Adjustment disorders: the state of the art

Wistar-Kyoto rats and chronically stressed Wistar rats present similar depression- and anxiety-like behaviors but different corticosterone and endocannabinoid system modulation

The interplay of social, psychological, and biological stresses can trigger mental health conditions such as major depressive disorder (MDD), adjustment disorder, and posttraumatic stress disorder (PTSD). The endocannabinoid system (ECS), comprising endocannabinoids and cannabinoid receptors, is the critical pathway that mediates responses to stress stimuli. This study aimed to investigate the ECS's impact on responding to chronic social instability stress (SIS). Wistar (WIS) rats and an endogenously depressed rat model, Wistar-Kyoto (WKY), were used to evaluate depression- and anxiety-like behavioral responses, cognitive function, hormone levels, and ECS function. The animals in the stress group (WIS-STS and WKY-STS) were exposed to TMT (predator odor) for 10 mins (two exposures in total: one in light cycle and one in dark cycle) and daily roommate changes (30 days in total), while the control group (CTL) rats were exposed to a sham odor stimulus (distilled water) and did not undergo roommate changes. The results in the open field test suggest that WKY rats had significantly lower locomotor activity than WIS rats. In contrast, WKY rats and chronically stressed WIS rats presented similar depression- and anxiety-like behaviors and impaired cognitive function in the elevated plus maze, forced swimming test, and novel objective recognition test. However, chronic SIS did not exacerbate these behavioral changes in WKY rats. ELISA and Western blot analysis indicated that chronic SIS did not induce further upregulation of endocannabinoids and CB1R downregulation in WKY rats compared to WIS rats. In addition, the Luminex assay revealed that WKY rats showed a higher resilience on the HPA-axis modulation towards chronic SIS, distinguished by the hyperactivity of the HPA-axis modulation in WIS rats. Overall, the study revealed that the chronic SIS animal model (stressed WIS rats) and an animal model of endogenous depression (WKY rats) can generate similar behavioral changes in anxious behavior, behavioral despair, and cognitive impairment. Both animal models present hyperactivity of the ACTH modulation and ECS activity, while WKY rats are more resilient on CORT modulation towards chronic SIS.

Diagnosed Posttraumatic Stress Disorder and Other Trauma-Associated Stress Disorders and Risk for Suicide Mortality

OBJECTIVE

Strong evidence exists for posttraumatic stress disorder (PTSD) as a risk factor for suicidal thoughts and behaviors across diverse populations. However, few empirical studies have examined PTSD and other trauma-associated stress disorders as risk factors for suicide mortality among health system populations. This study aimed to assess trauma-associated stress diagnoses as risk factors for suicide mortality in a U.S. health system population.

METHODS

This case-control, matched-design study examined individuals who died by suicide between 2000 and 2015 and had received care from nine U.S. health systems affiliated with the Mental Health Research Network (N=3,330). Individuals who died by suicide were matched with individuals from the general health system population (N=333,000): 120 individuals with PTSD who died by suicide were matched with 1,592 control group members, 84 with acute reaction to stress were matched with 2,218 control individuals, and 331 with other stress reactions were matched with 8,174 control individuals.

RESULTS

After analyses were adjusted for age and sex, individuals with any trauma-associated stress condition were more likely to have died by suicide. Risk was highest among individuals with PTSD (adjusted OR [AOR]=10.10, 95% CI=8.31-12.27), followed by those with other stress reactions (AOR=5.38, 95% CI=4.78-6.06) and those with acute reaction to stress (AOR=4.49, 95% CI=3.58-5.62). Patterns of risk remained the same when the analyses were adjusted for any comorbid psychiatric condition.

CONCLUSIONS

All trauma-associated stress disorders are risk factors for suicide mortality, highlighting the importance of health system suicide prevention protocols that consider the full spectrum of traumatic stress diagnoses.

The prevalence of adjustment disorder and predisposing factors in infertile women

BACKGROUND

Infertility is a stressful life event that increases the risk of developing mental disorders, particularly adjustment disorder (AD). Given the paucity of data on the prevalence of AD symptoms in infertility, the purpose of this study was to ascertain the prevalence, clinical presentation, and risk factors for AD symptoms in infertile women.

METHOD

In a cross-sectional study, 386 infertile women completed questionnaires including the Adjustment Disorder New Module-20 (ADNM), the Fertility Problem Inventory (FPI), the Coronavirus Anxiety Scale (CAS), and the Primary Care Posttraumatic Stress Disorder (PC-PTSD-5) at an infertility center between September 2020 and January 2022.

RESULT

The results indicated that 60.1% of infertile women exhibited AD symptoms (based on ADNM > 47.5). In terms of clinical presentation, impulsive behavior was more common. No significant relationship was observed between prevalence and women's age or duration of infertility. Infertility stress (β = 0.27, p < 0.001), coronavirus anxiety (β = 0.59, p = 0.13), and a history of unsuccessful assisted reproductive therapies (β = 2.72, p = 0.008) were several predisposing factors for AD symptoms in infertile women.

CONCLUSIONS

The findings suggest that all infertile women be screened from the start of infertility treatment. Additionally, the study suggests that infertility specialists should focus on combining medical and psychological treatments for individuals predisposed to AD, particularly infertile women who exhibit impulsive behaviors.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have a negative impact in terms of quality of life, compliance with anticancer treatment, suicide risk and possibly the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy, tolerability and acceptability of antidepressants in this population are few and often report conflicting results.

OBJECTIVES

To evaluate the efficacy, tolerability and acceptability of antidepressants for treating depressive symptoms in adults (aged 18 years or older) with cancer (any site and stage).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was November 2022.

SELECTION CRITERIA

We included RCTs comparing antidepressants versus placebo, or antidepressants versus other antidepressants, in adults (aged 18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was 1. efficacy as a continuous outcome. Our secondary outcomes were 2. efficacy as a dichotomous outcome, 3. Social adjustment, 4. health-related quality of life and 5. dropouts. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We identified 14 studies (1364 participants), 10 of which contributed to the meta-analysis for the primary outcome. Six of these compared antidepressants and placebo, three compared two antidepressants, and one three-armed study compared two antidepressants and placebo. In this update, we included four additional studies, three of which contributed data for the primary outcome. For acute-phase treatment response (six to 12 weeks), antidepressants may reduce depressive symptoms when compared with placebo, even though the evidence is very uncertain. This was true when depressive symptoms were measured as a continuous outcome (standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.92 to -0.12; 7 studies, 511 participants; very low-certainty evidence) and when measured as a proportion of people who had depression at the end of the study (risk ratio (RR) 0.74, 95% CI 0.57 to 0.96; 5 studies, 662 participants; very low-certainty evidence). No studies reported data on follow-up response (more than 12 weeks). In head-to-head comparisons, we retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants (TCAs) and for mirtazapine versus TCAs. There was no difference between the various classes of antidepressants (continuous outcome: SSRI versus TCA: SMD -0.08, 95% CI -0.34 to 0.18; 3 studies, 237 participants; very low-certainty evidence; mirtazapine versus TCA: SMD -4.80, 95% CI -9.70 to 0.10; 1 study, 25 participants). There was a potential beneficial effect of antidepressants versus placebo for the secondary efficacy outcomes (continuous outcome, response at one to four weeks; very low-certainty evidence). There were no differences for these outcomes when comparing two different classes of antidepressants, even though the evidence was very uncertain. In terms of dropouts due to any cause, we found no difference between antidepressants compared with placebo (RR 0.85, 95% CI 0.52 to 1.38; 9 studies, 889 participants; very low-certainty evidence), and between SSRIs and TCAs (RR 0.83, 95% CI 0.53 to 1.22; 3 studies, 237 participants). We downgraded the certainty of the evidence because of the heterogeneous quality of the studies, imprecision arising from small sample sizes and wide CIs, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, the available studies were few and of low quality. This review found a potential beneficial effect of antidepressants against placebo in depressed participants with cancer. However, the certainty of evidence is very low and, on the basis of these results, it is difficult to draw clear implications for practice. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which drug to prescribe may be based on the data on antidepressant efficacy in the general population of people with major depression, also taking into account that data on people with other serious medical conditions suggest a positive safety profile for the SSRIs. Furthermore, this update shows that the usage of the newly US Food and Drug Administration-approved antidepressant esketamine in its intravenous formulation might represent a potential treatment for this specific population of people, since it can be used both as an anaesthetic and an antidepressant. However, data are too inconclusive and further studies are needed. We conclude that to better inform clinical practice, there is an urgent need for large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer who have depressive symptoms, with or without a formal diagnosis of a depressive disorder.

