The Role of Illness Severity and Emotional Distress in General and Cognitive Rehabilitation of Individuals with Post-COVID-19

Main Article Content

Sheer Shabat Anat Marmor Jeanna Tsenter Isabella Schwartz Zeev Meiner Shimon Shiri


Background and aims: Emotional distress is widespread among individuals recovering from COVID-19. The present study examined the relationships between illness severity and emotional distress and the outcomes of a general and cognitive rehabilitation program.

Methods: Participants were 61 post-acute COVID-19 patients who participated in a multidisciplinary rehabilitation program. Data were collected at admission and discharge, 6 months later. Medical evaluations and self-reported emotional, neuropsychological and functional measures were used.

Results: Mild illness was associated with higher levels of self-reported anxiety and depression and with lower self-reported executive functioning. Elevated anxiety levels and lower cognitive profile at admission were significantly linked to poorer cognitive outcomes, but not to motor or general functioning level at discharge. 

Conclusions: The results of the study indicate the significance of monitoring emotional characteristics, particularly anxiety, in post-COVID-19 individuals during multidisciplinary rehabilitation.

Keywords: COVID-19, emotional distress, multi-disciplinary rehabilitation, cognitive functioning, executive functioning

Article Details

How to Cite
SHABAT, Sheer et al. The Role of Illness Severity and Emotional Distress in General and Cognitive Rehabilitation of Individuals with Post-COVID-19. Medical Research Archives, [S.l.], v. 11, n. 4, apr. 2023. ISSN 2375-1924. Available at: <>. Date accessed: 29 may 2023. doi:
Research Articles


