Depression, demoralisation or adjustment disorder? Understanding emotional distress in the severely medically ill

Abstract

-As emotional distress is often seen as an understandable reaction to a severe or lifethreatening illness, clinicians are reluctant to make a diagnosis of depression and resort to alternative diagnoses such as adjustment disorder (AD) or demoralisation. This paper introduces these concepts and critically examines their clinical utility. It concludes that neither AD nor demoralisation can be clearly distinguished from depression on variables such as clinical symptoms, outcome or treatment response. Since AD and demoralisation are considered transient or understandable reactions, the risk of using these diagnoses as alternatives to depression in a clinical setting is that a simplistic approach of psychological therapies for the former and antidepressants for the latter will be adopted. Instead, a working diagnosis of a general distress syndrome complemented by a personalised formulation is advocated. This would lead to the generation of a problem list and a pragmatic management plan.

Depression as a risk factor for adverse outcomes in coronary heart disease

“…The cognitive and emotional symptoms of depression in cardiac patients are sometimes disregarded as well, but for a very different reason: The importance of these symptoms is minimized because they are ‘understandable’, as in, ‘Of course he’s feeling down, he just had a heart attack’ [16]. This view is unjustified.…”

The MMPI‐2 in chronic psychiatric illness

“…When it comes to explaining scores on questionnaires and tests performed by chronic patients, the concept of demoralization plays an important role (O'Keeffe & Ranjith, ). Demoralization may be seen as a somewhat normal response to a long and debilitating disease and has been found in patients with long‐term schizophrenia (Restifo, Harkavy‐Friedman & Shrout, ) as well as in patients with long‐term depression (Koekkoek, van Meijel, Schene & Hutschemaekers, ).…”

“…Differences between the Clinical Scales and the RC Scales are a result of removing the non‐specific variance associated with demoralization, the K correction, and subtle items (Tellegen et al ., ). With respect to demoralization, distinct from of O'Keeffe & Ranjith () who defined the concept as transient or understandable reactions to severe or life‐threatening illness, Tellegen and colleagues () used the Watson and Tellegen () two‐dimensional model of affect to explain the construct of demoralization. This mood model consists of two orthogonal bipolar dimensions, “Positive Affect or Arousal” and “Negative Affect or Arousal,” and a third dimension called “Pleasantness versus Unpleasantness,” positioned midway between the previously described two dimensions (Tellegen, Watson & Clark, , ).…”

Pharmacotherapy of adjustment disorder: A review

“…At the same time, adjustment disorder is associated with considerable morbidity and even mortality, and the evidence base for non-medical interventions is also limited. Thus an individualised approach must be employed, with a plan made for each patient based on a rigorous clinical assessment, as well as a consideration of the literature as a whole (O'Keeffe and Ranjith 2007). An evidence base on pharmacotherapy of adjustment disorder has gradually emerged; placebo-controlled trials provide some support for the herbal agent euphytose, comparator trials provide limited support for a number of antidepressant agents, and taken together a series of studies indicate that etifoxine is superior to buspirone and benzodiazepines for adjustment disorder with anxiety.…”