Adjustment disorders: the state of the art

Adjustment disorders as a stress-related disorder: a longitudinal study of the associations among stress, resources, and mental health

OBJECTIVE

Adjustment disorders are re-conceptualized in the DSM-5 as a stress-related disorder; however, besides the impact of an identifiable stressor, the specification of a stress concept, remains unclear. This study is the first to examine an existing stress-model from the general population, in patients diagnosed with adjustment disorders, using a longitudinal design.

METHODS

The study sample consisted of 108 patients consecutively admitted for adjustment disorders. Associations of stress perception, emotional distress, resources, and mental health were measured at three time points: the outpatients' presentation, admission for inpatient treatment, and discharge from the hospital. To evaluate a longitudinal stress model of ADs, we examined whether stress at admission predicted mental health at each of the three time points using multiple linear regressions and structural equation modeling. A series of repeated-measures one-way analyses of variance (rANOVAs) was performed to assess change over time.

RESULTS

Significant within-participant changes from baseline were observed between hospital admission and discharge with regard to mental health, stress perception, and emotional distress (p<0.001). Stress perception explained nearly half of the total variance (44%) of mental health at baseline; the adjusted R2 increased (0.48), taking emotional distress (i.e., depressive symptoms) into account. The best predictor of mental health at discharge was the level of emotional distress (i.e., anxiety level) at baseline (β= -0.23, R2corr=0.56, p<0.001). With a CFI of 0.86 and an NFI of 0.86, the fit indices did not allow for acceptance of the stress-model (Cmin/df=15.26; RMSEA=0.21).

CONCLUSIONS

Stress perception is an important predictor in adjustment disorders, and mental health-related treatment goals are dependent on and significantly impacted by stress perception and emotional distress.

Efficacy of psychotherapy on diurnal cortisol patterns and suicidal ideation in adjustment disorder with depressed mood

AIMS

The aims were to examine the effects of psychotherapy on depressive and anxiety symptoms, the occurrence of suicidal ideations and diurnal cortisol patterns in patients with adjustment disorder (AD) with depressed mood.

METHODS

Participants recruited from an outpatient department of psychiatry at a general hospital were randomly assigned to one of two groups: 34 in psychotherapy group and 37 in control group. The control group consisted of one-session psychoeducation. Psychotherapy included the eight-weekly body-mind-spirit (BMS) group psychotherapy. Measures included Beck Depression Inventory-II and State Trait Anxiety Inventory. Salivary cortisol samples were collected from the patients at their homes on awakening; 30 and 45 min after awakening; and at 1200, 1700 and 2100 h. Measurements were taken at baseline and at months 2 (end of intervention), 5, 8 and 14.

RESULTS

There was no differential change over time between the BMS and control groups in self-reported depression or anxiety symptoms. However, suicidal ideation appeared to be reduced in the psychotherapy group. Changes in diurnal cortisol patterns were also significantly different in group × time interactions, in favor of BMS group.

CONCLUSIONS

Psychotherapy likely provides improvements in psychobiological stress responses and decreases the occurrence of suicidal ideation in patients with AD.

Common mental disorders in women and men in the first six months after the birth of their first infant: a community study in Victoria, Australia

INTRODUCTION

Studies of postpartum mental health have focused predominantly on women and on depression. There is limited evidence regarding men's postpartum mental health and about other common mental disorders, such as anxiety and adjustment disorders, which may also be relevant at this life phase. The main aim of this study was to establish the period prevalence of depression, anxiety, and adjustment disorders in primiparous women and their male partners in the first six months postpartum

METHODS

English-speaking couples were recruited in five local government areas in Victoria, Australia. Women and men completed separate telephone interviews which included the Edinburgh Postnatal Depression Scale (EPDS) and selected Depression and Anxiety modules of the Composite International Diagnostic Interview. DSM-IV criteria were used to classify adjustment disorders, based on subclinical symptoms not meeting criteria for diagnoses of major or minor depression or generalised anxiety disorder. The main outcome was any common mental disorder (depression, anxiety or adjustment disorder) in the first six months postpartum

RESULTS

Complete data were available for 172 couples. The 6-month period prevalence of mental health problems was 33% for women and 17% for men. The most common diagnosis in both women and men was adjustment disorder with anxiety symptoms

LIMITATIONS

Unpartnered women and men, women whose partners were not willing to participate and those who did not have sufficient English fluency to complete the interviews were excluded from the sample. The results of this study cannot be generalised to these populations.

CONCLUSION

The most common postnatal mental health problem in both women and men in this community sample was anxiety.