Elderly patients with adaptive disorder diagnosis in psychogeriatry interconsultation: clinical profile and therapeutic approach

Adaptive disorder is a frequent diagnosis but poorly studied in the elderly population hospitalized. Despite it is considerate benign and non-subsidiary entity of improvement through pharmacological treatment. It can evolve in a difficult way and the pharmacological treatment is widespread. The use of drugs could be harmful the elderly population with pluripathology and polypharmacy.

Validation of the brief Adjustment Disorder New Modules with Australian oncology patients

BACKGROUND

Evidence suggests that up to 30% of cancer patients may meet the criteria for adjustment disorder. However, no assessment instruments have been validated for use with cancer patients. The Adjustment Disorder New Module (ADNM)-8 and ADNM-4 are brief screening tools for adjustment disorder mapped directly to the new ICD-11 criteria. The aim of this study was to investigate the factor structure and validity of both instruments in an Australian sample of adult oncology patients.  METHODS: A total of 405 participants with a cancer diagnosis were recruited online from across Australia. Participants reported cancer-specific information, such as time since diagnosis, treatment stage, cancer stage, type of cancer, and the following questionnaires: 8-item Adjustment Disorder New Module (ADNM-8), the World Health Organisation Well-Being Index (WHO-5), and the short form Depression Anxiety and Stress Scale (DASS-21). The predictiveness of stressors was assessed using multiple regression analysis and the structure of the ADNM-8 and the ADNM-4 was tested using confirmatory factor analysis.  RESULTS: Six previously tested models were examined, and the results suggested a 2-factor structure reflecting the two ICD-11 diagnostic criteria clusters of preoccupation with the stressor and failure to adapt was a good fit for both scales. The ADNM-4 outperformed the longer version of the scale on numerous fit indices though the ADNM-8 and ADNM-4 were highly correlated. Correlations of both scales with the psychological distress scale, the stress subscale, and the wellbeing index indicated good construct validity.

CONCLUSIONS

Our results suggest that the ADNM-8 and ADNM-4 are useful screening tools for assessing adjustment disorder symptoms in cancer patients. The prompt screening of cancer patients encourages early intervention for those at risk of adaptation difficulties and informs research and clinical decisions regarding appropriate treatments.

Is depression the missing link between inflammatory mediators and cancer?

Patients with cancer are at greater risk of developing depression in comparison to the general population and this is associated with serious adverse effects, such as poorer quality of life, worse prognosis and higher mortality. Although the relationship between depression and cancer is now well established, a common underlying pathophysiological mechanism between the two conditions is yet to be elucidated. Existing theories of depression, based on monoamine neurotransmitter system dysfunction, are insufficient as explanations of the disorder. Recent advances have implicated neuroinflammatory mechanisms in the etiology of depression and it has been demonstrated that inflammation at a peripheral level may be mirrored centrally in astrocytes and microglia serving to promote chronic levels of inflammation in the brain. Three major routes to depression in cancer in which proinflammatory mediators are implicated, seem likely. Activation of the kynurenine pathway involving cytokines, increases tryptophan catabolism, resulting in diminished levels of serotonin which is widely acknowledged as being the hallmark of depression. It also results in neurotoxic effects on brain regions thought to be involved in the evolution of major depression. Proinflammatory mediators also play a crucial role in impairing regulatory glucocorticoid mediated feedback of the hypothalamic-pituitary-adrenal axis, which is activated by stress and considered to be involved in both depression and cancer. The third route is via the glutamatergic pathway, whereby glutamate excitotoxicity may lead to depression associated with cancer. A better understanding of the mechanisms underlying these dysregulated and other newly emerging pathways may provide a rationale for therapeutic targeting, serving to improve the care of cancer patients.

Outcomes and prognosis of adjustment disorder in adults: A systematic review

Adjustment disorder (AD) is one of the most commonly diagnosed mental health disorders and is generally conceptualized to be mild and short-lived. Despite the frequent use of AD in clinical settings, little is known about the prognosis of this condition. Our goal was to systematically review research on a range of AD outcomes in order to provide a broad characterization of AD prognosis. We conducted searches in MEDLINE, EMBASE, and PsycINFO. We included 31 cohort or randomized controlled trials with a total of 1,385,358 participants. Many patients maintained an AD diagnosis or were diagnosed with another mental health disorder months to years after initial diagnosis. Patients with AD tended to show symptom improvement at higher rates and to utilize less treatment than did patients with other disorders. AD-diagnosed groups experienced subsequent development of numerous physical conditions, such as infection, cancers, Parkinson's disease, and cardiovascular events, at higher rates than did control groups. Results were mixed regarding suicidality and occupational impairment. We rated most studies as having a moderate risk of bias. Based on limited findings, AD appears to progress as a milder disorder than do other disorders, but it not uncommonly transitions to more severe mental health states and may predict the development of future health issues, both mental and physical. Future prospective research that conforms to prognosis study guidelines is needed to better understand the course of this common disorder.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

Investigating characteristics of patients with mental disorders to predict out-patient physician follow-up within 30 days of emergency department discharge

BACKGROUND

Prompt follow-up at emergency department discharge is a key indicator of healthcare quality and patient recovery. To improve services, better knowledge of predictors for out-patient physician follow-up within 30 days after discharge is needed.

AIMS

We investigated clinical and sociodemographic characteristics and service use to predict patients with mental disorders with or without physician follow-up after emergency department use.

METHOD

This study used data extracted from clinical administrative databases for 9514 patients who attended an emergency department in Quebec (Canada) in 2014-2015 (index visit) for mental health reasons. Patient clinical and sociodemographic characteristics from 2012-2013 to 2014-2015, and service use 12 months before the index visit, were investigated as predictors for patients with or without prompt follow-up, using hierarchical logistic regression.

RESULTS

Two-thirds of patients did not receive prompt physician follow-up. Patients with level 1-2 illness acuity at emergency department triage (needing immediate or urgent care); those with adjustment or bipolar disorders, but without alcohol-related disorders (clinical characteristics); and patients with higher continuity of physician care, more psychosocial interventions in community healthcare centres and prior hospital admission (service use characteristics) were more likely to receive prompt out-patient follow-up.

CONCLUSIONS

Access to medical care was poor, considering the high needs of this population. The role of the emergency department as a gateway for accessing out-patient care may be strengthened by strategies like screening, brief intervention including motivational treatments, brief case management offered by emergency department staff, timely referral to services and better post-discharge planning. Collaborative care for patients attending emergency departments should also be improved.

Preexisting stress-related diagnoses and mortality: A Danish cancer cohort study

BACKGROUND

This study evaluated the association between preexisting stress-related diagnoses and mortality in a Danish population-based cancer cohort.

METHODS

This study included Danish patients with cancer diagnosed in 1995-2011 who had a stress-related diagnosis before their cancer diagnosis. Cancer patients without a prior stress-related diagnosis were matched 5:1 to the stress disorder cohort by cancer site, age group, calendar period, and sex. The 5-year cumulative incidence of cancer-specific and all-cause mortality was computed by stress-related diagnosis category. Hazard ratios and 95% confidence intervals (CIs) associating stress-related diagnoses with mortality were computed by follow-up time, stress-related diagnosis category, stage, comorbidity status, and cancer type.

RESULTS

This study identified 4437 cancer patients with a preexisting stress-related diagnosis and 22,060 matched cancer cohort members. The 5-year cumulative risk of cancer-specific mortality was 33% (95% CI, 32%-35%) for those with a preexisting stress-related diagnosis and 29% (95% CI, 28%-29%) for those without a prior stress-related diagnosis. Cancer patients with a preexisting stress-related diagnosis had a 1.3 times higher cancer-specific mortality rate than the comparison cohort members (95% CI, 1.2-1.5). This increase persisted across categories of stress-related diagnosis. The association varied by stage and cancer type, with more pronounced associations found among those with a late stage at diagnosis and hematological malignancies.

