Introduction

Adjustment disorder is a commonly-used diagnosis among mental health clinicians, yet overlooked by researchers and insurers (₁). Adjustment disorder is among the top two most frequently coded diagnoses in specialty mental health claims, and commonly used by clinicians belonging to managed behavioral health organization panels for billing outpatient services related to interpersonal relationships, family, or workplace issues when the patient does not display a clear symptom picture that indicates another Axis I disorder (₂). Managed behavioral health organization claim counts for adjustment disorder and treatment costs are comparable to depression (₂,₃).

According to the DSM-IV-TR and DSM-IV sourcebooks (₄,₅,₆,₇,₈,₉), patients with adjustment disorder must become symptomatic within 3 months of a precipitating event, and if acute, the reaction should last no longer than 6 months after the stressor or its effects have terminated (or if chronic, the reaction persists longer than 6 months). Yet when considered among other Axis I disorders, it is difficult to differentiate adjustment disorder from more severe psychopathologies like depressive, anxiety, or substance abuse disorders (₁₀,₁₁,₁₂). This is particularly true for early cases of psychiatric illness that do not yet meet criteria for major syndromes (₁₃). Diagnostic accuracy is critical for appropriate treatment planning given associated medical co-morbid conditions (e.g., cancer and disabilities), higher service utilization (₁₄), as well as an increased risk of acute suicide attempts when compared to other disorders (₁₅,₁₆,₁₇).

This retrospective analysis examines adjustment disorder by describing service utilization patterns for patients from a managed behavioral health organization, and by comparing clinical outcomes for those who completed treatment within 6 months versus those who continued beyond 6 months.

Methods

Using retrospective data from an NIMH-funded study conducted at a large national managed behavioral health organization – United Behavioral Health (UBH) – with external institutional review board approval, administrative claims data from 2001 through 2003 were merged with the Member Wellness Survey (MWS) data at baseline, 6 weeks, and 6 months. The MWS was developed and validated in the parent study reported elsewhere (₁₈). The parent study included a psychometric analysis of the MWS which was developed based on subscales from commonly used and validated instruments (e.g., Symptom Check List-90, SF-36, and the CAGE).

Participants

Outcome Measures

Statistical Analyses

Results

Sample Characteristics

Service Utilization Pattern of Patients with an Exclusive Diagnosis of Adjustment Disorder

Differentiating Demographic and Clinical Characteristics

There were no demographic (i.e., age group, gender, geographic region of the country, or relation to insured) or MWS clinical outcome (e.g., Total Symptoms, Functioning, etc.) differences between the NT and the ET group at baseline (see Table 1). However, the NT group compared to the ET group showed significantly improved mean change scores (from baseline to 6 months) in Total Symptoms (m = -0.59 vs. -0.27, p < 0.05), Wellness (m = -0.60 vs. -0.35, p < 0.05) and Global Outcome (m = -0.58 vs. -0.31, p < 0.01). Negative mean change scores reflect decrements from baseline to 6 months on key scale indices. Results are reported in Table 1.

Figure 1

Table 1: Comparison Between Patients in the Normative Treatment (NT) Group versus the Extended Treatment (ET) Group

Discussion

It is important to note that although the DSM-IV-TR describes two forms of adjustment disorder – acute and chronic - (₄), results of our study indicate that almost half of the patients with a single adjustment disorder diagnosis covered by a managed behavioral health organization remained in treatment for over 6 months, suggesting that the chronic form of adjustment disorder is quite common. Some patients carrying the adjustment disorder diagnosis had their treatment extending over two years. Furthermore, despite both groups starting at similar levels of clinical distress, NT patients achieved significantly more improvement using half the number of sessions and at significantly lower costs than the ET patients. These findings would support the validity of having both an acute and chronic form of adjustment disorder.

