulmonary system ‒respiratory failure, pneumonia, pulmonary vascular damage, pulmonary vascular damage, and pulmonary fibrosis‒, cardiovascular system ‒myocardial hypertrophy, cardiac hypertrophy‒, gastrointestinal, hepatic and renal systems ‒diarrhea, nausea, vomiting, abdominal pain, anorexia, gastrointestinal bleeding‒; musculoskeletal system ‒immune‒mediated skin diseases, psoriasis, and lupus‒, nervous system ‒loss of smell, taste and hearing, convulsions, confusion, nerve pain, cognitive impairment‒, and in mental health ‒stress, depression, and anxiety‒ (Mandal et al., 2020; Leta et al., 2021; Silva et al., 2021; The Lancet Neurology, 2021).

Without leaving aside the physical impact of these sequelae, there have been calls to consider equally pressing the psychosocial impact of long COVID (Llach & Vieta, 2021), since, according to the authors, two thirds of hospitalized patients present clinically relevant cognitive impairments that impact both their quality of life and their daily functioning, reaching affected rates of up to 80% for severe cognitive difficulties even four months after discharge from hospital (Taboada et al., 2021; Miskowiak et al., 2021).

From the above, it has been observed the presence of post-traumatic stress in the population who suffered from the infection, as well as sleep problems, so it has been suggested to address the self-stigma and work on mental health to reduce stress and anxiety resulting from the disease (Mahmoudi et al., 2021). In this sense, the deterioration of mental health has been argued to be due to stressful experiences during and after the disease, especially in people with pre-existing psychiatric conditions (Sher, 2020a), the process of adaptation and learning about the diagnosis, self-care behaviors to avoid infecting close people, managing the symptoms of the disease, coping with the hospitalization process, possible admission to intensive care units and loss of income due to the convalescence of the disease (Sher, 2020b). Considering the previous, it is suggested that, in people with long COVID, the presence of psychiatric symptoms ‒depression, anxiety, PTSD, and cognitive impairment‒, neurological symptoms ‒anosmia, ageusia, dizziness, headache, and seizures‒, as well as physical symptoms ‒cough, fatigue, dyspnea, and pain‒ would contribute to the presence of suicidal ideation and suicidal behaviors (Sher, 2021).

While it appears that the literature related to long COVID focuses on persistent symptoms in adults, it has been reported that the pediatric population is also similarly affected, with up to 17% of the population under 16 years of age infected with persistent symptoms up to five weeks after illness (Office for National Statistics, 2021). The symptoms presented by the pediatric population are similar to those presented by the adult population, however, it appears that the symptoms are described as “fluctuating” and of “late onset” (Simpson, Chew-Graham, & Lokugamage, 2021).

Identification of long COVID

Due to the impact addressed in the previous section that the long COVID condition has on people’s health, it has been posited that, even if a small percentage of the total population that has become ill with COVID-19 were to go on to develop long COVID, it would be enough to place a large demand on health services for monitoring the effects and treatment (Meeting the challenge of long COVID, 2020). In this situation, in a disperse approach, proposals have been made for the diagnosis of this condition. One case is that proposed by Raveendran (2021a) who, based on clinical criteria such as the presence of long COVID symptoms, and considering a specific period after SARS-CoV-2 infection, would establish confirmed, probable, possible, or doubtful diagnoses of long COVID. Despite this, Sykes et al. (2021) have found a lack of correlation between the severity of the disease with the symptoms experienced in the follow-up, suggesting that a relevant aspect in the approach to long COVID should consider psychological and neuropsychiatric elements to treat the possible post-traumatic stress caused by the irruption of a lethal virus in people’s daily lives. This is relevant because qualitative studies (see Ladds et al., 2020; Humphreys, Kilby, Kudiersky, & Copeland, 2021) highlight the psychological burden of adapting daily routines to physical capacities weakened by the long-term effects of the disease, in addition to coping with stress and uncertainty about the prognosis of their condition, so that a multidisciplinary approach, both in the definition and treatment, is necessary when considering the physical, cognitive, psychological, and social manifestations present in the condition (Halpin, O’Connor, & Sivan, 2021; Higgins et al., 2020).

