Pharmacotherapy of adjustment disorder: A review

Adjustment Disorder Presenting as Syncope in a Patient With Wolf-Parkinson White Syndrome

Adjustment disorder encompasses maladaptive emotional, behavioral, and physiologic symptomatology that is related to an identifiable psychosocial stressor. Adjustment disorder manifesting as syncope in a patient with Wolf-Parkinson White (WPW) Syndrome is uncommon and has not previously been documented in medical literature. In this case, we discuss a 24-year-old male with a history of WPW who presented with unexplained, episodic syncope in the setting of acute life stressors. A patient with no prior neurologic or psychiatric history was referred to the hospital for more than 15 unexplained syncopal episodes in the preceding week. The patient was confirmed to have WPW based on EKG interpretation, but cardiac work-up, including telemetry, troponins, and orthostatic vital signs, were within normal limits. Additionally, WPW was ruled out as the cause of syncope since there were no cardiac electrophysiologic changes during the syncopal episodes. While in the hospital, the patient had episodic syncopal episodes every three to four hours, with no identified triggers or patterns. A thorough seizure work-up consisting of EEG and neurological consultation was normal. After discussion with psychiatric services, the patient was diagnosed with adjustment disorder in the setting of significant psychosocial stressors following a recent legal arrest. The patient was discharged with escitalopram and was instructed to follow up closely with cardiology for cardiac event monitoring. This case report illustrates the importance of considering psychosocial factors when creating a differential diagnosis for syncope.

"I was very sad, but not depressed": phenomenological differences between adjustment disorder and a major depressive episode

Introduction

Adjustment disorder (AD) is a diagnosis that must be differentiated from major depressive episode (MDE) because of the therapeutic implications. The aim of this study is to understand the experience of patients who in their lifetime have been diagnosed with AD as well as MDE to establish the characteristics of each disorder.

Methods

A descriptive phenomenological approach was used with in-depth interviews to four patients and the method proposed by Colaizzi to understand the experiences and reach the description of both disorders.

Results

Three women and one man, with advanced schooling were interviewed. The participants emphasized the existence of differences that were grouped in: the attribution made by the individual, the theme of cognitions, the variability in the course, the possibility of mood modulation, the syndrome severity, the presence of hopelessness and the perceived course.

Conclusion

Phenomenological differences were found in the subjective experience of MDE and AD. The MDE would be described as an intense state of generalized shutdown of the subject's own life, with little response to events, and the AD, as a dynamic reaction attributed to a stressful event, with high variability in the course of symptoms due to the dependence on such event, with the preserved hope that it will end.

Liaison psychiatry before and after the COVID-19 pandemic

INTRODUCTION

the COVID-19 pandemic had an impact on hospital admissions. The clinical profiles of patients referred to liaison psychiatry teams (LPT) remained stable over the last few decades. We postulate changes in patient profiles due to the COVID-19 pandemic.

MATERIALS AND METHODS

a total of 384 patients admitted to a tertiary care University Hospital in Madrid (Spain) and referred to LPTs were recruited. Patients referred 5 months before and after the first admission for COVID-19 were included. Clinical and sociodemographic characteristics were collected, and non-parametric hypothesis contrast tests were used to study possible differences between both periods.

RESULTS

patients referred during the pandemic were significantly older (U = 2.006; p = .045), most of them were admitted to medical hospitalization units (χ2 (2) = 5.962; p = 015), and with a different reason for admission. There was an increase in the rate of adjustment disorders (χ2 (1) =7.893; p = 005) and delirium (χ2 (1) =9.413; p = 002), as well as psychiatric comorbidity (χ2 (2) = 9.930; p = .007), and a reduction in the proportion of patients treated for substance misuse (χ2 (5) = 19.152; p = .002). The number of deaths increased significantly (χ2 (1) = 6.611; p = .010). In persons over 65 years inappropriate prescription was significantly lower (χ2 (1) = 8.200; p = .004).

