Depression in Patients: Helping Those Who Have Lost So Much

From the wildfires decimating California to the tornados and hurricanes in the Gulf States to the novel coronavirus taking tens of thousands of lives and leaving others with significant physical and emotional losses, 2020 is shaping up to be a year when many people could lose everything—or feel like they have.

“Americans are now grappling with one of the worst unemployment rates in recent history, added to social isolation in order to comply with physical distancing recommendations and topped off with the unfolding communal unrest regarding systemic racism and police brutality,” testified Jeffrey Geller, MD, MPH, president of the American Psychiatric Association to the U.S. House Committee on Energy & Commerce’s Subcommittee on Health. 

“Each of these situations alone would generally increase the feelings of anxiety, depression and other mental health and substance use disorders for many Americans,” he continued. “When combined, these factors produce alarming statistics.”

Although Geller provided information from earlier in the pandemic, more recent data reported by the Centers for Disease Control and Prevention in August 2020 produced some startling insights into the magnitude of the mental health problem in this country. 

The COVID-19 pandemic has led to more than 30 percent of the nation feeling depressive or anxiety symptoms, and 10.7 percent having recent thoughts about suicide, according to the CDC-reported study. 

“This COVID health crisis has had a major impact on us, medically, socially, economically, and it has disrupted our lives and daily routines,” said Susan J. Noonan, MD, MPH, at Massachusetts General Hospital in Boston, and the author of four books, including Helping Others with Depression: Words to Say, Things to Do. 

Uncertainty about life, fear of contracting the virus, isolation from friends and healthcare providers, lack of routine and purpose—all of these can lead to depression and concern about the future, Noonan said. 

Yet physicians can help their patients through this. 

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Start with screening for depression

“Given the global stresses of COVID, screening for depression is vital,” said Ruth M. Brocato, MD, a primary care provider specializing in family medicine at Mercy Personal Physicians at Lutherville, Maryland. “Screening for depression can and does save lives.”

The U.S. Preventive Services Task Force recommends screening adults for depression, with validated tools and “with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” 

“Screening for depression is extremely valuable for overall patient care and well-being,” said Robert Winston, MBA, MSW, LCSW, vice president of behavioral health at Jersey City Medical Center in New Jersey. “Often, depressive symptoms are under-recognized and underreported by both the provider and the patient.”

Winston added that mental health influences physical health. For example, in a person with diabetes, low-level depressive “symptoms can impede their ability to manage their nutrition, therefore leading to episodic diabetic crises.” 

Screening can be as quick as a couple of questions, such as, “Are you feeling down, depressed or hopeless?” and “Have you lost interest in doing things you formerly enjoyed?” according to the American Academy of Family Physicians, which indicates screening can be woven into routines, with office and rooming staff asking the questions. 

Brocato said that simply asking “How are you?” or saying “You do not look yourself,” can provide an opening to talk about depression. 

Patients also may present with irritability, anger, or changes in sleep or diet, Noonan said. 

The Centers for Medicare & Medicaid Services reimburses for annual depression screening, as do some commercial insurers. 

Treat or refer

“Depression is most definitely treatable,” Noonan said.

Winston suggested a primary care physician, or PCP, “spend time with the patient exploring the issues,” if the screening indicates depression.

“An empathetic, normalizing approach should be maintained to assist the patient with mitigating any perceived stigma associated with mental health issues and the exploration should also include the providers’ concern for appropriate support for the patient,” Winston added. “Options such as psychotropic medication, clinical evaluation by a psychiatrist and psychotherapy should be introduced so the patient may understand the appropriate course of treatment.”

Support during treatment can benefit most people, even those with situational depression, Winston added. 

Brocato manages most of her patients with depression herself but refers to specialists if basic medication management is not successful or the patient needs emergency access to care. She also recommends therapy.  

“Most primary care physicians are quite comfortable managing basic depression and anxiety,” Brocato said. Also, “often there are numerous physical symptoms connected to depression/anxiety, and it can take some time to dig deeper to find the root cause.”

Jeffrey Huttman, Ph.D., chief clinical officer for iRecovery in Boca Raton, Florida, on the other hand, recommends “a PCP refer patients with symptoms of depression, either due to the individual’s self-disclosure or the result of standardized screening measures, be referred to a behavioral health specialist.”

Winston agreed that a referral to a psychiatrist is indicated if the PCP is not familiar with mental health treatments.

“Mental health conditions should be addressed in the same manner as a provider would refer to another specialist to ensure the patient receives the best care,” Huttman said. “The exception to this is when specialized providers are not available due to the patient’s lack of access, such as residing in a remote geographic area in which there are no psychiatrists accepting new patients.”

However, a 2019 review article in Current Psychiatry Reports indicated that a majority of patients with depression are treated in the primary care setting with only a minority referred to mental health professionals. Patients tend to prefer psychotherapy, which can be performed by the physician or other healthcare professional in the office. 

Self-care advice also can help patients. Remind depressed patients about the importance of healthy eating, getting enough rest, exercise, reading to escape, avoiding excessive alcohol, and creating new routines. But remain mindful that a depressed person may find self-care difficult to do.

Ted Sun, Ph.D., DM, president of Transcontinental University in Dublin, Ohio, suggested depressed patients should reflect on their own emotions, focus on something positive and make a positive action plan. 

In some practices, behavioral health professionals have been co-located with primary care, making hand-offs easy. Other practices may network within the greater community. 

Noonan recommends working as a team. 

“There is value in having an established relationship between a PCP and psychiatrist and a psychotherapist, so the PCP feels comfortable in screening every patient and knows they have a support system in place when a screening indicates a potential for depression or other mental health concern,” Winston added. 

Even before the pandemic, telehealth visits for mental health issues were gaining in popularity. It’s provided in the privacy of the patient’s home and eliminates the stigma of going into a mental health provider’s office. 

“The social stigma surrounding mental health often serves as an impediment from receiving the best care,” Huttman said. “But the support and recommendation of a primary physician may be essential in helping the patient to overcome this.” 

Sources:
Screening Your Adult Patients for Depression - AAFP
Psychological Treatment of Depression in Primary Care: Recent Developments - Current Psychiatry Reports
Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — the United States, June 24–30, 2020 – CDC’s Morbidity and Mortality Weekly Report

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