Differentiating major depression from adjustment disorder with depressed mood in the medical setting

The Role of Vortioxetine in the Treatment of Depressive Symptoms in General Hospital Psychiatry: A Case-Series and PRISMA-Compliant Systematic Review of the Literature

Depressive symptoms are a customary finding in hospitalized patients, particularly those who are undergoing long hospitalizations, underwent major surgical procedures or suffer from high levels of multimorbidity and frailty. The patients included in this case series shared high degrees of frailty-complexity and were evaluated within the ordinary consultation and liaison psychiatry service of the University Hospital in Pisa, Italy, from September 2021 to June 2023. Patients were administered at least one follow-up evaluation after a week and before discharge. To relate this case series to the extant literature, a comprehensive systematic review of vortioxetine safety and efficacy was performed. None of the six patients included developed serious safety issues, but one patient complained of mild-to-moderate nausea for some days after the vortioxetine introduction. Five out of six patients exhibited at least a slight clinical benefit as measured by the clinical global impression scale. Of the 858 entries screened via Scopus and Medline/PubMed, a total of 134 papers were included in our review. The present case series provides preliminary evidence for vortioxetine's safety in this healthcare domain. The literature reviewed in this paper seems to endorse a promising safety profile and a very peculiar efficacy niche for vortioxetine in consultation and liaison psychiatry.

A descriptive study of claims for occupational mental disorder: adjustment disorder

Background

The number of claims of Industrial Accidents Compensation Insurance (IACI) for mental illness has increased. In particular, the approval rate was higher in cases with confirmed incident circumstances such as adjustment disorder, acute stress disorder, and post-traumatic stress disorder. With increased numbers of filed IACI applications and their approval rates, the need to evaluate various work-related incidents and stressors consistently is also increasing.

Method

In January 2015–December 2017, among the cases of industrial accidents filed for mental illness and suicide by the Korea Workers' Compensation and Welfare Service, 76 filed or approved adjustment disorder cases were included. The cases of adjustment disorder were applied in this study to the “Criteria for Recognition of Mental Disorders by Psychological Loads” established in Japan in 2011 and investigated if cases were approved/rejected consistently. Additionally, features with the greatest influence on approval/rejection were examined quantitatively.

Results

The number of applications more than doubled from 2015 to 2017, with the approval rate rising from 66.7% to 90.6%. Among the major categories, applications of adjustment disorder related to “interpersonal relationships” were the largest number of applications. Applications related to “sexual harassment”, “interpersonal relationships”, and “accidents and experiences including fires” showed relatively higher approval rate. The approval rate was the lowest in the case of “change in the amount and quality of work”.

Conclusions

Approved cases tend to have special precedents and strong intensity. The main reasons for the rejection were that there were no special precedents and that the intensity of the case was weak. These 2 were the most important factors in determining approval/rejection.

Depressive symptoms in patients with epilepsy and clinically associated features in a single tertiary center

Although depressive symptoms are the most common psychiatric comorbidity in epilepsy, they remain underestimated and untreated in a large proportion of patients. The purpose of this study was to evaluate depression severity and related clinical features in people with epilepsy using a well-reliable self-report index of mood, the Beck Depression Inventory-II (BDI-II). One-hundred seventeen adult patients with epilepsy were recruited from a tertiary epilepsy center and completed the BDI-II. A single-item analysis of the 21 questions of the BDI-II was computed and differences between women and men in each depressive symptom were evaluated. Correlation and regression analyses were used to identify clinical features associated with the severity of depression. Results showed gender differences in some items, with women reporting overall higher depression severity than men. The most common symptoms regarded domains of sleeping patterns, tiredness, and loss of energy. Regression evidence suggested that being female, having an epilepsy duration < 10 years, as well as being treated with psychotropic drugs and reporting generalized seizure, were associated with higher depression severity. Despite its cross-sectional nature, this study reinforces the importance of investigating and possibly treating depressive symptoms in adult patients with epilepsy, since they negatively impact well-being, daytime activities, and sleep. Further studies identifying pharmacological and non-pharmacological treatments for depression in epilepsy need to be planned.

Comparison of Autonomic Reactivity to the Stress between Adjustment Disorder and Major Depressive Disorder

OBJECTIVE

Adjustment disorder (AD) remains an ambiguous diagnosis that overlaps with major depressive disorder (MDD). This study compared autonomic reactivity to the stress between AD and MDD to test for biological differences.

METHODS

Physically healthy Korean male soldiers admitted to a psychiatric ward were recruited for participation. Clinical diagnoses indicated that 62 patients with AD and 47 with MDD were selected. Procedures consisted of electrocardiogram measurements according to three consecutive phases lasting five minutes each [i.e., resting, stress (including a mental arithmetic task and Stroop color word test), and recovery].

RESULTS

The reactive trends of all heart rate variability (HRV) parameters related to the stress tasks in participants with AD did not differ from those with MDD. High-frequency HRV (a proxy of parasympathetic activity) increased during times of stress for participants with AD and MDD. Despite similar reactive trends, AD participants had higher HRV values than participants with MDD during whole phases, particularly for variables reflecting overall autonomic activity.

CONCLUSION

AD is associated with higher basal activity in the autonomous nervous system when compared to MDD. However, both are associated with pathophysiology indicating an altered autonomic reactivity to stress.

Adolescent adjustment disorder: Precipitant stressors and distress symptoms of 89 outpatients

Objective

Research on adolescent adjustment disorder (AD) is scarce. We characterized adolescent outpatients with AD in psychosocial background and treatment received compared with patients with other non-psychotic disorders (OND). Furthermore, we explored precipitant stressors, distress symptoms and behavioral problems among males and females with AD.

Method

Data were collected prospectively on 290 consecutive psychiatric outpatients, aged 12–22 yrs, at a secondary care clinic in Finland. DSM-III-R diagnoses were assigned, based on all available information, at the end of treatment.

Results

AD was the second most common diagnosis among non-psychotic patients (31% of 290). Compared to OND-patients, those with AD were predominantly female and had less severe psychosocial impairment. In multivariate comparisons school-related stressors, problems with law and restlessness characterized males, and parental illness and internalizing symptoms females with AD. Intensity and duration of treatment of AD-patients varied widely.

Conclusions

Adjustment disorder comprised a common clinical entity among adolescent outpatients. Psychiatric assessment and treatment should be individually targeted by taking into account gender-specific stressors and distress symptoms among young people with AD.

Assessment of Anxiety and Depression in Oral Mucositis Patients Undergoing Cancer Chemoradiotherapy: A Randomized Cross-sectional Study

INTRODUCTION

Oral mucositis is an unavoidable complication occurring during the treatment of cancer by radiotherapy, concurrent chemoradiotherapy (CCRT), or chemotherapy. This is a painful sequelae, significantly affecting the nutritional intake and quality of life.

MATERIALS AND METHODS

A multicentric cross-sectional study was done at four cancer centers in Hyderabad. About 455 subjects of both genders between 20 and 80 years undergoing cancer treatment such as chemotherapy (Group I), CCRT (Group II), radiotherapy within 14 days of initiation (Group III), and radiotherapy after 14 days of initiation of therapy (Group IV) who had oral mucositis were included in the study. A self-addressed Hospital Anxiety and Depression Scale questionnaire was used to assess the anxiety/depression in cancer therapy-induced oral mucositis patients.