CONCLUSIONS

the pandemic had an impact on the activity of the LPTs due to the change in the clinical profile and evolution of referred patients, maintaining standards of care that are reflected through prescription.

When Is Being Sad on the Burn Unit Pathological? Differential Diagnosis of Demoralization, Adjustment Disorder and Major Depressive Disorder in Burn Survivors

Many burn survivors have pre-existing psychiatric conditions or develop psychological or psychiatric symptoms over the course of their hospital stay. Patients often present with low mood and neurovegetative symptoms which can be conceptualized as demoralization, adjustment disorder, or major depressive disorder. We review the literature on these syndromes in burn survivors and present three cases that highlight the continuum of these syndromes for patients who present with symptoms of depression following a burn injury. We discuss the clinical challenges of differentiating these syndromes as well as psychotherapeutic and psychopharmacologic considerations and recommendations.

Differential effects of the translocator protein 18 kDa (TSPO) ligand etifoxine and the benzodiazepine alprazolam on startle response to predictable threat in a NPU-threat task after acute and short-term treatment

RATIONALE

Benzodiazepines have been extensively investigated in experimental settings especially after single administration, which mostly revealed effects on unpredictable threat (U-threat) rather than predictable threat (P-threat). Given the need for pharmacological alternatives with a preferable side-effect profile and to better represent clinical conditions, research should cover also other anxiolytics and longer application times.

OBJECTIVES

The present study compared the acute and short-term effects of the translocator protein 18 kDa (TSPO) ligand etifoxine and the benzodiazepine alprazolam on P-threat and U-threat while controlling for sedation.

METHODS

Sixty healthy male volunteers, aged between 18 and 55 years, were randomly assigned to receive a daily dose of either 150 mg etifoxine, 1.5 mg alprazolam, or placebo for 5 days. On days 1 and 5 of intake, they performed a NPU-threat task including neutral (N), predictable (P), and unpredictable (U) conditions, while startle responsivity and self-reports were studied. Sedative effects were assessed using a continuous performance test.

RESULTS

Neither alprazolam nor etifoxine affected startle responsivity to U-threat on any of the testing days. While etifoxine reduced the startle response to P-threat on day 1 of treatment for transformed data, a contrary effect of alprazolam was found for raw values. No effects on self-reports and no evidence of sedation could be observed for either drug.

CONCLUSIONS

None of the anxiolytic substances had an impact on startle potentiation to U-threat even after several days of intake. The effects of the anxiolytics on startle responsivity to P-threat as well as implications for future studies are discussed.

COVID-19 and mental health: challenges and first conclusions

Under the conditions of the COVID-19 pandemic, a rapid change in the epidemiological situation, and introduced quarantine measures, there are conditions for a sharp deterioration in the mental health of a wide range of people. There are specific stressors that negatively affect mental health; there are population groups that are more vulnerable to psychological stress and the development of pathological psychological defense reactions; there is a sharp rise in the number of cases of heterogeneous mental disorders (depression, anxiety, post-traumatic stress disorders, etc.) among the population and healthcare workers in the foci of infection. The manifestation or exacerbation of mental illness in turn contributes to the spread of viral infection and is associated with a more frequent development of somatic complications and a poor prognosis. The practical problem is to choose effective psychopharmacological agents for the relief and treatment of mental disorders, by taking into account the need to combine the agents with antiviral drugs in somatically weakened COVID-19 patients.

[Diagnosis and treatment of adjusment disorder in primary care]

Adjustment disorder (AD) corresponds to the combination of affective, cognitive and behavioral symptoms that appear after a stressful event. It is a frequent reason for consultation in primary care and is one of the most common diagnoses in suicide attempts attended in the emergency department. Its essential feature is that the symptoms must appear in direct relation to an event perceived as stressful, so it tends to be transitory if the event ceases or the patient adapts. The mainstay of treatment are psychosocial interventions, aimed at modifying the event or its consequences, supporting adaptation and optimizing resources to cope with the event. However, prescription of psychotropic drugs is favored in practice, when its use should be limited to symptomatic relief. This highlights the need to properly identify and treat it. This article presents the strategies for diagnosis and treatment of AD in primary care.

