This article has been written by psychologists working alongside hospitals during the COVID-19 (also known as the Coronavirus) pandemic. It is written for people who are now well enough to leave hospital after being very ill with COVID-19. It can be a strange time in the early days of being back at home, with some recovery time ahead. Some may find recovery at home is straightforward and steady. For others, things might feel a little more difficult.

This article will cover some common physical and psychological challenges some people may experience after being discharged from hospital to continue their recovery from COVID-19. These can include fatigue, anxiety, depression, and trauma responses, changes in the ability to think clearly and concentrate, as well as the impact upon relationships with partners and others with whom you may live.

For each set of challenges, we have suggested strategies that could help with coping in these situations – you may not find you need to read all of this booklet, so we invite you to read sections you find most helpful and refer to their corresponding strategies. We hope you find the information and advice helpful and we wish you all the best in your continuing recovery.

Going home after hospital admission

Going home after being in hospital with COVID-19 is often a very positive experience. You may see it as the best sign that you are getting better, mostly as the chance to rest and continue your recovery in your home environment. It is also true that some patients can continue to feel unwell after being discharged and face a long recovery at home.

COVID-19 is a new virus which everyone is still learning about. Whilst you might have heard about or witnessed signs of a healthcare system under strain at times, it is important you contact your GP if you are experiencing any symptoms that are concerning you. The NHS is continuing to function and respond to patients’ concerns about symptoms whether related or unrelated to COVID-19.

Life at home: The impact on you and those around you

Some post-viral symptoms after COVID-19 may be less visible to others, or maybe difficult for others to understand, especially if they persist for some time after you are discharged from hospital. Sometimes, post-viral fatigue (feeling tired after contracting a virus) may make it hard to find the energy to communicate your needs to those around you.

If your voice has been affected temporarily by COVID-19, you may find written communication a useful alternative, particularly with school-age children. Additionally, you could develop shorthand for communication for a while, or use agreed gestures and body language.

Your family were unable to visit you whilst you were in the hospital. It is likely that they will continue to worry about your health and want to look after you once you are home. For some family members or carers, this worry can feel very difficult and overwhelming. Your family might not understand if you are feeling sad or anxious. If you feel that anyone close to you might be experiencing this, it may be helpful to share this booklet with them.

Post-viral fatigue

After recovering from a virus, it can be common to continue to feel significantly fatigued for a period of time. You may find yourself needing to spend a lot more time in bed, or that everyday tasks you used to do easily before COVID-19 now seem more of a struggle.

If you are a parent with your children at home, the experience of post-viral fatigue may give rise to unpleasant feelings of guilt. It can be hard for children to understand when a parent does not seem like themselves. Try to remember that whilst you need rest and can’t do all the things you want to do during your period of recovery, you are still fully their parent during this time. No doubt you will still be thinking, listening, advising, and directing in any way you feel able.

Sometimes, we can get stuck in ‘boom and bust’ cycles. The ‘boom’ is where we can overdo our activity because on that particular day we feel able to do more. Perhaps we feel motivated and are pushing through the fatigue. The cost of overdoing it can lead to the ‘bust’, where after long periods of activity we need to rest more to compensate, which can set back our recovery. Usually, by pacing ourselves, resting, and gradually increasing activity, we can achieve more in the long run.

You may find it helpful to track your levels of activity and rest. It can also help to use SMART goals to pace yourself and gradually increase your activity in steps. See Strategy C.

Additionally, maintaining a good, balanced diet during your recovery can help boost your mood and energy levels. If you have little appetite or are struggling to eat, try having smaller portions more often during the day. Try to drink clear fluids to stay hydrated.

The impact of the mind on the body

It is normal to worry about managing daily life at home without regular monitoring and support from hospital staff. You may also worry about how you will regain strength if you have become physically weak. If you felt breathless when you had COVID-19, this may also make you feel anxious or panicky.

This is normal. However, when we are anxious, this can give rise to physical symptoms such as breathlessness (see How our bodies react to danger), which can make us more anxious and form a vicious cycle. See Strategy E.