RESULTS

Group III had established anxiety (58.82%) followed by Group IV (47.5%) of patients showing severe oral mucositis. In Group I, 47.17% and in Group II, 40% patients with borderline anxiety had mild mucositis, which was statistically significant (P = 0.01). Group III had established depression in 56.36%, followed by Group IV with 39.62% patients showed severe oral mucositis. Group I and II had mild to moderate mucositis, which was associated with established depression at statistically significant result (P = 0.02).

CONCLUSION

Group IV had maximum participants with anxiety and depression, closely followed by Group II, Group III, and least in Group I. Thus appropriate intervention in the form of nonpharmacological and pharmacological treatment is warranted.

[Adjustment disorder and DSM-5: A review]

INTRODUCTION

This paper exposes the complexity and discrete characteristic of the adjustment disorder with reference to its clinical and scientific diagnosis. Even though the disorder occurs in frequent clinical circumstances after important life events, such as mobbing, burn-out, unemployment, divorce or separation, pregnancy denial, surgical operation or cancer, the adjustment disorder is often not considered in the diagnosis since better known disorders with similar symptoms prevail, such as major depression and anxiety disorder. Ten years ago, Bottéro had already noticed that the adjustment disorder diagnosis remained rather uncommon with reference to patients he was working with while Langlois assimilated this disorder with an invisible diagnosis.

METHODOLOGY

In order to maximize the data collection, we used the article review below and challenged their surveys and results: National Center for Biotechnology Information (NBCI - Pubmed) for international articles and Cairn.info for French literature. Moreover, we targeted the following keywords on the search engine and used articles, which had been published from 1 February 1975 to 31 January 2015: "adjustment", "adjustment disorder" and the French translation "trouble de l'adaptation".

RESULTS

One hundred and ninety-one articles matched our search criteria. However, after a closer analysis, solely 105 articles were selected as being of interest. Many articles were excluded since they were related to non-psychiatric fields induced by the term "adaptation". Indeed, the number of corresponding articles found for the adjustment disorder literally pointed-out the lack of existing literature on that topic in comparison to more known disorders such as anxiety disorder (2661 articles) or major depression (5481 articles). This represents up to 50 times more articles in comparison to the number of articles we found on adjustment disorder and up to 20 times more articles for the eating disorder (1994), although the prevalence is not significantly higher than for the adjustment disorder. According to their relevance and their content, we have split the articles into seven subcategories: 1. General description: most scientific articles generally describe the adjustment disorder as being a transition diagnosis, which is ambiguous, marginal and difficult to detect. The findings claim that only a few studies have been conducted on the adjustment disorder despite a high prevalence in the general population and in the clinical field. 2.

CLASSIFICATION

the DSM-5 defined the adjustment disorder as a set of different outcomes and syndromes induced by stress after a difficult life event. While the link to other disorders has not been mentioned, the diagnosis of this disorder is no longer excluded or perceived as a secondary diagnosis. The DSM-5 faced criticism from three points of view: the operationalization of the concept of stress, the differential diagnosis and the description. 3. Prevalence: different samples have shown a significantly high prevalence of the adjustment disorder within the population. In addition to the psychiatric pain induced by difficult life events we need to emphasize the fact that 12.5 to 19.4 percent of the patients faced heavy and severe pathologies and depended on clinical care and treatment. 4. Etiology, comorbidity or associated symptomatology: the literature identified the tendency to commit suicide and stressful life events as being two fundamental characteristics of adjustment disorder. The third one is the personality profile. 5.

DIFFERENTIAL DIAGNOSIS

that motivates researchers to focus on the adjustment disorder: the differentiation approach as to the major depression. Indeed, the aetiology, the symptomatology and the treatment differ from the adjustment disorder. 6.

ASSESSMENT

very recently, Dutch researchers have developed and validated the Diagnostic Interview Adjustment Disorder (DIAD). 7.

TREATMENT

in 2014, no data or meta-analysis recommended drug treatment in addition to therapy. In fact, several authors have demonstrated the ineffectiveness of drug therapy. The literature suggests a psychotherapeutic approach to treat adjustment disorder.

CONCLUSION

Emotional reactions triggered by life events are responsible for full therapy agendas and for the rush in emergency rooms and hospitals. The reflex when faced with crying, insomnia or suicidal thoughts to give a diagnostic of major depressive disorder s is generally accepted by everyone. The elevated risk to commit suicide and the approved success of remission or healing through treatment (psychotherapy) are two major reasons why several studies promote the importance and the need to identify the adjustment disorder of our patients.

Mindfulness-based cognitive therapy for psycho-oncology patients: an exploratory study

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is a group-based intervention similar to mindfulness-based stress reduction, but which includes cognitive therapy techniques. This study investigates its usefulness in the treatment of depressive, anxiety and stress/distress symptoms in cancer patients referred to a psycho-oncology service. It also examines whether effect on depression is mediated by self-compassion.

METHOD

In phase 1 of this study, 16 cancer patients with mild/moderate psychological distress were randomised to MBCT (n=8) or treatment as usual (TAU; n=8), and assessed pre- and post-treatment. Analysis of variance was performed to examine the effect of treatment on anxiety and depression. In phase 2, the TAU group received the intervention, and results of pre- and post-MBCT assessments were combined with those receiving MBCT in phase 1. Finally, both groups were followed up at 3 months.

RESULTS

In phase 1, the MBCT group had a significant improvement in mindfulness and a decrease in anxiety. Statistically significant improvements in both depression and anxiety were found at 3 month follow-up. Self-compassion appeared to mediate the effect on anxiety/depression.

CONCLUSION

This small pilot study suggests that MBCT may have a beneficial effect on psychological variables often adversely affected in cancer in a heterogeneous cancer population.

A descriptive study of adjustment disorder diagnoses in general hospital patients

Objective: A descriptive survey of the characteristics of medical and surgical patients given the diagnosis of adjustment disorder.

Method: 124 case notes of patients with adjustment disorder diagnoses seen over a one year period in a tertiary care hospital were reviewed to describe their characteristics. Patient demographic data, medical illness, hospitalisation details and psychiatric consultation notes were examined.

Results: This diagnosis represented 18.5% of consultation-liaison referrals. The length of hospitalisation for the adjustment disorder patients was more than twice that of general medical admissions. At least one psychosocial stressor was noted in 93% of all patients; in 59% of patients the medical illness was one of the stressors noted. About a third of patients had a past psychiatric history. Only 9% of patients had new courses of antidepressants recommended and in only 2% was inpatient psychiatric admission required. The diagnosis was used especially in patients with serious medical conditions, self-harm, injury and poisoning, and in cases presenting with a mixture of somatic and psychic symptoms.

Conclusions: The results suggest that this is a commonly used diagnosis in the medical consultation setting; it is largely being used in a way consistent with DSM criteria, whilst there were indications that it was also used for a range of problem behaviours that are difficult to classify.