Other approaches to the diagnosis of long COVID have been made by Sudre et al. (2021), who identified related attributes such as having presented more than five symptoms during the disease, being older, having a higher body mass index and female sex. Graham et al. (2021) have suggested that the higher prevalence of long COVID in women, and comorbidities such as cardiovascular disease, diabetes, and hyperlipidemia, would suggest an autoimmune etiology for the condition.

Despite the heterogeneity of the symptoms reported in this and the previous section, rapid guidelines for the management and care of long COVID have already been developed by both the World Health Organization (WHO; Rajan et al., 2021) and the National Institute for Health and Care Excellence (NICE, 2020a), which, among other documents, will be addressed in the following section.

Current approaches to long COVID

It has been proposed to approach the symptomatology of long COVID based on the affected organs, allowing an action in line to anticipate complications and the management of chronic COVID-19 affectations (Baig, 2021). Similarly, the importance of multidisciplinary work has been emphasized for the management of the condition, involving physicians, occupational therapists, medical rehabilitation specialists, physiotherapists, and mental health personnel for the management of physical and psychological symptomatology (Mendelson et al., 2020).

It has been argued that guidelines for the management of long COVID should represent the complexity of the condition by providing clear information on the natural history of long COVID, guidance addressed to the healthcare professional for its identification, and the correct management of symptomatology (Gorna et al., 2021). The WHO, as well as researchers, have raised the need to prepare health policies to address this situation that emphasize the registration of affected people, the development of guidelines and multidisciplinary services, involving the patients themselves to improve these offers through their experiences (Ladds et al., 2021; Rajan et al., 2021).

The National Institute for Health and Care Excellence (NICE, 2020b) has considered important aspects such as self-care, multidisciplinary rehabilitation, monitoring and follow-up of symptomatology, considering a special emphasis on geriatric and pediatric population. However, it is true that this first version has been questioned due to the vagueness of its recommendations given the lack of knowledge about the nature, development and efficacy of treatments for long COVID (Sivan & Taylor, 2020; Venkatesan, 2021). In an attempt to provide clarity at least on what might be considered “non-medical management” of long COVID, the objective of this narrative review is to describe possible psychological strategies to address the recommendations made by both WHO (Rajan et al., 2021) and NICE (2020a) for the management of long COVID.

Health psychology

Health psychology encompasses both behavioral medicine and behavioral health and is understood as an area of psychology focused on the educational, scientific, and professional contribution to health promotion, disease prevention, and etiological identification of disease, as well as elucidation of the association between health, disease, and related dysfunctions (Matarazzo, 1980). It plays an important role in the evaluation, diagnosis, explanation, treatment, and modification of behaviors related to the process of health and disease, as well as in the improvement of the health system (Oblitas, 2008a; 2008b). Thus, health psychology provides a theoretical and conceptual framework to elucidate the relationship between health and lifestyles (Bazán, 2003).

Specific to the current pandemic context, it has been argued that health psychology would provide insight into how people respond to and cope with the changes in their lives brought about by the pandemic (Arden & Chilcot, 2020). The involvement of health psychology professionals would mean being able to meet educational needs regarding illness to address gaps in care between inpatient and outpatient settings (Edwards et al., 2020).

Considering that scarce psychological literature has covered health behaviors, focusing mostly on associated psychopathology, there is a need for the dissemination of strategies that focus on protective aspects of health recovery aimed at people with long COVID (Freedland et al., 2020; Hansel, Saltzman, & Bordnick, 2020). Therefore, the aim of this study is to make a narrative review on the management of long COVID by proposing psychological intervention strategies that, following the recommendations of the NICE and WHO guidelines for the management of this disease, may be appropriate.

