 Good evening everybody and welcome to tonight's MHPN webinar. I am actually not quite sure how many people are on tonight but someone will probably magically tell me and I'll let you know I'm confident that there's several hundred people from all over Australia and it's fantastic to have you here. We would like MHPN would like to acknowledge the traditional custodians of the lands seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respects to the elders past, present and future for the memories, the traditions, the culture and the hopes of Aboriginal and Torres Strait Islander Australia. I'm Mary Emma Layas and I'll be facilitating tonight's session. My background is in general practice and psychotherapy and now I'm also a psychiatry training in my final year of psychiatry training. I would really like to welcome our panel tonight and you did receive people's bios beforehand so rather than going over them all I would just like to ask each of our panelists just a little question just for us to kind of get to know them a bit before we get started. So first of all Monica I'd like to welcome you. So you're a GP and I you could let us know where you are and what sparked your interest in this topic of adjustment disorder. Good night everyone and thank you for inviting me to to be on this panel and this discussion because I feel quite strongly about it and Mary like you I'm a GP and although I'm not a psychiatrist or a registrar I have gone into psychotherapy as my special interest but had over 20 years of work as a GP and I was talking to my friend Julie Ann White about transitions in our lives and we were discussing how in general practice we often diagnose depression when really we should be diagnosing adjustment disorder it was a fascinating discussion where she was talking about grief and and it's really made me think about it quite deeply and so that's why I'd like to you know hear what everybody else has to say and and have a chat about this tonight. Thanks Monica and you're in Sydney aren't you? Yes yes I'm in Sydney and I work in Sutherland. Welcome it's great to have you. Thanks. Now Maria I wonder if you could let us know where you are and also in your practice for which type of client referrals would you be considering adjustment disorder as a potential viable diagnosis relative to mood disorders including depression? Good evening everyone thanks for that introduction Mary. I'm based in Sydney as well and my background is I'm an endorsed clinical psychologist as well as an academic at Macquarie University. In terms of the question asked in with clients that I see I'd be very careful to screen for adjustment disorder when clients talk about stress related conditions including any trauma particularly if it's early onset and it's not complex and particularly with the changes with DSM-5 I have had referrals where they were misdiagnosed received a different treatment and then someone picked it up later on through the mental health system that they may be benefiting more from a stress related type of paradigm due to adjustment. Thank you and welcome Maria and Curtis you are psychiatrist and I believe that like me you might be in Queensland and what what would be a couple of points that distinguish normal adjustment from adjustment adjustment disorder? Yeah that's one of the key issues I think actually Mary it's an excellent question probably one of the first things all of us dealing with patients with possible adjustment disorder need to consider but at the end of the day there's really two things that one wouldn't look for one is whether or not the symptoms of the adjustment disorder which are usually depression, anxiety, stress related and maybe associated behavioural or sometimes somatic difficulties are sort of in excess of what you might expect for the nature of the stress or and the other is whether a person might be sort of struggling with some functional impairment in association with what's happened and that could be across any of the typical domains of function doesn't have to be severe not all adjustment disorder is severe some mild but you know either vocational or non vocational impairment that's what I would look for. Thank you and it's great to have you on the panel as well the way this is going to work tonight is that each of our panellists is going to give a short presentation in response to the case from their perspective of the discipline that they come from and then we're going to have a question and answer discussion between the panel we've also I've reviewed all the questions that you submitted before at your registration now I can promise you this is going to go really quickly and I know that there'll be people who are disappointed that their question submitted at registration doesn't get asked but I would like to reassure you that a lot of the things you asked will be addressed in the presentations and discussion so I think it's going to be a really great evening just to quickly go over the learning outcomes we're going to be looking at the symptoms of adjustment disorder looking at the association's comorbidities and patterns of treatment seeking behavior so what kind of people come to see us about this describing tips and strategies to help improve the mental health and well-being of people with adjustment disorder which is what we're all here for and then also to look at collaboration and appropriate referrals now you have also received the case study before we start so again I'm not going to go over it again you can see it in the resources if you want to reread it and but just to remind you this is a story about a woman called Melissa who has recently separated from her husband and has a number of things going on now she first of all goes to visit her general practitioner and so I'm going to invite Monica to respond to Melissa and the ways that you would think about addressing her issues when she comes to see you thanks Monica thank you Mary so yeah so so as a GP we see a lot of people with with depression in the room you know they have that sense of despair that that loss of hope and you know we can really feel it and there's an automatic response to say oh well this is depression and you know let's treat it as depression but I think that curiosity that we have and that ability to see people over and over again and have a relationship with them as a GP allows us to know that patient and perhaps that this is a fleeting mood rather than a true depression and so you know treating the whole person the physical and mental aspect allows us to also know you know their connections their social support so you know we know that Melissa has a mum who's recommended her you know to come and seek some help with her sleep and so we might already know some of her strengths her resources the people around her but also the sorts of issues that she's had to deal with which are documented in the the case notes and so if I was thinking of of you know initially depression I'd be thinking of you know the early morning waking and and and the sense of not having any joy at all and so I'd be asking her about what is her sleep about problems about you know because she's come for sleep problems I'd be asking whether she has you know sort of guilt and blame that is out of proportion to the situation itself and I'd be curious about her concentration at work and whether the conflict with the coworker is related to a personality clash or whether it's in fact she's finding it difficult to concentrate