Reasons for referral and consultation liaison psychiatry diagnoses

Objectives:

Focused management strategies, including effective distribution of available resources is dependent on ongoing analysis of referral type in any liaison psychiatry consultation service. This survey sought to measure rate of diagnoses in an Irish liaison psychiatry consultation service, and compare the results with other similar services.

Method:

A survey of referral reasons and diagnoses was performed on all patients presenting to a Dublin based inpatient liaison psychiatry consultation service over two six month periods. The results were subsequently compared with other similar international studies.

Results:

Commonest referral reasons were for depressive disorders, while commonest diagnoses included alcohol related disorders, depressive disorders, and delirium, with notably higher rates of alcohol related disorders than in other similar international studies.

Conclusions:

This study provides valuable information for referral reasons and diagnoses present in an Irish liaison psychiatry consultation service. The differences noted between diagnoses in our study and other international studies, as well as some of the difficulties in establishing these diagnoses, are discussed.

The ‘afterthought’ diagnosis: rehabilitating adjustment disorders

Although a common diagnosis, adjustment disorder has received little scientific attention, and instead the focus has been on major depression. It is likely that adjustment disorder and major depression have been conflated and the reasons for this are explored. Delineating one from the other clearly has crucial therapeutic and financial implications.

Distinguishing Quantitative Electroencephalogram Findings between Adjustment Disorder and Major Depressive Disorder

OBJECTIVE

Adjustment disorder (ADJ) is a common diagnosis. However, it is difficult to distinguish ADJ from other major Axis I disorders, such as major depressive disorder (MDD). The aim of this study was to determine the distinguishing neurophysiological characteristics between ADJ and MDD using quantitative analysis of an electroencephalogram (QEEG).

METHODS

The study included 30 patients with ADJ and 51 patients with MDD. Resting (eye closed) vigilance controlled EEG recordings were assessed at 19 electrode sites according to the international 10/20 system. QEEG absolute power and coherence were calculated for the delta, theta, alpha and beta bandwidths.

RESULTS

Absolute powers of alpha and high beta bands, particularly at the frontocentral area, differed between MDD and ADJ group (p<0.05). Interhemispheric coherence values for the delta and beta bands were lower in the ADJ group than in the MDD group (p<0.05). Intrahemispheric coherence values for the alpha band were also lower in the ADJ group (p<0.05).

CONCLUSION

The differences in QEEG power and coherence in our investigation suggest that underlying pathophysiologic mechanisms may be different between ADJ and MDD.

Adjustment disorder: current diagnostic status

Adjustment disorder is a common diagnosis in psychiatric settings and carries a significant rate of morbidity. However, diagnostic criteria are vague and not much helpful in clinical practice. Also there has been relatively little research done on this disorder. In this article, we review the information that is available on the epidemiology, clinical features, validity, and current diagnostic status of adjustment disorder. In this article, the controversy surrounding the diagnosis is also highlighted. It also discusses the differential and comorbid diagnosis. The various recommendations for DSM-V and ICD-11 conclude the article.

Depression and coronary heart disease

There are exciting findings in the field of depression and coronary heart disease. Whether diagnosed or simply self-reported, depression continues to mark very high risk for a recurrent acute coronary syndrome or for death in patients with coronary heart disease. Many intriguing mechanisms have been posited to be implicated in the association between depression and heart disease, and randomized controlled trials of depression treatment are beginning to delineate the types of depression management strategies that may benefit the many coronary heart disease patients with depression.

Adjustment disorders in primary care: prevalence, recognition and use of services

BACKGROUND

Within the ICD and DSM review processes there is growing debate on the future classification and status of adjustment disorders, even though evidence on this clinical entity is scant, particularly outside specialised care.

AIMS

To estimate the prevalence of adjustment disorders in primary care; to explore whether there are differences between primary care patients with adjustment disorders and those with other mental disorders; and to describe the recognition and treatment of adjustment disorders by general practitioners (GPs).

METHOD

Participants were drawn from a cross-sectional survey of a representative sample of 3815 patients from 77 primary healthcare centres in Catalonia. The prevalence of current adjustment disorders and subtypes were assessed face to face using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Multilevel logistic regressions were conducted to assess differences between adjustment disorders and other mental disorders. Recognition and treatment of adjustment disorders by GPs were assessed through a review of patients' computerised clinical histories.

RESULTS

The prevalence of adjustment disorders was 2.94%. Patients with adjustment disorders had higher mental quality-of-life scores than patients with major depressive disorder but lower than patients without mental disorder. Self-perceived stress was also higher in adjustment disorders compared with those with anxiety disorders and those without mental disorder. Recognition of adjustment disorders by GPs was low: only 2 of the 110 cases identified using the SCID-I were detected by the GP. Among those with adjustment disorders, 37% had at least one psychotropic prescription.

CONCLUSIONS

Adjustment disorder shows a distinct profile as an intermediate category between no mental disorder and affective disorders (depression and anxiety disorders).

Parental bonding in males with adjustment disorder and hyperventilation syndrome

BACKGROUND

The purpose of the study was to identify the style of parental bonding and the personality characteristics that might increase the risk of hyperventilation and adjustment disorder.

METHODS

A total of 917 males were recruited, 156 with adjustment disorder and hyperventilation syndrome (AD + HY), 273 with adjustment disorder without hyperventilation syndrome (AD-HY), and 488 healthy controls. All participants completed the Parental Bonding Instrument, Eysenck Personality Questionnaire, and Chinese Health Questionnaire.

RESULTS

Analysis using structural equation models identified a pathway relationship in which parental bonding affected personality characteristics, personality characteristics affected mental health condition, and mental health condition affected the development of hyperventilation or adjustment disorder. Males with AD-HY perceived less paternal care, and those with AD + HY perceived more maternal protection than those with adjustment disorder and those in the control group. Participants with AD-HY were more neurotic and less extroverted than those with AD + HY. Both groups showed poorer mental health than the controls.

CONCLUSIONS

Although some patients with hyperventilation syndrome demonstrated symptoms of adjustment disorder, there were different predisposing factors between the two groups in terms of parental bonding and personality characteristics. This finding is important for the early intervention and prevention of hyperventilation and adjustment disorder.

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

BACKGROUND

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

SAMPLING AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Mixed anxiety and depressive disorder outcomes: prospective cohort study in primary care

BACKGROUND

Mixed anxiety and depressive disorder (MADD) is common yet ill-defined, with little known about outcomes.

AIMS

To determine MADD outcomes over 1 year.

METHOD

We recruited 250 adults attending seven London general practices with mild-moderate distress. Three groups were defined using a diagnostic interview: MADD, other ICD-10 psychiatric diagnosis, no psychiatric diagnosis. We assessed symptoms of distress (General Health Questionnaire-28), quality of life (12-item Short Form Health Survey), general practitioner (GP) diagnosis and consultation rate at baseline, 3 months and 1 year.

RESULTS

Two-thirds of participants with MADD had no significant psychological distress at 3 months (61%) or 1 year (69%). However, compared with those with no diagnosis, individuals had twice the risk of significant distress (incidence rate ratio 2.39, 95% CI 1.29-4.42) at 3 months but not 1 year, and persistently lower quality of life (mental health functioning). There was no significant difference in GP consultation rate/diagnosis.