Day-to-day cause-effect relations between cellular immune activity, fatigue and mood in a patient with prior breast cancer and current cancer-related fatigue and depression

This study of a breast cancer patient with cancer-related fatigue (CaRF) and depression investigated the bidirectional cause-effect relations between cellular immune activity, fatigue and mood during 'life as it is lived'. The 49-year-old patient (breast cancer diagnosis 5 years earlier, severe CaRF and increase in depressiveness since then) collected her entire urine for 28 days in 12-h intervals (from 8 p.m. to 8 a.m. and from 8 a.m. to 8 p.m.; total: 55 measurements) for the determination of urinary neopterin (immune activation marker) and creatinine levels using HPLC. Furthermore, she completed questionnaires twice each day (at approx. 8 a.m. and 8 p.m.), which yielded information on mood (3-Skalen-Eigenschaftswörterliste [EWL]) and fatigue levels (visual analog scale [VAS]). Cross-correlational analyses showed complex connections between urinary neopterin concentrations and mood and fatigue in terms of direction of effect, temporal delay and response pattern. Increases in urinary neopterin levels significantly preceded increases in fatigue intensity with a temporal delay of 60-72h (lag 5: r=0.298; p=0.027), whereas increases in positive mood co-occurred with neopterin level increases (lag 0: r=+0.302; p=0.025) and preceded decreases in neopterin concentrations with a temporal delay of 132-144h (lag 11: r=-0.323; p=0.017). These results confirm and extend our previous findings and show that in order to obtain an adequate understanding of the dynamic relations among cancer-related variables, the characteristics of everyday-life conditions need to be considered.

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11

The diagnostic concepts of post-traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro- and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD-11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non-specific symptoms; a new complex PTSD category that comprises three clusters of intra- and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of "adjustment disorder" involving increased specification of symptoms; and a conceptualization of "acute stress reaction" as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low- and high-income countries.

Predictors of suicidal behaviour in 36,304 individuals sickness absent due to stress-related mental disorders -- a Swedish register linkage cohort study

Background

Stress-related mental disorders (SRMD), which correspond to the diagnostic code F43 in the International Classification of Diseases, version 10, rank among the leading causes of sickness absence in several European countries. Despite the size of this health problem, research on risk factors for severe medical outcomes, like suicidal behavior, is lacking to date. The aim of this study was to investigate predictors of suicide attempt and suicide among sickness absentees with SRMD.

Methods

A cohort of 36,304 non-retired individuals, aged 16–64 years on 31.12.2004, with at least one sickness absence spell due to SRMD, initiated in 2005, was followed up with regard to suicide attempt (2006–2009) and suicide (2006–2008). Univariate and multivariate hazard ratios (HR) with 95% confidence intervals (CI) were estimated for a number of predictors.

Results

During the follow-up period, 266 individuals attempted suicide and 34 committed suicide. In the multivariate analyses, the following factors increased the risk of suicide attempt: =< 25 years of age, low educational level, lone parenthood, > 1 sickness absence spell, long duration of the first spell of sickness absence due to SRMD (> 180 days), > 4 and > 8 days of inpatient care due to somatic or mental diagnoses (2000–2005), and > 4 and > 1 outpatient visits due to somatic or mental diagnoses (2001–2005), respectively. Hazard ratios ranged from 1.4 to 4.2. Health care due to mental diagnoses and > 1 spell of sickness absence regardless of diagnosis were predictive of suicide.

Conclusions

Several predictors related to socio-demographics, sickness absence and health-care consumption were identified as risk factors for suicidal behavior. Consideration of these risk factors is of both clinical and public health importance.

Classification issues and challenges in child and adolescent psychopathology

The major advances that have taken place over the last half century are reviewed with a focus on those that are particularly important with respect to classification issues in the field of child and adolescent psychopathology. Attention is paid to the conceptual issues in DSM and ICD development and differences between the two classifications. Specific recommendations for changes in ICD-11 are presented and an online supplement provides specific details with respect to diagnostic categories that are in need of further testing.

A nosological review of depressive disorders based on observations in clinical practice, part 1: Terminology and phenomenology

OBJECTIVE

The purpose of this paper is to describe the problems with the contemporary nosology of 'depression' and to discuss the key linguistic and phenomenological aspects that are essential prerequisites for a clinically meaningful typology of depressive disorders. The paper comprises observations and reflections drawn from clinical work.