CONCLUSIONS

Cancer patients with preexisting stress-related diagnoses had increased rates of cancer-specific and all-cause mortality. The results suggest that psychiatric comorbidities may be an important consideration for cancer prognosis, and cancer treatment informed by a patient's history may improve outcomes.

Trajectories of adjustment disorder symptoms in post-treatment breast cancer survivors

Objective

Breast cancer survivors (BCS) may experience problems to adjust to their situation after cancer treatment completion. In case of severe distress, an adjustment disorder (AD) might develop. This study investigates the course of AD symptoms during 1 year and its predictors in BCS up to 5 years post-treatment.

Methods

BCS completed the Hospital Anxiety and Depression Scale (HADS) at baseline, 3, 6, and 12 months. HADS total scores were defined as no mental disorder (MD) symptoms (≤ 10), AD symptoms (11–14), and any other MD symptoms (≥ 15). Over the course of four assessments, symptom trajectories were a priori defined as no MD symptoms, AD symptoms, fluctuating AD symptoms below and above cut-offs, or any other MD symptoms. Complementary, latent class growth analysis (LCGA) was used to identify data-driven trajectories.

Results

Among 293 BCS with complete data, the majority was classified as no MD symptoms (54.4%), followed by 37.5% in the fluctuating AD symptoms trajectory. Only 1.4% had AD symptoms, and 6.8% had any other MD symptoms. With LCGA (N = 459), three trajectories were found: stable no MD symptoms (58.6%), stable AD symptoms (32.9%), and high increasing any other MD symptoms (8.5%). Compared to BCS with no MD symptoms, BCS with fluctuating AD symptoms or any other MD symptoms were younger, less able to handle daily activities, and showed more social support discrepancy, neuroticism, and less optimism.

Conclusions

Results of our study showed that AD symptoms in BCS up to 5 years post-treatment fluctuate over 1 year. It is thus important to appropriately assess AD over the course of 5 years post-treatment as AD symptoms can fluctuate.

ICD-11 posttraumatic stress disorder, complex PTSD and adjustment disorder: the importance of stressors and traumatic life events

Background: Although ICD-11 adjustment (AjD), posttraumatic stress (PTSD) and complex posttraumatic stress (CPTSD) are commonly diagnosed disorders following exposure to stressful or traumatic life events, their dimensional structure and co-occurrence has never been tested in a single study. The present study explored the latent structure of AjD, PTSD, and CPTSD symptoms and their relationship to stressful and traumatic life events to determine the degree of distinctiveness between these constructs.Methods: Participants were clinical patients (N = 331) who completed self-report measures of stressful and traumatic life events, AjD (The Adjustment Disorder - New Module 8 (ADNM-8)) and PTSD / CPTSD (The International Trauma Questionnaire - ITQ).Results: Using confirmatory factor analysis, a second-order model comprised of correlated latent variables of AjD, PTSD, and CPTSD provided the best fit of the data. It was also found that stressors and traumatic life events were positively associated with all of these conditions although childhood trauma was only associated with CPTSD.Conclusions: The current findings support the ICD-11 model of related-but-distinct stress-related disorders. We discuss the existence of a stress-response continuum and how the current findings impact the development of clinical interventions that may be shared across, or unique to, each stress-related disorder.

Factors Related to 30-day Readmission following Hospitalization for Any Medical Reason among Patients with Mental Disorders: Facteurs liés à la réhospitalisation à 30 jours suivant une hospitalisation pour une raison médicale chez des patients souffrant de troubles mentaux

OBJECTIVE

This study evaluated the contributions of clinical, sociodemographic, and service use variables to the risk of early readmission, defined as readmission within 30 days of discharge following hospitalization for any medical reason (mental or physical illnesses), among patients with mental disorders in Quebec (Canada).

METHODS

In this longitudinal study, 2,954 hospitalized patients who had visited 1 of 6 Quebec emergency departments (ED) in 2014 to 2015 (index year) were identified through clinical administrative databanks. The first hospitalization was considered that may have occurred at any Quebec hospital. Data collected between 2012 and 2013 and 2013 and 2014 on clinical, sociodemographic, and service use variables were assessed as related to readmission/no readmission within 30 days of discharge using hierarchical binary logistic regression.

RESULTS

Patients with co-occurring substance-related disorders/chronic physical illnesses, serious mental disorders, or adjustment disorders (clinical variables); 4+ outpatient psychiatric consultations with the same psychiatrist; and patients hospitalized for any medical reason within 12 months prior to index hospitalization (service use variables) were more likely to be readmitted within 30 days of discharge. Patients who made 1 to 3 ED visits within 1 year prior to the index hospitalization, had their index hospitalization stay of 16 to 29 days, or consulted a physician for any medical reason within 30 days after discharge or prior to the readmission (service use variables) were less likely to be rehospitalized.

CONCLUSIONS

Early hospital readmission was more strongly associated with clinical variables, followed by service use variables, both playing a key role in preventing early readmission. Results suggest the importance of developing specific interventions for patients at high risk of readmission such as better discharge planning, integrated and collaborative care, and case management. Overall, better access to services and continuity of care before and after hospital discharge should be provided to prevent early hospital readmission.

Mental disorders and utilization of mental health services in newly diagnosed cancer patients: An analysis of German health insurance claims data

OBJECTIVE

People with cancer are often confronted not only with the burdens of medical treatment but also with psychological strain, which can lead to mental disorders (MD). To date, the prevalence of MD in newly diagnosed cancer patients and their utilization of mental health services (MHS) are mainly estimated through data of primary studies than considering healthcare-related claims data.

METHODS

Statutory health insurance claims data of the AOK/KV Hesse from 2011 to 2014 was analyzed. The number of incident cancer patients with MD and the utilization of MHS within the period of the quarter of incident cancer diagnosis and three subsequent quarters were determined. For incident cancer patients with an incident MD, the predictive values of sex, age group, and tumor entity on the documentation of MD diagnosis and utilization were investigated.

RESULTS

The 12-month prevalence of MD in incident cancer patients was 31.1% for depression, 11.2% for anxiety disorders, and 9.2% for post-traumatic stress/adjustment disorder (PTSD/AD). Of these, 65.9% received outpatient psychotherapy and 43.0% at least one psychopharmacological drug prescription. Men had a significantly lower chance of receiving an MD diagnosis following cancer.

CONCLUSIONS

The prevalence of MD observed was higher for depression and lower for PTSD/AD compared to meta-analyses of clinical trials. Male cancer patients had a lower chance of receiving an MD diagnosis than females, which coincides with existing results.

Postoperative Psychological Disorders Among Heart Transplant Recipients: A Meta-Analysis and Meta-Regression

OBJECTIVE

This meta-analysis evaluates the pooled prevalence of depression, anxiety, adjustment disorder, and posttraumatic stress disorder (PTSD) among heart transplant recipients globally and determines underlying moderators.

METHODS

The authors searched PubMed, Embase, PsychINFO, BIOSIS, Science Direct, and Cochrane CENTRAL databases from inception to March 1, 2019, and 1321 records and 42 full-text articles were selected and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated the pooled prevalence proportion of depression, anxiety, adjustment disorder, and PTSD using random-effects models. Meta-regression was performed to identify important moderators that contribute to heterogeneity.

RESULTS

Twenty studies met the inclusion criteria and comprised 2169 patients. The pooled prevalence of depression was 21.6% (95% confidence interval [CI] = 16.8%-27.3%), anxiety 11.1% (95% CI = 3.8%-28.5%), adjustment disorder 11.0% (95% CI = 3.1%-32.1%), and PTSD 13.5% (95% CI = 8%-21.8%). There was significant heterogeneity. Meta-regression was conducted to account for the heterogeneity of the prevalence proportion. Predisposing factors, for example, New York Heart Association classes II and III/IV, steroid treatment, and acute rejection of transplant (<3 months), were associated with high prevalence of depression. Protective factors, for example, age and higher ejection fraction after transplant of patients, were associated with low prevalence of depression. Female sex, single status, and number of months since transplant were associated with high prevalence of anxiety. Single status was associated with high prevalence of both adjustment disorder and transplant-related PTSD.