Etifoxine is non-inferior than clonazepam for reduction of anxiety symptoms in the treatment of anxiety disorders: a randomized, double blind, non-inferiority trial

OBJECTIVE

To determine whether etifoxine, a non-benzodiazepine drug of the benzoxazine family, is non-inferior compared with clonazepam in the treatment of anxiety disorders.

METHOD

A randomized controlled double blind trial with parallel groups was conducted. A total of 179 volunteer patients with a diagnosis of anxiety disorder (DSM-IV), between 18 and 64 years of age, participated in this study. The experimental group received 150 mg/day of etifoxine and the control 1 mg/day of clonazepam, both in three daily doses for 12 weeks. This treatment was completed by 87 participants, and 70 were available for follow-up at 24 weeks from start of treatment. The primary objective was a non-inferiority comparison between etifoxine and clonazepam in the decrease of anxiety symptoms (HAM-A) at 12 weeks of treatment. Secondary outcomes included the evaluation of medication side effects (UKU), anxiety symptoms at 24 weeks of treatment, and clinical improvement (CGI). Data analysis included multiple imputation of missing data. The effect of etifoxine on the HAM-A, UKU, and CGI was evaluated with the intention of treatment, and a sensitivity analysis of the results was conducted. Non-inferiority would be declared by a standardized mean difference (SMD) between clonazepam and etifoxine not superior to 0.31 in favour of clonazepam.

RESULTS

Using imputed data, etifoxine shows non-inferiority to clonazepam on the reduction of anxiety symptoms at the 12-week (SMD = 0.407; 95% CI, 0.069, 0.746) and 24-week follow-ups (SMD = 0.484; 95% CI, 0.163, 0.806) and presented fewer side effects (SMD = 0.58; 95% CI, 0.287, 0.889). LOCF analysis shows that etifoxine is non-inferior to clonazepam on reduction of anxiety symptoms and adverse symptoms even when no change was assigned as result to participant whom withdrew. Non-inferiority could be declared for clinical improvement (SMD = 0.326; 95% CI, - 0.20, 0.858).

CONCLUSION

Etifoxine was non-inferior to clonazepam on reduction of anxiety symptoms, adverse effects, and clinical improvement.

[Problems of mental health in the situation of COVID-19 pandemic]

The WHO declared COVID-19 pandemic, the deterioration of the epidemic situation in Russia, the lockdown and the growing fear in society caused by panic rumors and misinformation spread on social networks and the media pose urgent organizational and medical tasks for our psychiatric service. Based on the experience of other countries that have already encountered the massive spread of COVID-19, the author presents a review of the proposed urgent and preventive organizational and treatment measures and suggests practical recommendations on urgent temporary reorganization of the psychiatric service, and the provision of psychological and psychotherapeutic support to the most vulnerable groups of the population, including medical personnel working with patients with COVID-19, and the management of mentally ill patients with severe acute respiratory syndrome. As the primary goals, it is proposed to separate the flows of people in need of psychological support and psychiatric care, and organize the remote provision of these services (hotline phones and telemedicine consultations). Particular attention is paid to the management of mentally ill patients with coronavirus respiratory syndrome and the characteristics of psychopharmacological therapy with an overview of the potential risks of side-effects and complications related primarily to respiratory function, including those due to adverse drug interactions.

Association of Early Treatment With Chronicity and Hazard of Hospitalization After New Adjustment Disorder

OBJECTIVE

This study aimed to examine the effect of early treatment with psychotherapy or psychoactive medications on later hospitalizations for patients with a new diagnosis of adjustment disorder.

METHODS

Commercial claims data from Truven Health MarketScan were used. Patient-level propensity score matching was performed, and the authors fit an inverse probability of treatment weighting to a Cox proportional hazard model.

