Anxiety in post-covid-19 syndrome – prevalence, mechanisms and treatment

In addition to the general impact of the COVID-19 pandemic on anxiety-related mental state, anxiety and anxiety disorders have also been implicated within ‘post-COVID-19 syndrome’, i.e. following a SARS-CoV-2 infection. The present narrative review provides an update on the current state of knowledge on anxiety and anxiety disorders in the context of post-COVID-19 syndrome, on epidemiological, psychological, and biological factors that may contribute to anxiety following a SARS-CoV-2 infection, as well as on therapy options available for anxiety in the context of post-COVID-19 syndrome. A multi-step systematic literature search of PubMed and Web of Science databases was performed applying the following broad search terms: (“anxiety” OR “anxiety disorder”) AND (“COVID” OR “COVID-19” OR “corona” OR “pandemic” OR “Post-COVID” OR “Long-COVID”). Eligible articles published until November 15, 2022 were included. Meta-analyses identified anxiety prevalence rates ranging from 16.6% to 29.6% after a SARS-CoV-2 infection. Premorbid anxiety has not reliably been shown to be associated with post-COVID-19 syndrome. Female sex, older age, severity of COVID-19 infection, hospitalization, reduced mobility, uncertainty, loneliness and low social support, anxiety sensitivity and cognitive inflexibility as well as biological factors such as immune dysregulation, alterations in the angiotensin system and hypothalamus-pituitary-adrenal axis activation have been identified as potential anxiety risk factors in the context of post-COVID-19 syndrome. Treatment options comprise pharmacotherapy with selective serotonin/noradrenaline reuptake inhibitors and (internet-/computer-based) cognitive behavioral psychotherapy, possibly augmented by mindfulness-based techniques, physical exercise and non-invasive brain stimulation. Provided corroboration of the currently suggested increased risk of anxiety in the context of post-COVID-19 syndrome by future large-scale, prospective studies, a standardized screening for anxiety in patients with a SARS-CoV-2 infection – particularly in individuals with risk factors – and a psychiatric consultation and liaison service should be established to provide preventive and therapeutic interventions as early as possible.