CONCLUSIONS

The prevalence of psychiatric conditions, particularly depression, is high in heart transplant recipients. The identified protective and risk factors may guide psychological interventions in heart transplant recipients.

Adjustment disorder with anxiety in old age: Comparing prevalence and clinical management in primary care and mental health care

Purpose:

Adjustment disorder with anxiety (AjD-A) is a common cause of severe anxiety symptoms, but little is known about its prevalence in old age.

Methods:

This cross-sectional study examined the prevalence of AjD-A in outpatients over the age of 60 who consecutively consulted 34 general practitioners and 22 psychiatrists during a 2-week period. The diagnosis of AjD-A was obtained using the optional module for diagnostic of adjustment disorder of the Mini International Neuropsychiatric Interview (MINI). The study procedure also explored comorbid psychiatric conditions and documented recent past stressful life events, as well as social disability and current pharmacological and non-pharmacological management.

Results:

Overall, 3651 consecutive subjects were screened (2937 in primary care and 714 in mental health care). The prevalence rate of AjD-A was 3.7% (n = 136). Up to 39% (n = 53) of AjD-A subjects had a comorbid psychiatric condition, mostly of the anxious type. The most frequently stressful life event reported to be associated with the onset of AjD-A was personal illness or health problem (29%). More than 50% of the AjD-A patients were markedly to extremely disabled by their symptoms. Compared to patients who consulted psychiatrists, patients who were seen by primary care physicians were older, had obtained lower scores at the Hamilton Anxiety Rating Scale, benefited less frequently from non-pharmacological management and received benzodiazepines more frequently.

Conclusions:

AjD-A appears to be a significantly disabling cause of anxiety symptoms in community dwelling elderly persons, in particular those presenting personal health related problems. Improvement of early diagnosis and non-pharmacological management of AjD-A would contribute to limit risks of benzodiazepine overuse, particularly in primary care settings.

Defining and Evaluating Overdiagnosis in Mental Health: A Meta-Research Review

BACKGROUND

Overdiagnosis is thought to be common in some mental disorders, but it has not been defined or examined systematically. Assessing overdiagnosis in mental health requires a consistently applied definition that differentiates overdiagnosis from other problems (e.g., misdiagnosis), as well as methods for quantification.

OBJECTIVES

Our objectives were to (1) describe how the term "overdiagnosis" has been defined explicitly or implicitly in published articles on mental disorders, including usages consistent (overdefinition, overdetection) and inconsistent (misdiagnosis, false-positive test results, overtreatment, overtesting) with accepted definitions of overdiagnosis; and (2) identify examples of attempts to quantify overdiagnosis.

METHOD

We searchedPubMed through January 5, 2019. Articles on mental disorders, excluding neurocognitive disorders, were eligible if they usedthe term "overdiagnosis" in the title, abstract, or text.

RESULTS

We identified 164 eligible articles with 193 total explicit or implicit uses of the term "overdiagnosis." Of 9 articles with an explicit definition, only one provided a definition that was partially consistent with accepted definitions. Of all uses, 11.4% were consistent, and 76.7% were related to misdiagnosis and thus inconsistent. No attempts to quantify the proportion of patients who were overdiagnosed based on overdetection or overdefinition were identified.

CONCLUSIONS

There are few examples of mental health articles that describe overdiagnosis consistent with accepted definitions and no examples of quantifying overdiagnosis based on these definitions. A definition of overdiagnosis based on diagnostic criteria that include people with transient or mild symptoms not amenable to treatment (overdefinition) could be used to quantify the extent of overdiagnosis in mental disorders.

ZIEL: Internet-Based Self-Help for Adjustment Problems: Results of a Randomized Controlled Trial

Adjustment Disorder (AjD) represents a healthcare paradox. On the one hand, it is one of the most diagnosed mental disorders worldwide. On the other hand, AjD and its possible treatment options remain a severely neglected field of research. In this context, we developed a self-guided online intervention for adjustment problems, named ZIEL, and tested its efficacy. It is based on and extends a bibliotherapeutic treatment approach for symptoms of AjD. In our study, a total of 98 individuals who had experienced a life event in the last two years, were randomly assigned to care as usual (CAU) or an online intervention group (CAU + online intervention). The primary endpoint was AjD symptom severity measured by Adjustment Disorder–New Module 20 (ADNM-20). Secondary endpoints were depressive symptoms, quality of life and other variables such as satisfaction and usability. Both the intervention and the control group improved comparably well regarding the severity of adjustment disorder symptoms post-treatment. However, participants in the intervention group showed significantly fewer depressive symptoms and a significantly higher quality of life (Cohen’s d: 0.89 (BDI) and −0.49 (SF-12)). The intervention was well-received by users with an above average usability rating. Overall, the results suggest that the ZIEL intervention has the promise to contribute to the treatment of AjD and reduce symptom burden by means of a scalable low-barrier approach.

Adjustment Disorder: Current Developments and Future Directions

Despite its high prevalence in clinical and consultant liaison psychiatry populations, adjustment disorder research has traditionally been hindered by its lack of clear diagnostic criteria. However, with the greater diagnostic clarity provided in the Diagnostic and Statistical Manual of Mental Disorders – fifth edition (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems, 11th edition (ICD-11), adjustment disorder has been increasingly recognised as an area of research interest. This paper evaluates the commonalities and differences between the ICD-11 and DSM-5 concepts of adjustment disorder and reviews the current state of knowledge regarding its symptom profile, course, assessment, and treatment. In doing so, it identifies the gaps in our understanding of adjustment disorder and discusses future directions for research.

Psychotherapy of adjustment disorders: Current state and future directions

OBJECTIVES

This narrative review article provides an overview of current psychotherapeutic approaches specific for adjustment disorders (ADs) and outlines future directions for theoretically-based treatments for this common mental disorder within a framework of stepped care.

METHODS

Studies on psychological interventions for ADs were retrieved by using an electronic database search within PubMed and PsycINFO, as well as by scanning the reference lists of relevant articles and previous reviews.

RESULTS

The evidence base for psychotherapies specifically targeting the symptoms of AD is currently rather weak, but is evolving given several ongoing trials. Psychological interventions range from self-help approaches, relaxation techniques, e-mental-health interventions, behavioural activation to talking therapies such as psychodynamic and cognitive behavioural therapy.

CONCLUSIONS

The innovations in DSM-5 and upcoming ICD-11, conceptualising AD as a stress-response syndrome, will hopefully stimulate more research in regard to specific psychotherapeutic interventions for AD. Low intensive psychological interventions such as e-mental-health interventions for ADs may be a promising approach to address the high mental health care needs associated with AD and the limited mental health care resources in most countries around the world.

Adjustment disorder and type-specific cancer incidence: a Danish cohort study

BACKGROUND

Although adjustment disorder is common, there is a dearth of research on its physical health consequences. Earlier studies, biological mechanisms and stress-related behaviors suggest that cancer may be a potential sequelae of adjustment disorder. This study examined the association between adjustment disorder and type-specific cancer incidence in a nationwide cohort.

METHODS

Data were obtained from the comprehensive nationwide medical and administrative registries of Denmark. We calculated the incidence of type-specific cancers from 1995 to 2013 in patients with a prior adjustment disorder diagnosis (n = 58,712), and compared it with the incidence in the general population by calculating standardized incidence ratios (SIRs) with accompanying 95% confidence intervals (CIs). SIRs were adjusted using semi-Bayes shrinkage.

RESULTS

The SIR for any type of cancer was 1.0 (95% CI: 0.99, 1.1). Adjustment disorder was associated with a 10% lower rate of immune-related cancers (SIR = 0.9, 95% CI: 0.84, 0.97) and with a 20% higher rate of smoking- and alcohol-related cancers (SIR = 1.2, 95% CI: 1.1, 1.3). We found null associations for hematological (SIR = 1.1, 95% CI: 0.89, 1.3) and hormone-related (SIR = 0.98, 95% CI: 0.91, 1.1) malignancies. After semi-Bayes adjustment, type-specific cancer SIRs indicated no association between adjustment disorder and cancer incidence.

CONCLUSIONS

This study provides persuasive evidence for a null association between adjustment disorder and type-specific cancer incidence in a nationwide study cohort.