RESULTS

Early receipt of psychoactive medication instead of psychotherapy was associated with an increased hazard of later psychiatric hospitalization (hazard ratio [HR]=2.61, 95% confidence interval [CI]=2.07-3.28) and overall hospitalization (HR=1.12, 95% CI=1.04-1.21). Specifically, benzodiazepines were associated with increased hazard of later psychiatric hospitalization (HR=1.59, 95% CI=1.02-2.51), which did not differ from medications overall. In contrast, early receipt of psychotherapy was associated with a small decrease in the hazard of later psychiatric hospitalization (HR=0.85, 95 % CI=0.73-0.99) but had no effect on overall hospitalizations.

CONCLUSIONS

Early medication treatment for adjustment disorder was associated with greater overall and psychiatric hospitalization compared with no early medication treatment. This study suggests that an observed provider preference to use medications to treat patients who have comorbid physical illness may have deleterious long-term effects.

Pharmacological management of depression: Japanese expert consensus

BACKGROUND

Clinically relevant issues in the real-world treatment of depression have not always been captured by conventional treatment guidelines.

METHODS

Certified psychiatrists of the Japanese Society of Clinical Neuropsychopharmacology were asked to evaluate treatment options regarding 23 clinical situations in the treatment of depression using a 9-point Likert scale (1="disagree" and 9="agree"). According to the responses of 114 experts, the options were categorized into first-, second-, and third-line treatments.

RESULTS

First-line antidepressants varied depending on predominant symptoms: escitalopram (mean ± standard deviation score, 7.8 ± 1.7) and sertraline (7.3 ± 1.7) were likely selected for anxiety; duloxetine (7.6 ± 1.9) and venlafaxine (7.2 ± 2.1) for loss of interest; mirtazapine for insomnia (8.2 ± 1.6), loss of appetite (7.9 ± 1.9), agitation and severe irritation (7.4 ± 2.0), and suicidal ideation (7.5 ± 1.9). While first-line treatment was switched to either an SNRI (7.7 ± 1.9) or mirtazapine (7.4 ± 2.0) in the case of non-response to an SSRI, switching to mirtazapine (7.1 ± 2.2) was recommended in the case of non-response to an SNRI, and vice versa (switching to an SNRI (7.0 ± 2.0) in the case of non-response to mirtazapine). Augmentation with aripiprazole was considered the first-line treatment for partial response to an SSRI (7.1 ± 2.3) or SNRI (7.0 ± 2.5).

LIMITATIONS

The evidence level of expert consensus is considered low. All included experts were Japanese.

CONCLUSIONS

Recommendations made by experts in the field are useful and can supplement guidelines and informed decision making in real-world clinical practice. We suggest that pharmacological strategies for depression be flexible and that each patient's situational needs as well as the pharmacotherapeutic profile of medications be considered.

Metacognitive Therapy for Adjustment Disorder in a Patient With Newly Diagnosed Pulmonary Arterial Hypertension: A Case Report

Adjustment disorders (ADs) belong to the worldwide most diagnosed mental disorders and are particularly frequent in patients with an underlying physical illness. Pulmonary arterial hypertension (PAH) is a severe and disabling disease, which significantly impacts on quality of life and has high mortality rates. The authors here present the case of a young female who developed a severe adjustment disorder with both anxious and depressive symptoms after a diagnosis of PAH requiring intensive care treatment due to right heart failure. Psychosocial functioning was severely impaired, and physical health reduced. Following hemodynamic stabilization and the establishment of PAH treatment, the patient was admitted to the Department of Psychiatry, Social Psychiatry and Psychotherapy and received metacognitive therapy (MCT). AD with mixed anxiety and depressed mood was diagnosed according to DSM-V criteria. At the start of treatment, she reported significant mental distress, indicated by a total sum score of the Hospital Anxiety and Depression Scale (HADS) of 20 points. The 6-min walking distance was only 358 m before the patient was exhausted. She then was treated with MCT without further psychopharmacological drugs. After only four MCT sessions, she fully remitted from AD which was accompanied by an 11-point reduction in the HADS (to 9 points). MCT specific scores also improved (MCQ-30 sum score decreased from 77 to 35). Notably, physical capacity improved as well, documented by an improved walking distance (439 m; +22%). This is the first case of a patient with AD in the context of PAH treated with MCT. The case report suggests that MCT is a possible psychotherapeutic treatment option for AD in the context of a potentially life-threatening disease. The study design does not permit an attribution of outcome to MCT but it suggests MCT is a potentially viable and acceptable treatment option.

