Depression After COVID-19: Identification and Treatment in Primary Care

This is the second installment of a 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, the authors discuss identifying and treating depression in children and adults in primary care.

A 35-year-old woman presents to a primary care office complaining of depressed mood daily, some anxiety but not daily, not sleeping well, and overeating when she is “stressed.” She reports that she is not interacting much with friends and family and has not been exercising as she has in the past. The patient is a nurse in a medical-surgical unit at an urban hospital and has been caring for patients with COVID-19 over the last 2 years. She also reports having COVID-19 approximately 7 months ago. She was able to isolate and manage her symptoms on an outpatient basis.

The patient reports having had depressive symptoms in the past and that the symptoms decreased over time but returned over the last 6 months. She has been attending weekly individual therapy with a social worker for the last 6 weeks with minimal improvement. In the past, her symptoms were effectively treated with paroxetine, but she gained weight and does not want to restart this agent. She also notes having trouble falling asleep and not feeling rested in the morning. She sleeps approximately 5 hours per night.

Her medical history is significant for hyperlipidemia; she does not currently take a lipid-lowering medication. Her family history includes a mother with bipolar disorder (diagnosed at age 39 years) and a sister with depression (diagnosed at age 28 years). No family history of suicide ideation or completions is reported.  

Laboratory results are normal and do not show any abnormalities that may explain the current symptoms (Table 1).

Table 1. Laboratory Results

Test	Results
Complete blood cell count	Normal
Comprehensive metabolic count	Normal except hyperlipidemia: LDL: 175 mg/dL  HDL: 32 mg/dL Triglycerides: 202 mg/dL
Pregnancy test	Negative
Thyrotropin	2.32 (Normal range: 0.5-4)
Triiodothyronine and free thyroxine are needed if thyrotropin is abnormal	N/A
Urine drug screen	Negative
Vital signs	Blood pressure: 124/76 mm Hg Respiratory rate: 18 bpm Pulse: 84/min Temperature: 97.7 ºF

Mental Status Examination

The patient is appropriately dressed and her body mass index falls in the overweight but not obese category. Her thoughts are organized and logical. She denies any hallucinations and does not appear to be attending to internal stimuli currently. She does not verbalize anything that could be considered delusional. She reports depressive symptoms for the last 6 months.

She describes her mood as sad and reports she is much more tearful than she has been in the past. She reports an increase in irritability and being easily frustrated. The patient appears to have a depressed mood. She is going to work as scheduled but then comes home and isolates herself until bedtime. She is not interacting much with her family or friends and has been declining invitations. She reports somatic complaints such as headaches and stomach aches and uses these somatic complaints to avoid doing things. She reports anxiety at times, typically when someone is trying to get her to do something she does not want to do.

She denies suicidal and homicidal ideations and has not had these thoughts in the past. She denies any past hypomania or mania after being educated on the symptoms of these conditions and denies any current or past substance abuse. Her attention and judgment are intact and her speech is normal tone and rate, with no pressured speech. Her insight on depression is fair, she will benefit from additional education regarding disease process. The patient scores a 15 on the Patient Health Questionnaire (PHQ-9). She is diagnosed with recurrent major depressive disorder of moderate severity.

Discussion

The COVID-19 pandemic has had a severe effect on the mental health of people in the US and globally. In the first year of the COVID-19 pandemic, the prevalence of anxiety and depression increased by 25%, according to the World Health Organization.¹ 

In 2020, an estimated 21.0 million US adults (or 8.4% of all US adults) had at least 1 major depressive episode.² In approximately 14.8 million episodes, the impairment was severe. The prevalence of depressive disorder was approximately 4 times high in the first 2 quarters of 2022 compared to the second quarter of 2019 (24.3% vs 6.5%), according to the Centers for Disease Control and Prevention (CDC).³ Although concern was raised that these numbers may have been exaggerated by the method of the study and the symptoms were not lasting, evidence suggests that the rate of depressive disorders increased with the onset of the COVID-19 pandemic.³

The most recent data (June 29-July 11, 2022) from the Household Pulse Survey conducted by National Center for Health Statistics and the US Census Bureau, shows that 10% to 37% of Americans report symptoms of depressive disorder, with those aged 18 to 29 years showing the highest rates (Figure).⁴

In some cases, depression may be the result of isolation and increased stress faced during the COVID-pandemic. Research also suggests that depression is one of the many symptoms of long COVID.⁵

In a systematic review and meta-analysis of 1-year follow-up data from 8591 patients with COVID-19, depression was reported in 23%.⁶ In an observational study of 273 patients in India, 12% of patients developed depressive symptoms immediately (14-21 days) after a positive COVID-19 test and 5% of patients developed depressive symptoms approximately 3 months (90-97 days) after a positive test.⁷ A greater number of COVID-19 symptoms at the time of diagnosis and comorbid diabetes mellitus were associated with a greater risk for depression.⁷  