The Reliable Change Index (RCI) of the WHO-5 in primary prevention of mental disorders. A measurement-based pilot study in positive psychiatry

INTRODUCTION

Primary prevention of mental disorders is a major issue in positive psychiatry. Adjustment disorder is one of the very few discrete mental disorders linked to an etiological factor, namely psychosocial stressors given rise to a maladaptive reaction with a course of symptoms vanishing with the removal of the stressor. We have focused on a measurement-based method to prevent the development of an adjustment disorder.

AIM

The aim of this study has been to analyze from an ongoing Worklife Barometer Survey in which the World Health Organization Well-Being Scale (WHO-5) has been applied to prevent distress leading to an adjustment disorder.

METHODS

Persons identified with a decrease of 15 points in their repeatedly WHO-5 ratings over three months were through a brief psychological intervention by experienced psychologists. The Reliable Change Index (RCI) was used to determine the clinically meaningful change in the WHO-5 ratings.

RESULTS

Within the group who received the psychological intervention (N = 1338), 35% of the persons were identified by the RCI analysis to have developed a clinically reliable change in the WHO-5 at the time of the intervention. The remaining 65% of the persons obtained changes in the WHO-5 which might be considered as spontaneous fluctuations. In the month after the intervention, the persons with a clinically reliable change in the WHO-5 were restored.

CONCLUSION

In this measurement-based pilot study, the repeatedly WHO-5 ratings identified a group of persons with a clinically reliable change in WHO-5 and a clinically significant improvement after a brief psychological intervention.

Screening of adjustment disorder: Scale based on the ICD-11 and the Adjustment Disorder New Module

In line with ICD-11 new conceptualization of Adjustment disorder (AjD), a self-report Adjustment Disorder-New Module (ADNM) was developed and validated. Nevertheless, the ADNM-20 is a long research tool and potentially problematic in the use in epidemiological and clinical studies. The present study introduces the brief ADNM-8 and the ultra-brief ADNM-4, examines their validity and establishes cut-off scores for their clinical use. The study used a representative national sample of 1003 Israelis who reported on the ICD-11 stress spectrum ranging from AjD, PTSD, complex PTSD and complicated grief. Construct validity was assessed via confirmatory factor analysis and cut-off scores were established through ROC analysis. The original and brief instruments were highly correlated (r > 0.918 or better). Cronbach's Alpha for the Brief ADNM-8 and the Ultra-Brief ADNM-4 were above 0.800. Correlations with stress related conditions indicated a good convergent and construct validity for both instruments as well. The ultra-brief ADNM-4 was found to have a very good fit with the data. These findings indicate that the brief ADNM-8 and the ultra-brief ADNM-4 can serve as a brief screening tools for assessing AjD symptoms according to the ICD-11 definition.

Unified neural structured model: A new diagnostic tool in primary care psychiatry

Overlap of multiple mental disorders in each psychiatric patient has been emphasized and the style of assessment and intervention in each patient has been gradually changed. A new practical structured model that can comprehensively explain and assess the major mental disorders integratedly has been desired. In this report, the relationships between each of the major mental disorders and each neuropsychiatric component like personality, reward system, or reinforcement learning have been comprehensively reviewed to construct a new integrated structured model for assessing the overlapped mental conditions in primary care psychiatry. This new structured model contains the following three loops: "input-output-feedback loop" (external/environmental loop), "reward-learning loop" (learning loop), and "mood-reward sensitivity loop" (mood loop), which are connected by the functions of prefrontal cortex and basal ganglia. With this new concept, overlapped mental conditions in each psychiatric patient could be theoretically much simply and logically explained. In conclusion, with the proposed psychiatric structured model, we can simply explain and understand the overlapped mental disorders in each patient. Inventing and developing such basic psychiatric structured model would offer us new diagnostic and therapeutic tools to realize personalized medicine, especially in the field of primary care psychiatry.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have been shown to have a negative impact in terms of quality of life, compliance with anti-cancer treatment, suicide risk and likely even the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy, tolerability and acceptability of antidepressants in this population are few and often report conflicting results.

OBJECTIVES

To assess the efficacy, tolerability and acceptability of antidepressants for treating depressive symptoms in adults (aged 18 years or older) with cancer (any site and stage).

SEARCH METHODS

We searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 6), MEDLINE Ovid (1946 to June week 4 2017), Embase Ovid (1980 to 2017 week 27) and PsycINFO Ovid (1987 to July week 4 2017). We additionally handsearched the trial databases of the most relevant national, international and pharmaceutical company trial registers and drug-approving agencies for published, unpublished and ongoing controlled trials.

SELECTION CRITERIA

We included RCTs comparing antidepressants versus placebo, or antidepressants versus other antidepressants, in adults (aged 18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis).

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a form specifically designed for the aims of this review. The two authors compared the data extracted and then entered data into Review Manager 5 using a double-entry procedure. Information extracted included study and participant characteristics, intervention details, outcome measures for each time point of interest, cost analysis and sponsorship by a drug company. We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We retrieved a total of 10 studies (885 participants), seven of which contributed to the meta-analysis for the primary outcome. Four of these compared antidepressants and placebo, two compared two antidepressants, and one three-armed study compared two antidepressants and placebo. In this update we included one additional unpublished study. These new data contributed to the secondary analysis, while the results of the primary analysis remained unchanged.For acute-phase treatment response (6 to 12 weeks), we found no difference between antidepressants as a class and placebo on symptoms of depression measured both as a continuous outcome (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -1.01 to 0.11, five RCTs, 266 participants; very low certainty evidence) and as a proportion of people who had depression at the end of the study (risk ratio (RR) 0.82, 95% CI 0.62 to 1.08, five RCTs, 417 participants; very low certainty evidence). No trials reported data on follow-up response (more than 12 weeks). In head-to-head comparisons we only retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants, showing no difference between these two classes (SMD -0.08, 95% CI -0.34 to 0.18, three RCTs, 237 participants; very low certainty evidence). No clear evidence of a beneficial effect of antidepressants versus either placebo or other antidepressants emerged from our analyses of the secondary efficacy outcomes (dichotomous outcome, response at 6 to 12 weeks, very low certainty evidence). In terms of dropouts due to any cause, we found no difference between antidepressants as a class compared with placebo (RR 0.85, 95% CI 0.52 to 1.38, seven RCTs, 479 participants; very low certainty evidence), and between SSRIs and tricyclic antidepressants (RR 0.83, 95% CI 0.53 to 1.30, three RCTs, 237 participants). We downgraded the certainty (quality) of the evidence because the included studies were at an unclear or high risk of bias due to poor reporting, imprecision arising from small sample sizes and wide confidence intervals, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, the available studies were very few and of low quality. This review found very low certainty evidence for the effects of these drugs compared with placebo. On the basis of these results, clear implications for practice cannot be deduced. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which agent to prescribe may be based on the data on antidepressant efficacy in the general population of individuals with major depression, also taking into account that data on medically ill patients suggest a positive safety profile for the SSRIs. To better inform clinical practice, there is an urgent need for large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer who have depressive symptoms, with or without a formal diagnosis of a depressive disorder.

An empirical assessment of adjustment disorder as proposed for ICD-11 in a general population sample of Israel

BACKGROUND

A new diagnostic concept of Adjustment Disorder (AjD) was proposed for inclusion in the International Classification of Diseases, 11th version (ICD-11). However, the symptom structure of AjD is poorly understood. The aim of the present study was to investigate the dimensionality of AjD as a stress-response syndrome.

METHODS

A general population sample of the Israeli population (N = 1003) completed the Adjustment Disorder - New Module 20 and the WHO-5 Wellbeing Scale. We compared seven alternative models of AjD using confirmatory factor analysis (CFA). A latent profile analysis (LPA) was performed to determine if subtypes of AjD were present. The performance of the unidimensional and multidimensional models of AjD were evaluated using regression analyses.

RESULTS

CFA results supported a unidimensional model of AjD. The LPA identified three quantitatively distinct classes (low, medium, and high) with no evidence of any subtypes of AjD. The criterion validity of AjD was superior when treated as unidimensional. AjD was associated with lower levels of psychological wellbeing (β = -.32, p < .001).

CONCLUSIONS

Our results suggest that AjD is better conceptualised as a unidimensional construct. Future work should focus on a reduction of required symptoms in order to improve clinical utility and validity of the diagnosis.