Pharmacotherapy of psychiatric inpatients with adjustment disorder: current status and changes between 2000 and 2016

Adjustment disorder is a temporary change in behaviour or emotion as a reaction to a stress factor. Therapy consists of psychotherapy, and pharmacotherapy can be advised. However, data on the real-life pharmacological treatment are sparse. Prescription data for 4.235 psychiatric inpatients diagnosed with adjustment disorder in the time period 2000-2016 were analysed. The data were obtained from the Drug Safety Programme in Psychiatry (AMSP). Data were collected on two reference days per year; prescription patterns and changes over time were analysed. Of all patients, 81.2% received some type of psychotropic drug. Mostly antidepressants (59.8%), antipsychotics (35.5%), and tranquilisers (22.6%) were prescribed. Prescription rates for antidepressants decreased slightly over the years, while rates for antipsychotics increased, especially for atypical antipsychotics. It is important to note that the diagnosis "adjustment disorder" is most likely a working diagnosis that is used for patients in immediate need of psychiatric aid. Overall, pharmacotherapy for inpatients with this diagnosis is mostly symptom-oriented and focuses on depressive moods, agitation and anxiety. Therapy regimes changed over time and show an increased use of atypical antipsychotics with sedative properties. However, for most of the medication, there are neither evidence-based studies nor guidelines, and drugs might be contraindicated in some cases.

An update on the anxiolytic and neuroprotective properties of etifoxine: from brain GABA modulation to a whole-body mode of action

Treating the signs and symptoms of anxiety is an everyday challenge in clinical practice. When choosing between treatment options, anxiety needs to be understood in the situational, psychiatric, and biological context in which it arises. Etifoxine, a non-benzodiazepine anxiolytic drug belonging to the benzoxazine class, is an effective treatment for anxiety in response to a stressful situation. In the present review, we focused on several aspects of the cerebral and somatic biological mechanisms involved in anxiety and investigated the extent to which etifoxine's mode of action can explain its anxiolytic activity. Its two mechanisms of action are the modulation of GABAergic neurotransmission and neurosteroid synthesis. Recent data suggest that the molecule possesses neuroprotective, neuroplastic, and anti-inflammatory properties. Etifoxine was first shown to be an effective anxiolytic in patients in clinical studies comparing it with clobazam, sulpiride, and placebo. Randomized controlled studies have demonstrated its anxiolytic efficacy in patients with adjustment disorders (ADs) with anxiety, showing it to be superior to buspirone and comparable to lorazepam and phenazepam, with a greater number of markedly improved responders and a better therapeutic index. Etifoxine's noninferiority to alprazolam has also been demonstrated in a comparative trial. Significantly less rebound anxiety was observed after abrupt cessation of etifoxine compared with lorazepam or alprazolam. Consistent with this finding, etifoxine appears to have a very low dependence potential. Unlike lorazepam, it has no effect on psychomotor performance, vigilance, or free recall. Severe adverse events are in general rare. Skin and subcutaneous disorders are the most frequently reported, but these generally resolve after drug cessation. Taken together, its dual mechanisms of action in anxiety and the positive data yielded by clinical trials support the use of etifoxine for treating the anxiety signs and symptoms of individuals with ADs.