Diagnosing Depression

The patient interview is an important element of the initial assessment for depression and should include patient history as well as current medical and mental status (Table 2).⁸ Assessment tools include the PHQ-2 and PHQ-9 for depressive symptoms, Columbia Suicide Severity Rating Scale for suicidal ideations and intent, Generalized Anxiety Disorder 7-item Scale (GAD-7) for anxiety, and CAGE for alcohol use disorder.^9-12

Table 2. Signs and Symptoms of Major Depressive Disorder⁸

Decrease in interest in normal activities

Decreased concentration

Depressed mood

Fatigue

Feelings of worthlessness

Inappropriate guilt

Insomnia or hypersomnia

Psychomotor agitation or retardation

Recurrent thoughts of death and/or suicidal ideation

Significant unintentional weight loss

When asking patients about sleep, it is important to clarify what “not sleeping well” means to the patient. Does she have trouble falling asleep, staying asleep, or both? What time does she go to bed? What time she normally gets out of bed in the morning? Does she take any over-the-counter or prescribed medications for sleep or has she in the past? Does she drink alcohol or use any other substances to help her sleep? Does she have a history of sleep apnea? If so, is she following the recommendations for sleep apnea treatment?

It is always important to assess for thoughts of suicide and past suicide attempts or thoughts. If a patient presents with suicidal ideation, ask if the patient has a plan. If the patient is actively having suicidal ideation with a viable plan, a safety plan must be made before the patient leaves the office. This may mean a transfer to an inpatient facility, so it is important to have a plan in advance. Is it appropriate to call 911, is there security in the building, and what are the policies to commit a patient against their will? It is important to have these details understood prior to an emergency. If a patient is not actively suicidal, has community resources, agrees to continue outpatient treatment, has family or social support, and does not verbalize intent then the patient may be treated on an outpatient basis.

In adults, the differential diagnosis should include hypothyroidism or hyperthyroidism; anemia; bipolar disorder, and current episode depressed; and adjustment disorder with depressed mood. Routine laboratory studies should be completed to rule out hypothyroidism and any other medical conditions that could explain the current symptoms. Common symptoms of hypothyroidism are fatigue, depression, and weight gain.13 Common symptoms of hyperthyroidism are increased anxiety, weight loss, and fatigue.14 Fatigue from anemia can be confused with depressive symptoms. A complete metabolic panel needs to be completed to rule out any electrolyte imbalances.

It is imperative to assess for any history of hypomania or mania in the past (Table 3).⁸ Patients may have a history of bipolar disorder or an undiagnosed bipolar disorder and present with depressive symptoms. It is possible to induce mania or hypomania if an antidepressant is initiated in such patients.

Table 3. Signs and Symptoms of Hypomania and/or Mania⁸

Decreased sleep or need to sleep

Elevated, expansive, or irritable mood

Flight of ideas or racing thoughts

Grandiosity

Hyperverbal or pressured speech

Increased activity in general

Increased risky behavior such as overspending, sexual indiscretions, or poor financial decisions

Poor concentration

Symptoms need to be present for at least 1 week and present most of the day to meet the criteria for mania

Symptoms need to be present for at least 4 consecutive days for most of the day to meet the criteria for hypomania

Treatment of Depression

The American Psychological Association (APA) recommends that clinicians offer either psychotherapy or second-generation antidepressant in the first-line treatment of depression; a combination of these 2 strategies may also be used.¹⁵ Several medications are available for the treatment of depression in the primary care setting (Table 4).

Table 4. Medications Used to Treat Depression Among Adults in Primary Care

SSRIs	SNRIs
Citalopram	Desvenlafaxine
Escitalopram	Duloxetine
Fluoxetine	Levomilnacipran
Fluvoxamine	Venlafaxine
Paroxetine
Sertraline

The case patient had a positive response to paroxetine in the past but had significant weight gain. The patient should respond well to the other selective serotonin reuptake inhibitors (SSRI). She could also benefit from a serotonin-norepinephrine reuptake inhibitor (SNRI). Both SSRIs and SNRIs can decrease depressive symptoms as well as anxiety. Several SSRIs are weight neutral including fluoxetine, escitalopram, and sertraline.¹⁶

Nonpharmacologic Treatments for Adults With Depression

Effectiveness studies have shown similar effects across various forms of psychotherapy used to treat depression and the APA does not recommend one form over another.¹⁵ General models recommended by the APA include:

• Behavioral therapy
• Cognitive, cognitive behavioral (CBT), and mindfulness-based cognitive therapy
• Interpersonal psychotherapy
• Psychodynamic therapies
• Supportive therapy

Cognitive behavioral therapy has been found to be as effective as medication in some cases. The focus of CBT is to change distorted thinking. Cognitive behavioral therapy improves a person’s mood by teaching appropriate and healthy coping mechanisms, increasing self-confidence, addressing fears instead of avoidance, and teaching patients to manage their stress independent of the therapist.¹⁷

Follow-up and Discussion

The patient continues with weekly individual therapy with a social worker and is initiated on fluoxetine 10 mg once daily taken in the morning. She is asked to return to the clinic in 2 to 4 weeks.