Measuring the ICD-11 adjustment disorder concept: Validity and sensitivity to change of the Adjustment Disorder - New Module questionnaire in a clinical intervention study

Adjustment disorder (AjD) is a frequent but under-researched diagnosis due in part to a lack of specific symptom criteria and adequate tools of measurement. The ICD-11 for the first time proposes a positive symptom catalogue to define AjD. This study presents a validation of the Adjustment Disorder - New Module (ADNM), the first symptom severity measure for AjD according to the ICD-11 concept. Validity and sensitivity to change were investigated in a sample of 190 individuals with a DSM-IV diagnosis of AjD. The ADNM scales demonstrated convergent and discriminant validity for anxiety symptoms (Hamilton Anxiety Scale; psychic anxiety r = 0.18-0.31), functional impairment (Sheehan Disability Scale; r = 0.18-0.47), and depression (Montgomery-Asberg Depression Scale; r = 0.13-0.30). At baseline 78% of the individuals with a DSM-IV diagnosis of AjD were also classified so by the ADNM. Repeated-measures ANOVA indicated significant ADNM-symptom decrease during treatment, replicating the patterns of the Hamilton Anxiety Scale, Sheehan Disability Scale, and Clinical Global Impression Scale. This article presents the first use of the ADNM as a measure for ICD-11 AjD in a randomized-controlled intervention study of AjD. It provides support for the construct validity and sensitivity to symptom change of this scale during pharmacological treatment.

Do previous experience and geographic proximity matter? Possible predictors for diagnosing Adjustment disorder vs. PTSD

The minority of people who have experienced a traumatic event and were diagnosed as either suffering from PTSD or from Adjustment disorder, may suggest that victims of a traumatic event vary in risk factors for the disorders. The current research aimed at examining the association between reports of Adjustment disorder and PTSD symptoms (In accordance with the proposed revisions of the ICD-11) and several vulnerability variables: previous traumatic event, previous stressful event and physical proximity to the terror attack. Using an online survey, 379 adult participants were recruited, and filled out Adjustment disorder, PTSD symptomatology scales, as well as a previous exposure, magnitude of exposure and death anxiety scales. Findings revealed that previous experience of traumatic events was a significant predictor associated with both PTSD and Adjustment disorder symptoms. Previous experience of stressful events was a significant predictor associated with Adjustment disorder alone. Physical proximity to the site of the attack was a significant predictor associated with PTSD symptoms but not Adjustment disorder symptoms. The importance of previous traumatic events, previous stressful events and physical proximity to the terror attack as factors which are associated with Adjustment disorder and PTSD symptomatology is discussed.

Ten-year prevalence of mental disorders in patients presenting with chronic pain in secondary care: A register linkage cohort study

BACKGROUND

Prevalence rates of mental disorders in patients with chronic pain vary and may be overestimated when assessed by screening instruments only. Objectives were to estimate the 10-year prevalence of different mental disorders diagnosed by psychiatrists in patients with chronic pain compared with the Danish general population.

METHODS

Patients (n = 7197) consulted in the interdisciplinary Pain Clinic South at Odense University Hospital, Denmark, from 2005 to 2015 were included. Data from the Pain Clinic were linked to the Danish National Patient Register-Psychiatry and the Danish Civil Registration System. Age and gender standardized prevalence ratios (SPR) were calculated.

RESULTS

In all, 17.8% of patients with chronic pain had been diagnosed with a mental disorder. The most frequent diagnoses were adjustment disorders (subcategory of anxiety disorders) (8.9%), depression (6.1%), personality disorders (3.8%), and substance abuse disorders (3.5%). Women and men with chronic pain had higher rates of anxiety disorders (SPR 3.1; 95% CI 2.9-3.4) and depression (SPR 2.5; 95% CI 2.3-2.8), whereas men had higher rates of substance abuse disorders (SPR 1.6; 95% CI 1.3-1.9) than found for the general population.

CONCLUSIONS

Although depression and anxiety were noted more frequently among patients with chronic pain than the general population, prevalence rates were lower than previously reported. The most frequent diagnoses were adjustment disorders.

SIGNIFICANCE

Prevalence rates of anxiety and depression diagnosed by psychiatrists in patients with chronic pain were found to be lower than previous findings using screening instruments. Adjustment disorders were the most frequent disorders diagnosed, as this study is the first to investigate.

Adjustment disorder: Prevalence, sociodemographic risk factors, and its subtypes in outpatient psychiatric clinic

BACKGROUND AND OBJECTIVE

This study aims at assessing the prevalence and risk factors of Adjustment disorder (AD), the AD subtypes, and the common causing stressors.

PATIENTS AND METHODS

A cross sectional study was conducted at outpatient psychiatric clinic in Duhok City from July 2008 to July 2009. 637 patients equal and above 18 of both genders were selected randomly. SCID-I/P (Version 2.0) was adopted to diagnose patients with AD. SPSS (version 21), was used for data analysis.

RESULTS

The study showed that the prevalence of AD was 11.5%. It was more common among youngest age group (15-25 years) with a rate 69.9% (p=0.001) while lowest educational level (illiterate and primary) 53.5% (p=0.040), single 54.8% (p<0.001), students 39.7 (p<0.001) and from urban areas 71.2% (p=0.012) with statistically significant association. Although AD was more common among females (61.6%), no significant association was found between AD and gender (p=0.380). The most common subtype of AD was AD with mixed anxiety and depressed mood (34.2%) and was the commonest among females (19.2%) followed by AD with Anxiety subtype 30.1% which was the commonest among males (13.7%). The commonest psychosocial stressor was the illnesses (28.8%) followed by love affairs (26%) and domestic problems (16.4%).

CONCLUSIONS

The prevalence of AD was found to be high. The risk factors included young, low educational level, single, students, and those from urban areas. The most common subtype was AD with mixed anxiety and depressed mood and the commonest psychosocial stressor was the illnesses followed by love affairs and domestic problems.

Prevalence and prognosis of stress disorders: a review of the epidemiologic literature

Given the ubiquity of traumatic events, it is not surprising that posttraumatic stress disorder (PTSD) - a common diagnosis following one of these experiences - is characterized as conferring a large burden for individuals and society. Although there is recognition of the importance of PTSD diagnoses throughout psychiatry, the literature on other diagnoses one may receive following a stressful or traumatic event is scant. This review summarizes the literature on stress disorders (classified according to the International Classification of Diseases, 10th Edition [ICD-10]), including acute stress reaction, PTSD, adjustment disorder and unspecified stress reactions. This review focuses on the literature related to common psychiatric and somatic consequences of these disorders. The prevalence and incidence of each disorder are described. A review of epidemiologic studies on comorbid mental health conditions, including depression, anxiety and substance abuse, is included, as well as a review of epidemiologic studies on somatic outcomes, including cancer, cardiovascular disease and gastrointestinal disorders. Finally, the current literature on all-cause mortality and suicide following stress disorder diagnoses is reviewed. Stress disorders are a critical public health issue with potentially deleterious outcomes that have a significant impact on those living with these disorders, the health care system and society. It is only through an awareness of the impact of stress disorders that appropriate resources can be allocated to prevention and treatment. Future research should expand the work done to date beyond the examination of PTSD, so that the field may obtain a more complete picture of the impact all stress disorders have on the many people living with these diagnoses.

A scoping review of ICD-11 adjustment disorder research

Background: Adjustment disorder (AjD) is one of the most used mental disorder diagnoses among mental health professionals. Important revisions of the AjD definition in the 11th edition of the International Classification of Diseases (ICD-11) are proposed. AjD is included in a chapter of disorders specifically associated with stress in ICD-11. Objective: This paper aims to review recent developments in ICD-11 AjD research, and to discuss the available ICD-11 AjD diagnosis validation studies, AjD measures, treatment studies, and outline the future perspectives for AjD research and clinical practice. Methods: In total, 10 empirical studies of AjD ICD-11 were identified and included in this review. We searched for studies in Embase, PubMed, PsycINFO, Scopus, PILOTS, SocINDEX, and via additional search by contacting authors of published empirical studies and reference screening. Results: Review of the studies revealed a lack of validation studies of the ICD-11 AjD symptom structure. AjD validation study findings are ambiguous, and there is still little support for the proposed two symptom structure of AjD for the ICD-11. A self-report AjD measure 'Adjustment Disorder New Module' (ADNM) based on the ICD-11 definition has been developed and used in all 10 reviewed studies. Two self-help interventions have been developed for the ICD-11 AjD, and findings from these studies indicate that self-help low-intensity cognitive-behavioural interventions, delivered via bibliography or internet-based, might be effective treatment of AjD. Conclusions: The AjD definition in ICD-11 with a description of a new symptom profile facilitates AjD measurement and AjD-focused treatment developments. More studies and insights from clinical practice are needed to move the field of AjD research and practice forward.

