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“The amount of devastation that has occurred from this infection is unparalleled by any pandemic that we have faced on this continent or any war that we have faced.”

Avindra Nath, MD, a neurologist in Bethesda, Maryland, discussed the neurological and neuropsychiatric complications of COVID-19 at the 2022 American Psychiatric Association (APA) Annual Meeting, beginning with the recent statistics related to COVID-19. To date, there have been 100 million infections and 1 million deaths in the United States alone, with 500 million infections and 50 million deaths globally. 

The effects of long COVID—particularly on the brain—are also of concern. “The brain gets overlooked. But what is primary and most important at the end of any pandemic is what happens to the brain because those are the things that cause the long-term consequences,” said Nath, who is also senior investigator and clinical director in the Section of Infections of the Nervous System, Division of Neuroimmunology & Neurovirology, at the National Institute of Neurological Disorders and Stroke.

Nath explained that individuals who develop COVID-19 can be divided into 2 groups: (1) those who have very severe symptoms at the time of COVID-19 onset, but then gradually improve, and (2) those who have mild symptoms at onset or even improve for a while, but then develop new symptoms weeks or months later.

“If you look at patients acutely and they have lots of symptoms, over 3 to 5 months, many will get better, but some will not. And if they don’t get better by then, chances are they won’t,” Nath said.

Some of these symptoms that may occur in cases of long COVID—or the chronic stage of COVID-19—include exercise intolerance; mood, cognition, and sleep disorders; pain syndromes (eg, myalgia, neuropathic pain, paresthesia, headache, tinnitus); and dysautonomia (eg, palpitations, postural orthostatic tachycardia syndrome, hypotension, hypothermia, fever).

“First onset of major depressive illness, anxiety, or psychosis [with none] in the past history is directly related to this infection,” Nath added, also noting that some symptoms of long COVID overlap with symptoms of other diseases such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), Gulf War illness, and post Lyme disease syndrome. “It’s quite possible that all of these are related to one another,” Nath said. “It’s just that the event that precipitated them may be somewhat different.”

In order to learn more about what happens to the brain during and following COVID-19 infection, Nath shared that he and colleagues analyzed the brains of individuals who had died of COVID-19 in MRIs. They found, in part, that perivascular fibrinogen leakage indicated vascular injury, and that platelets were activated and formed clots in small blood vessels. 

Based on this and additional neurological and neuropsychiatric research, Nath suggested that future directions should include more clinical trials involving immunomodulatory agents and more research involving biomarkers for neuronal injury (NfL, pNfH, GFAP, SNAP-25), vascular injury (sICAM, VEGF, P-selectin, E-selectin, MMP-3, antibodies to ACE2), and immune activation.

In terms of treatment, “there is symptomatic treatment—but can you affect the course of the disease?” Nath said. “…I think you need to tailor the treatment to the patient you’re seeing and depending on what you think is the major underlying pathophysiological mechanism. And now we have the tools to be able to refer to that.”

An expert discusses the effects of long COVID on the brain at the 2022 APA Annual Meeting.

Neurological and Neuropsychiatric Complications of COVID-19

The prevalence of attention-deficit/hyperactivity disorder (

) in the worldwide pediatric population has been stable over the past 30 years except in the United States, where cases have increased.

 According to a 2016 parent survey, approximately 6.1 million US children (9.4%) had received a diagnosis of ADHD.

 Worldwide, ADHD is the third most common mental health disorder, following depression and anxiety.

 Overall, girls (5.6%) are less likely to be diagnosed with ADHD than boys (12.9%).

A 2021 global systematic review and meta-analysis suggested that the prevalence of persistent adult ADHD was 2.58% and the prevalence of symptomatic adult ADHD was 6.76%, with 139.84 million and 366.33 million affected adults worldwide in 2020, respectively.

 ADHD appears to impact men more than women. In adults, ADHD appears to decrease as an individual ages.