At the follow-up appointment, the clinicians should assess the effectiveness of the medication, current mental status, suicidal ideation, and sleep pattern. If the patient is not having any adverse effects from the selected medication but is still reporting symptoms, the medication dose can be increased until symptoms resolve or the patient has adverse effects. If the patient cannot tolerate the first medication option, it is appropriate to change to another agent in the same class. If the patient fails 2 agents in the same class, it is appropriate to change to another class of medication such as an SNRI.¹⁸

Conclusion

The rising rates of depression stemming from the COVID-19 pandemic remain a major burden to overcome in the primary care setting. Screening for depressive symptoms can be part of the initial intake and subsequent visits in primary care. Education regarding the signs and symptoms of depression may be needed as people may not recognize their symptoms as those of depression. Patients may present with insomnia and not verbalize that they are feeling more irritable or have been isolating. Primary care providers can provide appropriate treatment including prescribing medication, referrals to a therapist, or in some cases referrals to a mental health provider. The pandemic led many patients to be neglectful of regular medical appointments. Now, these patients may be seeking treatment for the first time in 2 years. Being alert to possible symptoms associated with depression in all patients will help improve overall care.

The next installment in the mental health series will be on suicide. The first installment of this series “Anxiety in Children and Adults Ballooned in US at Start of COVID-19 Pandemic” is available here.

Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.

Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.

Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.

References

1. World Health Organization. Mental Health and COVID-19: Early evidence of the pandemic’s impact. Scientific brief. March 2, 2022. Accessed July 19, 2022. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1
2. Major depression. National Institute of Mental Health. Updated January 2022. Accessed July 20, 2022. https://www.nimh.nih.gov/health/statistics/major-depression
3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057.
4. Household pulse survey — anxiety and depression. Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed August 1, 2022. http://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
5. Centers for Disease Control and Prevention. Evaluating and caring for patients with post-covid conditions: interim guidance. Updated June 2021. Accessed April 28, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-workup.html
6. Han Q, Zheng B, Daines L, Sheikh A. Long-term sequelae of COVID-19: a systematic review and meta-analysis of one-year follow-up studies on post-COVID symptoms. Pathogens. 2022;11(2):269. doi:10.3390/pathogens11020269
7. Shah A, Bhattad D. Immediate and short-term prevalence of depression in COVID-19 patients and its correlation with continued symptoms experience. Indian J Psych. 2022;64(3):301-306. doi:10.4103/indianjpsychiatry.indianjpsychiatry_840_21 
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5thed, text revision. American Psychiatric Association; 2022. 
9. Patient health questionnaire-9 (PHQ-9). Accessed July 20, 2022. https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf
10. Interian A, Chesin M, Kline A, et al. Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to classify suicidal behaviors. Arch Suicide Res. 2018;22(2):278-294. doi:10.1080/13811118.2017.1334610  
11. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092
12. CAGE substance abuse screening tool. Johns Hopkins Medicine. Accessed July 2, 2022. https://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdfhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf.
13. Hypothyroidism (underactive thyroid). Mayo Clinic. November 19, 2020. Accessed July 20, 2022. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284
14. Hyperthyroidism (overactive thyroid). Mayo Clinic. Accessed July 20, 2022. https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/symptoms-causes/syc-20373659
15. Guideline Development Panel for the Treatment of Depressive Disorders. Summary of the clinical practice guideline for the treatment of depression across three age cohorts. Am Psychol. 2021 Nov 29. doi:10.1037/amp0000904
16. Gill H, Gill B, El-Halabi S, et al. Antidepressant medications and weight change: a narrative review. Obesity (Silver Spring). 2020;28(11):2064-2072. doi:10.1002/oby.22969
17. What is cognitive behavioral therapy? American Psychology Association. July 2017. Accessed July 23, 2022. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
18. Gelenberg AJ, Freeman MP, Rosenbaum J, et al. Practice guideline for the treatment of patients with major depressive disorder, 3rd Edition. American Psychiatric Association: 2010.  https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

From the Sept/Oct 2022 Issue of Clinical Advisor