When Mental Health Medications Meet Paxlovid: Choosing Between Treating the Body or Managing the Mind

Mental health has long been a taboo topic in my life. I am the daughter of Baby Boomers, one of whom belongs to the Blackfoot Nation, and across both respective identities is a strictly held policy: no one airs out the dirty laundry, with mental health being the most unmentionable of all. Unsurprisingly, in a childhood of severe abuse and abject neglect, the refusal to speak of what took place did nothing to prevent the invisible scars that formed in response. In adulthood, that which was unspoken nevertheless garnered a name: Complex Post-Traumatic Stress Disorder.

Unlike Post-Traumatic Stress Disorder, which develops in response to a singular traumatic event, C-PTSD is reserved for individuals who have repeated exposure to traumatic events. In my case, this diagnosis is far from the complete picture; a defining feature of my diagnosis happens to be Survivor Guilt. Though this ailment is most frequently associated with combat veterans, it also appears in individuals who managed to live in situations where others did not. Therapists have theorized the foundation of this was, for me, being born after two of my eldest siblings had already died. Subsequent traumatic events, including escaping human sex trafficking as a teenager, losing one of my closest friends to suicide five years ago, and surviving the devastation of California’s most destructive wildfire in 2018 also contributed to the lens through which I presently view the world.

I provide this background because it is essential to understand why, when the then-presidential Trump administration opted for an approach of wait and see about COVID, my fear kicked into overdrive. As someone with a background in public health, I understood that COVID would prove to be among the most formidable viral antagonists seen in my lifetime, and I instinctively knew that that meant a lot of people were going to die. While the death toll climbed, my own mental health waned considerably. I tried to just feel gratitude to have a job that cared about the world and me as a worker, but in my most vulnerable moments, I struggled to accept being alive and relatively healthy in a world that was awash with so many dead and dying. I tried to be proactive, channeling my energy into prevention wherever I could.

I still managed to contract a mild case in February. I returned to work after a few days of rest, mostly back to normal but for two considerable exceptions. First, the notorious COVID brain fog lingered for a few months, dealing a harsh blow to how I viewed my intellectual capability as words, which had always been mine to command, now eluded me. Second, I noticed a reappearance of some of my PTSD symptoms related to surviving an illness still killing people by the dozens. There were moments where the guilt completely overwhelmed me. During staff meetings, hearing the details of patients succumbing to the COVID fate I had escaped, I would turn my camera off and cry. The question that had so often plagued my earlier experiences of trauma continued to haunt me: why had I survived, whereas so many others had not? Without an answer, I still tried diligently to be proactive in managing my mental health.

While modern medicine has ushered in numerous breakthroughs for countless health challenges, there is no singular cure for conditions which develop in response to severe psychological trauma. For most of us, the way forward means participating in talk therapy with a licensed clinician and possibly even taking medications. In my own experience, I felt fortunate I had uncovered a regimen that worked for me. For several months, I managed to have my life as close to how I wanted it to be as I ever had, riding a wave of accomplishment around the role I played in securing MacKenzie Scott’s historical $5 million gift, participating in several opportunities for professional development, and looking forward to the next phase of my career. I felt like the living embodiment of hope.

Unfortunately, that changed in mid-June, when I fell ill with what felt like a severe cold. Within 48 hours, the assessment of cold had given way to a record-breaking fever, buckets of sweat soaking through my mattress pad, and burning sensations across my body. At different points, I suffered fever dreams so intense they were akin to hallucinations happening in real-time. Since my family happened to be visiting relatives out-of-town, I convalesced alone, unaware of the passage of time and spending nearly all of it unconscious, because being awake meant feeling pain in every inch of my body from the top of my hair to the tips of my toes.

Two days after I initially fell ill, I attempted to eat some comfort food, and realized I could not taste what I had put into my mouth. An at-home test confirmed it: I had again tested positive for COVID, which I had not even considered as a possibility. Not wanting to take any unnecessary time off from work, I decided to see what options could be available to expedite my recovery. I secured a telehealth appointment with a provider through my local clinic, where I ran into the first of what would be several hurdles that would put my well-being at risk.

After reviewing some basic data with me, the physician confirmed that I met the eligibility guidelines to be prescribed Paxlovid, an oral antiviral that combines two separate medications: nirmatrelvir, a SARS-CoV-2 protein inhibitor and ritonavir, which is most famously known for use in the treatment of HIV/AIDS. Together, the medication seeks to disrupt the pace of COVID’s infection by preventing the replication of coronavirus cells. Currently, Paxlovid is regarded as the most effective strategy for keeping COVID-infected patients out of the hospital; the clinical trials determined that Paxlovid could reduce the likelihood of serious consequences — meaning the risk of hospitalization and death — by 89 percent. I was ready to charge, full speed ahead — only for the provider to explain that as an outside contractor for the clinic, he could not personally prescribe it to me, and I would have to locate a test and treat site in my area.