Etiology is still not clearly understood; however, combinations of genetic, neurological, and environmental factors likely contribute to its pathogenesis and symptom expression.

 Genetic factors are implicated, but the mechanism of action is not completely clear. Family, twin, and adoption studies have strongly suggested that ADHD is highly inheritable. Moreover, genetic studies have documented the gene sets interfering with neurotransmitter pathways in the brain that implicate rare copy number variants or the collection of higher deletions, as well as the duplications impacting gene transcriptions that are more likely to be found in individuals with ADHD.

Pre-, peri-, and postnatal environmental factors play a significant role in the development of ADHD. Some evidence suggests prenatal factors include the mother’s lifestyle during pregnancy.

 For example, prenatal alcohol exposure can lead to hyperactive, disruptive, and impulsive behaviors and increase the risk of psychiatric disorders.

 Maternal smoking during the prenatal developmental period has been linked to increased risk of ADHD

 Perinatal factors, such as very low birthweight, can result in a 2-fold increase in the likelihood of ADHD.

ADHD is conceptualized as a disorder of childhood that gradually diminishes over the lifespan.

 However, several prospective longitudinal studies have challenged the prevailing assumption that childhood ADHD and adult ADHD affect the same individuals, and that they share the same neurodevelopmental vulnerabilities.

 The results of these studies suggest that more than two-thirds of individuals with adult ADHD never had childhood ADHD. Adult ADHD had been generally neglected in epidemiological studies, until recently, as researchers attempt to estimate the true prevalence of ADHD in adults. Furthermore, researchers are exploring whether ADHD is solely a neurodevelopmental disorder that presents in childhood, or whether ADHD can be acquired during other developmental periods. The prevalence of persistent adult ADHD from childhood and that of symptomatic adult ADHD were 2.58% and 6.76% in 2020, respectively.

The diagnostic assessment of ADHD can be complicated, as inattention, impulsivity, and difficulties with concentration can be driven by myriad factors. It is well documented that children and adolescents diagnosed with ADHD often have 1 or more cooccurring disorders

According to a study by Elia and colleagues, oppositional defiance disorder was the most common comorbid disorder at 41%, followed by depression/dysthymia at 22% and general anxiety disorder at 15%.

Approximately 60% to 100% of children with ADHD have 1 or more comorbid disorders that persist into adulthood. Autism spectrum disorder, with a comorbid rate of 42%, and learning disorders (math, reading, and spelling), account for 10% and 92% of comorbidities. Tourette syndrome accounts for 55% comorbidity. Children with ADHD experience major depression at a rate higher than children without ADHD (12% to 50%). Regarding anxiety symptoms, children with ADHD have a prevalence rate between 15% and 35%.

In adults with ADHD, the most common cooccurring psychiatric disorders are bipolar disorder, depression, anxiety disorders, substance use disorders (SUDs), and personality disorders.

 ADHD has a high cooccurring prevalence with bipolar disorder: Estimates range between 9.5% and 21.2%, with bipolar I disorder being more likely.

 ADHD and depression commonly cooccur at even higher rates, ranging from 18.6% to 53.3%.

 Individuals with ADHD are also at higher risk for developing anxiety disorders than the general population, with rates approaching 50%.

 SUDs are likely the most common cooccurring condition with ADHD—specifically, alcohol and/or nicotine, cannabis, and cocaine use.

Research support for the intersection of ADHD and personality disorders is scant compared with the support of other psychiatric cooccurring conditions. However, reports indicate that personality pathology is present in approximately 50% of adults with ADHD—most commonly cluster B and C personality structures—and up to 25% of adults with ADHD have 2 or more personality conditions.

Diagnosing ADHD can be a complicated process. It is imperative to obtain historical information such as academic performance records and previous psychological testing reports, if ever tested.