CONCLUSIONS

First, the use of the unqualified, stock term 'depression' is counterproductive, as are the diagnostic non-entities of 'major depression' and 'dysthymia'. Second, the core psychopathology in melancholic depression is a loss of self-confidence, which helps explain the frequent co-occurrence of 'anxiety' with 'depression'. Third, descriptive, non-technical terms such as 'demoralisation' and 'grief' are most helpful in formulating non-melancholic forms of depression and thus useful in differential diagnosis.

Sickness absence due to specific mental diagnoses and all-cause and cause-specific mortality: a cohort study of 4.9 million inhabitants of Sweden

Background

Despite the magnitude and increase of sickness absence due to mental diagnoses, little is known regarding long-term health outcomes. The aim of this nationwide population-based, prospective cohort study was to investigate the association between sickness absence due to specific mental diagnoses and the risk of all-cause and cause-specific mortality.

Methods

A cohort of all 4 857 943 individuals living in Sweden on 31.12.2004 (aged 16–64 years, not sickness absent, or on retirement or disability pension), was followed from 01.01.2005 through 31.12.2008 for all-cause and cause-specific mortality (suicide, cancer, circulatory disease) through linkage of individual register data. Individuals with at least one new sick-leave spell with a mental diagnosis in 2005 were compared to individuals with no sickness absence. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated by Cox regression, adjusting for age, sex, education, country of birth, family situation, area of residence, and pre-existing morbidity (diagnosis-specific hospital inpatient (2000–2005) and outpatient (2001–2005) care).

Results

In the multivariate analyses, mental sickness absence in 2005 was associated with an increased risk for all-cause mortality: HR: 1.65, 95% CI: 1.47–1.86 in women and in men: 1.73, 1.57–1.91; for suicide, cancer (both smoking and non-smoking related) as well as mortality due to circulatory disease only in men. Estimates for cause-specific mortality ranged from 1.48 to 3.37. Associations with all-cause mortality were found for all mental sickness absence diagnostic groups studied.

Conclusions

Knowledge about the prognosis of patients sickness absent with specific mental diagnoses is of crucial clinical importance in health care. Sickness absence due to specific mental diagnoses may here be used as a risk indictor for subsequent mortality.

DSM-5: proposed changes to depressive disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is currently undergoing a revision that will lead to a fifth edition in 2013. Proposed changes for DSM-5 include the creation of several new categories of depressive disorder. Some nosologists have expressed concern that the proposed changes could yield many 'false-positive diagnoses' in which normal distress is mislabeled as a mental disorder. Such confusion of normal distress and mental disorder undermines the interpretability of clinical trials and etiological research, causes inefficient allocation of resources, and incurs risks of unnecessary treatment. To evaluate these concerns, I critically examine five proposed DSM-5 expansions in the scope of depressive and grief disorders: (1) a new mixed anxiety/depression category; (2) a new premenstrual dysphoric disorder category; (3) elimination of the major depression bereavement exclusion; (4) elimination of the adjustment disorder bereavement exclusion, thus allowing the diagnosis of subsyndromal depressive symptoms during bereavement as adjustment disorders; and (5) a new category of adjustment disorder related to bereavement for diagnosing pathological non-depressive grief. I examine each proposal's face validity and conceptual coherence as well as empirical support where relevant, with special attention to potential implications for false-positive diagnoses. I conclude that mixed anxiety/depression and premenstrual dysphoric disorder are needed categories, but are too broadly drawn and will yield substantial false positives; that the elimination of the bereavement exclusion is not supported by the evidence; and that the proposed elimination of the adjustment-disorder bereavement exclusion, as well as the new category of grief-related adjustment disorder, are inconsistent with recent grief research, which suggests that these proposals would massively pathologize normal grief responses.

Diagnosis of adjustment disorder: reliability of its clinical use and long-term stability

BACKGROUND

Adjustment disorder is a common diagnosis in mental health services. However, the diagnostic reliability and stability of this nosological construct are unclear.

SAMPLING AND METHODS

Clinical chart records of patients who had been discharged with a clinical diagnosis of adjustment disorder were re-evaluated by two independent raters using ICD-10 criteria. On the basis of the chart material, the frequency of readmissions and diagnostic changes were recorded.

RESULTS

Of 142 patients with a clinical diagnosis of adjustment disorder, only 91 (64.1%) retrospectively met ICD-10 criteria for this diagnosis. Eighteen of these 91 patients (19.8%) were readmitted to a mental health hospital within a 5-year period and 9 (9.9%) showed a diagnostic change at readmission, 5 of them to substance use disorders (5.5%).

CONCLUSIONS

The dramatic divergence between the clinical diagnosis and ICD-10 criteria challenges the validity and usefulness of the current nosological concept of adjustment disorder.