Major depression vs adjustment disorder

[sprawl2]

Quick question about adjustment disorder vs major depression.
Take this pt for example. He told me that he's been having depressed mood for over a year because he always had to date behind his dad. Recently he got kicked out of his house (college kid) because his dad found out about his gf, so he had to crash at his friend's. His depressed mood worsened significantly... you know... difficulty with sleep (3-6 hrs a night), decreased energy, concentration, and interest, with passive death wishes.

I was thinking about adjustment with depression but my supervisor said his symptoms and signs alone meet criteria for major depression. On the other hand, I have worked with attendings who would favor the adjustment disorder diagnosis based on severe stressors alone.

Where do we draw the line between major depression vs adjustment disorder when there is a clearly significant stressor?

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[nitemagi]

People get depressed for reasons (though the FF's of the system often make the "chemical imbalance," no reason for depression argument). By this rationale, though, taken to an extreme, anyone with stressors and depression would be adjustment.

What I think about in particular is:
Chronicity (repeated episodes, sometimes on and off throughout the life)
Severity (level of life impairment is severe)
Duration (there's a point where the impact of a single stressor should be expected to lift if it's adjustment)
Doesn't go away when the stressor lifts.

Others I know just say "if it's severe enough to meet all the criteria for MDD, label it MDD." I believe if you follow the DSM proper, then adjustment is precluded by meeting criteria for MDD.

If someone has no history of depression before and they get depressed in the context of a single isolated stressor (such as a breakup), personally adjustment is higher on my list.

 

[splik]

concur with nitemagi - if you meet the criteria for MDD (unfortunately it is depression not adjustment d/o with depressed mood). Adjustment disorder is for depression (and/or anxiety) which is less severe, is obviously precipitated by a (usually) specific ongoing stressor, and if that stressor were to dissipate then we assume the mood would return to normal. The only life event exclusion for MDD currently is bereavement. Read Wakefield and Horwitz The Loss of Sadness - they are the construct of depression as it stands is meaningless because it pathologizes normal reactions to life events by not allowing reactions to other loss events to go without a dx of depression and think the bereavement criteria should be expanded. In contrast, others (e.g. Sid Zisook) have argued that there is nothing different symptomatologically from depressed mood following bereavement and other types of depression, and so the bereavement exclusion should be expunged from the DSM. I think the latter seems to be what is going to happen in DSM-5 but someone can correct me If I'm wrong.

 

[nitemagi]

Good post Splik. I trained under Sid, and I appreciate his rationale, but can see both sides of the argument on the bereavement exclusion. I think we should appreciate bereavement, but the 2 mo period seems arbitrary (as is much of the DSM IV - created via the BOGSATS method).

 

[whopper]

You could go with Depressive DO NOS. If it don't meet the criteria for MDD by the DSM IV, it don't meet the criteria. Of course someone could be depressed worse than Adjustment Disorder but not meet the criteria of MDD.

 

[toothless rufus]

Wow! Your attending would allow Adjustment disorder as the AXIS I?! Is that even billable? It should be, as the symptoms are still real regardless, no?

How common is "tweaking" diagnoses on AXIS I so they can get paid?

Happens were I am a lot with a certain attending in particular. Dementia as SAD, SCPT. I even saw MR (purely behavioral) as SAD BPT!

Its incredibly annoying. I've heard of this trend happening in general. You basically can't trust anyone's diagnosis to be accurate. Or their meds.

Primarily seems forced by insurance not paying certain diagnoses, or wanting to get more time for treatment, or pure ineptitude. Its all such BS.

 

[nitemagi]

Wow! Your attending would allow Adjustment disorder as the AXIS I?! Is that even billable?

Depends on the insurance/other coverage.

 

[toothless rufus]

Depends on the insurance/other coverage.

Ugh. I see. It should just depend on the doctor's clincial assessment/judgment. I think I'd like to avoid insurance. Their behavior is most often contemptible. Pity its so difficult to do cash only.

 

[vistaril]

Quick question about adjustment disorder vs major depression.
Take this pt for example. He told me that he's been having depressed mood for over a year because he always had to date behind his dad. Recently he got kicked out of his house (college kid) because his dad found out about his gf, so he had to crash at his friend's. His depressed mood worsened significantly... you know... difficulty with sleep (3-6 hrs a night), decreased energy, concentration, and interest, with passive death wishes.

I was thinking about adjustment with depression but my supervisor said his symptoms and signs alone meet criteria for major depression. On the other hand, I have worked with attendings who would favor the adjustment disorder diagnosis based on severe stressors alone.

Where do we draw the line between major depression vs adjustment disorder when there is a clearly significant stressor?

you don't, and it's a completely irrelevant and meaningless distinction created by other people in meetings.....some people think of adjustment disorder as being rather mild, so if someone is suicidal and has severe symptoms(ie is truly psychomotor ******ed which is fairly uncommon amongst the typical "depressed" person out there) they would make an argument to call it MDD or at least depressive d/o NOS.

Another similar line of thinking is that if there was one obvious thing that stands out in triggering a change in mood, you should label it adjustment d/o rather than MDD.

Me? I just call it all depressive d/o NOS and treat *the patient* and not try to fit them into some man made checklist creation......