There are several significant barriers to diagnosis and treatment in ADHD, including overlapping symptomology between ADHD and mood and anxiety disorders, SUDs, learning disabilities, information processing disorders, auditory processing disorders, and psychosocial factors. It is important to note that some individuals overcome ADHD-related deficits by developing and mastering compensating skills. This also can impact the accuracy of ADHD diagnosis.

Evidenced-based assessment includes multi-informant/multimethod procedures and validated measures. This approach should be guided by current research and include test data to support clinical observations and, ultimately, an accurate ADHD diagnosis. 

 highlights several measures used in ADHD assessments.

Treatment considerations should be informed by functional outcomes including symptom reduction, increased quality of life, and improved daily, academic, and occupational functioning.

 Efficiency at working or studying, maintaining stable relationships, containing or curbing impulsivity, and being satisfied with life overall are indicators of improved functioning. Moreover, adherence to treatment is key to successful management of ADHD.

First-line treatments for ADHD are pharmacologic: stimulants and nonstimulants. Stimulant medications include methylphenidate, mixed amphetamine salts, and lisdexamfetamine dimesylate. Nonstimulants used in ADHD treatment include atomoxetine and alpha-2-adrenergic agonists. 

 highlights several ADHD medication options, although the effectiveness of psychopharmacological treatments is beyond the scope of this paper.

For children and adolescents, a well-established body of evidence supports the effectiveness of psychosocial treatments, including behavioral management interventions (eg, parent training, classroom interventions, peer-based interventions), training interventions (eg, cognitive training, neurofeedback, organization), cognitive behavioral therapy (CBT), and physiological treatments (eg, play and other physical activities).

CBT, the preferred nonpharmacological treatment for adult ADHD, consistently reduces its core behavioral symptoms.

Usually first diagnosed in childhood and sometimes persisting into adulthood, ADHD has extensive implications for academic achievement, relationships, finances, and employment. In addition, untreated ADHD carries greater risk of accidental injuries and substance abuse. Thus, careful assessment is of utmost importance to properly diagnose and then treat the disorder.

is an assistant professor and licensed clinical psychologist at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas. 

 is a psychology fellow at Baylor College of Medicine.

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Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children?

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Maternal smoking and hyperactivity in 8-year-old children

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A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder

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The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

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The effect of personality disorder symptoms on response to treatment with methylphenidate transdermal system in adults with attention-deficit/hyperactivity disorder

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Correlation of symptomatic improvements with functional improvements and patient-reported outcomes in adults with attention-deficit/hyperactivity disorder treated with OROS methylphenidate

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Behavior management for school-aged children with ADHD

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Non-pharmacological interventions for adult ADHD: a systematic review

Is it ADHD—or something else? The importance of careful assessment for the proper diagnosis and effective treatment of the third most common mental health disorder worldwide.

ADHD Update: Diagnosis, Assessment, and Treatment Issues

“We have clinical guidelines for the treatment of some disorders, and we have clinical guidelines that motivate the way we use certain treatments. But, for new and emerging treatments, we often don’t have guidelines on how best to use them, who to recommend for a particular intervention, and who not to do so,” said Eric Achtyes, MD, MS, in a presentation at the 2022 American Psychiatric Association (APA) Annual Meeting.

The presentation, chaired by Achtyes—a staff psychiatrist and researcher at Michigan State University with appointments at Pine Rest Christian Mental Health Services, Cherry Street Health Services, and Network180—focused on assessing current gaps and opportunities in the guidelines for electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and deep brain stimulation (DBS).

Although ECT has been used in the treatment of severe mental and medical conditions for more than 80 years, it is one of the few medical procedures that is regulated by state laws not based on medical guidelines, according to Georgios Petrides, MD, associate professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. “These laws are not based on medical guidelines—they’re mostly based on politics,” Petrides said. “Powerful antipsychiatry groups target ECT nationwide.” Today, 44 US states have specific ECT regulations, 21 states have specific regulations for ECT in minors, and 9 states mandate ECT reporting.

