This is the second installment of a 6-component series on mental well being troubles exacerbated by the COVID-19 pandemic. In this installment, the authors go over identifying and treating depression in youngsters and adults in key care.
A 35-year-old lady presents to a key care workplace complaining of depressed mood everyday, some anxiousness but not everyday, not sleeping effectively, and overeating when she is “stressed.” She reports that she is not interacting a great deal with good friends and loved ones and has not been working out as she has in the previous. The patient is a nurse in a healthcare-surgical unit at an urban hospital and has been caring for patients with COVID-19 more than the final 2 years. She also reports obtaining COVID-19 roughly 7 months ago. She was in a position to isolate and handle her symptoms on an outpatient basis.
The patient reports obtaining had depressive symptoms in the previous and that the symptoms decreased more than time but returned more than the final 6 months. She has been attending weekly person therapy with a social worker for the final 6 weeks with minimal improvement. In the previous, her symptoms have been efficiently treated with paroxetine, but she gained weight and does not want to restart this agent. She also notes obtaining problems falling asleep and not feeling rested in the morning. She sleeps roughly 5 hours per evening.
Her healthcare history is considerable for hyperlipidemia she does not at the moment take a lipid-lowering medication. Her loved ones history involves a mother with bipolar disorder (diagnosed at age 39 years) and a sister with depression (diagnosed at age 28 years). No loved ones history of suicide ideation or completions is reported.
Laboratory outcomes are typical and do not show any abnormalities that could clarify the present 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 variety: .5-4) |
| Triiodothyronine and cost-free thyroxine are required if thyrotropin is abnormal |
N/A |
| Urine drug screen | Negative |
| Vital indicators | Blood stress: 124/76 mm Hg Respiratory price: 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 seem to be attending to internal stimuli at the moment. She does not verbalize something that could be thought of delusional. She reports depressive symptoms for the final 6 months.
She describes her mood as sad and reports she is a great deal more tearful than she has been in the previous. She reports an boost in irritability and becoming quickly frustrated. The patient seems to have a depressed mood. She is going to work as scheduled but then comes household and isolates herself till bedtime. She is not interacting a great deal with her loved ones or good friends and has been declining invitations. She reports somatic complaints such as headaches and stomach aches and utilizes these somatic complaints to prevent carrying out issues. She reports anxiousness at occasions, normally when somebody is attempting to get her to do one thing she does not want to do.
She denies suicidal and homicidal ideations and has not had these thoughts in the previous. She denies any previous hypomania or mania immediately after becoming educated on the symptoms of these situations and denies any present or previous substance abuse. Her interest and judgment are intact and her speech is typical tone and price, with no pressured speech. Her insight on depression is fair, she will advantage from more education relating to illness course of action. The patient scores a 15 on the Patient Health Questionnaire (PHQ-9). She is diagnosed with recurrent important depressive disorder of moderate severity.
Discussion
The COVID-19 pandemic has had a extreme impact on the mental well being of persons in the US and globally. In the 1st year of the COVID-19 pandemic, the prevalence of anxiousness and depression enhanced by 25%, according to the World Health Organization.1
In 2020, an estimated 21. million US adults (or 8.4% of all US adults) had at least 1 important depressive episode.2 In roughly 14.8 million episodes, the impairment was extreme. The prevalence of depressive disorder was roughly 4 occasions higher in the 1st 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 could have been exaggerated by the technique of the study and the symptoms have been not lasting, proof suggests that the price of depressive issues enhanced with the onset of the COVID-19 pandemic.3
The most current information (June 29-July 11, 2022) from the Household Pulse Survey performed by National Center for Health Statistics and the US Census Bureau, shows that 10% to 37% of Americans report symptoms of depressive disorder, with these aged 18 to 29 years displaying the highest prices (Figure).4
In some instances, depression could be the outcome of isolation and enhanced strain faced through the COVID-pandemic. Research also suggests that depression is a single of the lots of symptoms of extended COVID.5
In a systematic evaluation and meta-evaluation of 1-year stick to-up information from 8591 patients with COVID-19, depression was reported in 23%.6 In an observational study of 273 patients in India, 12% of patients created depressive symptoms straight away (14-21 days) immediately after a positive COVID-19 test and 5% of patients created depressive symptoms roughly 3 months (90-97 days) immediately after a positive test.7 A higher quantity of COVID-19 symptoms at the time of diagnosis and comorbid diabetes mellitus have been related with a higher danger for depression.7
Diagnosing Depression
The patient interview is an crucial element of the initial assessment for depression and need to involve patient history as effectively as present healthcare and mental status (Table 2).8 Assessment tools involve 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 typical 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 crucial to clarify what “not sleeping well” suggests to the patient. Does she have problems falling asleep, staying asleep, or each? What time does she go to bed? What time she ordinarily gets out of bed in the morning? Does she take any more than-the-counter or prescribed drugs for sleep or has she in the previous? Does she drink alcohol or use any other substances to enable her sleep? Does she have a history of sleep apnea? If so, is she following the suggestions for sleep apnea remedy?