Evaluation and treatment of depression in adult trauma patients

A retrospective study examined in-hospital antidepressant medication (ADM) use in adult trauma patients with an intensive care unit stay of 5 or more days. One fourth of patients received an ADM, with only 33% of those patients having a documented history of depression. Of patients who received their first ADM from a trauma or critical care physician, only 5% were discharged with a documented plan for psychiatric follow-up. The study identified a need for standardized identification and management of depressive symptoms among trauma patients in the inpatient setting.

Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.

Postpartum anxiety and adjustment disorders in parents of infants with very low birth weight: Cross-sectional results from a controlled multicentre cohort study

BACKGROUND

Both preterm delivery and survival rates of very low birth weight (VLBW: <1500 g) infants are increasing. To date, the focus on studies about postpartum mental health after preterm birth has been on depression and on women. There is a paucity of research regarding prevalence, risks, and predictors of postpartum anxiety in parents after VLBW birth.

METHODS

Parents with VLBW infants and parents with term infants were recruited into the longitudinal HaFEn-study at the three largest centers of perinatal care in Hamburg, Germany. State anxiety was assessed with the State-Trait-Anxiety Inventory and anxiety and adjustment disorders with a clinical interview one month postpartum. Psychiatric lifetime diagnoses, social support, trait anxiety, stress during birth, socioeconomic status, risks during pregnancy, and mode of delivery were also evaluated. To examine predictors of postpartum state anxiety in both parents simultaneously a multiple random coefficient model was used.

RESULTS

230 mothers and 173 fathers were included. The risk for minor/major anxiety symptoms and adjustment disorders was higher in parents with VLBW infants compared to the term group. The risk for anxiety disorders was not higher in parents with VLBW infants. The most important predictors for postpartum state anxiety were high trait anxiety, the birth of a VLBW infant, high stress during birth, and low social support.

LIMITATIONS

Data reported here are cross-sectional. Thus, temporal relationships cannot be established.

CONCLUSIONS

Our results emphasize the importance of early screening for postpartum anxiety in both parents with VLBW infants.

Psychiatric Status across Body Mass Index in a Mediterranean Spanish Population

Background

Mental and body weight disorders are among the major global health challenges, and their comorbidity may play an important role in treatment and prevention of both pathologies. A growing number of studies have examined the relationship between psychiatric status and body weight, but our knowledge is still limited.

Objective

The present study aims to investigate the cross-sectional relationships of psychiatric status and body mass index (BMI) in Málaga, a Mediterranean city in the South of Spain.

Materials and Methods

A total of 563 participants were recruited from those who came to his primary care physician, using a systematic random sampling, non-proportional stratified by BMI categories. Structured clinical interviews were used to assess current Axes-I and II mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). BMI was calculated as weight (Kg) divided by square of height in meters (m²). Logistic regression was used to investigate the association between BMI and the presence of any mental disorder. BMI was introduced in the models using restricted cubic splines.

Results

We found that high BMI values were directly associated with mood and adjustment disorders, and low BMI values were directly associated with avoidant and dependent personality disorders (PDs). We observed an inverse relationship between low BMI values and cluster A PDs. There were not significant relationships between anxiety or substance-related disorders and BMI.

Conclusion

Psychiatric status and BMI are related in a Mediterranean Spanish population. A multidisciplinary approach to both pathologies becomes increasingly more necessary.

Associations between stress disorders and cardiovascular disease events in the Danish population

OBJECTIVES

Post-traumatic stress disorder (PTSD) is a well-documented risk factor for cardiovascular disease (CVD). However, it is unknown whether another common stress disorder-adjustment disorder--is also associated with an increased risk of CVD and whether gender modifies these associations. The aim of this study was to examine the overall and gender-stratified associations between PTSD and adjustment disorder and 4 CVD events.

DESIGN

Prospective cohort study utilising Danish national registry data.

SETTING

The general population of Denmark.

PARTICIPANTS

PTSD (n=4724) and adjustment disorder (n=64,855) cohorts compared with the general population of Denmark from 1995 to 2011.

PRIMARY OUTCOME MEASURES

CVD events including myocardial infarction (MI), stroke, ischaemic stroke and venous thromboembolism (VTE). Standardised incidence rates and 95% CIs were calculated.

RESULTS

Associations were found between PTSD and all 4 CVD events ranging from 1.5 (95% CI 1.1 to 1.9) for MI to 2.1 (95% CI 1.7 to 2.7) for VTE. Associations that were similar in magnitude were also found for adjustment disorder and all 4 CVD events: 1.5 (95% CI 1.4 to 1.6) for MI to 1.9 (95% CI 1.8 to 2.0) for VTE. No gender differences were noted.

CONCLUSIONS

By expanding beyond PTSD and examining a second stress disorder-adjustment disorder-this study provides evidence that stress-related psychopathology is associated with CVD events. Further, limited evidence of gender differences in associations for either of the stress disorders and CVD was found.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have been shown to have a negative impact in terms of quality of life, compliance with anti-cancer treatment, suicide risk and likely even the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy and tolerability of antidepressants in this population group are few and often report conflicting results.

OBJECTIVES

To assess the effects and acceptability of antidepressants for treating depressive symptoms in adults (18 years or older) with cancer (any site and stage).

SEARCH METHODS

We searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 3), MEDLINE Ovid (1946 to April week 3, 2014), EMBASE Ovid (1980 to 2014 week 17) and PsycINFO Ovid (1987 to April week 4, 2014). We additionally handsearched the trial databases of the most relevant national, international and pharmaceutical company trial registers and drug-approving agencies for published, unpublished and ongoing controlled trials.

SELECTION CRITERIA

We included RCTs allocating adults (18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis) comparing antidepressants versus placebo, or antidepressants versus other antidepressants.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a form specifically designed for the aims of this review. The two authors compared the data extracted and then entered data into RevMan 5 with a double-entry procedure. Information extracted included study and participant characteristics, intervention details, outcome measures for each time point of interest, cost analysis and sponsorship by a drug company. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We retrieved a total of nine studies (861 participants), with seven studies contributing to the meta-analysis for the primary outcome. Four of these compared antidepressants and placebo, two compared two antidepressants and one-three armed study compared two antidepressants and a placebo arm. For the acute phase treatment response (6 to 12 weeks), we found very low quality evidence for the effect of antidepressants as a class on symptoms of depression compared with placebo when measured as a continuous outcome (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -1.01 to 0.11, five RCTs, 266 participants) or as a proportion of people who had depression (risk ratio (RR) 0.82, 95% CI 0.62 to 1.08, five RCTs, 417 participants). No trials reported data on the follow-up response (more than 12 weeks). In head-to-head comparisons we only retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants, providing very low quality evidence for the difference between these two classes (SMD -0.08, 95% CI -0.34 to 0.18, three RCTs, 237 participants). No clear evidence of an effect of antidepressants versus either placebo or other antidepressants emerged from the analyses of the secondary efficacy outcomes (dichotomous outcome, response at 6 to 12 weeks, very low quality evidence). We found very low quality evidence for the effect of antidepressants as a class in terms of dropouts due to any cause compared with placebo (RR 0.87, 95% CI 0.49 to 1.53, six RCTs, 455 participants), as well as between SSRIs and tricyclic antidepressants (RR 0.83, 95% CI 0.53 to 1.30, three RCTs, 237 participants). We downgraded the quality of the evidence because the included studies were at an unclear or high risk of bias due to poor reporting, imprecision arising from small sample sizes and wide confidence intervals, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, available studies were very few and of low quality. This review found very low quality evidence for the effects of these drugs compared with placebo. On the basis of these results clear implications for practice cannot be made. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which agent should be prescribed may be based on the data on antidepressant efficacy in the general population of individuals with major depression, also taking into account that data on medically ill patients suggest a positive safety profile for the SSRIs. Large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer with depressive symptoms, with or without a formal diagnosis of a depressive disorder, are urgently needed to better inform clinical practice.

