Vol. 11 •Issue 4 • Page 51
Adjustment Disorder with Depressed Mood
A Review of Diagnosis and Treatment
Adjustment disorder is a disabling mental health problem that is a common diagnosis in inpatient and outpatient settings.
The essential defining feature of adjustment disorder is the development of significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor.1 These symptoms develop within 3 months of the onset of the precipitating stressor.1 The subjective distress or impairment in functioning associated with adjustment disorder is frequently manifested as decreased performance at work or school, or temporary changes in social relationships.1
Between 5% and 20% of patients receiving outpatient mental health treatment have a primary diagnosis of adjustment disorder.1 People from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for this disorder.1 Other risk factors for adjustment disorder may be the recent diagnosis or exacerbation of a physical illness, changes in work responsibilities, recent loss and family discord.
Adjustment disorder is also common in the inpatient consultation liaison setting, where it has an estimated incidence of 5% to 21%, according to one study.2 Another study examined the consultation liaison services of seven university teaching hospitals in the United States, Canada and Australia. The researchers used a common clinical database to examine 1,039 consecutive referrals and found that 125 patients (12%) had been diagnosed with adjustment disorder. Adjustment disorder was the sole diagnosis in 81 patients (7.8%) and co-existed with other Axis I and Axis II diagnoses in 44 patients (4.2%).3
Case Example
“Barbara” is a 35-year-old single African-American woman self-referred to the emergency department at a busy urban hospital for feelings of hopelessness and being fearful of these feelings. The patient reported that she had been feeling “stressed” and could not stop crying. Her feelings of being “down in the dumps” had been present for about 2 months.
Barbara was recently fired from her job as a nursing assistant and now stays in bed most of the day watching television. She gets up only to eat or use the restroom. The patient said she had gained 10 pounds over the past 5 weeks. She reported decreased social interactions and activities, but was still attending church on Sundays and talking on the telephone with friends and relatives every evening.
Barbara attributed her stress and depressed mood to the following: getting fired from her job as a nursing assistant due to a charge of stealing; difficulty disciplining her 11-year-old son, who is chronically truant from school; arguing with her live-in boyfriend about bills; and difficulty falling asleep due to “thinking about everything.”
When asked how she typically deals with stressful situations, Barbara talked about how she was raised to “just figure it out” and not dwell on things. The patient said her father drank alcohol to calm down and avoid tension and that her family never really discussed their problems.
Barbara said that when dealing with anxiety-producing situations, she usually smokes more cigarettes, has a glass or two of wine, and eats more than usual. She said she was aware that her current coping techniques were not therapeutic.
Barbara has no prior history of psychiatric treatment and reported no family history of mental illness. She said her grandfather was an alcoholic and that hypertension and type 2 diabetes ran on both sides of the family. Barbara takes no medication and reported having no acute medical issues. She denied the use of illicit drugs and reported drinking a glass of wine on the weekends. Barbara has been smoking half a pack of cigarettes a day for the past 15 years. She rarely receives health care due to lack of insurance.
Barbara’s mental status exam was as follows: 35-year-old African-American woman dressed casually. She is clean and appears her stated age. She is overweight. Her gait is steady. No psychomotor retardation or agitation. Her mood is “stressed” and she states, “I feel like I’m at the end of my rope.”
Affect is full range. Speech is within normal limits, and her thoughts are organized and goal-directed. Barbara denies paranoia and does not endorse any delusions. She denies auditory and visual hallucinations. She denies current suicidal and homicidal ideation. Barbara further reports that she came to the hospital for help because she wants to learn how to deal with her “stress.”
The physical exam was unremarkable and the results of her laboratory data were within normal limits (CBC with differential, renal and hepatic profiles, urinalysis, drug screen and thyroid-stimulating hormone). The provider made a diagnosis of adjustment disorder with depressed mood, and Barbara made an appointment with the outpatient mental health clinic the next day.