METHOD

A narrative review was made with the aim of developing an interpretation of the theoretical contributions and results that may contribute to the management of long COVID, according to the objectives proposed by the guidelines of recommendations published by NICE and WHO. A literature search was conducted on the topics that, within the guideline recommendations, were considered as the objectives of the “non-pharmacological management of long COVID,” such as “Educational interventions,” “Self-care,” “Support networks,” “Relaxation techniques,” and “Goal setting”. To ensure that the topics listed were included in psychology literature, literature searches were carried out using Boolean operators in specific searches in the MEDLINE, EBSCO, Google Scholar, SciELO, PsycINFO, PubMed, Cochrane, and CONRICYT databases, searching both in English and Spanish from 1990 to 2021. Those Booleans operator used were “Educational intervencions” AND “Psychology,” “Self-care” AND “Psychology,” “Support networks” AND “Psychology,” “Relaxation techniques” AND “Psychology,” and “Goal setting” AND “Psychology.” Additionally, to achieve a more exhaustive search, key words were used in each of the searches, such as “interventions,” “COVID-19,” and “SARS-CoV-2,”

Exclusion criteria used were that the year of publication was older than 1990, articles were not approved by two independent health professionals who revised articles, and that the article was not made by psychologists. This information can be seen on Figure 1. It is important to highlight that, during the literature review, an article in portuguese (Belomé & Ondere, 2017) was found and included because the two health professionals considered it relevant for the conceptual contribution it would provide for educational interventions, being the sole study included that did not fulfill the language of publication criteria.    

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The analysis plan for the articles retrieved was based on the relevance of the theoretical and practical arguments proposed by the authors, which were then evaluated by two health professionals not related to this narrative review. From the total 25 articles reviewed, six were theoretical articles, two qualitative studies, nine descriptive studies, two narrative reviews, five studies with experimental designs, and one systematic review. The diversity of research designs was accepted due to the aim of this narrative review, which is to provide both theoretical and conceptual overviews as well as the practical implications of psychological intervention strategies for the management of long COVID.

RESULTS

The characteristics of the studies reviewed that will be used as bibliographic support for the strategies proposed by WHO (Rajan et al., 2021) and NICE (2020a) are shown in Table 1.    

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Psychoeducation

In the review of the evidence for the intervention’s designs for the management of long COVID by NICE (2020a), the importance of educational interventions to provide information and thus reduce aspects such as anxiety before monitoring behaviors (such as the use of the oximeter, whose results can be affected by anxiety-related alterations), is emphasized. Therefore, from the field of health psychology, the use of psychoeducational strategies is proposed (Belomé & Ondere, 2017) focused on explaining and clarifying doubts about the management of long COVID symptomatology to reduce possible anxious reactions or psychosocial problems such as catastrophic conceptions and hopelessness when faced with the physical or psychological condition that the person with long COVID is undergoing. The benefit of this type of strategies has been highlighted by Seidel et al. (2020), who, through audiovisual materials, brochures, and online campaigns, propose psychoeducation as a viable way to keep the population updated on relevant information about wellness care in times of the COVID-19 pandemic.

Considering the need to preserve social distancing, distance modalities of psychoeducational interventions were implemented (Seidel et al., 2020; Smith, Harman, & Brenner, 2020). This type of strategies were oriented to emotional management, including learning to cope adequately with negative emotions. This was considered an appropriate strategy to provide information for the well-being of individuals, as well as the identification of people in vulnerable situations (Lambregtse-van den Berg & Quinlivan, 2020).

Therefore, considering the recommendations of NICE (2020a) on the importance of providing adequate information for the management of persistent COVID symptomatology, this review has relied on the literature on psychoeducation to propose the involvement of health psychologists to achieve this goal in multidisciplinary health teams.

Self-care

NICE (2020a) recommends that healthcare professionals promote and facilitate self-care behaviors in people with long COVID, emphasizing behaviors such as taking prescribed medications, adjusting and implementing regular physical activity to their lifestyle, constant self-monitoring of signs and related symptomatology such as oxygenation level, shortness of breath, fatigue, etc., and relaxation. However, the implementation of these and other behaviors often involves other behavioral processes, such as self-management, decision making, learning skills, and appropriate coping styles for the health condition, in addition to considering the particular needs of the affected population (Galindo-Vázquez et al., 2020).

Self-care involves the identification of discomfort, fatigue and body monitoring considering a set of behaviors oriented to the adequate coping of health risks (Cancio-Bello, Lorenzo & Alarcó, 2020), seeking to preserve the areas of physical and mental health, as well as personal, spiritual, and social well-being (Cancio-Bello, Barcenas, & Martín, 2020). WHO (2020) have made recommendations about strategies to promote self-care like the establishment of healthy sleep and rest habits, the promotion of adequate family interaction, strategies to adapt to their new physical capacities that, due to the disease, could have been diminished, and the development of pleasant leisure activities.

