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How did the rate of depression triple over a single month in 2020? In this episode you’ll learn how to distinguish clinical depression from normal stress, so you’re better prepared to take care of the 1 in 3 U.S. adults who are currently endorsing the DSM criteria. [Study Link]

Published On: 9/28/2020

Duration: 22 minutes, 7 seconds

Rough Transcript:

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Depression, alcoholism, opioid overdoses, internet addiction…. Psychiatric problems have gone up since the outbreak of Coronavirus. There are two reasons for this rise – the virus brings with it a wave of stressors, and infection with the virus has direct effects on the brain, causing a host of psychiatric disorders. In this month’s Carlat Report we featured an update by Paul Riordan from Duke on the CNS effects of coronavirus, including a handy table to help you classify and recognize the level CNS involvement. And in today’s podcast we’ll focus on the psychosocial effects.

In the month of April alone, the rate of depression in the US tripled – from 9 to 28% compared to the rates in 2017-2018. That’s according to a new study in JAMA psychiatry by Catherine Ettman and colleagues at Boston University. They used the PHQ-9 – a popular self-screening tool for depression – and compared the rates in over 6000 adults from two population studies – one from in 2017-2018 – and the other just after the outbreak in April 2020. These figures seem high, but they are consistent with the rates after other tragedies such as 9/11 and the Ebola outbreak, and the rates are even higher in studies of college students – where 1 in 2 had moderate to severe depression and 1 in 5 had suicidal thoughts after COVID. So far we’ve identified a few groups that are more vulnerable: younger adults, racial and ethnic minorities, essential workers, adults who are caregiving for a family member. This new study adds economic strain to the list…. And sadly it’s these patients who may fall out of the system because 65% of psychiatrists do not accept Medicaid and 45% don’t take even take commercial insurance.

Kellie: Yes but how do we know that’s real depression – I mean this was a self-screening instrument and it just be the culturally norm to endorse depression when the entire culture is under severe stress. Like when people greet they say “Hi how are you?” and the normal response is “I’m fine how are you” even if you’re not fine – but I think people feel more free to say they aren’t doing so great during this outbreak.

Dr. Aiken: That’s a good point and no doubt some of what they are picking up on is a normal stress reaction and not clinical depression, even if they did score above 10 on the PHQ-9. Waves of sadness and withdrawal are a normal part of life, and in times like these it may be a sign of health – a sign that people are seeing things clearly.

Kellie: I’m looking at the PHQ and it’s really just a list of DSM-5 symptoms – each one is rated 1-4. But we don’t diagnose psychiatric illness based on symptoms – no one has a psychiatric illness unless it causes significant distress or impairment.

Dr. Aiken: The PHQ-9 actually does have a final item that asks about functioning – how difficult do these symptoms make it to take care of responsibilities at work or home. But strangely in the final scoring that item is not necessary for the diagnosis. In practice, that would be the most important – and most difficult – step in diagnosing depression. But what we’re likely seeing here is an increase in normal stress reactions like adjustment disorder and depression – and the fact that people are more unhappy during a global disease outbreak is really not breaking news. What I’m interested in is: Is this outbreak causing true psychiatric illness. But I looked closer at the data and it looks like it is.

Kellie: What do you mean?

Dr. Aiken: Honestly, I was expecting most of the increase to be in the milder cases that might be normal stress. But no. When they broke it down by severity, the increase in depression got steeper as the symptoms got more severe. Let me read you the numbers – I’ll round up to simplify:

• Mild depression: 2 fold higher
• Moderate depression: 3 fold higher
• Moderately severe depression: 4 fold higher
• Severe depression: 8 fold higher

The PHQ instrument does acknowledge that some of the depression it picks up may not warrant treatment – but based on prior research with the PHQ once the score is in the moderately severe or severe range they’ve found that treatment is almost always warranted – and this is where we see the 4 to 8 fold increase.

Kellie: The PHQ is available free online along with a similar screen for anxiety – the GAD-7 – at www.phqscreeners.com. And if you want to run a culturally sensitive practice, go to that website. They’ve translated it into 100 different languages and dialects. But back to stress and depression – I am seeing a lot of patients come in feeling worse – how do you distinguish between normal stress and clinical depression in times like these?

Dr. Aiken: Well, I have a definition of depression that’s a little different from the DSM, although I borrowed it from the editor of DSM-4. In 2013 he wrote a book criticizing what he saw as the overexpansion of psychiatric diagnosis in DSM-5, Saving Normal. Kelly can you read what he wrote here:

Kellie: “We can feel sadness, grief, worry, anger, disgust and terror because these are all adaptive. At times, our emotions may temporarily get out of hand and cause considerable distress or impairment. But homeostasis and time are great natural healers, and most people resiliently right themselves and regain their normal balance. Psychiatric disorder consists of symptoms and behaviors that are not self-correcting – a breakdown in the normal homeostatic healing process.”