Petrides explained that, in 1975, the US Food and Drug Administration (FDA) gave ECT class III classification—for “unknown efficacy and risk”—with cleared indications for use in the treatment of unipolar and bipolar depression, schizophrenia, bipolar mania and mixed states, schizoaffective disorder, schizophreniform disorder, and catatonia. Although the FDA’s original aim was to reevaluate ECT and reclassify it as class II (“known efficacy”), reevaluation did not occur until 2018. In response to some scandals in the 2000s, the FDA reclassified ECT class II in 2018, but only for the treatment of severe depressive episodes and catatonia.

“This means that, according to the FDA, there is evidence of efficacy, but only for depression and catatonia,” Petrides said. “The rationale for these restrictions is a lack of double-blind, placebo-controlled trials in the other diagnoses. Scientific literature and the global clinical experience of more than 80 years has been completely disregarded.”

The ramifications of these restrictions are that treatment will remain off-label for a significant number of patients, and there is a need for investigational device exemption for research in diagnoses other than depression and catatonia. However, these restrictions have also drawn attention to informed consent processes, documentation, and database creation, presenting opportunities to reduce/eliminate the stigma associated with ECT; conduct efficacy and outcomes research in disorders considered “unproven”; and create comprehensive databases.

The most recent consensus guidelines for rTMS were developed by the APA Council on Research Task Force and the National Network of Depression Centers (NNDC) rTMS Task Force in 2018, according to Tracy Barbour, MD.

“These guidelines were based on literature published from 1990 to 2016. Given that TMS is a rapidly evolving field, and we have a lot of research in this field, these guidelines likely have some updating that needs to occur,” said Barbour, who is medical director of Massachusetts General Hospital, instructor at Harvard Medical School, and program director of the Interventional Neuropsychiatry and Neuromodulation Fellowship. These guidelines focus on rTMS as a treatment for patients with major depressive disorder (MDD), including patients who are medication-resistant and those who have significant comorbid anxiety. “Patients with significant comorbid psychotic disorders or acute suicidal ideation should consider other antidepressant treatments with established efficacy, such as ECT,” Barbour said.

Barbour discussed the 2018 consensus guideline recommendations for location and frequency, coil positioning, pulsing, motor threshold determination, treatment planning, and number of sessions, comparing the recommendations for each area to findings from more recent research. In regard to location and frequency, for example, most evidence supports high-frequency stimulation (10Hz) to the left DLPFC; however, there is also evidence that using the H1 coil is effective for bilateral PFC stimulation, and that right DLPFC low-frequency stimulation is also safe and effective for patients who are at risk of seizure, or who do not tolerate/respond to high-frequency left DLPFC stimulation. More recent studies have shown that theta burst stimulation (iTBS) can be applied for a shorter period of time, allow for more sessions per day, and have longer-lasting physiological and cognitive effects compared to high-frequency alternatives.

In 1 study, “the FDA-cleared protocol took 27 minutes, compared to iTBS, which took only 3 minutes,” Barbour said. “I think updated guidelines would definitely comment on iTBS.” And, when compared to a new type of rTMS called Stanford neuromodulation therapy (SNT), the FDA-cleared iTBS protocol involves 1 session per day for 36 days at 600 pulses iTBS per session, versus the SNT protocol of 10 sessions per day, with 50-minute intersession intervals for 5 days, at 1800 pulses iTBS per session. “If patients can get better that quickly and it has the efficacy,” Barbour said, “I think it is something to be excited about.”

Because DBS is not yet FDA-approved, it remains a thoroughly investigational, off-label treatment, and there are no official guidelines for its usage, according to Alik Widge, MD, PhD, assistant professor in the University of Minnesota Department of Psychiatry. However, some research has suggested its efficacy for the treatment of depression. “Open-label data showed an average of 50% loss of depressive symptom burden and then retention—back in 2009,” Widge said. “So, why is DBS still not FDA-approved and available at an academic medical center near you? Because we’ve had a devil of a time getting it through randomized clinical trials.” Widge explained that, because depression is heterogenous—and doubly so in patients who are treatment-resistant—this leads to difficulty passing the randomized controlled trials necessary for FDA approval.