If your breathlessness does not go down after a while and your symptoms are still of concern, do not hesitate to contact your GP for help. It can help to catch signs of stress and anxiety early to use strategies to prevent things from getting worse. Grounding techniques can help us feel calmer and more in control. See Strategy H.

If you felt in reasonable health prior to contracting COVID-19, the sudden experience of feeling very weak with a loss of strength and stamina may come as a shock and bring about anxiety or low mood. See Strategy B.

After a serious illness, it is also normal to worry about becoming unwell again. You may seek comfort and reassurance from your friends and family, or your GP, or check your body for symptoms.

You may also avoid things that may expose you to further worries, for example, going outside. This can be a normal part of your emotional recovery from COVID-19, and will likely ease as you gradually feel better. However, for some people, health anxiety can become a problem if it persists for a long time after recovery and gets in the way of normal life. See Strategies B, D and H, or speak to your GP or a healthcare professional if you find health anxiety getting in the way of your normal life.

Emotional distress (trauma)

For some patients, the experience of being severely ill and hospitalised with COVID-19 may have been highly distressing. It may be that particular medical procedures or treatments were frightening or difficult to tolerate, for example, wearing a mask for oxygen, or not being able to see the faces of medical staff. Some patients might have had experiences such as hallucinations. It can be normal after being discharged to remember some of those aspects of being in hospital and to feel distressed by them all over again.

It may be that those difficult memories frequently intrude into your mind, uninvited. For most people, after a month or so, recalling these memories becomes much less distressing. However, some patients may find things continue to be difficult for much longer and develop post-traumatic stress disorder.

This article is intended for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

You may need to contact your GP to access more support if you notice that, after around six weeks or so, you are continuing to experience overwhelming sadness or anxiety when recalling your stay in hospital, or are having nightmares and trouble sleeping. Support may be helpful if this significantly affects home life or relationships. It may also be helpful if you notice you are coping with feelings by drinking to excess, by smoking more, or by using drugs.

How we can be affected by trauma

Trauma affects everyone differently. You may recognise some of the experiences listed below, and you may also have other experiences that are not mentioned here.

How our bodies react to danger

When we feel stressed or threatened our bodies release hormones called adrenaline and cortisol. This is the body’s automatic way of preparing to respond to danger and we have no control over it.

Our bodies can react in different ways:

“Fight” (battling, struggling or protesting)
“Flight” (running away), or
“Freeze” (feeling paralysed or unable to do anything).

The body’s reactions to stress signals can continue long after the distressing event, even after the danger is long gone, and the hormonal reaction may trick us to act as if we were in danger again. This not only affects our bodies, but how we think, feel and behave.

What can happen when our minds are tricked to think that we are in danger again

You may recognise some of the following normal and common reactions. These reactions can be understood as our mind’s ways of keeping us safe after a distressing event:

Experience	Description	Recommended strategy
Flashbacks and nightmares	Re-living parts of the traumatic event, or feeling as if it was happening again,. Going over the events, again and again, can be understood as the mind’s way of trying to make sense of the situation, in order to prevent it from happening again in the future.	Strategy D
Hyper-arousal	Feeling very anxious, or unable to relax, as if you were constantly on a lookout for danger,. This can be understood as your mind’s best effort to keep you safe at all costs by spotting danger as early as possible.	Strategy D
Panic	An intense fear response, which may occur out of the blue. During a panic attack, physical symptoms can build up very quickly, such as a pounding or racing heartbeat, feeling light-headed, feeling hot or cold, sweating, trembling/shaking or pain in your chest.	Strategy H
Low mood	This may not stop you leading your normal life but may make everything harder to do and seem less worthwhile. Feeling low may make you feel more tired. As a consequence, you may feel overwhelmed or be tearful, and it is common to also feel irritable.	Strategy G
Feeling guilty	Going through a difficult event can sometimes make you feel as if you are to blame. It can be one way your mind tries to make sense of what has happened and to avoid other overwhelming feelings such as anger or grief. Even though self-blame can be very difficult to cope with, it can be a way your mind tries to protect you, so it might take time and support to be able to start feeling differently. You might feel confused or overwhelmed if someone else says it wasn’t your fault, although hearing this can also be a relief.	Strategies F and G
Sleep problems	You might find it hard to fall or stay asleep, feel unsafe at night, or feel anxious or afraid of having nightmares.	Strategies H and I

Cognitive difficulties

Cognitive skills are what our brains use to think, read, learn, remember and pay attention. When recovering from COVID-19 it may feel that your thinking and reasoning skills are not good as they used to be before contracting the virus.