CONCLUSIONS

The majority with MADD improved, but individuals had an increased risk of significant distress at 3 months and a lower quality of life. As we cannot currently predict those with a poorer prognosis these patients should be actively monitored in primary care.

Depressive and adjustment disorders - some questions about the differential diagnosis: case studies

BACKGROUND

Diagnosis and treatment of mood disorders in youth are still problematic because in this age the clinical presentation is atypical, and the diagnostic tools and the therapies are the same as that used for the adults. Mood disorders are categorically divided into unipolar disorders (major depressive disorder and dysthymic disorder) and bipolar disorder in Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision), but mood symptoms are also comprised in the diagnostic criteria of the adjustment disorder (AD), which occur in many different psychiatric disorders, and may also be found in some physical conditions. The differential diagnosis is not much addressed in the midst of clinical investigation and so remains the major problem in the clinical practice.

AIMS

The associations between some variables and the depressive disorder and AD were analyzed to make considerations about differential diagnosis.

PATIENTS AND METHODS

We reported a retrospective study of 60 patients affected by depressive disorder and AD. The analysis has evaluated the association between some variables and the single diagnostic categories. We have considered 10 variables, of which 6 are specific to the disorders, and 4 have been considered related problems.

RESULTS

The statistical analysis showed significant results for the associations of 3 variables (prevalent symptoms, treatment, and family history) with the single diagnostic categories.

CONCLUSION

The discriminate analysis resulted in statistically significant differences between patients with depressive disorders and those with AD on 3 variables, of which 2 are specific to the disorders, and 1 is included in the related problems. The other variables were weakly associated with the single diagnostic categories without any statistically significant differences. The 3 variables that were associated with the single diagnostic categories support the distinct construct validity of the 2 diagnostic categories, but, to date, it is difficult to establish if these variables can be considered diagnostic predictors. On the other hand, the other variables did not support the distinct construct validity of the 2 diagnostic categories, which suggest an overlapping and dimensional concept. The spectrum approach could unify categorical classification that is essential with a dimensional view. Combination of dimensional and categorical principles for classifying mood disorders may help to reduce the problems of underdiagnosis and undertreatment.

Differentiating and managing common psychiatric comorbidities seen in chronic pain patients

Pain patients often have comorbid psychiatric disorders that can complicate their management. Failure to recognize and address psychological comorbidities often limits pain treatment success. This paper describes some of the more commonly seen psychiatric comorbidities in pain patients, briefly discusses how the diagnoses are made, and provides some initial treatment guidelines. The multiaxial diagnostic system of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is described. Three common psychiatric issues seen in pain patients: anxiety, depression, and adjustment disorder, are discussed. A brief history of the DSM is also discussed.

The spectrum of adjustment disorders: too broad to be clinically helpful

The clinical value of the current Diagnostic and Statistical Manual of Mental Disorders diagnosis of adjustment disorder is controversial. The aim of this article is to review the literature on adjustment disorder and to present suggestions for the improvement of this diagnostic category in future classification systems. The literature utilized for this review was retrieved by MEDLINE (1967 until May 2009) and was supplemented by a manual search of the literature. The analysis of the literature indicates that the diagnosis of adjustment disorder is not characterized by consistent clinical description and prognosis, adequate differentiation from other disorders, or specific psychometric and neurobiologic features. The spectrum of affective disturbances entailed by the diagnosis of adjustment disorder appears to be too broad. A major problem seems to lie in the fact that it is an exclusion diagnosis that overlaps with subthreshold manifestations of mood and anxiety disorders. More precise characterizations of stress-related disturbances are available.

It is time to adjust the adjustment disorder category

PURPOSE OF REVIEW

A recent review highlighted the existing lack of evidence concerning adjustment disorders. It concluded that we should wait to adjust adjustment disorders until evidence is available. This is circular reasoning, fixing the poor definition of adjustment disorders. The present article outlines why we should amend adjustment disorders and which major obstacles need to be removed when revising this category.

RECENT FINDINGS

Adjustment disorder is a frequent disorder at least in medical settings. Many of these patients do not fulfill the criteria of a more specific diagnosis, but are still regarded as 'in need of treatment'. Clinicians appreciate the possibility of assigning adjustment disorders as 'wild card' diagnoses. The drawback of this clinical utility consists in the lack of operational diagnostic specificity. This leads to the resistance of adjustment disorders being researched properly, resulting in a substantial proportion of patients receiving treatments that are not evidence based. Thus, there is a need for revision of adjustment disorders. Thereby, the border disputes of what differentiates adjustment disorders from normal human adaptation processes and from other (more specific) disorders need to be solved.

SUMMARY

Given the high prevalence rates of adjustment disorders and their scientific neglect, it is time to revise adjustment disorders.

Adjustment Disorder: epidemiology, diagnosis and treatment

BACKGROUND

Adjustment Disorder is a condition strongly tied to acute and chronic stress. Despite clinical suggestion of a large prevalence in the general population and the high frequency of its diagnosis in the clinical settings, there has been relatively little research reported and, consequently, very few hints about its treatments.

METHODS

the authors gathered old and current information on the epidemiology, clinical features, comorbidity, treatment and outcome of adjustment disorder by a systematic review of essays published on PUBMED.

RESULTS

After a first glance at its historical definition and its definition in the DSM and ICD systems, the problem of distinguishing AD from other mood and anxiety disorders, the difficulty in the definition of stress and the implied concept of 'vulnerability' are considered. Comorbidity of AD with other conditions, and outcome of AD are then analyzed. This review also highlights recent data about trends in the use of antidepressant drugs, evidence on their efficacy and the use of psychotherapies.

CONCLUSION

AD is a very common diagnosis in clinical practice, but we still lack data about its rightful clinical entity. This may be caused by a difficulty in facing, with a purely descriptive methods, a "pathogenic label", based on a stressful event, for which a subjective impact has to be considered. We lack efficacy surveys concerning treatment. The use of psychotropic drugs such as antidepressants, in AD with anxious or depressed mood is not properly supported and should be avoided, while the usefulness of psychotherapies is more solidly supported by clinical evidence. To better determine the correct course of therapy, randomized-controlled trials, even for the combined use of drugs and psychotherapies, are needed vitally, especially for the resistant forms of AD.

A preliminary assessment of adjustment disorder among first-year college students

Using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000) criteria, we investigated whether the diagnosis adjustment disorder (AD) described first-year college students' adjustment problems. We found that a substantial portion of students experienced a set of adjustment symptoms meeting the AD criteria. Another portion of students reported adjustment concerns that were problematic but did not meet the AD diagnosis threshold. Female students tended to report more symptoms than do male students. College counseling implications are presented.

It is too early for adjusting the adjustment disorder category

PURPOSE OF REVIEW

Despite the relative frequency with which the diagnosis of adjustment disorder is made, there is a very limited research literature in regard to its cause, epidemiology and treatment. This review summarizes recent papers and findings in relation to this diagnostic category.