Diagnosis
The diagnosis of adjustment disorder can be difficult to determine. The provider must examine the patient’s behavior and assess whether it is beyond the normal range expected in the particular situation.4 The diagnosis of adjustment disorder with depressed mood should be made when the predominant manifestations are symptoms such as depressed mood, tearfulness or feelings of hopelessness.1 To meet the established criteria for adjustment disorder with depressed mood, the development of emotional or behavioral symptoms in response to an identifiable stressor or stressors must present within 3 months of the stressor’s onset.
The symptoms of adjustment disorder are clinically significant, evidenced by marked distress in excess of what would be expected from exposure to the stressor or by significant impairment in social or occupational (academic) functioning. The symptoms of adjustment disorder cannot represent the symptoms of bereavement. The symptoms of adjustment disorder also cannot meet the criteria for another Axis I disorder, such as major depressive disorder, or the criteria for an Axis II disorder, such as borderline personality disorder.1 Adjustment disorder does not continue longer than 6 months after the stressor or stressors (or its consequences) have been terminated.5
Management
The treatment of choice for adjustment disorder is a combination of counseling and psychotherapy. Several therapeutic modalities exist, but brief, solution-focused therapy and crisis intervention are most appropriate. These therapeutic modalities are cost-effective, brief and help the patient understand his or her situation. The goal of therapy is to help the patient develop and use problem-solving skills to cope with difficulties.
Counseling and psychotherapy can be provided by a psychiatrist, psychiatric mental-health nurse practitioner, psychiatric clinical nurse specialist, psychologist, licensed clinical counselor or master’s-prepared social worker. The difference between counseling and psychotherapy is that counselors mainly offer advice and aid in problem-solving, whereas psychotherapists investigate the psychosocial and dynamic issues involved and use a specific psychotherapeutic modality such as family therapy, supportive psychotherapy or crisis intervention in conjunction with counseling strategies.
Counseling and psychotherapy aid the patient in pinpointing his or her own stressors and identifying ways to allay and decrease the anxiety and dysphoria associated with them. Counseling and psychotherapy help the patient maintain control and a sense of equilibrium during stressful situations; help the patient explore several options with consideration of possible outcomes; and offer continued support.
The therapist can suggest ways to manipulate the patient’s stressors in the environment, social situations, family and so on. Therapists encourage the patient to use strategies and coping skills that have been helpful in the past.
Treatment for adjustment disorder is based on the understanding that it stems from an overwhelming psychological reaction to a stressor. The stressor or stressors need to be identified, described and shared with the patient. A strategy to mitigate the stressor or stressors is needed. Atypical responses may be attenuated if the stressor can be eliminated or reduced.4
The duration of treatment for adjustment disorder depends on the patient’s specific situation, level of functioning prior to the stressor, social supports, and several other factors, but typically therapy is short term.
When a patient with adjustment disorder presents in a primary care setting, it is important for you to collaborate with other mental health care providers to ensure optimal care. Consult with a psychiatrist, psychiatric-mental health NP or psychiatric CNS for correct diagnosis and pharmacologic management. Additionally, collaboration with mental health professionals aids in proper referrals for the patient — to individual, group, brief or long-term therapy, or case management services.
In one study, patients with adjustment disorder were referred significantly more often for problems with anxiety, coping and depression than patients with other Axis I or Axis II disorders and required a similar amount of clinical time.5
In the case of Barbara, she had multiple stressors that she was able to identify. The purpose of counseling in this scenario would be to aid the patient in her coping skills, her organization and with self-esteem issues. Barbara could also benefit from counseling and psychotherapy, which would allow her to vent about her current stressors to a “neutral” person who could give non-biased opinions, recommendations and, of course, reassurance.
Pharmacotherapy
Pharmacologic treatment is indicated for adjustment disorder when symptoms continue or worsen, even with counseling and psychotherapy. Medications should never be used as the primary treatment for adjustment disorder. Their appropriate use is in conjunction with counseling and psychotherapy when needed.