As it turned out, the next available appointment happened to be the following evening. I could do nothing but accept it and wait for the next day. At that appointment, the new provider introduced a fresh complication into my quest for Paxlovid: as long as I remained medication compliant with the psychotropics designed to ease my symptoms of C-PTSD, no provider would actually give me that prescription, due to contraindications with 22 fairly common and routine medications, including mine. Her compromise was to offer molnupiravir instead — a similarly five-day protocol medication with less than half of the efficacy rate as Paxlovid. She also advised me that the clock happened to be ticking; the antivirals are only effective if administered within the first five days of symptoms, and we were already at day four. The only other alternative, she explained, would be for me to call my own psychiatrist and ask him to prescribe me Paxlovid since he could also monitor my withdrawal.

Of course, this late-in-the-day appointment meant that my psychiatrist’s office had been closed for several hours, so I had no choice but to wait. I made sure to cease taking my medication in anticipation that the Paxlovid might materialize faster. At one minute after eight a.m., I called my psychiatrist’s office and reached a receptionist with whom I have always shared a friendly relationship. As soon as I explained the situation, she immediately got him involved and within minutes, the prescription had been sent to a local pharmacy. By that afternoon, I was primed to take my first dose of Paxlovid. I popped two pills of nirmatrelvir and one of ritonavir out of the blister pack and waited for the magic to happen.

My relief proved to be temporary, as it wasn’t long before I spiraled into the most fragile mental state I have ever been in. Plenty of people saw me floundering, but there was little anyone else could do. Even my job could not offer me a distraction. While several of my colleagues contracted COVID and were able to bounce back after a short period of quarantining, I suffered — and the people trying to support me suffered as well. We all felt adrift. The confirmation of a positive COVID case meant resources I depended on to work in tandem with medication — like talk therapy — were also unavailable to me. When the suicidal thoughts began to overtake my waking hours, I had no outlet in which to process them. Even finishing out Paxlovid did little to relieve the pain; it took another week after having my liver and kidney enzymes checked before I received permission to resume taking the medication I had spent the last month whiteknuckling my way without.

Now, almost a month outside of resuming my medication plan, I have the clarity that the second half of my go-round with COVID was exacerbated by unsupervised prescription drug withdrawal. The fingerprints were everywhere: even aside from the emotional toll, I had spent the first few days on Paxlovid also battling nausea, vomiting, abdominal cramping, excessive sweating, and diarrhea. These are not common symptoms for active COVID infections for most people; they are, however, quite common among individuals withdrawing “cold turkey” from psychotropic medication, Mental health clinicians are all too familiar with the emergence of these occurrences in the wake of patients quitting anti-depressants and have named the condition Antidepressant Continuation Syndrome. Most describe it as an intensely nasty flu bug punctuated by intrusive thoughts or images.

I experienced both — and as I am working at regaining my equilibrium, including overcoming the shame and embarrassment of how I reacted with virtually no awareness or insight into how my conduct was impacting others, I am also frustrated. Mental health has become a prominent topic of conversation in recent years, but the dialogue has largely centered on the state of mental health in response to the stressors of the pandemic — the costs of social distancing, overwhelming helplessness of hospitals crowded with the dead and the dying. Remarkably little discussion about individuals who are already managing mental health issues and thus may find themselves in a position like mine, forced to choose between treating their body or managing their mind, has happened.

Like a lot of Millennials living life as an open book online, I take to social media accounts to educate, explore, and connect. Feeling like I had emerged from something akin to a war zone, I conducted informal research amongst my modest social network to get an idea of how many people in my life might have faced the same impossible choice. My investigation yielded only one person willing to acknowledge having had a similar experience. They chose to treat with Paxlovid as well, which required them to discontinue medications designed to assist them with sleep and pain. The subsequent side effects have made them much more open to the possibility of pursuing other treatment options for future COVID infections, such as antibody fusion — a therapy they are considering, despite their trauma around IVs. Stepping outside of my bubble, even fewer narratives describing experiences like mine can be found.

Prescription drug withdrawal is not something to be cavalier about, or indifferent to. Neither, for that matter, is COVID and the cost of recovery. So why is this very subject so under addressed as to suggest to the lay researcher that there is no story here? After all, it is unlikely that the issue is rare; figures published in a National Center for Health Studies Data Brief by the Center for Disease Control and Prevention determined that 15.8 percent of adults were taking prescription medication for their mental health in 2019. Three years later, that number has climbed to nearly a quarter, with antidepressants and stimulants experiencing a surge among clinicians who are no longer beholden to certain legal requirements, such as meeting with their patients in person, in order to prescribe a controlled substance like Adderall.

Such shifts in both accessibility and availability have lead some mental health experts to quip that although the full extent of the pandemic’s effect on mental health will not be clear for some time, the medicine cabinets of America provide a preview of what is to come, which could spell disaster for individuals between a rock and a hard place, like me.