The role of peri-traumatic stress and disruption distress in predicting post-traumatic stress disorder symptoms following exposure to a natural disaster

BACKGROUND

Few studies have examined the contribution of specific disaster-related experiences to post-traumatic stress disorder (PTSD) symptoms.

AIMS

To examine the roles of peri-traumatic stress and distress due to lingering disaster-related disruption in explaining linkages between disaster exposure and PTSD symptoms among a cohort exposed to the 2010-2011 Canterbury (New Zealand) earthquakes.

METHOD

Structural equation models were fitted to data obtained from the Christchurch Health and Development Study at age 35 (n=495), 20-24 months following the onset of the disaster. Measures included: earthquake exposure, peri-traumatic stress, disruption distress and PTSD symptoms.

RESULTS

The associations between earthquake exposure and PTSD symptoms were explained largely by the experience of peri-traumatic stress during the earthquakes (β=0.189, P<0.0001) and disruption distress following the earthquakes (β=0.105, P<0.0001).

CONCLUSIONS

The results suggest the importance of minimising post-event disruption distress following exposure to a natural disaster.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Antidepressants for the treatment of depression in people with cancer

BACKGROUND

Major depression and other depressive conditions are common in people with cancer. These conditions are not easily detectable in clinical practice, due to the overlap between medical and psychiatric symptoms, as described by diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). Moreover, it is particularly challenging to distinguish between pathological and normal reactions to such a severe illness. Depressive symptoms, even in subthreshold manifestations, have been shown to have a negative impact in terms of quality of life, compliance with anti-cancer treatment, suicide risk and likely even the mortality rate for the cancer itself. Randomised controlled trials (RCTs) on the efficacy and tolerability of antidepressants in this population group are few and often report conflicting results.

OBJECTIVES

To assess the effects and acceptability of antidepressants for treating depressive symptoms in adults (18 years or older) with cancer (any site and stage).

SEARCH METHODS

We searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 3), MEDLINE Ovid (1946 to April week 3, 2014), EMBASE Ovid (1980 to 2014 week 17) and PsycINFO Ovid (1987 to April week 4, 2014). We additionally handsearched the trial databases of the most relevant national, international and pharmaceutical company trial registers and drug-approving agencies for published, unpublished and ongoing controlled trials.

SELECTION CRITERIA

We included RCTs allocating adults (18 years or above) with any primary diagnosis of cancer and depression (including major depressive disorder, adjustment disorder, dysthymic disorder or depressive symptoms in the absence of a formal diagnosis) comparing antidepressants versus placebo, or antidepressants versus other antidepressants.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data using a form specifically designed for the aims of this review. The two authors compared the data extracted and then entered data into RevMan 5 with a double-entry procedure. Information extracted included study and participant characteristics, intervention details, outcome measures for each time point of interest, cost analysis and sponsorship by a drug company. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We retrieved a total of nine studies (861 participants), with seven studies contributing to the meta-analysis for the primary outcome. Four of these compared antidepressants and placebo, two compared two antidepressants and one-three armed study compared two antidepressants and a placebo arm. For the acute phase treatment response (6 to 12 weeks), we found very low quality evidence for the effect of antidepressants as a class on symptoms of depression compared with placebo when measured as a continuous outcome (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -1.01 to 0.11, five RCTs, 266 participants) or as a proportion of people who had depression (risk ratio (RR) 0.82, 95% CI 0.62 to 1.08, five RCTs, 417 participants). No trials reported data on the follow-up response (more than 12 weeks). In head-to-head comparisons we only retrieved data for selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants, providing very low quality evidence for the difference between these two classes (SMD -0.08, 95% CI -0.34 to 0.18, three RCTs, 237 participants). No clear evidence of an effect of antidepressants versus either placebo or other antidepressants emerged from the analyses of the secondary efficacy outcomes (dichotomous outcome, response at 6 to 12 weeks, very low quality evidence). We found very low quality evidence for the effect of antidepressants as a class in terms of dropouts due to any cause compared with placebo (RR 0.87, 95% CI 0.49 to 1.53, six RCTs, 455 participants), as well as between SSRIs and tricyclic antidepressants (RR 0.83, 95% CI 0.53 to 1.30, three RCTs, 237 participants). We downgraded the quality of the evidence because the included studies were at an unclear or high risk of bias due to poor reporting, imprecision arising from small sample sizes and wide confidence intervals, and inconsistency due to statistical or clinical heterogeneity.

AUTHORS' CONCLUSIONS

Despite the impact of depression on people with cancer, available studies were very few and of low quality. This review found very low quality evidence for the effects of these drugs compared with placebo. On the basis of these results clear implications for practice cannot be made. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which agent should be prescribed may be based on the data on antidepressant efficacy in the general population of individuals with major depression, also taking into account that data on medically ill patients suggest a positive safety profile for the SSRIs. Large, simple, randomised, pragmatic trials comparing commonly used antidepressants versus placebo in people with cancer with depressive symptoms, with or without a formal diagnosis of a depressive disorder, are urgently needed to better inform clinical practice.

A cluster randomised controlled trial of a brief couple-focused psychoeducational intervention to prevent common postnatal mental disorders among women: study protocol

INTRODUCTION

Postnatal common mental disorders among women are an important public health problem internationally. Interventions to prevent postnatal depression have had limited success. What Were We Thinking (WWWT) is a structured, gender-informed, psychoeducational group programme for parents and their first infant that addresses two modifiable risks to postnatal mental health. This paper describes the protocol for a cluster randomised controlled trial to test the clinical effectiveness and cost-effectiveness of WWWT when implemented in usual primary care.

METHODS AND ANALYSIS

48 maternal and child health (MCH) centres from six diverse Local Government Areas, in Victoria, Australia are randomly allocated to the intervention group (usual care plus WWWT) or the control group (usual care). The required sample size is 184 women in each group. English-speaking primiparous women receiving postpartum healthcare in participating MCH centres complete two computer-assisted telephone interviews: baseline at 4 weeks and outcome at 6 months postpartum. Women attending intervention MCH centres are invited to attend WWWT in addition to usual care. The primary outcome is meeting Diagnostic and Statistical Manual-IV (DSM-IV) diagnostic criteria for major depressive episode; generalised anxiety disorder; panic disorder with or without agoraphobia, agoraphobia with or without panic, social phobia, adult separation anxiety or adjustment disorder with depressed mood, anxiety or mixed depressed mood and anxiety within the past 30 days at 6 months postpartum. Secondary outcomes are self-rated general and emotional health, infant sleep problems, method of infant feeding, quality of mother-infant relationship and intimate partner relationship, and healthcare costs and outcomes.

ETHICS AND DISSEMINATION

Approval to conduct the study has been granted. A comprehensive dissemination plan has been devised.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12613000506796. UTN: U1111-1125-8208.

Development and validation of the Diagnostic Interview Adjustment Disorder (DIAD)

Adjustment disorders (ADs) are under-researched due to the absence of a reliable and valid diagnostic tool. This paper describes the development and content/construct validation of a fully structured interview for the diagnosis of AD, the Diagnostic Interview Adjustment Disorder (DIAD). We developed the DIAD by partly adjusting and operationalizing DSM-IV criteria. Eleven experts were consulted on the content of the DIAD. In addition, the DIAD was administered by trained lay interviewers to a representative sample of disability claimants (n = 323). To assess construct validity of the DIAD, we explored the associations between the AD classification by the DIAD and summary scores of the Kessler Psychological Distress 10-item Scale (K10) and the World Health Organization Disability Assessment Schedule (WHODAS) by linear regression. Expert agreement on content of the DIAD was moderate to good. The prevalence of AD using the DIAD with revised criteria for the diagnosis AD was 7.4%. The associations of AD by the DIAD with average sum scores on the K10 and the WHODAS supported construct validity of the DIAD. The results provide a first indication that the DIAD is a valid instrument to diagnose AD. Further studies on reliability and on other aspects of validity are needed.

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.