The medications of choice are the selective serotonin reuptake inhibitors (SSRIs). SSRIs are considered first-line treatment for depression in the primary care setting. SSRIs are safe and easy to use due to their once-daily dosing. They have the ability to target specific symptoms other than depressed mood. For example, SSRIs may also be used to treat symptoms such as anxiety, poor concentration and insomnia. Certain SSRIs, such as fluoxetine (Prozac) and sertraline (Zoloft), tend to be more activating, whereas paroxetine (Paxil) is generally sedating and can be optimal for patients with sleep deprivation.6
Other antidepressants to consider are nefazodone, mirtazepine and venlafaxine. Tricyclic antidepressants may be considered if the side effects of SSRIs or the previous medications cannot be tolerated.
However, tricyclic antidepressants are rarely used as a first-line medication for depressive symptoms due to their potential for unfavorable side effects such as urinary retention, constipation, dry mouth and blurred vision.
Your primary care patient with adjustment disorder requires your ongoing collaboration with his or her mental health providers. You can monitor the patient for any adverse side effects to medications and assess general health and overall appearance as indicators of patient improvement.
Differential Diagnoses
Other diagnoses to consider when assessing for adjustment disorder are major depressive disorder, dysthymia, bereavement, post-traumatic stress disorder and personality disorders. These conditions have distinguishing characteristics; see the Diagnostic and Statistical Manual of Mental Disorders for specifics.1 It is important to make an accurate diagnosis because the course and treatments for each of these conditions are quite different.
Precise Diagnosis Needed
Adjustment disorders are stress related-phenomena in which psychosocial stressors result in the development of maladaptive states and psychiatric symptoms. Adjustment disorders are common and require intensive psychotherapeutic involvement to allay the stressor and enhance coping.5 The condition is presumed to be time-limited, and the symptoms decrease when the stressors are removed or a new state of adaptation is defined.4
Although adjustment disorder is considered a mild psychiatric disorder and rarely the cause of prolonged work dysfunction or disability, it can often impair work function and increase the risk of suicide attempt.1 Some patients with adjustment disorder may become clinically depressed if they do not receive early and proper treatment.5 Accurate assessment can be performed by taking a thorough history that includes input from caregivers, performing a physical examination, obtaining laboratory data and, most importantly, collaborating with qualified mental health professionals.
Precise diagnosis of adjustment disorder can prevent the development of other mental health disorders and can be effectively treated with nonpharmacologic and pharmacologic measures.
References
1. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Vol. IV. Washington, D.C.: American Psychiatric Association; 1994.
2. James R, Yates WR, Williams S, Zhou M, Hardman L. Outline for adjustment disorders with depressed mood. Journal of Affective Disorders. 1999;55(1):5-16.
3. Snyder S, Strain J, Wolf D. Differentiating major depression from adjustment disorder with depressed mood in the medical setting. General Hospital Psychiatry. 1990;12:139-149.
4. Tasman A, Kay J, Lieberman J. Pocket Companion to Accompany Psychiatry. Philadelphia: W.B. Saunders; 1998:406-407.
5. Strain SJ, Smith GC, Hammer SJ, et al. Adjustment disorder: a multi-site study of its utilization and interventions in the consultation-liaison psychiatry setting. General Hospital Psychiatry. 1998;5(20):139-149.
6. Feldman M. Managing psychiatric disorders in primary care. Depression. 2000;35(6):75-90.
Jennifer Sampang is a psychiatric-mental health nurse practitioner practicing in the department of psychiatry at St. Elizabeth Medical Center in Edgewood, Ky.
Table 1 Symptoms of Major Depressive Disorder
• Depressed mood
• Loss of pleasure from activities that previously were pleasurable
• Significant weight changes
• Insomnia or hypersomnia
• Fatigue or loss of energy
• Feelings of worthlessness
• Excessive guilt
• Diminished concentration
• Thoughts of death
• Psychomotor retardation or agitation
Table 2 DSM-IV Criteria for Adjustment Disorder
Development of symptoms in response to identifiable stressors:
• Onset is within 3 months of stressor
• Marked distress that is in excess of what would be expected
• Social or occupational impairment
• Symptoms do not meet criteria for another Axis I or Axis II disorder
• Symptoms do not represent bereavement
• Once the stressor is terminated, symptoms do not persist for more than 6 months