And the consequences carry high stakes that demand a deeper look. More than 100,000 drug overdose deaths took place in 2021, representing an increase of more than 30 percent from the previous year. Some within the medical community suggest that this figure is inaccurate, and that “some suicides are misclassified as drug overdose deaths” according to a report through the Kaiser Family Foundation. The report also notes that communities of color face higher rates of suicide death over time in contrast to their white peers. Yet this, too, seems notoriously under addressed. In February, even as the CDC reported that suicide rates had declined by three percent overall, it also noted the existence of significant disparities with respect to Hispanic males.

Such an observation is just the beginning; drilling down further into the data from the start of the pandemic shows that the year-over-year rate, instead of dropping among Hispanics, actually rose by nearly six percent among males. The number was even higher for non-Hispanic, multiracial females at 29 percent. Both figures challenge the conventional wisdom that the pandemic did not see an uptick in suicide, and these findings have been echoed in other studies and critical evaluations examining suicide rates among communities of color. Further complicating the picture is that people of color have born a disproportionate amount of the pandemic’s burden; they were more likely to contract COVID, and with it, faced increased odds of severe complications and death. The impact has been so significant that the life expectancy for Black and Hispanic people fell by more than three years, while whites saw a drop of less than a year and a half.

Amidst all of these grim findings, mental wellness is in steep decline among these same communities of color across other metrics. July is actually BIPOC Mental Health Awareness month, and the necessity is spelled out in sobering figures. In one recent report from the CDC, over 40 percent of the respondents — who identified as Hispanic — reported increased rates of depression, substance abuse, and suicidal thoughts with astonishing frequency, experiencing suicidal ideation between two and four times as much as other groups. Despite the long-established prevalence of mental health issues within the Latino community, a number of studies have found that they are less likely to seek out help, but even those that do are less likely to be prescribed medication to address their mental health. This is true even with conditions, like bipolar and schizoaffective, that may require rigid medication schedules to manage.

This phenomenon is not new but takes on a different shape in a lens refined by COVID and the release of the first vaccine 18 months ago. While many whites rushed to get immunized as quickly as possible, communities of color were significantly more hesitant, fearful of the possible consequences that could emerge down the road. Chief among them, especially within Latino families who participated in a study about vaccination hesitancy in Oregon last year, concerned fertility. The fear is far from misplaced; the American government has an appalling track record of forcibly sterilizing women of color — even the beloved birth control pill exists courtesy of experimental testing performed on poor Puerto Rican women who faced incredible backlash from their own country about willingly surrendering their ability to bear children. Long after white women began taking the pill en masse, demanding a better contraceptive due to a host of unpleasant side effects, the women who participated in the study were still expected to follow the protocols with the original pills.

Much like the women of that time did not openly discuss their reproductive choices, or the struggles which could have been aided by medication, today’s communities of color face a similar dilemma with mental health. This may seem like a good thing; after all, doesn’t that mean that there will be fewer of the most at-risk people placed in the unenviable position that I was in?

The answer is: it depends. On the one hand, people who are not prescribed medication to manage their mental health do not have to suffer the grueling agony of withdrawing from it in order to address some other equally pressing health concern, such as COVID. Yet on the other hand, the same people declining medication for mental health are also likely to opt out of the available treatment options for COVID, from vaccinations to even Paxlovid itself. Couple this reality with the increased vulnerability that this same community faces in contracting COVID and dying from it in the first place, and suddenly my ordeal, as difficult as it proved to be, seems like a significantly better alternative.

Especially as the full picture of mental health has not yet come into focus. And with my own respective diagnoses firmly at the forefront of my mind, I wonder how many more people will pass, leaving me with the question of why I didn’t.

For those with a diagnosis and a treatment regimen who then fall ill with COVID, Paxlovid may not be the best choice, as I discovered. Clinicians need to explain treatment options while recognizing and respecting the cultural taboos around mental health care, and weighing the option against the comorbidities that may elevate a patient’s COVID infection into a severe case. Knowledge is power — and being deprived of the information about the risks meant that I went into my own treatment completely unaware of what would happen to me. At a time when we are already overrun with battling a viral enemy who keeps changing the rules, the guidelines of informed consent matter more than ever.

Especially as the landscape continues to shift. Exactly one month after my own positive diagnosis, I awoke with chills, fatigue, body aches, a rash, and a mid-grade fever. Unbeknownst to me, this would just be the beginning of yet another bizarre and confusing chapter in my COVID journey. I have been plagued with these symptoms every day since — “COVID rebound,” possible after Paxlovid, appears to be the culprit, or perhaps a form of long COVID. The future likely only holds more questions for me.

Yet as I look at my own pain, exhaustion, and the incomprehensible stress of being sick for so long, I envision people across the country in similar situations, but with poor access to health care, little knowledge of the health system, limited English proficiency, limited access to COVID information in their language and at their reading level, and no ability to work from home or take advantage of other work arrangements, and I send my gratitude to clinicians who are working nonstop to remove those barriers, so that migrants, immigrants, agricultural workers, and others who are typically left out can get basic care, empathy, and support in the midst of a series of poor options.