Adjustment disorders — diagnosis, risk and stepped care (MEQ)

(i) Formulation and differentials. Working diagnosis: adjustment disorder with mixed anxiety and depressed mood, acute, following redundancy 8 weeks ago (onset well within the DSM 3-month window), with clinically significant distress/impairment, not meeting full MDE (no pervasive daily anhedonia/worthlessness pattern described; PHQ-9 9 is mild band monitoring, not diagnosis). Specifier and acute course stated. Differentials with discriminators: MDD (needs full episode criteria — recheck); GAD (needs multi-domain worry ≥6 months, not only post-redundancy); PTSD/ASD (no Criterion A trauma); normal stress reaction (impairment and disproportion argue clinical AD); substance-induced mood (alcohol contributing, not sole cause yet); medical (prior TSH normal; recheck if new features). Exclude dual-coding full MDD as AD.^[1][6]

(ii) Risk. Expand passive burden thoughts: frequency, intent, plan, means, prior attempts, hopelessness, impulsivity, alcohol-related disinhibition, protective factors (children, future job search). Safety plan, means advice, crisis contacts, early review. Literature shows suicidality occurs in AD populations — including youth samples — so the AD label never justifies a truncated risk assessment.^[2][6]

(iii) Stepped management. Psychoeducation on stress-response syndromes; reduce alcohol with motivational approach; sleep hygiene. If mild–moderate and engaged: brief problem-solving therapy (define financial/job problems, options, implement, review) plus brief CBT for catastrophic appraisals and behavioural activation; active monitoring with 2-week review if very mild and well supported.^[4][6] Antidepressant not automatic. If symptoms intensify toward MDD, remain severe, or fail psychological care: example sertraline 25–50 mg orally daily, early review 1–2 weeks for activation/suicidality, titrate as tolerated, measurement-based PHQ-9/GAD-7, several weeks at therapeutic dose. Avoid long-term benzodiazepines as primary plan.^[4][6]

(iv) Occupational principles. Early activation rather than indefinite sick certification without plan; graded return-to-work; address workplace barriers; evidence that activating interventions can reduce long-term sickness absence in AD.^[3]

(v) ICD-11. Emphasise preoccupation with the stressor/consequences and failure to adapt; typical onset about 1 month; usually resolves within 6 months unless stressor continues — name system when quoting numbers.^[5]