Because there are some promising recent and ongoing clinical trials on the efficacy of DBS, Widge recommended that clinicians connect their patients who may be good candidates with clinical trials so those patients can receive advanced care while also helping develop the necessary data for FDA approval. A good candidate typically is at least 30 years old; has had multiple either bipolar or unilateral depressive episodes that are severe/disabling; has responded to treatment in prior episodes but experiences consistent/faster relapse; is resistant to evidence-based, guideline-adherent therapies; and is able to handle the burden of participating in a clinical trial. Widge also made some recommendations for how to get these patients involved, when and how to screen trials and their investigators, and how to warn patients of the study burden.

Widge emphasized that managing patients with DBS would not be an added burden on clinicians, as the device does not cause any cognitive impairment or prevent any specific medications and is stable for years once it is programmed. “A patient with a neurostimulator is just like anybody else who’s in your office for regular management, except they now tend to be more responsive to other interventions,” Widge said.

Achtyes closed the presentation by discussing some national surveys gauging perceptions and opinions of these treatment modalities and the most important ethical considerations relating to them. Among the 505 participating psychiatrists who have referred or administered these interventions to patients within the past 5 years, the top 3 most important ethical considerations when developing practical guidelines for these treatments were (1) providing evidence of the safety and efficacy of the interventions (nearly 50%); (2) selecting patients who would be good candidates for the interventions (20%); and (3) having a standard accreditation system to assure and improve the quality of administration of the interventions (around 12%).

The presentation was organized by Laura Y. Cabrera, PhD, associate professor of engineering science and mechanics and philosophy, and Dorothy Foehr Huck and J. Lloyd Huck Career Chair in Neuroethics at Penn State University.

The 2022 APA Annual Meeting highlights the latest guidelines for these treatments, plus recommendations for updates and improvements.

Assessing Gaps and Opportunities in ECT, rTMS, and DBS Guidelines

The relationship between psychiatric illness and cerebrovascular disease is complex, with comorbidity and bidirectional influences common. And, with nearly 2 million brain cells dying every minute that a stroke goes untreated, it is no wonder that the neuropsychiatric implications are vast.

What do you need to know to best support your patients? In honor of National Stroke Awareness Month, 

Recent studies have highlighted the association of 

. How prevalent is depression among patients who have had a stroke, and how does depression affect these patients and their recovery and prognosis?

: Depression is very common after a stroke, and the symptoms of depression can limit the recovery from stroke as well. According to American Heart Association, the cumulative incidence of depression following stroke is 55%.

 It is likely that the stroke itself, and the situational effect of having suffered a stroke, both contribute to the association of stroke with depression. Regardless of the exact cause, however, it is important to address and manage depression appropriately to help promote patients’ recovery. There is even some evidence that the use of antidepressant medications helps not only treat depression after stroke but also may even help with other aspects of rehabilitation such as motor recovery.

Similarly, psychotic symptoms have been associated with stroke. Can you tell us more about this link?

 A certain subgroup of stroke patients does, unfortunately, have symptoms of 

. One meta-analytic study from 2018, while acknowledging a dearth of studies regarding psychosis poststroke, identified an estimated prevalence rate for delusions of 4.67% and hallucinations of 5.05%, for a combined prevalence of 4.86%.The same analysis identified a cumulative incidence rate for psychosis of 6.7% within the first 12 years poststroke in patients without premorbid psychiatric diagnosis.

Of the various neuropsychiatric consequences of stroke, psychosis is a particularly disabling one for obvious reasons. The exact cause may often be multifactorial, including the location of the ischemia, an underlying primary psychiatric diagnosis or, in some instances, sundowning, circadian rhythm disturbance, or even iatrogenesis. 