RECENT FINDINGS

The conceptual underpinnings of the diagnosis adjustment disorder is the subject of ongoing debate as is its differentiation from other psychiatric disorders such as depressive disorders. One group has proposed and tested a diagnostic model of adjustment disorder as a stress-response syndrome, related to posttraumatic stress disorder, which is a distinct psychopathological entity rather than a diagnosis of exclusion. Initial neuroimaging work in adjustment disorder indicates that this may be a helpful approach for increasing understanding of the biology of the disorder. Recent studies support the use of brief psychotherapy in the treatment of adjustment disorder.

SUMMARY

Although the studies and articles described in this review raise some interesting questions in relation to the diagnosis, cause, epidemiology and treatment of adjustment disorder, much more research is needed before we can draw some firm conclusions about the need for the redefinition and reclassification of this diagnostic category.

The adjustment disorders: the conundrums of the diagnoses

This article discusses the conundrums and the dilemmas of the conceptual framework of the diagnoses of the adjustment disorders (ADs). The psychiatric diagnoses that arise between normal behavior and the major psychiatric morbidities constitute the problematic subthreshold disorders. These subthreshold entities are also juxtaposed between problem-level diagnoses and more clearly defined major disorders. They present important taxonomic and diagnostic dilemmas in that they are often poorly defined, overlap with other diagnostic groupings, and have indefinite symptomatology. ADs were designed as a "wild card" to allow the coding of a psychiatric "diagnosis" for work done by psychiatrists and other mental health care specialists when the patient's symptoms do not reach the criterion of a major mental disorder. It is therefore not surprising that issues of reliability and validity prevail. The issues of diagnostic rigor and clinical utility seem at odds for the AD. Clinicians need a wild card, and field studies need to use reliable and valid concepts of AD and assessments instruments to determine more exact specification of the parameters of the diagnosis. Finally, appropriate and timely treatment is essential for patients with AD so that their symptoms do not worsen; their important relationships are not further impaired; or their capacity to work, study, or be active in their essential interpersonal pursuits is not compromised.

Posttraumatic embitterment disorder in comparison to other mental disorders

BACKGROUND

The term 'posttraumatic embitterment disorder' (PTED) was recently introduced to describe a subtype of adjustment disorders, characterized by prolonged embitterment, severe additional psychopathological symptoms and great impairment in most areas of life in reaction to a severe negative but not life threatening life event. The aim of this study is an empirical description and validation of the clinical concept of PTED, by comparing clinically defined PTED patients with patients suffering from other mental disorders on measures of posttraumatic stress and psychopathological distress.

METHODS

Fifty inpatients, suffering from PTED according to previously defined clinical diagnostic criteria, were compared with another 50 patients, matched by age and gender, who did not meet clinical criteria for PTED but for other mental disorders. Psychiatric diagnoses were assessed by the Mini International Neuropsychiatric Interview. Self-report measures included the Bern Embitterment Scale, the Impact of Event Scale, the PTED Self-Rating Scale and the SCL-90.

RESULTS

According to the Mini International Neuropsychiatric Interview both groups fulfilled the criteria for many disorders with a significantly higher occurrence of major depression and chronic adjustment disorder but less generalized anxiety disorder lifetime in PTED patients. Patients with PTED scored significantly higher on the global scores and on most subdimensions of the SCL-90, the Impact of Event Scale, the Bern Embitterment Scale and the PTED Self-Rating Scale.

CONCLUSIONS

Clear differences were found between PTED patients and patients with other mental disorders in regard to the quality and intensity of psychopathological as well as posttraumatic stress symptoms. PTED can help further subclassify and specify adjustment and reactive disorders.

Suicidal intent and the HPA-axis characteristics of suicide attempters with major depressive disorder and adjustment disorders

The main purpose of the study was to investigate Hypothalamic-Pituitary-Adrenal (HPA) axis characteristics in relation to suicidal intent among suicide attempters with Major Depressive Disorder (MDD) and Adjustment Disorders (AD). The relationship between suicidal intent, assessed by means of the Suicidal Intent Scale (SIS), and serum cortisol after a Dexamethasone Suppression Test (DST) was investigated in 78 suicide attempters, divided into diagnostic subgroups. There was a significant negative correlation between suicidal intent and post DST cortisol in patients with MDD. Our findings may be attributed to pathophysiological processes, where a high suicidal intent is revealed during a potential chronic course of MDD, which in turn results in a seemingly normal stress system.

Psychosomatic characterization of adjustment disorders in the medical setting: some suggestions for DSM-V

BACKGROUND

Adjustment disorders have been found to be the most frequent psychiatric diagnosis in the medically ill. Problems have been raised, however, as to their clinical value. The aim of the study was to characterize the psychosomatic features of adjustment disorders.

METHODS

One hundred patients with medical illness and a diagnosis of adjustment disorder according to DSM-IV criteria were interviewed according to the Diagnostic Criteria for Psychosomatic Research (DCPR) system, consisting of 12 clusters.

RESULTS

A considerable overlap was shown between adjustment disorders and DCPR clusters related to abnormal illness behavior (health anxiety, tanatophobia, nosophobia and illness denial) (54%), somatization (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction) (37%) and demoralization (33%). Only 13 of the patients with adjustment disorders did not present any DCPR syndromes.

LIMITATIONS

The study is cross-sectional and does not allow to determine the prognostic features of DCPR categorization.

CONCLUSION

The clinical information which derives from the concomitant application of the DCPR might improve and make more specific the treatment of patients with adjustment disorders.

Depressive symptoms, major depressive episode and cognition in the elderly: the three-city study

OBJECTIVES

The relationship between depression and dementia in the elderly has been extensively studied but the tools used to define depressed subjects are heterogeneous between studies. The objective of this study was to examine the relationship between depression and cognitive performances by using multiple measures of depressive state.

METHODS

A sample of 7,869 nondemented community-dwelling persons aged >or=65 years participated in the study. Depressive symptoms were evaluated by the Center for Epidemiological Study Depression Scale and the Mini-International Neuropsychiatric Interview was used to assess history of major depressive episodes (MDE). Cognitive function was evaluated by several tests including the Mini-Mental State Examination (MMSE), Trail Making Test, Isaacs Set Test and Benton Visual Retention Test.

RESULTS

When studied in separate models, depressive symptoms were significantly related to lower cognitive performances for all neuropsychological tests after adjusting for potential confounders (p<0.0001), whereas subjects with current MDE had significantly lower performances in MMSE and Isaacs Set Test. When studied concomitantly, only high levels of depressive symptoms were related to lower cognitive performance, whereas existence of MDE (past or current) was no longer associated with cognitive performances.

CONCLUSIONS

These data suggest that once current depressive symptoms are taken into account, major depression (past or current) is not associated with lower cognitive performances in a community-based sample of elderly people aged >or=65 years.

Predictors of psychosocial adjustment in people with physical disease

AIMS

The purpose of this paper was to examine the demographic, medical and psychosocial variables that result in the deterioration of psychosocial adjustment in patients with physical disease, the meaning their illness has for them and their coping style.