Cognitive difficulties you may experience
Problems concentrating	For example, trouble focusing on a book or struggling to keep up with the plot of a film.
Memory difficulties	For example, forgetting some recent conversations or something you have planned to do in the future.
Dividing attention between tasks	For example, finding it more challenging doing more than one thing at once, such as cooking and having a conversation, or finding it difficult to get back to what you were doing if you are interrupted.

Most of these experiences result from post-viral fatigue. Although they may be unpleasant and upsetting, they are a normal part of getting better.

It is natural to experience some “ups and downs”, but your ability to think and concentrate usually gets better given time. However, if any cognitive problems persist for a long time, or after your physical recovery, consider consulting your GP. Whilst you are recovering, using SMART goals may make these issues easier to manage (see Strategy C).

Helpful strategies

We hope you find the strategies below useful. Some may work better than others for different people. You may find you need to practice them a few times before they help, so don’t worry if you don’t notice a difference straight away, keep trying!

Strategy A: Making space for your experience

Try to be mindful that you have been involved in a traumatic incident and that the difficulties you are experiencing are because of this incident and are a part of the recovery.

Try to talk to someone and ask for help if you need it. Try not to let stress and worries to build up. Talk through your version of the events, what your thoughts are and how you have been feeling. If you need support from a professional, speak to your GP.

Try to maintain your usual routine as much as you can. Having structure to your day can be a useful distraction. However, take care to not place too much demand on yourself. Take things slower and easier if you need to.

Strategy B: Tracking how we are feeling

Use a rating scale from 0 to 10 (0 representing feeling as unwell/ fatigued as you could imagine feeling, and 10 representing feeling well at that moment).

When you feel able, explain briefly to others what 0 might be like for you, what 5 might be like etc. Also let them know in advance what you might need them to do, if anything, according to the rating you give. For example, you might have decided that at 3, you may need others to let you sleep, to not expect you to hold a long conversation, to bring you a drink etc.

You might decide in advance that, if you give a rating of 1 or 2, you call your GP. You decide what best fits different ratings. This strategy can save a lot of talking where, for some patients, talking make them more tired, or even physically painful.

Another even shorter version of the strategy above is the “traffic light system”. Using this strategy, identi-fy in advance what green (feeling OK), amber, and red (feeling dreadful/exhausted) would mean for you, and what you would like someone else to do for you when you are rating yourself as being at a particular colour, in the same way as above.

Strategy C: SMART goals

The road to recovery needs to be gradual and where possible, steady. Often people set out to do things and for a number of reasons, they don’t achieve them. This can lead to a reduction in confidence and self-esteem, and to low mood. The key is to break down goals into smaller, achievable steps. Start with what you can do now and practice regularly.

Take the next step only when you are achieving the current stage easily. A “SMART” goal structure can help with this:

Make it specific, for example, sitting down to read a chapter of a book, hoover the hall etc., rather than a vague goal, such as “I want to get stronger.”
Think about how you will know whether you have achieved your goal – how can you measure it? This is especially important to know that you have reached your goal, as by reaching goals you build your confidence again.
Decide if the goal you set yourself is achievable. It is better to think of your goal as a series of steps on a staircase. Your goal may be to walk to the top of the stairs and to reach that goal you are going to need to progress through smaller goals towards it. For example, achieving two steps, maintaining this for a few days then achieving four steps, then slowly building up to a full flight of stairs as you achieve each smaller goal along the way.
Are your goals realistic? It is better to start off with smaller steps and achieve them, than to set them too high and not achieve. It is important to be aware of your limitations – your goals need to be within your capabilities. Your goal might be to identify alternative activities if you can’t yet aim towards a preferred activity.
Set a time scale to achieve goals by. For example, by the end of the week or by the end of the month. We find it more manageable to set goals sooner rather than have a long time frame to achieve them in.