Dr. Aiken: So he’s suggesting that we all have the symptoms of mental illness – irritability, depression, insomnia – even hallucinations can occur in normal people – and that what characterizes mental illness is not the symptoms but the lack of adaptation – in other words it’s when those depressive symptoms are no longer an adaptive response to life that it’s clinical depression. Now, it’s a lot easier to run a symptom check list like they did in this study than to meaningfully assess whether someone is adapting well to life.

Kellie: So how would you do that – right now – during COVID.

Dr. Aiken: COVID presents certain stressors – job loss, isolation, health fears. I’d ask if they were looking for a job, if they were trying to find creative ways to connect with people during quarantine.

Kellie: But what if they can’t find a job or can’t find anyone to connect with?

CA: Then we’re moving into the arena of learned helplessness – which is a model of depression that’s fairly consistent with Frances’ definition. It’s based on a classic experiment where a mouse was kept in a cage and the floor of that cage delivered constant electric shock. The mouses’ first reaction is not to give up or get depressed – it’s to try hard to escape. After a while though it just lays there and gives up – and at that point the mouse has all the physiologic and behavioral symptoms of depression. It has learned to be helpless.

Kellie: Or you could say it’s smart and just conserving its energy.

Dr. Aiken: Yes, but here’s where we see that the depression is not adaptive. The researchers then raise the bars so the mouse can escape, and it doesn’t even try anymore. So its hopelessness is pervasive, and unrealistic. That’s a very sad story, and we want to look for traces of that story in our patients when we diagnose depression. Are they giving up in all areas when they’ve only lost in one? And can they see a way out when the bars are lifted?

Kellie: So if a person can’t find a job or any social connection – I would ask if they’ve made any positive changes to their life during COVID. Being home bound is awful, but it’s also a time to start a new hobby, like I’ve seen patients take up gardening, musical instruments, home cooking, reading, even genealogy. Or if getting a job is really critical and they don’t have any leads, I’d want to know if they’re taking online courses to build new skills.

Dr. Aiken: The way that symptoms change over time is also really important. That’s why the DSM has that 2 week cut off for depression – because it may be normal to stay in bed and withdraw for a few days after a major stress. Someone who does that is likely to change on their own – because after a while it gets boring and you’re going stir crazy and want to take action. That’s a healthy feedback loop – what Dr. Frances called homeostasis – which is the tendency of the body to maintain balance. So the more you drink water, the less you want to drink it. The more you stay in bed, the less you want to withdraw. Nearly physiologic system operates through homeostasis – there are a few exceptions that are rare events like blood clotting, child birth, and ovulation – and Frances is suggesting that mental illness is really a breakdown of homeostasis. When homeostasis breaks down people stop responding to their environment – they stop adapting – that’s what clinical depression is to me.

Kellie: I get that, because homeostasis is like the body’s natural defense against depression, and when that breaks down the person is going to need outside help – whether therapy of medication.

Dr. Aiken: Yes. Homeostasis breaks down in other mental illnesses too – in addiction where satiety is never reached; panic disorder where they become afraid of panic attacks which just causes more attacks and more fear. When homeostasis breaks down in depression the patient stops changing – they are unmoving much like the mouse in that cage – they react to every situation in the same few ways – anxiety, defeat, rejection – and they no longer learn from their environment. Behind that break down is a change in thinking, judgment, and problem solving – it’s not just that they feel bad – but that their mind is no longer working like it used to. Most of my patients with chronic depression are able to tell when it’s reached that level. You know, people with chronic depression do have a lot of stress in their lives, so they often feel bad, so it helps to clarify with them that depression is not defined by feelings.

Kellie: Yes I’ve noticed that people with mood disorders can become afraid of their own feelings – as if every bout of anger or sadness is going to trigger a new episode. But we know from mindfulness research that – when people accept their inner state and allow their feelings to come and go without judging them – it lowers their change of going back into depression.

Dr. Aiken: Yes. Many patients have been told they have an emotional disorder or are too emotional, and they appreciate this kind of education because it’s less stigmatizing – it’s also empowering because it gives them something to do. They are no longer passive victims of depression. If they see early signs coming on, they can intervene early before the self-correcting homeostatic loops break down. The best early intervention is to do the opposite of what your emotions are guiding you to do – to get active and try new things, take on risks, instead of avoiding.

Kellie: OK so back to this research – perhaps it’s better to say that 30% of people are showing early signs of depression during COVID – because at that stage they may be having the symptoms but they can still function and act wisely so they don’t sink further.

Dr. Aiken: Exactly. And you’ve hit on something very important there. You can’t diagnose depression with a snap shot of symptoms. You need to know how they are changing over time – if they are getting better – even if it’s slow – then there’s probably some self-correcting homeostatic mechanism at play and you don’t need to intervene. Things are moving in the right direction.

Kellie: When patients come in with a lot of symptoms after a major stress I’ll often ask them: “Do you think the way you’re feeling is going to get better with time – can you see a light at the end of the tunnel or do you feel like you’re sinking no matter what?”

