COVID-19 and Depression

Abstract

The COVID-19 pandemic embodies overwhelming stresses—unemployment, death, and isolation, among others. When called upon, clinicians must try to sort out demoralization from depression. This commentary discerns the characteristics of demoralization versus depression, and suggests solutions for both, together with a cautionary word on the use chloroquine and hydroxychloroquine in patients with COVID-19.

Like many Americans and others from around the world, I try to keep up to date on information about the COVID-19 pandemic. I was prompted to write this commentary by two headlines and several telephone calls and e-mails from colleagues and friends. These are the two headlines that recently caught my attention: “What We Must Do To Prevent a Global COVID-19 Depression"¹ and “COVID-19 Could Lead to an Epidemic of Clinical Depression, and the Health Care System Isn't Ready for That, Either."² By now there should be little doubt that this pandemic is causing immeasurable economic suffering for many, in addition to overwhelming the coping capacities of numerous people. Obviously, these two perspectives are intertwined. Yet at present we know nothing about any alterations of emotions or cognitive functioning from the direct effects of the virus on the brain per se.

The calls and e-mails generally were about this last point, or about informal advice on how to treat depression in patients with COVID-19. The following example describes a composite of several people.

A 40-ish woman (or man), now out of work and sheltering at home, says that after many days she is beginning to have trouble concentrating and is feeling little motivation to keep up with household tasks. She is easily frustrated. Her sleep is somewhat fragmented, and she feels drained of energy by late morning.

This truncated vignette raises the question: What is depression versus the consequences of what might be called “defeat stress” (ie, feeling unable to cope with adversity and make thing better)? Over the years, I have tried to teach about the importance of making this distinction.^{3 , 4} Defeat stress can lead to demoralization, a maladaptive response that is not likely to respond to antidepressants. Others have also made this distinction.5, 6, 7

The COVID-19 pandemic embodies many overwhelming stresses. A few of the obvious ones are loss of employment; deaths of family members, friends, or colleagues; financial insecurity; and isolation from others, particularly in those who live alone. When called upon, clinicians must try to sort out demoralization from depression. Demoralized persons benefit from encouragement and support and from engagement in any efforts that lead to a sense of mastery. Face-to-face contact with qualified mental health professionals is not likely to be readily available to all who need it. Clinicians, clergy, and friends who are familiar with the principles of cognitive–behavioral therapy may be able to be helpful through telephone, e-mail, or Internet-facilitated video contact. When those in need have no idea about whom to turn to, one possibility is the US Department of Health and Human Services' Disaster Distress Hotline (1-800-985-5990; or text TalkWithUs to 66746).⁸

When I was still treating patients, I used a few observations to support my decision making. If receiving good news or achieving mastery through problem solving or the completion of tasks did nothing to lift the spirits of a troubled person, and he or she had other signs and symptoms suggestive of depression, I would then carry out a defined, time-limited trial of an antidepressant about which I was knowledgeable. It is not appropriate for me to discuss the pros and cons of different antidepressants. Although he used the term “dispiritment,” Day⁹ provided a charming anecdote that further illustrates the distinction between demoralization and depression: If a dispirited person learned of a large inheritance, it would put him “right on the pig's back,” whereas in a seriously depressed person it would add to the guilt and sense of worthlessness.

I want to make one further point. There has been much touting of the use of chloroquine and hydroxychloroquine for the treatment of COVID-19 infections. Neither drug has been adequately tested to date, nor have I come across any discussion on the mental health dangers of these agents. In 1982, a colleague and I reviewed the behavioral side effects and lethality of chloroquine.¹⁰ Therapeutic doses of this agent have been linked to delirium, personality changes, psychosis, and depression.

We can only hope that leaders around the world realize that both economic depression and emotional depression/demoralization need to be addressed and given the attention and support they deserve. No remedies for either should be promoted without adequate evaluation of their risks and benefits.

Disclosures

The author has indicated that he has no conflicts of interest with regard to the content of this article.