What is the treatment for adjustment disorder?

Adjustment Disorder: Comprehensive Overview

Definition and Clinical Presentation

Adjustment disorder is a stress-related psychiatric condition characterized by emotional or behavioral symptoms that develop within 3 months of an identifiable stressor, manifesting as low mood, tearfulness, hopelessness, anxiety, nervousness, worry, or separation anxiety, with significant impairment in social or occupational functioning. 1

• According to DSM-5 classification, severe homesickness and similar stress reactions may be classified as adjustment disorder with mixed anxiety and depressed mood (diagnostic code 309.28) 2
• The defining feature is recurrent cognitions focused on the stressor and home/attachment objects, distinguishing it from other anxiety or mood disorders 2
• Adjustment disorder is among the most common depressive disorders in patients with cancer, alongside major depression 2

Epidemiology and Prevalence

• Prevalence ranges from 11-18% in primary care settings and 10-35% in consultation-liaison psychiatry 3
• Despite high prevalence, adjustment disorder remains significantly under-researched compared to major depression (which has 50 times more published literature) 4
• The disorder occurs across all cultures and age groups 3

Diagnostic Assessment

Comprehensive assessment must evaluate the nature and severity of distress, behavioral and psychological symptoms, psychiatric history, current medications, physical symptoms, and suicide risk. 1

• Use standardized tools including the Distress Thermometer (DT) with cutoff ≥4 and Brief Symptom Inventory-18 (BSI-18) to evaluate symptom severity 1
• Distinguish adjustment disorder from normal stress reactions and major depressive disorder—adjustment disorder is diagnosed longitudinally based on course in context of stressor, while major depression is a cross-sectional diagnosis based on symptom count 3
• Evaluate for comorbid conditions, as adjustment disorder frequently co-occurs with other psychiatric disorders 1

Common diagnostic pitfall: Concordance between clinical diagnosis and structured interview diagnosis is very poor, with adjustment disorder being diagnosed more commonly in clinical practice than diagnostic tools allow 3

Treatment Algorithm

For Mild Adjustment Disorder

Psychotherapy alone without medication is the first-line treatment for mild adjustment disorder. 1, 5

• Individual cognitive-behavioral therapy (CBT) is the most evidence-based psychological intervention, focusing on modifying cognition and behavior to reduce unpleasant feelings and improve social adjustment 5
• Self-help with support based on CBT principles is recommended for patients who prefer not to have face-to-face therapy 5
• Problem-solving treatment is an evidence-based approach for those with depressive symptoms 5
• Relaxation training as an adjunctive intervention is also recommended 5

For Moderate to Severe Adjustment Disorder

A combination of psychotherapy and medication is recommended as first-line treatment for moderate to severe adjustment disorder. 1

• Psychotherapy with focus on emotional adjustment and coping remains essential 1
• Pharmacological options include:
  • Anxiolytics (benzodiazepines) for short-term management of severe anxiety symptoms 1, 5, 6
  • Selective serotonin reuptake inhibitors (SSRIs) for adjustment disorder with depressive features 1, 5
• Given the high risk of suicidal ideation and suicide attempts in severe adjustment disorder, clinicians must consider the potential benefit of psychotropic agents 6

Critical caveat: No robust studies demonstrate benefits from antidepressants specifically for adjustment disorder, and pharmacotherapy should be limited to symptomatic management 3. However, when severe symptoms are present with suicide risk, medication is warranted 6

Psychotherapy Modalities

• Individual CBT is preferred and has the strongest evidence base 5
• Short-term dynamic psychotherapy has been studied 6
• Behavioral interventions including mirror therapy, yoga meditation, body-mind-spirit technique, and mindfulness have shown promise 6
• Bibliotherapy (self-help manuals) can be effective 6
• Family involvement should be incorporated whenever possible, particularly for children and adolescents 5

Pharmacological Options (Evidence-Based)

Studies have investigated various medications with mixed results 6:

• Benzodiazepines (lorazepam, diazepam, clorazepate, lormetazepam) for acute anxiety management 6
• Etifoxine showed benefit in some trials 6
• SSRIs (fluoxetine, sertraline) are recommended when depressive features predominate 1
• Other agents studied include viloxazine, trazodone, S-adenosylmethionine, pivagabine, afobazole, and plant extracts (Kava-kava, Euphytose, Ginkgo biloba) 6

Important limitation: The quality of evidence for both psychological and pharmacological treatments is ranked as low to very low according to GRADE criteria 7

Special Clinical Situations

Comorbidity with Major Depression or Generalized Anxiety Disorder

When adjustment disorder co-occurs with MDD or GAD, treatment should address all conditions, prioritizing the condition causing greatest functional impairment. 1

Cancer Patients

• For patients without access to first-line treatment, those expressing preference for pharmacotherapy, or those who do not improve with first-line psychological management, pharmacologic regimens may be offered 2
• Culturally adapted and linguistically appropriate information should be provided to patients and families 8

Children and Adolescents

• Parental management training is recommended for externalizing behaviors 2
• Individual therapy for internalizing behaviors (low self-esteem, depression, anxiety) 2
• Group therapy for social skills deficits 2
• Family therapy for adjustment difficulties and parent-child conflict 2

Monitoring and Follow-Up

Regular assessment of symptom improvement, treatment adherence, and adjustment of treatment plan based on response are crucial. 5

• If symptoms respond to initial treatment, follow-up with the primary care team is recommended 1
• If there is no response, reevaluation of the diagnosis and consideration of alternative treatments are necessary 1
• When pharmacological treatment is used, regularly evaluate symptom relief, side effects, and patient satisfaction 8
• After 8 weeks of treatment with little improvement despite good adherence, adjust the treatment approach 8

Psychosocial Support Interventions

Designating a care coordinator and providing proactive intervention to prevent social isolation are essential components of comprehensive care. 1

• Care coordinator should serve as point of contact for the family, schedule appointments, and facilitate communication with clinicians 2
• Promote patient independence and involvement in decision-making regarding medical care 2
• Modified/adapted sports, summer camps, youth groups, art groups, equestrian therapy, and aqua therapies can provide social support 2
• Palliative care is appropriate to relieve suffering and improve quality of life as needed 2

Critical Pitfalls to Avoid

• Premature discontinuation of treatment before adequate coping skills are developed 5
• Neglecting to involve family members in the treatment process when appropriate 5
• Reflexively diagnosing major depression when faced with crying, insomnia, or suicidal thoughts triggered by life events 4
• Failing to recognize the elevated suicide risk associated with adjustment disorder 4
• Over-reliance on pharmacotherapy without psychotherapy, as brief psychotherapeutic interventions are the mainstay of treatment 3

Prognosis and Long-Term Considerations

• Adjustment disorder requires therapeutic intervention because of significant complications, including elevated suicide risk 6
• The disorder is conceptually different from major depression and requires longitudinal assessment in context of the stressor 3
• Success of remission or healing through treatment (particularly psychotherapy) supports the importance of identifying and treating adjustment disorder 4