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

Use this specialized guide for conducting evaluations during the pandemic.

CITE THIS
American Psychological Association. (2020, April 9). Is your patient’s anxiety or depression related to COVID-19? http://www.apaservices.org/practice/news/anxiety-depression-covid-19
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.

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:
  • 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.

Develop and document initial diagnostic impressions and case formulation

  • Consider other assessments, screening and the plethora of personal, family, work, financial and existential stressors.

Motivational interviewing

  • 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.

Treatment planning

  • 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.