Groff D, Sun A, Ssentongo AE, et al.; Short-term and Long-term Rates of Postacute Sequelae of SARS-CoV-2 Infection: A Systematic Review. JAMA Netw Open. 2021 1;4:e2128568. doi: 10.1001/jamanetworkopen.2021.28568. PMID: 34643720
Raman B, Cassar MP, Tunnicliffe EM, et al.; Medium-term effects of SARS-CoV-2 infection on multiple vital organs, exercise capacity, cognition, quality of life and mental health, post-hospital discharge. EClinicalMedicine. 2021; 7: 31:100683
Mazza MG, De Lorenzo R, Conte C, Poletti S, Vai B, Bollettini I, et al. Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors. Brain Behav ImmunI. 2020; 89:594–600
Dutzi I, Schwenk M, Kirchner M, Bauer JM, Hauer K. Cognitive change in rehabilitation patients with dementia: prevalence and association with rehabilitation success. J Alzheimers Dis. 2017; 60:1171–1182.
Turner A, Phillips L, Hambridge JA, Baker AL, Bowman J, Colyvas K. Clinical Outcomes Associated with Depression, Anxiety and Social Support Among Cardiac Rehabilitation Attendees. Aust N Z J Psychiatry. 2010; 44: 658–666
Bryant RA, O'Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. The psychiatric sequelae of traumatic injury. Am J Psychiatry. 2010; 167 :312-20
Shimoda K, Robinson RG. Effect of anxiety disorder on impairment and recovery from stroke. J Neuropsychiatry Clin Neurosci.1998; 10:34-40.
Masskulpan P, Riewthong K, Dajpratham P, Kuptniratsaikul V. Anxiety and depressive symptoms after stroke in 9 rehabilitation centers. J Med Assoc Thai. 2008; 91: 1595.
Jaywant A, Toglia J, Gunning FM, O’Dell MW. Subgroups defined by the Montreal cognitive assessment differ in functional gain during acute inpatient stroke rehabilitation. Arch Phys Med Rehabil. 2020; 101:220–226.
Toglia J, Fitzgerald KA, O’Dell MW, Mastrogiovanni AR, Lin CD. The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: Relationship to functional outcome. Arch. Phys. Med. Rehabil. 2011; 92:792–8.
Patel R, Savrides I, Cahalan C, et al. Cognitive impairment and functional change in COVID-19 patients undergoing inpatient rehabilitation. Int J Rehabil Res. 2021; 44:285-288.
Daynes E, Gerlis C, Chaplin E, Gardiner N, Singh SJ. Early experiences of rehabilitation for individuals post-COVID to improve fatigue, breathlessness exercise capacity and cognition - A cohort study. Chron Respir Dis. 2021; 18:14799731211015691.
Marshall JC; Murthy S; Diaz J; et al. A minimal common outcome measure set for COVID-19 clinical research. Lancet. Infect. Dis. 2020, 20, e192–e197.
Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil. 1996; 77: 1226-1232.
Beninato M, Gill-Body KM, Salles S, Stark PC, Black-Schaffer RM, Stein J. Determination of the minimal clinically important difference in the FIM instrument in patients with stroke. Archives of physical medicine and rehabilitation. 2006;87(1):32-9.
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983; 67: 361–370
Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002; 52: 69–77.
Löwe B, Spitzer RL, Gräfe K, et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord. 2004; 78: 131–140.
Weiss D, Marmar C. The Impact of Event Scale–Revised. In Wilson J, Keane TM, Editors. Assessing psychological trauma and PTSD. Guilford Press; 1997.
Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale—Revised. Behav. Res. Ther. 2003; 41: 1489–1496.
Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. J Trauma Stress. 1996; 9 :455-471.
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology. 1989; 46:1121–1123.
Grace J, Mendelsohn A, Friedman JH. A comparison of fatigue measures in Parkinson's disease. Parkinsonism & related disorders. 2007; 13: 443-445.
Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983; 16: 87-101.
Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL & Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 2005; 53(4), 695-699.
Roth RM, Isquith PK, Gioia GA. Behaviour Rating Inventory of Executive Function-Adult Version. Lutz, FL: Psychological Assessment Resources, Inc; 2005.
Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A. Long-term conditions and mental health: the cost of co-morbidities. The King’s Fund and Centre for Mental Health. 2012
Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011; 39:371–9.
Moussavi S, Chatterj S, Verdes E, Tandon A, Patel V, Ustun, B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007; 370: 851-858.
Walker JG, Jackson HJ, Littlejohn GO. Models of adjustment to chronic illness: Using the example of rheumatoid arthritis. Clin Psychol Rev. 2004; 24:461–88.
Mazza MG, De Lorenzo R, Conte C, Poletti S, Vai B, Bollettini I, et al. Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors. Brain Behav ImmunI. 2020; 89:594–600.
Folkman S. Coping across the life span: Theoretical issues. Life-span developmental psychology: Perspectives on stress and coping. 1991:3-19.
Brand H, Speiser D, Besch L, Roseman J, Kendel F. Making Sense of a Health Threat: Illness Representations, Coping, and Psychological Distress among BRCA1/2 Mutation Carriers. Genes. 2021; 12:741.
Denollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation. 1998; 97:167-73.
Henry A, Tourbah A, Camus G, Deschamps R, Mailhan L, Castex C, Gout O, Montreuil M. Anxiety and depression in patients with multiple sclerosis: The mediating effects of perceived social support. Mult Scler Relat Disord. 2019; 1:46-51.
Boeschoten RE, Braamse AM, Beekman AT, et al. Prevalence of depression and anxiety in multiple sclerosis: a systematic review and meta-analysis. J Neurol Sci. 2017; 15:331-41.
Kudlicka A, Clare L, Hindle JV. Awareness of executive deficits in people with Parkinson's disease. J Int Neuropsychol Soc. 2013; 19:559-70.
Schiehser DM, Delis DC, Filoteo JV, et al. Are self-reported symptoms of executive dysfunction associated with objective executive function performance following mild to moderate traumatic brain injury?. J Clin Exp Neuropsychol. 2011;33:704-14.
Potvin O, Forget H, Grenier S, Préville M, Hudon C. Anxiety, depression, and 1-year incident cognitive impairment in community-dwelling older adults. J Am Geriatr Soc. 2011;59:1421-1428. doi: 10.1111/j.1532-5415.2011.03521.x. Epub 2011 Jul 28. PMID: 21797836.
Bierman EJM, Comijs HC, Jonker C, Beekman ATF. Effects of anxiety versus depression on cognition in later life. Am J Geriatr Psychiatry. 2005; 13: 686-693.
Paterniti S, Dufouil C, Bisserbe JC, Alperovitch A. Anxiety, depression, psychotropic drug use and cognitive impairment. Psychological Medicine. 1999: 9: 421-428.
Heruti RJ, Lusky A, Dankner R, et al. Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome. Arch Phys Med Rehabil. 2002;83:742-9.
Antomauro DF, Herrera AM, Shadid J, et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet. 2021; 398: 1700–1712
Robinson E, Sutin AR, Daly M, Jones A. A systematic review and meta-analysis of longitudinal cohort studies comparing mental health before versus during the COVID-19 pandemic in 2020. J Affect Disord. 2022; 296: 567–76.
Horn G, Lewis F, Russell R, Kemp D. Anxiety following traumatic brain injury: Impact on post-hospital rehabilitation outcomes. Phys Med Rehabil Res. 2017; 2: 1-6. DOI - 10.15761/PMRR.1000149
Ahn DH, Lee YJ, Jeong JH, Kim YR, Park JB. The effect of post-stroke depression on rehabilitation outcome and the impact of caregiver type as a factor of post-stroke depression. Ann Rehabil Med. 2015;39(1):74-80. doi:10.5535/arm.2015.39.1.74
Janiri D, Carfì A, Kotzalidis GD, et al., Against COVID-19 Post-Acute Care Study Group. Posttraumatic Stress Disorder in Patients After Severe COVID-19 Infection. JAMA Psychiatry. 2021;78:567-569. doi: 10.1001/jamapsychiatry.2021.0109. PMID: 33599709; PMCID: PMC7893542.
Sun W, Chen WT, Zhang Q, et al. Post-Traumatic Growth Experiences among COVID-19 Confirmed Cases in China: A Qualitative Study. Clin. Nurs Res. 2021;30:1079-1087. doi: 10.1177/10547738211016951. Epub 2021 May 21. PMID: 34018405.
Feingold JH, Hurtado A, Feder A, et al. Posttraumatic growth among health care workers on the frontlines of the COVID-19 pandemic. J Affect Disord. 2022; 296:35-40. doi: 10.1016/j.jad.2021.09.032. Epub 2021 Sep 16. PMID: 34587547.
Tedeschi RG, Calhoun LG. Posttraumatic growth: conceptual foundations and empirical evidence. Psychological inquiry. 2004; 15:1-18.