Adjustment Disorder with Mixed Anxiety and Depressed Mood
The most likely diagnosis for this patient is Adjustment Disorder with mixed anxiety and depressed mood, given the temporal relationship between retirement (a major life stressor occurring within the past year) and the onset of low mood and anxiety symptoms related to a relative's health. 1
Diagnostic Reasoning
Why Adjustment Disorder Fits Best
Adjustment disorders are characterized by emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the stressor's onset, presenting with low mood, tearfulness, feelings of hopelessness, anxiety, nervousness, worry, or jitteriness. 2 The retirement within the past year serves as the clear identifiable stressor. 1
Retirement represents a major life transition involving loss of routine, social relations, role, status, and accomplishments, which commonly triggers negative feelings and psychoemotional reactions including depression and anxiety. 3 This context makes adjustment disorder particularly likely when symptoms emerge temporally related to retirement. 3
The anxiety specifically focused on a relative's health suggests reactive worry to an external stressor rather than the pervasive, uncontrollable worry across multiple domains that would characterize Generalized Anxiety Disorder. 2 GAD requires excessive anxiety and worry about a variety of topics for at least 6 months with difficulty controlling the worry. 2
Ruling Out Major Depressive Disorder
Major Depressive Disorder requires at least 5 of 9 specific symptoms present during the same 2-week period, with at least one being either depressed mood or anhedonia (loss of interest/pleasure), plus clinically significant functional impairment. 4 The question describes only "low mood and anxiety" without specifying the full symptom constellation. 2
Before diagnosing major depression, you must rule out medical causes including uncontrolled pain, fatigue, delirium from infection or electrolyte imbalance, thyroid disorders, or medication side effects. 2 This is particularly important in older adults. 2
The PHQ-9 should be used for systematic assessment, starting with the two core symptoms (depressed mood and anhedonia), then completing all 9 items if either core symptom scores ≥2 (present more than half the days). 2, 4 A score ≥8 suggests clinically significant depression requiring further evaluation. 2
Ruling Out Generalized Anxiety Disorder
GAD requires the presence of excessive anxiety and worry about a variety of topics, events, or activities occurring more often than not for at least 6 months, which is clearly excessive and very challenging to control. 2 The anxiety must be accompanied by at least three of six physical/cognitive symptoms including restlessness, fatigue, impaired concentration, irritability, muscle tension, or sleep disturbance. 2
The GAD-7 screening tool should be used, with scores of ≥5,10, and 15 suggesting mild, moderate, and severe anxiety levels respectively. 2 Scores ≥10 warrant further diagnostic evaluation. 2
Critically, GAD patients worry about multiple areas of life, not just one specific concern. 2 This patient's anxiety appears focused on the relative's health rather than representing pervasive worry across domains. 2
Assessment Approach for This Patient
Initial Screening Tools
Use the PHQ-2 as a rapid first-line screen, asking about depressed mood and anhedonia over the past 2 weeks. 2 If either question is endorsed as occurring more than half the days, proceed to the full PHQ-9. 2
For elderly patients, consider the Geriatric Depression Scale (GDS-15 or GDS-30), which focuses on affective symptoms and excludes somatic items that may be confounded by medical illness. 2 A GDS-30 score ≥19 or GDS-15 score ≥5 suggests depression requiring follow-up. 2
Screen for anxiety using the GAD-7, which assesses feeling nervous/anxious, inability to stop worrying, excessive worry, trouble relaxing, restlessness, irritability, and feeling afraid. 2
Critical Safety Assessment
- Always assess for suicidal ideation—never skip this question even if other symptoms seem mild. 4 If any self-harm thoughts are endorsed, immediate referral for emergency psychiatric evaluation is required regardless of total score. 2, 4
Contextual Factors to Assess
Determine whether the retirement was voluntary, mandatory, due to illness, or anticipated, as involuntary and health-related retirement are associated with higher rates of depression. 3 Nearly 28% of retirees experience depression, with mandatory and illness-related retirement showing the highest rates. 3
Assess the patient's daily activities and sense of control, as retirees often experience lower sense of control due to loss of work-related structure and purpose. 5 However, retirement can also reduce anxiety and distress when it liberates people from alienating work. 5
Evaluate caregiver burden if the patient is caring for the ill relative, using the Caregiver Burden Scale. 2 Caregivers suffer from increased rates of depression and physical illness. 2
Common Pitfalls to Avoid
Do not normalize symptoms simply because the patient is older or recently retired. 6 Frail older people often have low expectations of wellbeing and normalize anxiety and mild depressive symptoms due to multiple physical health issues, leading to underdiagnosis. 6
Do not overlook comorbid anxiety when depression is present—about 85% of patients with depression have significant anxiety, and 90% of patients with anxiety have depression. 7 Both conditions require appropriate treatment. 7
Do not assume brief irritability or mood changes represent bipolar disorder without sustained episodes of elevated mood and increased energy lasting at least 7 days. 1 Brief reactive outbursts do not meet criteria for mania. 1
Recognize that approximately 40% of patients with depression or anxiety do not seek treatment, and of those who do, less than half receive beneficial treatment. 7 Proactive screening and engagement are essential. 7