COVID-19: Special Topics | The Impact of COVID-19: A Teenage Boy with Depression
Rachel Zuckerbrot, MD
Associate Professor of Clinical Psychiatry at Columbia University Irving Medical Center/New York State Psychiatric Institute
Families with children who have experienced depression face unique challenges during this stressful time. The ongoing COVID-19 pandemic has added more stress on families, and many who have children with special needs are feeling the effects of a significant change in routines, structure, and no longer having the same access to special education supports and services as they did pre-pandemic. One change that often follows treatment disruption is that patients return to their pediatric primary care providers to rebuild the care team and create an effective treatment plan. The following is a case example:
One month into the COVID-19 crisis, the 16-year-old boy’s mother called their pediatric office frantic. Her son ,who had been experiencing mild mood and worry issues for the last couple of years, was now suffering and in increasing distress. Being forced to stay home and do schoolwork online had really exacerbated the situation. And his therapist, with whom he had started treatment a couple of months ago, had stopped seeing him once the COVID-19 pandemic started in mid-March. The teen was sleeping late and not doing his work. He was easily annoyed by his family who had backed off from asking him to participate in school or family activities. The pediatrician asked a few questions, and decided that the patient was safe based on mom’s report of no suicidality. The pediatrician then called the Project TEACH warm line asking for a referral to a psychiatrist as soon as possible.
The warm line was answered by one of Project TEACH’s liaison coordinators, all of whom are trained mental health professionals. When taking down the information about the patient’s zip code and insurance, the liaison coordinator suggested a phone consultation with the on-call Project TEACH Child and Adolescent Psychiatrist (CAP). The Project TEACH CAP explained that it may be a while before the patient could get an appointment with a psychiatrist covered by the patient’s insurance, and that it seemed that the patient needed help now.
The pediatrician was happy to speak with the Project TEACH CAP, who suggested that the pediatrician meet with the patient via telehealth in order to assess the severity of the situation. The Project TEACH CAP was able to walk the pediatrician through a mental health telehealth appointment, including suggestions on how to get the patient to have privacy in the home, a common problem in the age of COVID-19. The pediatrician was directed to the Project TEACH website at www.projectteachny.org in order to prepare depression and anxiety rating scales for the teen to complete at his visit. The Project TEACH CAP helped the pediatrician choose the appropriate scales– in this case the GAD-7 and PHQ-9 modified for teens.
The pediatrician called back the Project TEACH warm line after the telehealth visit, grateful for the initial phone consultation. While reviewing the scales, the pediatrician was surprised to see that the patient said he had tried to commit suicide in the past. During the virtual visit, the patient spoke of experiencing suicidal ideation as well as cutting, and while denying current suicidal intent, was endorsing many symptoms of depression and anxiety. The Project TEACH CAP determined that the situation was much more urgent than originally thought, but did not think the patient warranted emergency treatment.
A Face-to Face consultation via telehealth was arranged with the Project TEACH CAP only nine days after the pediatrician’s first call asking for a referral for this patient. The Project TEACH CAP met first with the parents and then with the teen.
Going through the DSM-5 criteria for depression and reviewing the severity and frequency of symptoms, the Project TEACH CAP was able to determine that the boy was suffering from a current severe episode of Major Depressive Disorder overlaid on top of his chronic mild-to-moderate anxiety disorder. He had lost his appetite, could not concentrate, felt guilty and hopeless, was extremely fatigued and sad, and had daily thoughts of being better off dead. He was using marijuana but denied other substance use. The patient denied any recent suicide attempts or any current plans. The family was in distress too, unable to figure out how to help him.
Following the virtual Face-to-Face consultation, the Project TEACH CAP directed the pediatrician to the GLAD PC guidelines– (https://pediatrics.aappublications.org/content/141/3/e20174081 and https://pediatrics.aappublications.org/content/141/3/e20174082 ) — as well as the GLAD PC toolkit www.gladpc.org.
Following the treatment algorithm for MDD, severe, an SSRI was suggested by the Project TEACH CAP, and teletherapy referrals given. The pediatrician was also directed to handouts from the toolkit that could help with educating both the patient and family about depression and treatment options, as well as handouts that can help monitor symptoms and treatment response. Given the acuity of the situation and the family distress, a referral was made to the local HBCI, Home Based Crisis Intervention Services.
While the HBCI services are virtual at this time, they had im- mediate availability to work with the teen and his parents in their home to help contain the crisis and prevent hospitalization while the teen awaited his outpatient psychiatry appointment.
A phone call by the Project TEACH CAP to the pediatrician, as well as a prompt written consultation report, following the Face-to-Face virtual consultation enabled the pediatrician to choose an SSRI, in this case fluoxetine, and design a titration schedule up to the minimum therapeutic dose of 20 mg. The HBCI team helped contain the acuity of the situation, relieving the anxiety of the pediatrician as well as the parents.
Take home lessons:
- The Project TEACH child and adolescent psychiatrist can be helpful in those cases that the pediatrician thinks a referral is necessary.
- Assessing the child directly is important when it is the parent calling for help.
- Assuring patient privacy even in the age of telehealth appointments should be stressed.
- Rating scales can reveal a lot about a patient and help direct the conversation.
- The GLAD PC guidelines and toolkit should be consulted in cases of teen depression.
- The Project TEACH website has useful resources addressing depression and anxiety for parents and family members