Thus, it has been observed that self-care improves personal aspects ‒exercise, healthy alimentation, spiritual growth‒; social aspects ‒development of interpersonal relationships‒, and work aspects (Holguín-Lezcano, Arroyave-González, Ramírez-Torres, Echeverry-Lago, & Rodríguez-Bustamante, 2020). Finally, it has also been observed that medical self-care behaviors correlate with prosocial attitude, self-control, autonomy, and problem-solving strategies (Gómez, 2017), aspects that emphasize the importance of encouraging the active participation of patients in the recovery of the disease (WHO, 2020; NICE, 2020b; Rajan et al., 2021).

Support networks

With respect to support networks, both WHO (Rajan et al., 2021) and NICE (2020a) point out to the importance of support networks as a resource for sharing the experience of the COVID-19 disease and the symptomatology of long COVID, providing a space for care and support with the aim of preventing the deterioration of the quality of life of patients by allowing them to access a proper place where they can seek, receive, and share medical and psychological care (Giebel et al., 2021). Institutionally, these types of interventions have functioned in a face-to-face workshop format, but WHO and NICE have emphasized the need to implement this type of interventions through an online intervention format in order to maintain constant monitoring and support for people with long COVID.

These indications start from the rationale that support networks have been observed to have a positive impact on health status, as well as on recovery from the disease by fostering the feeling of belonging to a group in which constant interactions represent a factor of well-being for patients and encourage the acquisition of health-related behaviors (Rondón & Reyes, 2019).

Thus, the support received from these interactions can be emotional ‒empathy‒, instrumental ‒through the facilitation of monitoring equipment such as the oximeter‒ or informative (Alarcón-Mora, Hernández-Barrera, Argüelles-Nava, & Campos-Uscanga, 2017). Finally, since the aim of both WHO and NICE is the promotion and recovery of health, it has been discussed that support networks should encourage the commitment to perform healthy behaviors since these spaces imply a place for the expression of emotions, social relationships, and the collective selection of coping strategies, which would favor the active participation of patients in decision making to improve their health (Pérez, González, Mieles, & Uribe, 2017; Moore & Lucas, 2021).

Relaxation

Relaxation strategies have been recommended by WHO (2020) for all people in general who have recovered from COVID-19, but have also been recommended specifically for those experiencing long COVID-related symptomatology by both WHO (Rajan et al., 2021) and NICE (2020b). The aim of these strategies is the improvement of breathlessness, emotional well-being, stress reduction, and energy conservation in both acute COVID and long COVID patients (Khosravi, 2020).

Since the responses to stress can vary greatly from person to person depending on their background, environment, economic position, and available support networks, it is important to consider that the prolonged presence of stress has adverse effects on both physical and mental health, especially affecting the immune system (Taj, 2020).

This is why the WHO (2020) has made recommendations for the promotion of relaxation strategies in people with persistent COVID symptoms after hospitalization, considering individual strategies such as performing non-exhausting activities and controlled breathing techniques.

In order to follow the recommendations of WHO and NICE, some of the following relaxation techniques have been found to be effective in the context of the COVID-19 pandemic such as Kegel exercises, autogenic relaxation, progressive muscle relaxation ‒which has been reported to have a favorable impact on improving sleep quality in COVID patients‒; breathing techniques, and body-oriented guided imagery techniques; and even activities such as aerobic exercise adapted to the patient’s physical capacity and listening to music (Callus et al., 2020; Cheng et al., 2020; Zhang et al., 2022).

Goal setting

Goal setting is a strategy recommended by the NICE (2020a) to focus the patient’s available resources (physical, psychological, social, etc.) in an appropriate way to make him/her able to perform the self-management behaviors of the disease. The assessment of the degree of long COVID rehabilitation is achieved through the emphasis on a realistic and achievable health goal. The NICE recommendation is basically a strategy to encourage mutual agreement on the follow-up and monitoring of long COVID symptomatology for the prompt reporting of symptoms that may requires hospital referral.

