Adjustment disorder is a common diagnosis and occurs when a person fails to recover from a distressing experience (e.g., trauma or a stressful life event). A stressful life event might for example include the loss of a loved one, a relationship breakdown or dealing with a chronic illness. While many people will encounter traumatic events and life stressors, some people fail to adjust and return to normal day-to-day functioning following such an event. Even though this is considered a common diagnosis, there has been surprisingly little research investigating interventions for adjustment disorder.
A recent systematic review undertaken by O’Donnell, Metcalf, Watson, Phelps and Varker (2018) examined psychological and pharmacological interventions for adjustment disorder in adults in order to determine which interventions are most effective in treating adjustment disorder symptoms. This first ever systematic review of this area investigated the literature on adjustment disorder spanning almost four decades identifying 3,508 studies from the data base search. Of these only 29 studies met criteria for inclusion in the review and subsequent qualitative synthesis of the study findings. Twelve of the studies were published in the past five years. Most of the studies (n=17) investigated psychological interventions, primarily cognitive behaviour therapy (n=9) followed by psychodynamic interventions (n=3), behavioural interventions (n=3) with the final two involving relaxation techniques.
Ten studies investigated pharmacological treatments including commonly used psychotropic medications such as selective serotonin reuptake inhibitors (SSRIs) and benzodiazepine. One study specifically investigated combined pharmacotherapy and psychological interventions but no control group was included and the final study looked at plant extracts.
The researchers implemented the Grading of Recommendations Assessment, Development and Evaluation (GRADE)1 approach to rank the quality of the evidence in each study. The GRADE system allows researchers to rank the quality of the evidence as either:
- high (there is confidence that the true effect lies close to that of the estimate of the effect)
- moderate (there is a moderate level of confidence that the true effect lies close to that of the estimate of the effect, but there is a possibility that the effect is quite different)
- low (there is limited confidence the true effect lies close to that of the estimate of the effect; the true effect is likely to be different)
- very low (there is very little confidence that the true effect lies close to that of the estimate; it is likely that the true effect is substantially different)
Key findings
The systematic review identified few studies looking at interventions for the treatment of adjustment disorder that met inclusion criteria and those studies that were identified presented with serious limitations. Seventeen of the studies included in this review were randomised controlled trials (RCTs) with the remaining studies adopting a less rigorous methodology. Further, the RCTs were considered to be of poor quality with a range of limitations including high drop-out rates, poor randomisation approaches and non-blinding of assessors. A major limitation identified across almost all of the studies was the lack of focus on recovery from adjustment disorder or adjustment disorder symptoms. The studies tended to focus on pre- and post-treatment change in symptoms of depression and anxiety rather than adjustment disorder. In addition, across the studies there was a range of other limitations including inconsistencies in the diagnostic approach, small sample size, lack of follow-up data and lack of a control condition.
The GRADE rankings for studies included in the review were either ‘low’ or ‘very low’. As a result the researchers concluded that limited research has been undertaken investigating interventions for adjustment disorder and the research that exists is not of a sufficient quality to determine the effectiveness of the interventions evaluated. These findings underscore the importance of future high-quality research being undertaken to investigate treatment approaches to address adjustment disorder, a much neglected mental health presentation.
doi:10.1002/jts.22295
Re-evaluating the disorder
In the latest update of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) adjustment disorder was reconceptualised as one of the ‘trauma and stress-related disorders’ rather than a diagnostic category that is assigned when criteria for another disorder is not met. DSM-5 criteria for diagnosis include that:
- the distress experienced is out of proportion with expected reactions to the stressor
- symptoms are clinically significant and cause considerable distress and impairment in daily functioning
- the distress and impairment are not as a result of another existing mental health diagnosis or a recent bereavement
- the symptoms commence within three months of a specific stressor
- once the stressor is resolved or removed the person recovers within six months.
Recent research has examined the construct and diagnosis of adjustment disorder with a focus on two core symptoms of preoccupation with the stressor, and failure to adapt to the stressor. These changes are reflected in new diagnostic criteria for adjustment disorder as part of the upcoming eleventh revision of the International Classification of Disease (Kazlauska, Zelviene, Lorenz, Quero & Maercker, 2017). These new diagnostic criteria have the potential to significantly advance research into effective treatments for adjustment disorder.
1 See bit.ly/2zXArJm