Although not the norm, many individuals and families without pre-existing conditions, psychosocial vulnerabilities, and with the good fortune to have been able to avoid contagion, have in some cases done well and in certain respects have been able to do well emotionally during the lockdown and upheaval of the past year.  

This week’s newsletter discusses two disparate groups of the population that have had different overall responses to the pandemic, with recognition that the group data does not apply to all individuals in the groups — some in the negatively impacted group have done well, and some in the favorably impacted group have struggled and suffered mightily.       

Adults with Alcohol Use Disorder:

In adult populations, various studies have found increased rates of depressive and anxiety symptoms (Zeytinoglu et al., 2021; Pere-Cano et al., 2020) since the start of the pandemic. There have further been findings of disproportionate negative impacts on adults with substance use disorders. 

More recently, one study has delved into increased rates of alcohol (Kilgore et al., 2021).  In particular, the authors found that for adults who experienced “lock-down”, the rates of problematic alcohol use, or likely dependence increased with each month.  During the period from April to September 2020, adults experiencing lockdown showed increased rates of problematic and harmful alcohol use (as rated by the AUDIT questionnaire) from 21.0% in April to 40.7%.  Notably, those adults in the study who were not under significant restrictions did not show an increased rate.

This drives home the complex balance and, at times the countervailing pressures, between the societally critical public health ordinances and their impacts on physical well-being and mental well-being of various groupings of patients.  While more research is needed, it is clear that while primary care and mental health settings must find strategies to support our vulnerable communities with both outreach services and supports.   In retrospect, it is further suggested that population-focused strategies to screen for substance use difficulties might help those experiencing higher behavioral health risk because of public health restrictions. 

Adolescents:

Acknowledging again that individual responses may vary from large group collective data, it is remarkable to report that early findings from various population surveys note that adolescents as a group have fared much better during the pandemic than other age groups.  Data reported on by Professor Jean Twenge, Ph.D., of SDSU’S Department of Psychology, at the recent Critical Issues in Child & Adolescent Mental Health conference drawn from US Census Bureau Survey studies show the previously noted increased in behavioral health concerns for adults during the pandemic, with a 30% increase in recognized mental health conditions for the general population and a 40% increase for parents with minor children in the home. Anxiety screening with the GAD2 showed 30-35% increases in levels of anxiety during the pandemic and surveys for both depression and anxiety clearly demonstrated that depressive and anxiety symptomatology tracked closely with Covid surges over the past year. 

However, for teens (as a whole), the data was markedly different with a reversal of trends dating from around 2012–the time that cell phones became accessible and ‘indispensable’ for most American teens– showing increases in depression, self-injury incidents resulting in ER visit, and significant sleep deprivation in the absence of a pandemic and its social and environmental sequela.   Mood disorders in teens during the past decade have been at peak levels in the range of 18-20% prevalence, but these rates did not increase over the past year as many would have predicted.

The comparison for sleep deprivation in teens from 2018 (50% reported as sleep deprived) versus 2020 (@ 15%) is particularly notable.   Not surprisingly, family time was increased for 70% of those surveyed—most parents (even if stressed themselves) appear to be OK to be around for most adolescents.   The absence of in-person social interactions was apparently compensated for by sustained (and increased) vise chat time, access to positive video shows, video gaming and social media interactions. 

Even in the context of the loss of in-person school instruction and activities, the data showed little evidence of population data to suggest increased negative mental health responses in teens—sadly, it would appear that most teens find school, whether in person or remote, is not a favored activity and in both circumstances it is associated with significant stress. 

Why the favorable data?   What protective factors were in play for adolescents?  Time away from school pressures (it is not really a fun place for most kids), a slower pace of life with opportunity to follow their natural diurnal rhythms (up late but sleeping later and longer), and not, for most, being challenged economically as the case for their parents and many striving to be independent 20-30 yo, all are thought to have served teens well, in spite of the obvious challenges of the year.          

Takes homes from the data include:

1)     Better sleep is associated with happier and healthier adolescents

2)     Later school start times make sense

3)     iPhones don’t belong in bedrooms after ~ 10:00 or earlier as “vamping” into the wee hours is not good.

4)     TV time in the evening is better than an iPhone diet.

5)     Interpersonal time with parents, siblings and others really is healthy.

6)     Efforts to improve the quality of the school experiences of youth in junior and senior high schools ought to be a priority and a focus on providing both improved education and ongoing social-emotional support should be pursued.

7)     While the aggregate data is positive, youth with pre-existing behavioral health, psychosocial stressors and other vulnerabilities need special consideration and services.  

CDC Coping with Stress Resources:

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

 San Diego County Treatment Guide: https://www.sandiegocounty.gov/content/sdc/hhsa/programs/bhs/alcohol_drug_services/dmc_ods_consumer.html

Killgore WDS, Cloonan SA, Taylor EC, Lucas DA, Dailey NS. Alcohol dependence during COVID-19 lockdowns. Psychiatry Res. 2021 Feb;296:113676. doi: 10.1016/j.psychres.2020.113676. Epub 2020 Dec 25. PMID: 33385782.

Ornell, F., Moura, H. F., Scherer, J. N., Pechansky, F., Kessler, F., & von Diemen, L. (2020). The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry research, 289, 113096. https://doi.org/10.1016/j.psychres.2020.113096

Pérez-Cano HJ, Moreno-Murguía MB, Morales-López O, Crow-Buchanan O, English JA, Lozano-Alcázar J, Somilleda-Ventura SA. Anxiety, depression, and stress in response to the coronavirus disease-19 pandemic. Cir Cir. 2020;88(5):562-568. English. doi: 10.24875/CIRU.20000561. PMID: 33064695.

Zeytinoglu, S., Morales, S., Lorenzo, N. E., Chronis-Tuscano, A., Degnan, K. A., Almas, A. N., Henderson, H., Pine, D. S., Fox, N. A. (2021) A Developmental Pathway from Early Behavioral Inhibition to Young Adults’ Anxiety During the COVID-19 Pandemic. Journal of the American Academy of Child and Adolescent Psychiatry. doi: 10.1016/j.jaac.2021.01.021

Twenge, J; The mental health of youth and their parents during the pandemic; presentation at 6^th Annual CICAMH conference, 3/19/21; San Diego

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression, if that is being considered, and it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use), and duloxetine (because of limited data in children and adolescents). It is important to consider a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So for example if considering fluoxetine, a starting dose of 10mg qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.