METHODS

The study was carried out in inpatient clinics of the Istanbul Faculty of Medicine (n = 198). The following evaluation instruments were used: a semi-structured questionnaire, the Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR), the Meaning of Illness Questionnaire (MIQ), the Hospital Anxiety-Depression Scale, the Multivariate Perceived Social Support Questionnaire and the Ways of Coping Inventory (WCI). Variables to be related with psychosocial adjustment were analysed by using Forward Logistic Regression.

RESULTS

The mean age of patients was 36.9 (SD 12.9) (18-65), 55% of which were women, the average PAIS-SR score was 1.02 (SD 0.41) (0.7-2.26); 47% of the patients had poor adjustment scores. Univariate analysis showed that psychosocial adjustment was affected by having children (p = 0.02), anxiety, depression, locus of control, perceived social support (p < 0.001), information level about their illness and its treatment (p = 0.01), the subscales of WCI [escape-avoidance (p < 0.001), distancing (p = 0.002), planned problem solving (p < 0.001), positive re-appraisal (p = 0.02)]. The psychosocial adjustment of patients with respiratory or infectious illnesses or bone-muscle-skeletal disorders was even less (p = 0.03). All 33 items of the MIQ were found to have a significant impact on psychosocial adjustment (p < 0.001). According to the regression analysis, the best predictors of psychosocial adjustment were: depression (p < 0.001) and the meaning of illness for patient (p < 0.01).

CONCLUSIONS

Having a physical illness is an important stress factor. In providing assistance, a number of factors should be taken into consideration, including how the patient perceives his illness, the impact the illness has on the patient's life, and a determination of the degree of depression being experienced by the patient.

RELEVANCE TO CLINICAL PRACTICE

The study indicated some predictors in the assessment of psychosocial adjustment and care of patients with physical illness. In daily clinical practice, among the patients with physical illness, those with a negative perception of their illness and those who define depression should be given special attention for psychosocial support.

The psychopathology of posttraumatic embitterment disorders

BACKGROUND

The posttraumatic embitterment disorder (PTED) was introduced as a new subgroup of adjustment disorders. The trigger event in PTED is an exceptional, though normal negative life event that is experienced as a violation of basic beliefs and values. The predominant emotion in PTED is embitterment. This study presents first data on the psychopathological profile of PTED.

METHOD

48 inpatients were diagnosed by clinical judgment as suffering from PTED. Patients were then interviewed with the standardized Mini International Neuropsychiatric Interview (MINI) and an additional interview section on the diagnostic criteria for PTED. Patients also filled in the Symptom Checklist-90-Revision (SCL-90-R), and the Impact of Event Scale (IES-R).

RESULTS

According to the MINI68.8% of the patients fulfilled the criteria for adjustment disorders, 52.1% for major depression, 41.7% for dysthymia, and 35.4% for generalized anxiety disorders. 100% of patients reported that they were suffering from intrusive thoughts about the event. 97.9% of the patients complained about persistent negative mood, 91.7% about restlessness, 83.3% inhibition of drive and loss of interest, 77.1% phobic avoidance of places related to the event, and 75% resignation, but 91.7% reported normal mood when distracted. The SCL-90-R indicated a high load of general psychopathological complaints with an average positive symptom total score of 52.26. Characteristic were feelings of injustice (100%), embitterment (97.7%), and rage (91.7%). The IES-R scale indicated a high prevalence of posttraumatic stress, with an average total score of 3.23. The average duration of illness was 31.7 months.

CONCLUSIONS

The PTED patients are suffering from severe, multiform, and disabling symptoms. Their clinical features pose difficult diagnostic problems. The predominant complaints about feelings of injustice, embitterment, and rage and the results of the IES speak for the importance of the critical event for the development and understanding of such disorders.

Adjustment disorder and the course of the suicidal process in adolescents

BACKGROUND

Adjustment disorders are often associated with suicidal behaviour but there is little information regarding the nature of the relationship and the effect of adjustment disorders on the suicidal process. The authors' goal was to investigate the association of adjustment disorders (with depressed mood) and suicide in adolescents by means of a psychological autopsy study.

METHOD

Relatives and other informants of 19 suicide victims were interviewed by means of a semi-structured interview schedule. Differences in duration of the suicidal process between suicide victims diagnosed with adjustment disorder and suicide cases diagnosed with other psychiatric disorders were examined.

RESULTS

The suicidal process was significantly shorter in suicide victims diagnosed with adjustment disorder compared with suicide cases diagnosed with other disorders. No indications of a history of emotional or behavioural problems during early adolescence were found in suicide cases diagnosed with adjustment disorder.

LIMITATIONS

The study sample consists of a small sample size and retrospective interviews of relatives were used.

CONCLUSIONS

The suicidal process in suicide victims diagnosed with adjustment disorder appears to be short and rapidly evolving without any prior indications of emotional or behavioural problems. The importance of assessing the suicidal risk in patients diagnosed with adjustment disorder is underlined.

Definitions and distinctions among depressive syndromes and symptoms: implications for a better understanding of the depression-cardiovascular disease association

OBJECTIVES

A prognostic role for depressive disorder presence and/or elevated depressive symptoms in the onset and recurrence of cardiovascular disease has been largely supported. Depression is a multifaceted disorder, encompassing a wide range of somatic, cognitive, and mood symptoms; it varies in intensity, duration, frequency, course, and family history; it can be assessed continuously or categorically; it can be obtained by interview or by self-report; and importantly, the cardiac prognostic impact of these distinctions may vary. We provide an overview of definitions and possible assessment of depression, and we discuss key assessment distinctions.

CONCLUSION

Examining the predictive ability of these key distinctions of depression for acute coronary syndrome recurrence would be of benefit to future research in this field.

Mental health in prison populations. A review--with special emphasis on a study of Danish prisoners on remand

OBJECTIVE

To review the literature on mental health and psychiatric morbidity in prison populations and relate findings to a Danish study on remand prisoners.

METHOD

The literature is reviewed and subdivided in the following section: validity of psychometrics in prison populations, prevalence of psychiatric disorders prior to imprisonment, incidence of psychiatric disorders during imprisonment, psychopathy related to psychiatric comorbidity, dependence syndromes with special emphasis on different administrations of heroin use (smoke vs. injection). The results are compared with a longitudinal Danish study on remand prisoners in either solitary confinement (SC) or non-SC.

RESULTS

Many factors must be taken into consideration when dealing with prisoners and mental health, e.g. international differences, the prison setting, demographics and methodological issues. The prison populations in general are increasing worldwide. Psychometrics may perform differently in prison populations compared with general populations with the General Health Questionnaire-28 having a low validity in remand prisoners. Psychiatric morbidity including schizophrenia is higher and perhaps increasing in prison populations compared with general populations with dependence syndromes being the most frequent disorders. The early phase of imprisonment is a vulnerable period with a moderately high incidence of adjustment disorders and twice the incidence in SC compared with non-SC. Prevalence of psychopathy is lower in European than North American prisons. Medium to high scores of psychopathy is related to higher psychiatric comorbidity. Opioid dependence is the most frequent drug disorder with subjects using injection representing a more dysfunctional group than subjects using smoke administration. Many mentally ill prisoners remain undetected and undertreated.