These symptoms may be limited to the early period following a stroke and improve over time, but medication is often required to manage the psychosis. It is important to avoid sedating and prescribing potentially harmful medications like antipsychotics as much as possible. In addition to the multitude of adverse effects inherent to this class of medications, generally any sedation is detrimental to rehabilitation progress. Of particular relevant to the stroke patient population are the increased risk of metabolic syndrome and the association of such risk factors as obesity, diabetes, and dyslipidemia. When these medications are used, clinicians should prescribe the minimum effective dose.

The popular press has indicated an increase in the prevalence of stroke in younger patients. Is the causality and prognosis similar regardless of age?

: We are seeing an increase in strokes in 

. The Centre for Neuro Skills (CNS) has treated patients as young as 20 years old who have fortunately returned to productive lives. Their stories provide perspective and hope for families who are faced with this circumstance. [

According to a 2022 study published in the American Heart Association journal, 

, a certain type of stroke that causes bleeding in the brain is increasing in the United States, growing at a faster rate in younger adults.

Even earlier accounts have shown that stroke are not limited to older patients, with the Centers for Disease Control also reporting 38% of people hospitalized for stroke were less than 65 years old.

In older people, stroke is usually a consequence of chronic illnesses such as high blood pressure, high cholesterol, diabetes, cardiac conditions, etc. When stroke occurs in younger people, many times there is another contributing cause, such as a clotting disorder, trauma or a blood vessel abnormality.

How can psychiatrists help prevent strokes in their patients?

Appropriate management of stroke risk factors is the primary way we can prevent stroke. Prominent medical factors include hypertension, dyslipidemia, and diabetes. Clotting disorders or cardiac conditions in individuals that have an increased risk of stroke, such as atrial fibrillation, should be addressed appropriately as well. Other lifestyle factors should also be managed; clinicians should encourage patients to avoid smoking, alcohol and drug use, and to manage their weight.

Do psychiatric medications and/or conditions cause or exacerbate stroke risk?

 Many of the antipsychotic medications, unfortunately, can contribute to stroke risk by causing hyperglycemia, weight gain, or both. Metabolic syndrome increases stroke risk, so any medications that increase risk for metabolic syndrome can be problematic. Similarly, any prothrombotic medications such as birth control medications also can increase risk. Any strategy that can be used to reduce the use of medications that alter the metabolic profile is helpful.

 What advice do you have for psychiatrists treating patients who have recovered from strokes but are now experiencing psychiatric symptoms?

 Look for other treatable factors such as circadian rhythm disturbance, sundowning, or medications that might be contributing to the psychiatric complications. In the absence of those factors, psychiatrists should treat patients with the minimal dose of medication necessary to control the symptoms and allow for maximal recovery from stroke.

 Stroke prevention is important and should be encouraged for all patients. For individuals who have suffered a stroke, there is help in the form of rehabilitation and recovery.

, which operates postacute brain injury rehabilitation programs. He also serves as visiting assistant clinical professor in the department of neurology at the University of California, Los Angeles.

1. Towfighi A, Ovbiagele B, El Husseini N, et al. 

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

2. Chollet F, Tardy J, Albucher JF, et al. 

Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial

Poststroke psychosis: a systematic review

Deadly type of stroke increasing among younger and middle-aged adults

. February 4, 2022. Accessed May 2, 2022. American Heart Association. 

https://www.heart.org/en/news/2022/02/04/deadly-type-of-stroke-increasing-among-younger-and-middle-aged-adults

. Accessed May 2, 2022. https://www.cdc.gov/stroke/facts.htm

The neuropsychiatric implications of stroke are vast. Here's what you need to know to support your patients. 