Strategy D: Grounding

Return to the “here and now” so that your mind does not take you away from what you actually want to focus on:

Engage in some gentle physical movement if you can, for example, yoga stretches.
Check back in with the present and re-orientate yourself – remind yourself of where you are, what has been happening over the past few days.

Distract yourself from worries and refocus your attention:

Engage in your favourite activities that can also boost your mood, for example, music, favourite TV/films or play games.
Choose an object in the room and slowly focus your attention on them: notice the colours, shapes, textures etc.

Self-soothe using your senses:

Look at calming photos, for example, of nature or family.
Listen to soothing sounds or your favourite music.
Touch something soft and comforting, or put on some soothing hand cream.
Smell something pleasant or strong, e.g. essential oils, perfume.
Taste your favourite food or snacks.

In your current space, find:

Five things you can see.
Four things you can touch.
Three things you can hear.
Two things you can smell/like the smell of.
One thing you can taste/like the taste of.

Strategy E: Breathing

Belly breathing

Sit comfortably, with your knees bent and your shoulders, head and neck relaxed. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your belly move as you breathe.

Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain as still as possible.

Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. The hand on your upper chest must remain as still as possible.

Breathing round a square

Find a square in your environment, this could be a window or mirror. Following the outline of the square, begin by slowly exhaling fully. Then, gently inhale through your nose to a slow count of four. Hold at the top of the breath for a count of four. Then gently exhale through your mouth for a count of four.

At the bottom of the breath, pause and hold for the count of four. For more information, please visit the British Lung Foundation website: www.blf.org.uk/.

Strategy F: Being kind to yourself

Consider how you would treat someone else. The simplest thing you can do is to imagine what you’d do if someone you cared about was in your position. What would you say to that person? How would you treat them?

Comfort yourself with a physical gesture. Kind physical gestures have an immediate effect on our bodies, activating the soothing mind. For example, simple gestures such as gently holding your arm.

Memorise a set of compassionate phrases. Whenever you find yourself saying, “I’m horrible”, it helps to have a few phrases at the ready.

Pick statements that really resonate with you. Some people say things like:

“This is a moment of suffering”
“May I be kind to myself in this moment?”, or
“May I give myself the compassion I need?”.

Strategy G: Mindfulness

Mindfulness is a way of giving your full attention to the present moment, as opposed to being swept away from the present by worries about the future or strong feelings about the past. Research shows that practicing mindfulness can help people to handle many difficult emotions including low mood, guilt and self-blame.

Below are some free mindfulness downloads:

Mindfulness: Finding Peace in a Frantic World: franticworld.com
The Free Mindfulness Project: freemindfulness.org

Strategy H: Guided relaxation

Relaxation can be described as a state of being free from tension and anxiety. Relaxation is about resting your mind and body – it is an important part of taking care of yourself. It is a useful method for handling anxiety, stress and the fight/flight response.

For a wide range of free relaxation downloads, visit:

Wellbeing Services, South Glasgow: wellbeing-glasgow.org.uk/audio-resources/.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Relaxation Techniques: cntw.nhs.uk/resource-library/relaxation-techniques/.

Strategy I: Tips for better sleep

Try to avoid stimulants such as coffee or alcohol where possible around four hours before sleep.
Try to avoid stimulating activities such as exercise, and using your phone for a long time, before bed.
Make your bedroom as dark and quiet as possible, and at a cool temperature of around 18 degrees Celsius.
If you find yourself waking from sleep, try and do a relaxing activity such as reading a book or do some breathing (Strategy E) or mindfulness (Strategy G).
If you find it difficult to sleep well and need to nap during the day due to fatigue, try to keep your naps short (i.e. 30 minutes or less), to avoid impacting on your sleep at night.

Resources:

https://eput.nhs.uk/
https://www.euro.who.int/
https://www.webmd.com/
https://www.medpagetoday.com/
https://www.mind.org.uk/

Contributors:

Dr Marta Karczewska, Principal Clinical Psychologist
Dr Lisa Morgan, Principal Clinical Psychologist
Dr Jenn Zhang, Clinical Psychologist
Eve Webber, Assistant Psychologist

EPUT Clinical Health Psychology Services