CA: That’s a great question. And most patients have a good sense of that. Sometimes though I will see someone who keeps saying “it’s not depression, it’s just stress… it will get better” and yet they look worse and worse at each visit. It helps to track that – and the PHQ9 is a great tool to track symptoms I run a modified version of it at every visit – What I’ll do is show the person their graph and say “Look, at each visit you’ve said it’s only temporary, but your symptoms are steadily getting worse month by month. I’m wondering if we need to do something different to turn this around – and that might be a medication change or it could be a change in your lifestyle or starting psychotherapy.”

Kellie: Why do you use an adapted version of the PHQ9?

Dr. Aiken: There’s a movement to use more “patient centered outcomes.” The PHQ-9 is research centered – you’ll notice that every item on it corresponds to one of the DSM criteria for depression. That’s great for making standardized diagnoses, but patients don’t really care if they fit in the DSM categories or not – they have their own goals in mind and so we should be rating that as we follow their progress. Now, on the other hand we do want the rating to match somewhat with the DSM because we need to track symptoms that are likely to change with the medication. Anyway, that’s just a long way of saying that….

Kellie: Yes yes get to the point so how did you change the scale.

CA: Two things. The PHQ9 does not rate anxiety, and for patients with depression anxiety is often what bothers them the most. Now, anxiety tells us nothing about the diagnosis, but it is a good measure of progress. Also the PHQ9 doesn’t have a good measure of functioning. So I added one in: “Trouble making decisions, concentrating, planning, or organizing” – That measure is very interesting because I’ve noticed that when people come in under stress – but are not clinically depressed – they’ll rate depression and anxiety very high but they won’t have any indecision or concentration problems. See, acute stress sharpens your concentration – as it should – because you need to be sharp and decisive when the slings and arrows are coming at you. To make that even more patient centered – just ask the patient “If this treatment works for you, what do you want to see get better” and rate that.

Kellie: Still, from the numbers in this study it looks like depressive symptoms are on the rise for everybody – and they are rising even more for those with clinical depression. I find little consolation in these figures, and little reason to be optimistic about the mental health of the population.

Dr. Aiken: I agree, but I’m an eternal optimist and do see some hope.

Kellie: What’s that?

Dr. Aiken: COVID is showing us that we’re all in the same boat – people with depression are not weird or lazy or bad – it’s something we’re all prone to. So while that’s bad for the general population, it may offer some solace for those who’ve been stigmatized for having this disorder. And that can show up in a lot of ways – you know people with depression hate having to fake it everytime someone greets them with “Hey, how’s it going;” but during these COVID times it’s OK to be real and say “Thanks for asking. It’s not going so great.”

Kellie: OK, so you’re likely to see a lot of people come in with elevated distress during COVID – whether you measure that with the PHQ-9 or GAD-7 or just ask them. But the PHQ-9 is just a screening instrument; it tells us that the person might have depression, but we have to do the more difficult work of figuring out if they really do. That means we need to ask how they are living day to day and how they are managing stress – we need to get a sense of their judgment and problem-solving ability – and ultimately figure out if the problem is likely to resolve on its own or needs our intervention.

Kellie: And now for the word of the day…. Depression

Dr. Aiken: Depression was first used in medicine by cardiologists in the 1800’s, who used it to describe a reduction in cardiac function. Psychiatrists soon adopted it and it first appeared in medical dictionaries in the 1860’s where it was defined as “lowness of spirits in persons suffering under disease.” The word caught on, in part because it suggested a physiologic cause, and because it suggested the opposite of mania, which is how this mood disorder came to be conceptualized in the late 1800’s: “Depression is the state opposed to excitation. It consists of a reduction in general activity ranging from minor failures in concentration to total paralysis,” read an 1885 textbook by Emmanuel Regis, and here’s a sample of the colorful ways that psychiatrists described depression before the DSM locked in the 9 criteria that we know it by today:

Kellie: Sinking of the spirits, lack of courage or initiative, tendency toward gloomy thoughts, sleep is diminished, unrefreshing.

Dr. Aiken: The depression of cardiac function was duly noted:

“peripheral circulation is sluggish, the extremities cold and cyanotic. The pulse is small, of low tension, sometimes slowed. The heart-sounds are muffled. “

Dr. Aiken: And these authors emphasized the impairments of executive functioning that marked the illness:

“The patient is indifferent towards everything, and the execution of the simplest act necessitates an effort so great at times that the patient gives up the attempt. There is very marked weakening of the attention and a considerable sluggishness of the associations of ideas. All intellectual exertion, such as the narration of an event well known to the patient or a small calculation, is impossible or can be accomplished only after repeated and painful efforts. Though the lucidity is intact, the perceptions are incomplete, uncertain, and often inaccurate. The patient feels that he is changed, ill, and it seems to him that his mind is paralyzed.”

Dr. Aiken: Join us next week for a special patient edition of the podcast – “The Patient’s Guide to Lithium” – an audio guide you can share with your patients.

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