Is your patient’s anxiety or depression related to COVID-19?
Use this specialized guide for conducting evaluations during the pandemic.
The COVID-19 pandemic has caused a significant spike in anxiety and depression — especially grief and loss — worldwide. With most Americans under stay-at-home orders, psychologists are seeking guidance on telehealth to ensure patient access to high-quality care. This guide offers a potential protocol for conducting diagnostic “intake” evaluations for adults with depression and/or anxiety during the coronavirus pandemic. This evidence-based guidance is helpful in interviewing patients for COVID-19 stressors, health behaviors and risk management, health-care access, and family and sociocultural factors.
In addition, there are two clinical templates available for psychologists to use or modify as needed.
- Adult Health History (Word, 27KB) is for the patient to complete before a telehealth session.
- Psychological Diagnostic Assessment (Word, 29KB) is for the clinician to complete during the evaluation with a patient.
Note: Over-arching rules for the assessment is to be genuine, express empathy and don’t over-pathologize.
Complete the following items pre-session
- Discuss the potential risks/benefits of telehealth sessions with the patient(s).
- Get a signed informed consent from your patient(s) or patient’s legal representative. If the psychologist or patient is quarantined, informed consent must be signed electronically; use encrypted email/messaging.
- Do you have a back-up plan in case of technical difficulties? In case of a crisis? What contact information do you have? Do you know the local resources (e.g., emergency room) located near the patient?
- Provide information on how the session will be billed, including whether the patient will be billed if late/no-show.
- Request that the patient complete the Adult Health History form and GAD-7 and PHQ-9 (PDF, 151KB) prior to session.
Begin the assessment
- Welcome patients to your virtual office just as you would your traditional office. Engage in whatever rapport building you normally do in session.
- Explain that you are doing telehealth services to keep you and them, and your friends/family safe during the COVID-19 crisis.
- Ask them to provide a brief summary of why they are seeing you.
Assess depression and anxiety
- Review patient’s current symptoms of depression and anxiety, referencing PHQ-9 and GAD-7 screening.
- Follow-up with open-ended questions to identify unhealthy cognitions and behaviors related to COVID-19.
- Identify if behaviors are (a) Avoidant or (b) Over-Compensation.
- Identify whether avoidance strategies produce anxiety and/or depression.
Assess social resources and stressors
- Review Adult Health History about social, work, financial situation. Confirm and ask follow-up questions as needed.
- Ask for 1-10 SUDS rating regarding current family work status.
- Review Adult Health History about family situation.
- Identify strengths and stressors regarding partner/spouse, children, extended family and others.
- Identify function of stress in relationships (e.g., survival/wellness, social contact, intimacy).
- Collect 0-10 rating of happiness/satisfaction for current family relationships (0 = worst; 10 = best).
- Consider social/cultural issues.
- Inquire about patient’s perception of their sociocultural identities and how sociocultural factors (e.g., race/ethnicity, housing, utilities, food access, transportation finances), and the intersection of those factors, affect their coping with COVID-19.
Assess medical health
See CDC recommendations of high-risk conditions for COVID-19.
- Conduct standard health/medical history.
Note: The risk for hospitalization or intensive care is about two and a half times higher if a patient has one or more chronic health conditions.
- Interview for diagnoses of known health disorders related to increased risks from COVID-19.
- Identify type of disease, course of disease and treatments. Examples below:
- Heart diseases (including hyperlipidemia)
- Lung disorders
- Chronic renal disease
- Chronic liver disease
- Other chronic disorders (based on CDC with prevalence at or above 5% of the sample = hypertension; thyroid disease; gastrointestinal disorder; cancer or history of cancer; rheumatologic disorder; hematologic disorder; obesity; nonrheumatoid arthritis; musculoskeletal disorder other than arthritis; urologic disorder; cerebrovascular disease; obstructive sleep apnea; fibromyalgia; gynecologic disorder; pulmonary or venous embolism)
- Cigarette smoking history and current status
- Assess if the patient has access to primary and specialty heath care, and any recent use.
- Identify primary care physician (Last visit? Available for telehealth?)
- Identify specialty physicians/providers (Last visit? Available for telehealth?)
- Assess for COVID-19 protective habits and knowledge.
- Has 30 day or more supply of medications?
- Frequent hand-washing?
- Physical distancing?
- Essential travel only?
- Is aware of most relevant COVID-19 symptoms? They are fever, dry cough, trouble breathing, muscle aches and tiredness. If the patient is not aware of these symptoms, the psychologist should provide education.
- Review COVID-19 stressors on Adult Health History form. Follow-up as needed.
Develop and document initial diagnostic impressions and case formulation
- Consider other assessments, screening and the plethora of personal, family, work, financial and existential stressors.
- Asking permission to discuss treatment planning.
- Ask open-ended questions to help them identify what’s most important in their life.
- Ask open-ended questions about how treating (anxiety/depression) could help achieving what’s most important.
- Ask open-ended questions about how treating (anxiety/depression) could have costs like initial increase in stress or use of patient’s time.
- Ask open-ended questions about willingness to try treatment for (anxiety/depression) related to the pandemic.
- If the patient expresses readiness to, move to treatment planning.
- If the patient is not ready to change or ready for psychological treatment, explore their rationale with empathy. Consider delaying treatment, recommending alternatives, and/or consult with colleagues as needed.
- Offer treatment recommendations — virtual vs. in-person format, frequency, expected duration, areas of focus, etc.
- Consider patient preferences.
- Review patient’s satisfaction with session.
- Ask patient for any questions.
- Schedule next session if the patient says yes to treatment.
This guidance is based on Skillings and Arnold’s 2016 “Holistic CBT” model of biopsychosocial & integrated care. It was adapted from a protocol developed by the Center for Cognitive and Behavioral Therapy and Central Ohio Primary Care.