It is often crucial to assess for thoughts of suicide and previous suicide attempts or thoughts. If a patient presents with suicidal ideation, ask if the patient has a program. If the patient is actively obtaining suicidal ideation with a viable program, a security program ought to be produced ahead of the patient leaves the workplace. This could imply a transfer to an inpatient facility, so it is crucial to have a program in advance. Is it suitable to get in touch with 911, is there safety in the constructing, and what are the policies to commit a patient against their will? It is crucial to have these particulars understood prior to an emergency. If a patient is not actively suicidal, has neighborhood sources, agrees to continue outpatient remedy, has loved ones or social assistance, and does not verbalize intent then the patient could be treated on an outpatient basis.
In adults, the differential diagnosis need to involve hypothyroidism or hyperthyroidism anemia bipolar disorder, and present episode depressed and adjustment disorder with depressed mood. Routine laboratory research need to be completed to rule out hypothyroidism and any other healthcare situations that could clarify the present symptoms. Common symptoms of hypothyroidism are fatigue, depression, and weight get.13 Common symptoms of hyperthyroidism are enhanced anxiousness, weight loss, and fatigue.14 Fatigue from anemia can be confused with depressive symptoms. A full metabolic panel demands to be completed to rule out any electrolyte imbalances.
It is crucial to assess for any history of hypomania or mania in the previous (Table 3).8 Patients could have a history of bipolar disorder or an undiagnosed bipolar disorder and present with depressive symptoms. It is attainable 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 have to sleep |
| Elevated, expansive, or irritable mood |
| Flight of tips or racing thoughts |
| Grandiosity |
| Hyperverbal or pressured speech |
| Increased activity in common |
| Increased risky behavior such as overspending, sexual indiscretions, or poor monetary choices |
| Poor concentration |
| Symptoms need to have to be present for at least 1 week and present most of the day to meet the criteria for mania |
| Symptoms need to have 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 supply either psychotherapy or second-generation antidepressant in the first-line treatment of depression a mixture of these 2 methods could also be utilised.15 Several drugs are out there for the remedy of depression in the key 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 previous but had considerable weight get. The patient need to respond effectively to the other selective serotonin reuptake inhibitors (SSRI). She could also advantage from a serotonin-norepinephrine reuptake inhibitor (SNRI). Both SSRIs and SNRIs can lower depressive symptoms as effectively as anxiousness. Several SSRIs are weight neutral such as fluoxetine, escitalopram, and sertraline.16
Nonpharmacologic Treatments for Adults With Depression
Effectiveness research have shown related effects across several types of psychotherapy used to treat depression and the APA does not advise a single type more than one more.15 General models advised by the APA involve:
Cognitive behavioral therapy has been identified to be as powerful as medication in some instances. The focus of CBT is to transform distorted pondering. Cognitive behavioral therapy improves a person’s mood by teaching suitable and healthier coping mechanisms, rising self-self-confidence, addressing fears as an alternative of avoidance, and teaching patients to handle their strain independent of the therapist.17
Follow-up and Discussion
The patient continues with weekly person therapy with a social worker and is initiated on fluoxetine 10 mg as soon as everyday taken in the morning. She is asked to return to the clinic in 2 to 4 weeks.
At the stick to-up appointment, the clinicians need to assess the effectiveness of the medication, present mental status, suicidal ideation, and sleep pattern. If the patient is not obtaining any adverse effects from the chosen medication but is nevertheless reporting symptoms, the medication dose can be enhanced till symptoms resolve or the patient has adverse effects. If the patient can not tolerate the 1st medication alternative, it is suitable to transform to one more agent in the very same class. If the patient fails 2 agents in the very same class, it is suitable to transform to one more class of medication such as an SNRI.18
Conclusion
The increasing prices of depression stemming from the COVID-19 pandemic stay a important burden to overcome in the key care setting. Screening for depressive symptoms can be component of the initial intake and subsequent visits in key care. Education relating to the indicators and symptoms of depression could be required as persons could not recognize their symptoms as these of depression. Patients could present with insomnia and not verbalize that they are feeling more irritable or have been isolating. Primary care providers can provide suitable remedy such as prescribing medication, referrals to a therapist, or in some instances referrals to a mental well being provider. The pandemic led lots of patients to be neglectful of normal healthcare appointments. Now, these patients could be in search of remedy for the 1st time in 2 years. Being alert to attainable symptoms related with depression in all patients will enable increase all round care.
The next installment in the mental well being series will be on suicide. The 1st installment of this series “Anxiety in Children and Adults Ballooned in US at Start of COVID-19 Pandemic” is out there 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 system coordinator and master teacher of mental well being 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.
This short article initially appeared on Clinical Advisor