Stroke Awareness: Issues for Psychiatrists to Consider

How can we “clear the fog” surrounding brain fog? Experts addressed the cognitive dysfunction, or “brain fog,” observed in patients with long COVID—as well as those with fibromyalgia, with chronic fatigue syndrome, and undergoing chemotherapy treatment—at the 2022 American Psychiatric Association (APA) Annual Meeting.

Maria Tiamson-Kassab, MD, of the Moores Cancer Center at UC San Diego introduced the presidential session, which was delivered on behalf of the Academy of Consultation-Liaison Psychiatry. Durga Roy, MD, FACLP, of Johns Hopkins Bayview Neuropsychiatry Clinic and Johns Hopkins University School of Medicine discussed symptoms and pathophysiology of brain fog in long COVID, plus some ways clinicians can manage patients with brain fog after long COVID. Additional speakers included Jon Levenson, MD, of Columbia University Irving Medical Center and Susan Abbey, MD, FRCPC, of the University of Toronto.

Tiamson-Kassab explained that “brain fog” is a nonmedical term used to describe what patients feel in any condition that causes confusion, memory loss, inability to concentrate or focus, and difficulty with word-finding or multitasking. It is found in many conditions, including long COVID, fibromyalgia, chronic fatigue syndrome, pregnancy, multiple sclerosis, and systemic lupus erythematosus, as well as in cancer treatments and certain medications. Neurocognitive domains affected in brain fog include planning; decision-making; processing speed; complex, divided, and selective sustained attention; free and cued recall; and working, procedural, and autobiographical memory.

Cognitive dysfunction is a particular concern in long COVID, as many patients have reported symptoms such as brain fog weeks or months after SARS-CoV-2 infection, Roy explained. Current definitions of long COVID differ. The National institute for Health and Care Excellence defines it as a constellation of symptoms that develop during or following SARS-CoV-2 infection persisting for 12 weeks or more; the World Health Organization defines it as persistent symptoms occurring 3 months from onset in individuals with past confirmed or probable SARS-CoV-2 infection and persisting for at least 2 months; and the Centers for Disease Control and Prevention defines it as a range of symptoms that can last weeks or months after initial SARS-CoV-2 infection, which can appear weeks after infection. In all cases, the symptoms cannot be sufficiently explained by any alternative diagnosis, and they can present even if the initial SARS-CoV-2 infection was mild or asymptomatic.

Although a range of symptoms may present, “fatigue and cognitive impairment appear to be the most debilitating symptoms of long COVID,” Roy said. The exact cause of brain fog and other symptoms in long COVID is not yet clear, however: “We have to be cognizant of the fact that, potentially, anxiety and depression could be factors that are driving the fatigue and cognitive impairment,” Roy said. “And pathophysiology can stem from numerous hypotheses, neuroinflammation, or neurotropism, but the idea is that the frontal limbic pathway seems to consistently be something that we’re hearing about when it comes to cognitive problems in long COVID.”

In terms of treatment, Roy recommended both pharmacologic and nonpharmacologic interventions targeting mental fatigue and cognition. Pharmacologic interventions may include medications such as methylphenidate, donepezil, modafinil, luteolin, nicotinamide riboside, vitamin C or probiotic supplementation, monoclonal antibodies, or adaptogens. Suggested nonpharmacologic interventions include cognitive behavioral therapy, graded exercise therapy, pacing, and rehabilitation.

With studies on brain fog in long COVID still new and in development, however, Roy emphasized a need for more research to improve treatment and patient quality of life. “This is definitely a syndrome that we don’t know very much about,” Roy said. “It’s something that we really need to study more in order to get a better grasp on what’s going on.”

Experts address cognitive dysfunction found in patients with long COVID at the 2022 APA Annual Meeting.

Clearing the ‘Brain Fog’ in Long COVID

In a first-of-its-kind study, researchers looked at the effect of practice sparring on possible brain changes in mixed martial arts (MMA) fighters. The results were presented at the 

2022 American Psychiatric Association Annual Meeting 

by study author Aaron I. Esagoff, a medical student at Johns Hopkins University School of Medicine.

