What is the treatment for adjustment disorder?

Treatment of Adjustment Disorder

For mild adjustment disorder, psychotherapy alone—specifically cognitive-behavioral therapy (CBT)—is the first-line treatment without medication, while moderate to severe cases require combined psychotherapy and pharmacotherapy with SSRIs for depressive features or short-term benzodiazepines for severe anxiety. 1, 2

Treatment Algorithm Based on Severity

Mild Adjustment Disorder

• Psychotherapy alone is sufficient without pharmacological intervention 1, 2
• Individual CBT is the most evidence-based psychological intervention, targeting cognitive and behavioral modifications to reduce distress and improve social functioning 1, 2
• Self-help interventions based on CBT principles can be offered for patients who decline face-to-face therapy 1
• Problem-solving treatment is recommended specifically for those with depressive symptoms 1
• Relaxation training serves as a useful adjunctive intervention 1

Moderate to Severe Adjustment Disorder

• Combined approach with both psychotherapy and medication is first-line treatment 2
• The severity threshold requiring medication includes significant functional impairment, high suicide risk, or symptoms causing substantial distress 2, 3
• Pharmacotherapy should always be adjunctive to psychotherapy, never as monotherapy 2, 3

Pharmacological Options

For Anxiety-Predominant Symptoms

• Benzodiazepines (lorazepam, diazepam, clorazepate) for short-term management of severe anxiety symptoms 1, 2, 3
• These should be time-limited due to dependence risk and are intended for acute symptom control 3
• Etifoxine represents an alternative anxiolytic option with evidence in adjustment disorder 3

For Depressive Features

• SSRIs are recommended for adjustment disorder with depressive features 1, 2
• The evidence base for antidepressants in adjustment disorder is limited, with no robust studies demonstrating clear benefits 4
• Despite limited evidence, SSRIs are commonly prescribed in clinical practice for symptom-oriented treatment 5

Psychotherapy Modalities

Primary Interventions

• Individual CBT has the strongest evidence base and should be the preferred psychological intervention 1, 2, 6
• CBT components were present in 53% of studied psychological therapies for adjustment disorder 6
• Short-term dynamic psychotherapy represents an alternative evidence-based approach 3

Family and Social Interventions

• Family involvement should be incorporated whenever possible, particularly for children and adolescents 1, 2
• For children with externalizing behaviors (noncompliance, disruptive behavior), parental management training is recommended 7, 2
• For children with internalizing symptoms (low self-esteem, depression, anxiety), individual therapy is indicated 7, 2

Adjunctive Approaches

• Mindfulness-based interventions have emerging evidence 3
• Body-mind-spirit techniques and yoga meditation show promise 3
• Bibliotherapy (self-help manuals) can be effective for motivated patients 3

Special Clinical Situations

High Suicide Risk

• Given the significant suicide risk in severe adjustment disorder, clinicians must consider psychotropic agents including benzodiazepines, antidepressants, or etifoxine 3
• Regular assessment of suicide risk is crucial throughout treatment 2

Comorbid Conditions

• When adjustment disorder co-occurs with major depression or generalized anxiety disorder, treat all conditions simultaneously, prioritizing the disorder causing greatest functional impairment 2
• For cancer patients, pharmacologic regimens may be offered when psychological management is not accessible or when patients prefer medication 2

Children and Adolescents

• Parental management training for externalizing behaviors 7, 2
• Individual therapy for internalizing behaviors 7, 2
• Family therapy for adjustment difficulties and parent-child conflict 7
• Assess family functioning and parental adjustment, as parental distress impairs children's sense of safety 2

Monitoring and Follow-Up

• Regular assessment of symptom improvement, treatment adherence, and treatment plan adjustment based on response are essential 1, 2
• If symptoms respond to initial treatment, follow-up with primary care is appropriate 2
• If no response occurs, reevaluate the diagnosis and consider alternative treatments 2
• Use standardized tools including the Distress Thermometer (cutoff ≥4) and Brief Symptom Inventory-18 to evaluate symptom severity 2

Critical Pitfalls to Avoid

• Premature discontinuation of treatment before adequate coping skills are developed 1, 2
• Neglecting to involve family members when appropriate, especially for children and adolescents 1, 2
• Using antidepressants as first-line treatment for mild adjustment disorder without psychotherapy 4
• Prolonged benzodiazepine use beyond acute symptom management 3
• Failing to reassess the diagnosis if symptoms persist beyond 6 months, as this may indicate another psychiatric disorder 4

Evidence Quality Considerations

The overall quality of evidence for adjustment disorder treatments remains low to very low by GRADE criteria, despite several randomized controlled trials 6. Psychotherapy interventions have more robust support than pharmacological treatments 3, 6. Most medication use in adjustment disorder is symptom-oriented rather than evidence-based, with prescription patterns showing increased use of atypical antipsychotics despite lack of supporting guidelines 5. The concordance between clinical diagnosis and structured diagnostic tools is poor, contributing to research challenges 4.