CONCLUSION

There is a growing population of mentally ill prisoners being insufficiently detected and treated.

An empirically derived taxonomy of common distress syndromes in the medically ill

OBJECTIVE

Contemporary psychiatric classifications have not proved to be useful in the understanding and care of people with physical illness. Distress syndromes are common, but classifications fail to differentiate syndromes relevantly. We sought to take a fresh look at the common distress syndromes in the medically ill.

METHODS

312 medical inpatients were interviewed using a structured psychiatric interview [the Monash Interview for Liaison Psychiatry (MILP)] to elicit the presence of mood, anxiety and somatoform symptoms. A previously reported examination of these data using latent trait analysis revealed the dimensions of demoralization, anhedonia, autonomic anxiety, somatoform symptoms and grief. Patients were scored on these dimensions and, on the basis of these, subjected to cluster analysis. Derived classes were compared on a range of demographic and clinical data including psychiatric diagnosis.

RESULTS

Six classes were found, distinguished by general levels of distress (measured by demoralization, autonomic anxiety and somatoform symptoms), anhedonia and grief. The most distressed groups were Demoralization and Demoralized Grief. Anhedonic Depression showed moderate levels of distress but the highest level of social dysfunction. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) categories of mood disorders did not follow any particular pattern other than reflecting severity of distress. The classes of high distress (Demoralization and Demoralized Grief) were significantly associated with younger age, past history of psychiatric treatment, low Global Assessment of Functioning (GAF) scores over the previous 12 months and DSM-IV somatoform disorders. Patients with Demoralized Grief tended to acknowledge their illness as a significant and relevant stressor. Patients with Demoralization identified other stressors as significant.

CONCLUSION

Concepts of demoralization, anhedonia and grief differentiate between important clinical syndromes and have informed the development of a taxonomy of common distress syndromes in the medically ill. Research is required to further explore the validity and utility of these concepts.

Consultation-liaison psychiatry: stability and change over a 10-year-period

Few long term studies have reported observations of changes over time with Consultation-liaison (C-L) populations. This is a longitudinal observational study of a tertiary care psychiatric C-L-service over a ten-year-period (1988-1997) using a standardized computerized clinical database to examine 4,429 consecutive referrals. Sociodemographic variables, relative consultation rates, reasons for referral and psychiatric diagnoses, apart from a shift from adjustment disorders with depressed mood to major depressive disorders within the depressive syndrome group, did not demonstrate significant changes during the study period. Levels of psychosocial and somatic functioning of referred patients decreased. Changes occurred in the pattern of C-L-psychiatric recommendations, e.g., in the prescription of antidepressants where tricyclic antidepressants were replaced by newer agents such as the selective serotonin reuptake inhibitors. Consulting psychiatrists were more likely to refer to private psychiatrists to follow patients, and more patients were transferred to inpatient psychiatric units. Due to a decrease in length of stay over the ten year observation period, the correlation of lagtime (the time from admission to the hospital until referral to C-L psychiatry) and length of stay decreased from very strong to moderate.

Adjustment disorders: fault line in the psychiatric glossary

Adjustment disorder entered the DSM–II nomenclature in 1968 and was recognized in ICD–9 in 1978. Before then the term ‘transient situational disturbance’ was applied to such conditions. The addition of adjustment disorder to the ICD classification was in response to the confusion generated by the older concepts of reactive and endogenous depression. Both DSM–IV (American Psychiatric Association, 1994) and ICD–10 (World Health Organization, 1992) retain the category of adjustment disorder, which has utility as a clinical concept. However, it has been eclipsed by the focus on mood disorder among research and policy-makers. A consequence of this is the danger of exaggerating the need for expensive and sometimes unpredictable mental health interventions in those whose problems are likely to resolve spontaneously.

Suicidal Behavior in Patients with Adjustment Disorders

Summary: This retrospective study characterizes the suicidal behavior in 119 patients with Axis I adjustment disorders as assessed by psychiatrists at the University of Virginia Hospital. Results indicated that 72 patients (60.5%) had documented suicide attempts in the past, 96% had been suicidal during their admission to the hospital, and 50% had attempted suicide before their hospitalization. The most commonly used method of suicide attempts was overdosing. Of the sample group with suicide attempts in the past, 67% had Axis II diagnoses of borderline personality disorder and antisocial personality disorder. Adjustment disorder diagnosis in patients with the suicide attempts was associated with a high level of suicidality at admission, involuntary hospitalization and substance-abuse disorders. Axis II diagnoses in patients with adjustment disorders constituted risk factors for further suicidal behavior. Additional future prospective studies with reliability checks on diagnosis of adjustment disorders and suicidal behavior are needed.

Adult adjustment disorder: a review of its current diagnostic status

Adjustment disorder is a diagnosis that is commonly used, particularly in primary care and general medical settings. However, there has been relatively little research done on this disorder. In this article, the author reviews the information that is available on the epidemiology, clinical features, validity, measurement, and treatment of adjustment disorder. She first reviews the historical development of the diagnosis from transient situational personality disorder in DSM-I to its current definition in DSM-IV. The author also considers similarities and differences in how adjustment disorder is defined in the DSM and ICD systems. The clinical features of the disorder that distinguish it from disorders such as major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, and acute stress disorder are described. The author highlights a number of the common controversies concerning adjustment disorder, especially criticisms that the diagnostic criteria are often poorly applied and that the disorder itself involves the medicalizing of problems of living. Evidence in support of the validity of the adjustment disorder diagnosis is reviewed and the author concludes that the findings support the content and predictive validity of the diagnosis. The author then discusses the epidemiology of adjustment disorders, their comorbidity with other conditions, including personality disorders, substance abuse, and suicidal behavior, and their treatment and outcome. The article concludes with a discussion of the special problems involved in evaluating for and measuring adjustment disorder.

Dimensions of psychopathology in the medically ill. A latent trait analysis

The authors examined the latent structure of psychiatric symptoms occurring in patients with medical illness. Symptom data were collected from 312 hospitalized medically ill patients using the Monash Interview for Liaison Psychiatry and subjected to latent trait analysis. A model with 5 dimensions provided an acceptable fit to the data. Dimensions were characterized as demoralization, anhedonia, autonomic anxiety, somatic symptoms, and grief. The demoralization dimension was similar to the concept of demoralization described by Frank and to the "giving up-given up complex" described by Engel. The concepts of demoralization, grief, and anhedonia may be useful in increasing understanding of the minor depressions in people with medical illness and in increasing the specificity of psychological and pharmacological treatments for these disorders.

Relationship between depression and cerebrovascular disease: conceptual issues

OBJECTIVES

The association between cerebrovascular disease (CVD) and depression has been well described, but our understanding of various aspects of the relationship between these two disorders remains limited.

METHOD

Based on a selective literature review, this paper examines empirical evidence and discusses conceptual issues concerning hierarchical, interactive, and co-morbid relationships between CVD and depression.

