Is your patient’s anxiety or depression related to COVID-19?

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.

• 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.

• 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.

• 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.

• 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.

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:

• Diabetes
• Heart diseases (including hyperlipidemia)
• Lung disorders
• Immunocompromised
• Chronic renal disease
• Pregnancy
• Neurologic/neurodevelopmental
• 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.

• 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.