The role of depression as a moderator and mediator of functional status in post-acute sequelae of covid-19

Background In patients with post-acute sequelae of COVID-19 (PASC), depression has been associated with symptom severity, the duration since infection, and ongoing functional impairment. However, the interconnections between these factors remain inadequately understood. Objectives This study aimed to explore the roles of depressive symptoms in moderating and mediating the relationships between post-COVID-19 conditions and functional capacity. Methods The PERCEIVE study recruited 1,794 participants through online advertisements based on possible PASC for a cross-sectional study. Of these, 461 participated in the longitudinal study. Post-COVID-19 duration and symptoms were recorded, and depressive symptoms and functional capacity were self-reported using the 9-item Patient Health Questionnaire and the Duke Activity Status Index (DASI), respectively. The association of depression with functional capacity was explored using ordinary least squares (OLS) regression, with companion OLS models, Sobel-Goodman tests, and 1,000 bootstrap iterations to assess mediation. Longitudinal data were analysed to assess changes in functional capacity and depressive symptoms over time, with mediation analysis using mixed models to explore depression as a mediator. Results Participants had a mean DASI score of 35 (SD 21). Fatigue (18%), shortness of breath (11%), and chest pain (6%) were common symptoms, with severe depression linked to fatigue (93%) and shortness of breath (66%). The severity of post-COVID-19 symptoms was associated with severe depression (β = 6.31, CI [5.42, 7.21]) and reduced functional capacity (β = -6.40, CI [-9.20, -3.61]), with depression mediating 36% of the association between COVID-19 and functional capacity. PASC was associated with higher depression scores (β = 2.06, CI [1.15, 2.97]) and lower functional capacity (β = -3.99, CI [-6.21, -1.77]), with depression mediating 51% of the association between PASC and reduced functional capacity. The longitudinal analysis confirmed that depression mediates the relationship between PASC and the evolution of functional capacity (unstandardised estimate = -5.16, p < 0.001). Conclusion Depression plays a key role in exacerbating post-COVID-19 functional impairment. This observation underscores the need for targeted physical and mental health interventions to enhance long-term recovery for those with severe conditions.