The rationale for goal-setting strategies lies in explicitly encouraging behavioral changes for the adoption of healthy behaviors in a concise manner and considering the appropriate context for achieving it, as well as anticipating potential distracters and adverse events that may represent an obstacle to its achievement (Mann, de Ridder, & Fujita, 2013; Wan et al., 2016). Goal setting has been observed to contibute to better personal organization and task performance by focusing efforts on particular and clear aspects during a set period of time (Colineau & Paris, 2010; Zinchenko, Morosanova, Kondratyuk, & Fomina, 2020).

While setting a goal, such as coping with long COVID symptoms does not automatically lead to its achievement, doing so will help patients to invest more efforts to achieve it, especially when they are provided with adequate feedback on their health status. Therefore, it was considered to address this strategy at the end of this review, since to be able to set goals adequately as discussed on this review and indicated by NICE (2020a), patients require the development of appropriate skills and knowledge about the goal to achieve (Strecher et al., 1995), which in this case is the management of long COVID. It is suggested that this proper goal setting, on the scenario of long COVID can be obtained through the other four strategies discussed throughout this review and have been recommendated by WHO (Rajan et al., 2021; WHO, 2020) and NICE (2020a; 2020b).

DISCUSSION AND CONCLUSION

Although it is true that the problem of emphasizing the psychological burden over the physical burden in the management of long COVID has been warned about (Gorna et al., 2021), this is not the aim of this review, but to provide guidance on psychological strategies that worked out in coordination with the medical team, could offer additional support to the indications on the management of long COVID provided by the WHO and NICE.

It should be noted that the application of these strategies is not intended to have a direct effect on the symptomatology of long COVID, but rather to have an impact on the psychosocial well-being of these patients. The improvement of long COVID symptomatology could be mediated by these strategies by improving treatment adherence behaviors, seeking that, in this way, an improvement of symptomatology can be achieved through a multidisciplinary health team.

Health psychology provides an adequate theoretical and conceptual framework to influence healthy behaviors from a multidisciplinary work scenario (Matarazzo, 1980; Bazán, 2003) since has demonstrated its potential to address COVID-19 cases (Arden & Chilcot, 2020; Edwards et al., 2020; Freedland et al., 2020; Hansel et al., 2020), following the management guidelines of the WHO (WHO, 2020; Rajan et al., 2021) and NICE (NICE, 2020a; 2020b), this review has focused on trying to clarify the recommendations given by these institutions for future psychological interventions programs. Psychoeducation proposes strategies that not only focus on the passive reception of information by the patient, but also on appropriate strategies for its incorporation into their behavioral repertoire (Belomé & Ondere, 2017).

One way to understand this “behavioral repertoire” is through self-care behaviors such as following a healthy diet, physical activity, taking medications, medical follow-up, and social interaction following relevant health protocols (Cancio-Bello et al., 2020; Holguín-Lezcano et al., 2020).

The promotion of support networks constitutes a basis for the continuity of self-care behaviors as they can provide a constant source of motivation and different types of support ‒emotional, instrumental, and informational‒ influencing the patient’s psychosocial needs and promoting their emotional well-being (Rondón & Reyes, 2019; Giebel et al., 2021).

Different relaxation strategies were proposed, as well as the literature supporting them, as a set of appropriate strategies to strengthen immune response (Taj, 2020), in addition to the impact on other areas of health such as the sleep cycle (Callus et al., 2020).

Finally, goal setting was considered appropriate since, in the absence of conclusive evidence on the duration or severity of long COVID, setting realistic and achievable goals can provide a sense of control and security to the patient (Strecher et al., 1995), in addition to focusing effort and energy on activities in line with their health status.

Several limitations of this narrative review can be pointed out. The first is the design of the articles reviewed. The lack of studies using experimental and quasi-experimental designs is a methodological deficiency; however, in order to achieve the aim of this paper, a balance between theoretical and practical articles was sought to provide guidance on the contributions of health psychology in the management of long COVID. Another limitation, also related to the design of the studies, was that most of these studies were not designed for the treatment of COVID-19 or long COVID symptomatology. Although there is a lack of studies with experimental designs on these strategies, by basing the recommendations described in this narrative review on the WHO and NICE guidelines, it is hoped that this review provide an adequate guideline for future works.