RESULTS

The concept of vascular depression minimizes the importance of the contribution of psychosocial factors. The interactive and co-morbid relationships have been largely neglected in psychiatric research. There is evidence that depression may increase the risk of CVD morbidity in patients with vascular disease and delay recovery in stroke patients, implying an interactive relationship. The concurrent existence of these two disorders based on common etiological factors such as genetic vulnerability, alcoholism and personality traits seems plausible.

CONCLUSIONS

A modified comorbidity model may guide investigation into the hierarchical, interactive and common etiological relationships between CVD and depression.

Outcome for adjustment disorder with depressed mood: comparison with other mood disorders

BACKGROUND

A review of the research literature on the diagnostic category of adjustment disorder indicates that its construct validity has not been established. Nevertheless, the diagnosis is made frequently, with an estimated incidence of 5-21% in psychiatric consultation services for adults.

METHODS

Retrospective data was used to evaluate the construct validity of the adjustment disorder diagnostic category. The data primarily consisted of SF-36 Health Status Survey responses by a large group of adult psychiatric outpatients before treatment and again six months after beginning treatment. Subjects were divided into five diagnostic groups, and MANOVA, MANCOVA and chi square were used to clarify relationships among diagnoses, sociodemographic data and SF-36 scores.

RESULTS

Diagnostic categories were significantly different at baseline, but did not differ in terms of outcome at six-months follow-up. There was a significant gender difference at baseline and a significant difference in gender distribution across diagnostic categories.

LIMITATIONS

Structured interviews were not used for initial diagnoses, nor is there an estimate of the reliability of diagnoses among the clinicians. The patient attrition rate for six-months follow-up data was about 50%. Finally, patients received individualized treatment, with some patients receiving both medication and psychotherapy.

CONCLUSIONS

Female patients were significantly more likely to be diagnosed with major depression or dysthymia than with an adjustment disorder. Females were also more likely than males to score lower on the mental health related scales of the SF-36 at admission. Patients diagnosed with an adjustment disorder scored higher on all SF-36 scales than did the other diagnostic groups at baseline and again at follow-up. There was no significant difference among diagnostic groups with regard to treatment outcome, suggesting that the adjustment disorder group can benefit as much as the other groups from treatment.

A multicenter investigation of consultation-liaison psychiatry in Italy. Italian C-L Group

In order to evaluate the extent and quality of consultation-liaison (C-L) activity in Italy, a multicenter investigation was conducted in 17 general hospitals. All of the hospitalized patients referred to C-L psychiatry during a 1-year period were assessed by means of a specific instrument (Patient Registration Form, PRF-SF). Of 518,212 patients, 4182 were referred to C-L services (referral rate = 0.72%). Typical consultations were for female patients (60.1%), admitted to medical wards (71.5%), aged 55-75 years. Most interventions were carried out within 2 days; a minority (22%) were urgent requests. Gastrointestinal and cardiovascular disorders, and unexplained medical symptoms were the most frequent ICD-9 somatic diagnoses at admission. One-third of the patients were not informed of having been referred to C-L and half of them had a lifetime history of psychiatric disturbances. Most frequent ICD-10 psychiatric diagnoses were neurotic, stress-related, and somatoform syndromes (33.1%), affective syndromes (19.4%), and organic mental syndromes (10.7%). Two-thirds of the patients were given only one consultation whereas the reminder received two to four follow-up visits. The rate of transfer to psychiatric wards was low (2.1%). Psychopharmacological treatment was suggested in 65% of cases, and 75.5% of the patients were referred to community psychiatric care at discharge. The implications of the findings are discussed.

Consultation-liaison psychiatrists management of depression

Prospective data on 1,360 consecutive inpatients referred to the consultation-liaison psychiatry service of 2 metropolitan general teaching hospitals and diagnoses as having a Depressive Illness Spectrum Disorder were collected by using the MICRO-CARES clinical database system. The distribution of DSM-III-R diagnoses was major depression (MD) 49%; dysthymia (DYS) 15%; organic or substance-induced mood disorder or depressive disorder not otherwise specified (ORG/NOS) 14%; and adjustment disorder with depressed mood (AD) 29%s. Antidepressants were prescribed in 59% of the MD cases, 40% of the DYS cases, 36% of the ORG/NOS cases, and 17% of the AD cases. In confirmed MD, antidepressants were prescribed in 69%, and significantly more often in those who were older, female, had a prior history of physical illness, had a neoplasm or a disorder of the nervous or musculoskeletal systems, had higher Axis IV scores, or were referred because of pain or terminal illness. The patients with confirmed MD prescribed antidepressants had a longer length of stay and were referred later than those not prescribed antidepressants. The results illustrate the importance of all the forms of depression in consultation-liaison psychiatry and the vigor with which all forms are treated.

Depression, psychosocial variables and occurrence of life events among patients with cancer

Depressive disorders and psychosocial related factors were investigated in 113 patients one year after the diagnosis of cancer. Patients with an ICD-10 diagnosis of depression (31% of the sample) showed higher external locus of control, poorer social support, higher incidence of undesirable and/or uncontrollable events than non-depressed patients. They also differed in reporting more frequently a life-time history of emotional disorders, inability to adjust to the diagnosis of cancer and in having a lower score on the performance status. Of these factors, past psychiatric history, early maladjustment to cancer, poor social support and low performance status were predictors of depressive symptoms. However, because of the cross-sectional nature of the study, no conclusion regarding a causal relationship between depression and psychosocial variables is possible.

Problems in accurate medical diagnosis of depression in female patients

Research in women's health has revealed the difficulties female patients experience in their attempts to receive accurate medical diagnoses. Depression may be misdiagnosed in 30-50% of female patients. This difficulty is considerably enhanced when women have physical diseases characterized by symptoms that resemble a major depressive disorder. In addition, medical treatments may induce symptoms that are misdiagnosed as affective distress. Multiple causes contribute to an enhanced likelihood of misdiagnoses in women, including physicians' androcentrically orientated medical training and the two-to-one female-to-male ratio of depression treatment. The adverse consequences of incorrect diagnoses range from unnecessary expenditures of a woman's resources to potentially life-threatening medical conditions. Ironically, medical misdiagnoses of physical conditions may induce depressive reactions in female patients. A woman's age, sexual orientation, menstrual, occupational, and/or parental status represent potential areas of discrimination in diagnostic determinations. Suggestions are offered for improving the accuracy of health care providers' diagnoses in women.

Psychosocial morbidity and adjustment to illness among long-term cancer survivors. A six-year follow-up study

Psychiatric morbidity (DSM-III-R) and adjustment to illness (psychological stress, illness behavior, and coping) were prospectively studied in 52 cancer patients who had been evaluated at the time of cancer diagnosis 6 years earlier. The prevalence of psychiatric disorders decreased from 47% to 37%. Improvement in psychological adjustment (low interpersonal sensitivity, psychoticism, paranoia, disease conviction, and anxious preoccupation) was found between these two assessment points. A lifetime history of psychopathology and psychiatric problems at baseline was associated with a current mental disorder. External locus of control, low social support, abnormal illness behavior, emotional stress, and poor coping mechanisms, as evaluated at first assessment, were also associated with psychological symptoms and maladjustment to cancer at follow-up. From the data reported, the need to maintain a continuity of psychosocial care among cancer survivors is inferred.