The general public has been inundated with headlines about COVID-19’s impact on mental health. Cautionary articles abound, such as “The Coronavirus Pandemic is Pushing America Into a Mental Health Crisis” in the May 4 Washington Post or “The Full Toll of COVID-19 on Children’s Mental Health Won’t be Known for Years,” published online by CNN on May 28. On June 8, the Business Insider website described “13 Potential Long-Term Effects the Coronavirus Pandemic Could Have on Mental Health,” and a May 13 Reuters news story told readers that the “U.N. Warns of Global Mental Health Crisis Due to COVID-19 Pandemic.”
Of course, formal, well-designed and replicated medical studies evaluating COVID-19’s impact on mental health will not be available for some time. However, as patient care continues during the pandemic, it is important to have a quick assessment tool, in addition to the standard Patient Health Questionnaire-9 that is readily available and can be used by phone or during virtual visits. While physicians and healthcare practitioners are well-versed in screening and treatment of general depressive conditions, the 2019 novel coronavirus has added some nuances to the presentation of patient symptoms.
This is the first time most of the United States population has experienced the stressors of a nationwide (and global) pandemic. The last time people witnessed such extensive business shut-downs, unemployment levels and overloads of the healthcare system was during the polio crisis that peaked in the 1940s and 1950s. While the most common symptoms of depression are known to us—withdrawal, low mood, anhedonia, low energy, appetite and sleep disturbances, crying spells, and passive or active suicidal ideation—the stressors of COVID-19 have added subtleties that may be incorporated into our assessments and treatment planning.
For example, irritability is a prime symptom of COVID-19-related depression. Likewise, the persistence of irritability for hours or days is another indicator that suggests depressive symptoms. Irritability during the coronavirus pandemic is compounded by mandatory restrictions, use of masks, frustration with others who are not following recommended procedures, the challenges of conducting otherwise-routine errands, and media saturation. Those who have not had personal or family occurrences of COVID-19, and who have been furloughed or laid off, blocking their ability to afford basic living expenses, can appear “explosive” or “aggressive” with their irritability. Those who have had COVID-19 have the added burden of physical limitations, isolation beyond what is expected from society at large, and difficulties accessing or even tolerating the new methods of healthcare delivery. Waiting in parking lots for medical appointments, wearing masks, and navigating computer technology to “see” physicians and healthcare practitioners add to patients’ impatience and annoyance.
Anhedonia may be more challenging to assess in the time of COVID-19. Even people who are considered introverts are weary of having stores, restaurants, and other businesses closed or functioning at low capacity. Avoiding the gym, refraining from getting together with friends, not being able to attend plays or sporting events, and forgoing other activities constitute the new normal of COVID-19, a situation that is sometimes disheartening. However, a patient who reports a persistent loss of enjoyment may benefit from further evaluation.
A decline in day-to-day decision-making is another undercurrent of depression that can easily go unnoticed. As “COVID-19 fatigue” intensifies, an individual may be inclined to skip self-care, including trips to the pharmacy, showering and dressing, or tending to personal business. Increasingly, the person may avoid making the many micro-decisions that are a necessary part of daily life.
Upon first assessment, a patient may not appear to meet the minimum four of nine DSM criteria for depression. Yet, with additional analysis, by taking a few minutes to ask clarifying questions, screening physicians may better determine the proper diagnostic threshold. In order to further assess for COVID-19-related depression, consider using the following short assessment guide by asking patients to:
- Describe the level of hopelessness you have—the sense that “I am stuck in this forever; it will never get better.”
- Describe any irritability you are experiencing—what are some things that trigger irritability, and once irritable, how long does that feeling last?
- Describe how easily you are able to imagine fully returning to all the activities you enjoyed before COVID-19.
The Patient Health Questionnaire-2 (PHQ-2) is another tool that can help to pinpoint COVID-19-related depression. The PHQ-2 explores the frequency of anhedonia and low mood by having patients estimate occurrences of each over the past two-week period. Patients report their experiences using a four-item scale (not at all; several days; more than half of the days; or nearly every day). The PHQ-2 is available here.
For patients with medical issues that can complicate depression assessments, consider the Geriatric Depression Scale, which omits assessments of sleep, appetite, and energy levels, since all of these can be influenced by underlying medical conditions. Instead, the five questions on this instrument address satisfaction with life, boredom, helplessness, social withdrawal, and worthlessness. The Geriatric Depression Scale is available here.
Summary and Additional Resources
The coronavirus pandemic has brought about many changes. Among these changes are increases in the occurrence of depression and variations in patients’ depressive symptoms. Some ways physicians can provide adequate depression screening during COVID-19 are by incorporating
- Questions about irritability and its duration
- Assessment of level of hopelessness
- Inquiry into enjoyment/anhedonia
- Use of PHQ-2
- Alternate use of Geriatric Depression Scale 5-question
Some general articles on this topic that may be helpful to physicians are:
- Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817-818. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764404.
- Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic [published online ahead of print April 13, 2020]. N Engl J Med. doi: 10.1056/NEJMp2008017. https://www.nejm.org/doi/full/10.1056/NEJMp2008017.
- Maurer DM, Raymond TJ, Davis BN. Depression: screening and diagnosis. Am Fam Physician. 2018;98(8):508-515. https://pubmed.ncbi.nlm.nih.gov/30277728/.
- Bienenfeld D, ed. Screening Tests for Depression. Medscape website. https://emedicine.medscape.com/article/1859039-overview. Updated December 23, 2018.