Although previous studies have looked at other sports that involve 

, the real risk for MMA fighters occur during practice sessions, explained Esagoff. Fights/matches only happen a few times per year, but individuals can spend hundreds of hours sparring and practicing. MMA is a hybrid combat sport that includes moves from boxing, wrestling, karate, judo, and jujitsu.

“With MMA and a lot of combat sports, you are going to get hit in the head a good amount. And when you get hit a lot of times, that can lead to damage and disease,” Esagoff noted. The increasing awareness of repetitive brain trauma and its relationship to 

 inspired Esagoff and colleagues to study MMA fighters.

To better understand the effects, the investigators conducted a cross-sectional study of 92 active professional MMA fighters, looking at the relationship between customary sparring practice rounds per week on white matter hyperintensity volume and regional brain volumes.

In doing so, Esagoff and colleagues found customary sparring practice rounds per week were significantly associated with increased white matter hyperintensity volume, which he noted may be indicative of damage (eg, axonal injury, vascular damage, etc). However, the customary sparring practice rounds per week were also associated with increased relative size of the left and right caudate nucleus. The authors hypothesized that practice may help protect from injuries during official fights that damage the caudate.

“The one takeaway would be that sparring and practice is not all good or all bad, as there are some good effects, some not-as-good effects,” concluded Esagoff. “But it's all an association for now; we're not able to conclude anything with confidence.”

Esagoff’s co-authors included Michael J.C. Bray, MS; Andres A. Pasuizaca; Matthew E. Peters, MD; Bharat R. Narapareddy, MD; and Charles B. Bernick, MD.

Are you attending the 2022 American Psychiatric Association Annual Meeting? We want to hear your thoughts! Share recaps, reflections, and experiences with us at PTEditor@mmhgroup.com. Be sure to visit us at booth 1852.

What are the neuropsychiatric effects of sparring in mixed martial arts? New research presented at the 2022 APA Annual Meeting elucidates the issues.     

More Than a Knockout: Structural Brain Effects in MMA Sparring 

A quintessential neuropsychiatric disorder might be one that reflects the variety of ways that the brain and mind can be adversely affected. Neuropsychiatry would consist both of the direct neurological impact of some pathogen on the brain, which is what we used to call “organic,” as well as the psychological reactions to the impact, or what we used to call the “functional.”

At various times, there have been failed attempts to connect neurology and psychiatry into 1 specialty. Certification testing has always overlapped the fields to some degree. Some given examples of neuropsychiatric disorders are traumatic head injury, migraine headaches, menopause, and medication side effects.

Although the major pathology of COVID-19 is respiratory damage, over time it has become clearer that there also are neuropsychiatric ones. I apparently had an acute respiratory episode, but did not notice any neuropsychiatric aspects—that is, until recently, when I experienced more anxiety and uncertainly about how much risk to take outside of the home. I reluctantly decided that coming to the 2022 APA annual meeting next week was too risky.

Around this same time, I ran across a new COVID-19 study out of England.

 The results indicated that new and increased rates of anxiety disorder, dementia, psychosis, and bipolar disorder were occurring. It is unclear how much is the result of the viral pathogen, the psychological response, or both. Some also seem to be associated with long COVID including unexplained mood changes, brain fog, and language difficulties. When the illness is more severe or a loved one dies, posttraumatic stress disorders and prolonged grief disorders are likely to increase. Then there is the conscious and unconscious defense mechanism of denial of the risk we have encountered over the last 2 years.

All of this complexity and uncertainly suggests that COVID-19 would benefit from being studied at academic neuropsychiatric centers, if only more of them existed. In the meanwhile, I would suggest leaning to the safe side for now as the infections, and now even hospitalizations, are increasing.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Clift AK, Ranger TA, Patone M, et al. 

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