Depression? Demoralization? Adjustment d/o? Does it matter?

[heyjack70]

Depression? Demoralization? Adjustment d/o? Does it matter?

Any thoughts about the legitimacy of the term/diagnosis, "demoralization" and how it differs from the other two diagnoses that are in the DSMIV? Does this distinction drive treatment choices? From a brief review, demoralization appears to be related to an individual's "loss of efficacy" following life failures, illness, etc., and may not be rooted in a biologic pathology. In fact, one paper suggested coding demoralization on Axis IV which makes sense if it stems entirely from social stressors. Thoughts?

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[Doctor Bagel]

Would you treat it differently? And biologically rooted versus not biologically rooted -- what does that mean? People with personally disorders have observed physiologic changes in their brain, so that's biologically rooted and not really "characterologic."

I could see thinking about this "loss of efficacy" stuff in a patient's formulation. I guess then you would try to incorporate tools that could build up a sense of efficacy in your treatment plan. I'm not sure the actual label of demoralization or having a DSM diagnosis would be warranted, but then I'm not up on this discussion.

 

[TexasPhysician]

I find it as different as prostate cancer vs bph.

 

[F0nzie]

Good question.... The way our system is setup at the University is you have to put an Axis I or Axis II diagnosis if you're going to treat someone with medications or psychotherapy. If you don't have a diagnosis in Axis I or II you can't get reimbursement from insurance companies. Probably why we always throw in an "Adjustment d/o" because our system is setup that you can't have "No diagnosis". Whether we place demoralization under Axis I or Axis IV... I don't know what the data is... but my guess is the pt may respond well to psychotherapy. People get counseling all the time for Axis IV issues... Seems to me tossing an Adjustment d/o under Axis I is the safest bet if you want to provide your services under the insurance model.

 

[OldPsychDoc]

The reason God gave us 311...

 

[Apollyon]

The reason God gave us 311...

I'm guessing 311 is an ICD-9 code (let me google it to be sure - yes, depression NOS), but the first thing of which I thought was "indecent exposure", and that such was an interesting thing for which to thank God.

(And the band 311 took their name from the California penal code for "indecent exposure".)

 

[heyjack70]

Would you treat it differently? And biologically rooted versus not biologically rooted -- what does that mean? People with personally disorders have observed physiologic changes in their brain, so that's biologically rooted and not really "characterologic."

I could see thinking about this "loss of efficacy" stuff in a patient's formulation. I guess then you would try to incorporate tools that could build up a sense of efficacy in your treatment plan. I'm not sure the actual label of demoralization or having a DSM diagnosis would be warranted, but then I'm not up on this discussion.

I'm thinking of two patients. One is a 45 year old man, adopted by supportive stable parents, he has a strong family hx of depression, mother killed herself, and his two children have major depression. You could argue a strong genetic/biologic case for the patient/family depression. Another is a 70 year old woman, never had an episode of major depression. She's just retired, staying at home, mood is low,and now meets criteria for major depression. She likely has more psychosocial factors causing her symptoms. I'm not trying to split the biologic from the psychosocial in every patient, but the concept of demoralization has been written about to some extent but rarely gets talked about. I worked a consult service as a resident where a few attendings really hung hung their hats on a dx of demoralization in hospitalized patients dealing with significant illnesses. They would not start antidepressants on these patients. From a reductionist standpoint, if you believe the patient does not have a biologic component to their illness, medications shouldn't be indicated. But I think this oversimplifies our jobs actually. I'm just curious if others have seen this term used, in what context, and how has it driven treatment.

http://www.jpalliativecare.com/arti...e=12;issue=1;spage=8;epage=15;aulast=Jacobsen

http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=2088

http://www.wcprr.org/pdf/05-02/2010.02.86-98.pdf

 

[OldPsychDoc]

I'm guessing 311 is an ICD-9 code (let me google it to be sure - yes, depression NOS), but the first thing of which I thought was "indecent exposure", and that such was an interesting thing for which to thank God.

(And the band 311 took their name from the California penal code for "indecent exposure".)

I suppose there's a Freudian lesson somewhere in there...

 

[whopper]

On a related note, what does someone have, depression or adjustment disorder if they are facing serious prison time (e.g. decades) and try to commit suicide?

IMHO if I were facing that type of prison time, I'd consider suicide too. I'm not saying it's right but I'm diagnosing them with adjustment disorder so long as I believe the depressed mood is a result of the stressor of going to prison and it's not severe (e.g. the person is not vegetative). Nor do I believe it is mental illness when one considers suicide after reasonably coming to a conclusion that death is better than the alternatives.

Reason why this is important at least on my end is because if it's bona-fide depression, the person could be found incompetent to stand trial and thus not go to trial at all. From there the person could eventually be released without ever facing trial. Further, several patients try to appear suicidal whether they are or not in a forensic situation.

Clinically, for those outside of usual forensic psychiatry, this can be important if you work in a facility that will take up someone from jail who is determined to be a behvavioral problem. Unfortunately many of these times they really don't have a true Axis I disorder (other than substance use or IED, neither of which are eligible for an NGRI plea), but merely acted out in the hope they'd be put in nicer surroundings such as a hospital, especially if they are determined to escape as hospitals have less security. A passive psychiatrist could let such a person manipulate them into doing almost anything.