Given that the ET group did not improve at the same rate as those in the NT group, appropriate clinical care clearly would indicate that these patients with a chronic form of adjustment disorder needed to remain in treatment at least until they achieved a similar level of improvement as those with the acute form who completed treatment within 6 months. However, because both groups had similar levels of distress and symptom presentation at the beginning of treatment, the question remains as to why differences exist in the rates of improvement. A possibility is that patients in the ET group suffered from chronic stressors such as domestic violence, abuse, divorce, or chronic illnesses/disabilities that could result in maladaptive emotional or behavioral reactions persisting for longer than 6 months (₄,₅,₆,₇,₈,₉). This possibility reinforces the importance of the diagnostic category of a chronic form of adjustment disorder as described in the DSM-IV-TR.

Patients in the ET group may have been misdiagnosed, or they may have displayed sub-syndrome symptoms precipitated by a stressful event that made clear diagnosis difficult early on (₁, ₅, ₁₂). In either case, keeping patients in treatment for up to a year or more with a single adjustment disorder diagnosis could indicate an inadequate diagnostic assessment, particularly if the clinician did not take the time to rule out a possible diagnosis of a chronic form of adjustment disorder, which can only occur after six months have elapsed where the patient can them migrate to the chronic form of adjustment disorder. Also, patients in the ET group may have worsened and no longer qualified for any form of adjustment disorder (whether acute or chronic), yet the treating clinician did not change the diagnosis when billing services to avoid stigmatizing or ‘labeling' a patient. Furthermore, clinicians using automated billing systems may simply have sent the same billing forms with changed dates of service, but failed to change original diagnoses. Such errors or gaps in clinical information can compromise the ability to derive valid quality data from administrative claims data (₁₉). It is the responsibility of the clinician to alter the diagnosis if more serious pathology emerges.

In general, regardless of the diagnosis, it is also possible that patients in the ET group responded poorly to psychotherapy, or were “treatment resistant” (₂₀). Also it may be that some of the treatment resistant patients to psychotherapy alone should have had psychopharmacological agents added to the regimen. Research has shown that a proportion of patients do not benefit fully or at all from psychotherapy alone. On the other hand, patients in the ET group may have received inadequate or inappropriate clinical care and therefore failed to improve at the same rate as those seen in the NT group (₂₁,₂₂,₂₃). Because there is no official consensus on optimal treatment for adjustment disorder given the lack of treatment outcome research focused singly on this topic (₂₄), patients in the ET group may not have received brief counseling aimed directly at reducing the maladaptive response to the stressor, as well as the stressor itself and this may have turned into a chronic form of adjustment disorder or changed to a more severe psychiatric diagnosis (₂₄).

This brief descriptive report is subject to several limitations. First, the clinical information is limited because it does not include those who resolved their difficulties on their own, it is based solely on a self-report measure available only for those patients who responded to the MWS, and the MWS may not capture all of the differences in clinical severity. Second, the diagnosis is not based on a structured clinical interview but on the assessment of the treating clinician as recorded in billing forms. Third, the diagnosis of adjustment disorder in general is subject to error given the absence of symptom checklists, the subjective nature of this sub-syndrome classification, and the possibility of racial, ethnic, and cultural considerations. Fourth, there are methodological problems related to the use of bivariate and retrospective analyses, plus the inability to include medical or pharmacy claims data prevented examination of whether and how these common co-morbid factors influenced outcomes. Fifth, the MWS survey was last filled out at 6 months from intake, therefore there is no clinical information to assess improvement after the initial 6 months of treatment.

Conclusions

In conclusion, short-term outpatient services for adjustment disorder may not be the norm among managed behavioral health organization covered patients and some may necessitate further evaluation and clinical care. Patients not improving may benefit from medication evaluation, referral to self-help groups, education on coping strategies and relaxation training, as well as alternative non-mental health services such as exercise, yoga, and meditation. Further clinical research of adjustment disorder is needed, particularly for non-improved patients continuing in long-term treatment who may have a chronic form of adjustment disorder.

Acknowledgements

Correspondence to

Francisca Azocar, PhD United Behavioral Health 425 Market Street, 18^th Floor San Francisco, CA 94105 USA Telephone: 415-547-6148 Fax: 415-547-6164 e-mail: francisca_azocar@uhc.com