COVID Sequelae and Primary Care: An Interview with Author Samoon Ahmad, MD

"Being in isolation makes it easier to deny how serious any abuse has become--to others and to yourself."

NYU psychiatrist Samoon Ahmad, MD, was describing the potential dangers of COVID-19 pandemic-imposed social isolation that has kept people from interacting with one another on even the most basic level. New or increased substance use is a critical one, he warned.

Ahmad spent time with Patient Care Online to discuss his new book, "Coping with COVID-19: The Mental, Medical, and Social Consequences of the Pandemic." We asked him specifically to talk about signs and symptoms primary care physicians should be more sensitive to now than before the pandemic that could indicate patients' response to the prolonged stress or even lasting effects of infection with the virus.

Ahmad stresses, however, that an increased focus on pandemic sequelae must not divert attention from the deterioration in the general overall health of the public. In the conversation that follows, he offers guidance and perspective.

Samoon Ahmad, MD, is a clinical professor of psychiatry at New York University Grossman School of Medicine. He has been at Bellevue Hospital Center in Manhattan for 30 years, and has written in the past about human coping and resilience in the aftermath of disasters.

Available in April, 2022

The following transcript has been edited lightly for style and clarity.

Patient Care Online. You point out in the introduction and other places in your book to that the majority of us will, in fact, recover from our COVID-19 experience over time, and as we're able each on our own timeline, but not everybody will—and that as a society we need to be vigilant for the signs and symptoms of people who are having ongoing disturbance.

I'm thinking of primary care physicians who are truly on the front line with their panel of patients every day, the average patient who comes and goes. What should these primary providers be more sensitive to or for on a daily basis than they were before the pandemic?

Samoon Ahmad, MD. I think clinicians definitely need to be more sensitive to many physical and psychological issues, to be looking for signs of substance use disorders. A lot of people used food, or alcohol, or cannabis or other drugs to cope with the stresses of the pandemic. And there's nothing dangerous about using some of these substances in moderation and on occasion. However, the frequent use of drugs and alcohol in isolation is a recipe for disaster and trouble. There was an excellent article in the Atlantic, by Kate Julian. And she discussed how humanity is no stranger to alcohol. In fact, it has historically been used to strengthen social bonds and to celebrate. But—here is the big “but,” what is relatively new and problematic, in my opinion, is this phenomenon of drinking alone, which can quickly go from a minor crutch to the activity which one bases their whole day upon. This can be especially true when a person has no social obligations to tend to. Being in isolation makes it easier to deny—to others and to yourself—how serious any abuse has become. This is especially important if there is no one around to check on you and see or observe the change in your behavior, your self-care, and your daily routine. The important thing is the body doesn't lie. There are clinical signs you can check for. You can do blood work; I think primary care practitioners should be looking for these kinds of things.

Also importantly, I want to talk about the white elephant in the room. One of the most important and far less discussed issues in the press or media is the general overall health of the public. We have record levels of obesity and chronic medical issues that are in most cases preventable. Besides the known risk factors, including age, weight, gender, most recently there has been a report of a gene that doubles your risk of developing COVID, identified in South Africa. Most of the other conditions that we talk about, the preventable ones, predispose people to inflammation. These conditions can lead to life-threatening consequences of COVID. And now, with the COVID lockdown, a lot of people either stopped exercising, or significantly reduced the amount of time they move around during the day, which may manifest as weight gain. It puts patients at risk of more metabolic disorders, type two diabetes, dyslipidemia, which increase your risk of heart attacks, stroke, and COVID complications.

Now, the important thing I have felt as even as a psychiatrist is that broaching the subject can be quite difficult. No one likes to hear that it looks like they have gained unhealthy weight. But we have to do our duty. It’s important that clinicians advise their patients to do their best to engage in even a modest exercise routine. In addition to helping them with weight management, exercise can help relieve stress and improve mood. Let me define exercise—I don’t mean going to the gym and pumping iron and being on a treadmill, I am talking about being active: get out, walk, get fresh air, move around, take small steps daily, and it can have a positive effect on your health. We know such activity boosts immunity as well as the positive psychological effects.

We should be more aware of [our patient’s] living situation. We should inquire about their mental and physical health. Living a solitary lifestyle is by no means a bad thing in itself. But loneliness, which is undesired social isolation, can adversely affect our patients’ health. If I'm a clinician at the frontlines of primary care, I would inquire into patients’ experience during the pandemic, whether they've spent the majority of their time alone or with others. If I were doing a psych evaluation and found out the patient spends most of their time in the pandemic alone, I would consider trying to obtain family or collateral information. “Are you noticing any behavioral changes compared to what you normally see in your loved one?” I would inquire into stress related symptoms, which can be a brief screening in the primary care clinic, just general things. “Are you more irritable?” “Do you feel like you’re losing your cool more frequently?” “Do you feel more aggressive?” “Do you feel tired? Do you have any physical discomforts like psychosomatic symptoms, headaches, upset stomach, skin problems, GI problems, menstrual problems, sleep problems?”

I would put “sleep” in bold type and underlined because sleep difficulty has been widely reported throughout the pandemic. It often occurs in conjunction with mood disorders, like depression or predisposes people to the condition or adds to their physical ailments and lowers their immunity. So, I would say, pay special attention to those factors.

One last point, I think clinicians need to be more attuned to the symptoms of “long COVID” going forward. Most of us are focused on the Omicron surge right now. But once it passes, I think clinicians are going to be overwhelmed by the number of patients who have nonspecific symptoms, linked to long COVID. According to data that have just been published, there are an estimated 100 million cases of long COVID worldwide. There could be tens of millions more in the coming months. And we still don't fully understand the etiology of the conditions. There's a very interesting theory being developed right now by researchers in South Africa, about microclots developing in the vessels that may lead to these issues. However, talking about the etiology of the condition, the full range of treatment, the prognosis is premature. First, we need to develop diagnostic tests, and then we can move on from there.

In the best-case scenario, I think researchers will shift their attention to the condition and will discover some effective treatment. But in the worst-case scenario, there will be millions of people flooding our healthcare system, struggling with symptoms, and we will not know how to manage them. Either way it’s going to take a massive toll on our healthcare system in the coming months and years. Many clinicians, when people come in and complain of vague symptoms, may dismiss them, finding nothing of an acute nature. I would actually screen them very diligently to see what is happening. Then they could be followed up because many of these people with long-lasting COVID are developing psychological and psychiatric comorbidities. These conditions often translate into social issues like job loss which then may lead to overall workforce shortages. Families may have financial problems, children will suffer—a whole cascade of events may develop.

That's a long answer to your question, but that's how I see it.

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