 

[SuperSoccer19]

you don't, and it's a completely irrelevant and meaningless distinction created by other people in meetings.....some people think of adjustment disorder as being rather mild, so if someone is suicidal and has severe symptoms(ie is truly psychomotor ******ed which is fairly uncommon amongst the typical "depressed" person out there) they would make an argument to call it MDD or at least depressive d/o NOS.

Another similar line of thinking is that if there was one obvious thing that stands out in triggering a change in mood, you should label it adjustment d/o rather than MDD.

Me? I just call it all depressive d/o NOS and treat *the patient* and not try to fit them into some man made checklist creation......

Agree--i rarely call something more then NOS on a first visit and then as time goes by narrow it down more for acadmeic/treatment/so other people know what i was thinking purposes. Countless times I have seen someone and thought "wow, this person is really depressed...its looking like MDD" and then see them again the next morning or a week later and everything is great. That rapid a turn around makes me think adjustment even when someone meets all criteria for MDD at first...but really, a name is just a name.

Also, if you look at studies (I wish I could site some, but Im not feeling like looking this up--some of this is in Kaplan and Saddock), some suggest that adjustment disorders have very high suicide attempt rates.

Just some food for thought since I don't feel like studying for the ABPN anymore.

 

[kugel]

Wow! Your attending would allow Adjustment disorder as the AXIS I?! Is that even billable? It should be, as the symptoms are still real regardless, no?

How common is "tweaking" diagnoses on AXIS I so they can get paid?

Happens were I am a lot with a certain attending in particular. Dementia as SAD, SCPT. I even saw MR (purely behavioral) as SAD BPT!

Its incredibly annoying. I've heard of this trend happening in general. You basically can't trust anyone's diagnosis to be accurate. Or their meds.

Primarily seems forced by insurance not paying certain diagnoses, or wanting to get more time for treatment, or pure ineptitude. Its all such BS.

Generally, payment for Admit is based on acuity, no dx. Even for California Medicaid (MediCal), we get paid for almost everything as long as there is clear evidence the requires being behind a locked door today, including Adjust d/o, dementia (as long as there are delusions or halucinations), substance-induced mood or psychotic disorder, personality disorders (except antisocial) and even V codes - as long as the acuity is clear. Lots of attendings and even billing people believe myths that these dxs aren't paid, but they haven't bothered to look it up.

Changing a dx is Fraud, and doing it for Medicare orMedicaid is fed/state fraud. I won't do it, and when someone suggests I "must" I just ask them to put that demand to change dx for the express purpose of billing into writing. They roll their eyes and sometimes say they will just have another dr do it- but I won't.

I am no expert on outpt billing, but I know billing for MediCal for outpt is based on dysfunction, more than dx. Again, the key is identifying how the psych sxs keep them from performing normal role functions, not on dx or even presence of sxs.

 

[SmallBird]

you don't, and it's a completely irrelevant and meaningless distinction created by other people in meetings.....some people think of adjustment disorder as being rather mild, so if someone is suicidal and has severe symptoms(ie is truly psychomotor ******ed which is fairly uncommon amongst the typical "depressed" person out there) they would make an argument to call it MDD or at least depressive d/o NOS.

Another similar line of thinking is that if there was one obvious thing that stands out in triggering a change in mood, you should label it adjustment d/o rather than MDD.

Me? I just call it all depressive d/o NOS and treat *the patient* and not try to fit them into some man made checklist creation......

Yes, I think this is completely correct. I would think applying that rationale to bereavement makes sense too - if you suspect a patient who has recently suffered a bereavement would benefit from some kind of intervention, does it really matter what the diagnostic criteria say?

 

[toothless rufus]

Generally, payment for Admit is based on acuity, no dx. Even for California Medicaid (MediCal), we get paid for almost everything as long as there is clear evidence the requires being behind a locked door today, including Adjust d/o, dementia (as long as there are delusions or halucinations), substance-induced mood or psychotic disorder, personality disorders (except antisocial) and even V codes - as long as the acuity is clear. Lots of attendings and even billing people believe myths that these dxs aren't paid, but they haven't bothered to look it up.

Changing a dx is Fraud, and doing it for Medicare orMedicaid is fed/state fraud. I won't do it, and when someone suggests I "must" I just ask them to put that demand to change dx for the express purpose of billing into writing. They roll their eyes and sometimes say they will just have another dr do it- but I won't.

I am no expert on outpt billing, but I know billing for MediCal for outpt is based on dysfunction, more than dx. Again, the key is identifying how the psych sxs keep them from performing normal role functions, not on dx or even presence of sxs.

Very interesting! So, nearly any dx will gt paid, as long as there is the appropriate level of acuity causing the necessary level of dysfunction. Completely oppsite from what I have been told. What resources are there where one can "look it up" to see which dx are paid for? This is important stuff; you would think everyone would be aware of this, as its how you get paid, apparently.

 

[michaelrack]

Very interesting! So, nearly any dx will gt paid, as long as there is the appropriate level of acuity causing the necessary level of dysfunction. Completely oppsite from what I have been told. What resources are there where one can "look it up" to see which dx are paid for? This is important stuff; you would think everyone would be aware of this, as its how you get paid, apparently.

it varies depending on state and insurance company

 

[toothless rufus]

it varies depending on state and insurance company

Ah. I see. It really shouldn't though.

 

[michaelrack]

Ah. I see. It really shouldn't though.

In the US, medicine is regulated by the individual states. Insurance (including health insurance, at least before Obamacare) is also regulated by the individual states.