Mental Health and Wellbeing & Balancing the Stress Response
Adverse mental health consequences of Covid-19 have been widely predicted but not yet accurately measured. However, previous SARS based research demonstrates that respiratory viral diseases are particularly associated with acute and long-standing psychopathological consequences in survivors (Bohmwald et al., 2018). A review of mental-health post-SARS concludes that during onset of the virus there is a fear for survival and fear of infecting others followed in the latter stage by concerns around stigmatization, reduced quality of life and psychological distress following illness (Gardner & Moallef, 2015).
Pandemics can overwhelm psychological and emotional tolerance (Wade, 2020), and distress associated with fear of illness and uncertainty of the future can result in direct and vicarious traumatisation (Li et al., 2020). Gabor Maté (Youtube, 2020) discussed the impact of the fear response in highly traumatised populations, acknowledging that trauma changes the brains trajectory during developmental years. The amygdala, hippocampus and orbitofrontal cortex all mediate intense states of fear, anger and aggression which intensify or dampen responses. Therefore, populations with developmental trauma may experience a heightened fear response towards a pandemic. This is an under-researched area but one that should be considered when working from a trauma sensitive approach.
Longitudinal research (Daly & Robinson, 2020) found that perceived health risks play a key role in explaining the rising and falling levels of psychological distress. Those perceiving personal risk of infection as high, were shown to experience increased levels of anxiety and reduced psychological wellbeing in the early stages of the pandemic (Karatzias et al., 2020). This is compatible with health belief models that suggest those perceiving higher susceptibility to a severe disease, perceive the risk as particularly threatening which is likely to generate negative affective responses (Mukhtar, 2020).
Early indications suggest a bi-directional association between Covid-19 and psychiatric disorder (Taquet et al.,2020) with survivors at increased risk of psychiatric sequalae, and prior psychiatric diagnosis an independent risk factor for Covid-19. Biologically, the immune response to the virus itself may impact the Central Nervous System (CNS) by precipitating virus-induced psychopathological sequalae with research indicating that psychosocial stress can substantially reduce immune defences leading to levels of inflammatory responses resulting in tissue damage (Rohleder, 2012).
Researchers warn that the virus’s effects on the brain, manifesting as loss of taste (ageusia) and loss of smell (anosmia), could be a harbinger of more serious impacts such as confusion, delirium and even psychosis (Pantelis, 2020). Research indicates that ‘cytokine storms’ involved in the immune response could cause psychiatric symptoms by precipitating neuroinflammation (Dantzer, 2018) as the virus infiltrates the brain directly, via the olfactory nerve, and this impacts areas that regulate emotions and memory.
Meta-analysis from Rogers et al., (2020) of the neuropsychiatric manifestations of SARS revealed that in the post-illness stage, depression (10.5%), insomnia (12.1%), anxiety (12.3%), irritability (12.8%), memory impairment (18.9%), fatigue (19.3%), traumatic memories (30.4%) and sleep disorder (100%) were frequently reported. These findings are supported by preliminary data suggesting that post Covid-19 patients experience confusion, memory loss, depression, anxiety, and insomnia (NIHR, 2020). These conditions are all high-burden non-communicable conditions associated with reduced health and wellbeing and treatment plans should aim to treat individuals holistically (Mazza et al., 2020).
Autonomic Dysfunction: Balancing the Stress-Response
Yoga therapy can assist in the regulation of the nervous system via stimulation of the vagus nerve complex to enhance vagal tone and its physiological marker Heart Rate Variability (HRV). Robinson et al., (2015) states that there is evidence of Autonomic Nervous System (ANS) dysfunction in 90% of chronic fatigue patients. Assuming ANS dysfunction and HPA-Axis irregularity are part of the persistent fatigue puzzle within the range of Long Covid symptoms, then yoga absolutely has the capacity to improve both these aspects, in addition to improving feelings of vitality and wellbeing. Much evidence exists extolling the benefits of yoga to facilitate coordination of the homeostatic responses involving the autonomic nervous system, endocrine system and immune systems (Gard et al., 2014) and new research comparing the effectiveness of yoga and non-mindful exercise demonstrates that yoga is more beneficial in alleviating anxiety symptoms (So, Lu, Cheung and Tsang, 2020).
The fear and uncertainty fuelled by Covid-19 and long-term symptoms and physical and psychosocial stressors places extreme pressure on Long Covid populations, placing them more at risk of allostatic load (Peng et al., 2020). Yoga as a practice has long been known as a beneficial therapy for stress reduction (Streeter et al. 2012). Allostasis refers to the ability to achieve stability in response to stress. The concept of allostatic load refers to the cost of chronic stress on the mind and body (McEwan & Stellar, 1993). The consequences of allostatic load include brain fog, poor decision making and chronic fatigue. Recent research indicates that yoga practice reduces physiological measures of stress including, cortisol and autonomic measures of blood pressure and heart rate (Pascoe et al., 2017). In addition, allostatic load parameters were attenuated and decreased following yoga practice (Gothe et al., 2016), and these results correlated with lower self-reported stress and anxiety, alongside improved cognitive function, with neuroimaging studies demonstrating activation of the hippocampus and increased hippocampal volume, during yoga practice (Hölzel et al., 2011). As the experience of cognitive symptoms such as ‘brain fog’ and memory loss are a potential consequence of allostatic load, this is of particular relevance to Long Covid sufferers as the hippocampus plays a major role in learning and memory (Dhikav and Anand, 2012).
The brain and immune system both influence and regulate each other. Increased cytokine activity presenting as elevated levels of TNFa and IL-6, alter neurotransmitter transmission, via the HPA-Axis and this induces sleepiness, fatigue, loss of appetite and decreased libido (Berthold-Losleben & Himmerich, 2008). These ‘sickness behaviours’ are related to behavioural changes of clinical depression. Evidence uniformly supports yoga as a practice to down-regulate pro-inflammatory markers and significantly reduce levels of IL1, IL-6 and (TNFa) (Vijayaraghava, 2015) and is therefore, especially relevant to Long Covid populations dealing with inflammation and depression.
From a clinical perspective, therapeutic techniques of yoga have been shown to be beneficial against management of inflammatory cytokine-based pathogenesis of virulent infectious disease and cytokine storms as present in clinical presentations of Covid-19 (Bushell et al., 2020), and observational clinical data supports the potential of anti-TNF therapies as a treatment for Covid-19 (Robinson et al.,2020). In research based on those with increased risk of inflammation conditions, such as heart failure, even 8-week yoga interventions demonstrated sufficient reduction in inflammatory processes (Djalilova et al., 2018).