Adjustment Disorder

Adjustment disorder is emotional or behavioural symptoms developing within 3 months of an identifiable stressor, out of proportion to it or causing impairment, and resolving within 6 months after the stressor ends.

Occurs in 5 to 20% of psychiatric outpatients and up to 20 to 30% of patients with medical illness.

Subtypes: depressed mood, anxiety, mixed, conduct disturbance, mixed emotions and conduct.

Associated with increased suicide attempts; common in adolescents and in medically ill patients.

• Low mood, tearfulness, worry, irritability, poor concentration, sleep disturbance, reduced work performance, withdrawal, behavioural change.
• Symptoms do not meet criteria for major depression, GAD or PTSD.
• Triggers: job loss, relationship breakdown, illness, relocation, bereavement (not prolonged grief).

• Clinical diagnosis by temporal link and exclusion of other disorders.
• Screen with PHQ-9, GAD-7; assess suicide risk each visit.
• Exclude major depression, PTSD, prolonged grief, substance related disorders, organic causes (thyroid, medication effects).
• Review psychosocial context and supports.

• Supportive counselling, problem solving therapy, CBT or interpersonal therapy (4 to 8 sessions), stress management.
• Address the stressor (work, housing, social support).
• Medication is not first line; short term options: for insomnia, zopiclone 3.75 mg for up to 1 to 2 weeks; for significant anxiety or depression, SSRI (sertraline 50 mg) if persistent beyond several weeks.
• Avoid long term benzodiazepines.
• Monitor for progression to major depression, review at 4 to 6 weeks, and refer if risk or persistent beyond 6 months.