all of these things would be information that would be very important to make that diagnosis about how I treat when she comes and the the good thing about having a depression diagnosis for some people is that it gives them a sense of relief where they go yes you know there's depression in my family often the medication that a family member's taken is appropriate for another family member you know like themselves and they feel like it's an illness it's got a recurrent bouts like asthma but they can feel safe that you know they they've had it before they can get better again the thing about depression though as a GP that I used to find is that if you don't know some of his depression sometimes they you know rather than seeing it as well as being de-stigmatized you know I don't have to be worried about it they give up on trying to do anything about the circumstances they lose that sense of agency and that's not quite so helpful so I wanted to sort of see it more from the lens of you know adjustment disorder could that be more what it's about yes if it's depression it's important to diagnose it because you know the treatment management is slightly different but but yeah so could I have the next slide please and we'll talk about adjustment disorder from my perspective yeah so one of the things I find is that you know adjustment disorder really is that it's it's this ability that people have you know some people have this ability to listen to their emotions work themselves out connect to their resources and just you know whatever that transition might be you know the conversations Julianne and I were having on the podcast were about you know having a baby or getting older or you know all of these transitions but if we find that we don't have the skills or the resources then that's when we have all of these emotions and those of you who've watched the movie Inside Out will recognize the the little characters for the emotions and so that's in the way how as a GP I kind of go well this person's so distressed and you know to me that signifies that they're just struggling and they're struggling with the situation and so for Melissa struggling with the situation on multiple levels she's struggling with the end of her relationship she's struggling with the financial problem she's struggling with the loss of her friendship network and you know conflict at work there are lots of sort of areas where she's struggling and I'm sure she doesn't know where to start and so as a GP you know one of the things Julianne and I were talking about was the ability that we have to acknowledge the grief of all these losses and all these changes and to kind of go yeah it's really hard it's really difficult but you know this thing about not calling it a disorder if we just say this person's having real struggles adjusting to all these changes and that's the time when you know a referral to a group if she doesn't have the resources to go and see a clinician privately or you know and there are lots of groups and supports that that we can refer to or you know just coming back for regular visits as a GP and and having that save space and even just asking her what troubles her the most one of the women that I spoke to who was in a similar situation said that the thing was was really troubling her was having an STD and being able to do that STD screen and settle her mind so really asking her what would make the greatest difference and so if we if we do that and we also give a timeline to it you know that once they solve their problems or you know develop the strategies and the skills and and start things that they will be able to overcome it so next slide please so that's why as a GP I sort of think you know should we call it a pathology like a disorder should we talk about it as a life transition you know sometimes in medicine we tend to medicalize things and pathologize things but I often think about you know this old gentleman on the slide Rabbi Twersky he talks about this lobster metaphor of being a lobster where the lobster when it's a baby has to out it grows its shells and so it has to shed its shell hide under a rock it's vulnerable it's painful and then it grows that shell again so sometimes we can see that you know during this shell growing phase things are going to be hard but you can have the support that you need and as I mentioned earlier you know my last photo is you know playgroup is not it's not for the kids it's for the parents so having walking groups having you know any sort of group that will help Melissa to see things from a different perspective and she might actually have good friends who are not in this friendship group who might be able to help her so next slide please so when I'm thinking about you know the the framework in which I think about how to treat and how to talk to Melissa about the issues I think about things that happen outside of her that she's got no control other people again she's not good though control and the only thing she's got some control over and influence is is what she does for herself and so myself as a GP as well I'm wondering you know could the divorce in her childhood be playing into how she responds at the moment um you know sometimes we just GP see people who also have had other things happen in their lives or their brain wiring is different they have a personality disorder that needs to be taken into account as well and of course all the comorbidities you know the alcohol use and you know avoidance of certain things so all of these things need to be you know and as a GP you know we would sort of be asking about all these things so last slide please so I think well managed adjustment you know when we acknowledge as GPs it's hard when we grieve the losses together that even though it's a really adverse environment like those flowers growing in an unseasonal snowstorm that through this process that's how we get self knowledge and growth and so that's what I would be talking to Melissa about and hopefully we'd be working on it together so as a GP that's how I would approach it so thank you thanks Monica and just I'm going to invite Maria in just a moment but I would like to just say that there are around there's over 1500 people participating tonight so it's great to have everybody so Maria from a psychologist perspective thank you thank you Mary and thank you Monica so I would be referred such a case typically through a mental health plan via GPs or psychiatrists starting out I have some referral information but usually it's not extensive and in keeping with a case formulation approach that I use in the initial assessment I'd be looking at the key features that the client would present with and in this case what we know from the Melissa case and some of the key issues that even Monica raised is that she's experienced a number of significant stresses in her life in the last eight months the most significant being the separation from the husband and having and due to having an affair with a best friend which would sort of be what I would consider a double whammy for the for the client accompanying that there's a whole cascade of stresses that have resulted in the separation including the financial pressure which can really put clients under a lot more mental health strain including falling into her rears with her children's educational bills as a result there's also the pending sale of the family home and there's uncertainty about where she will live and obviously if there's displacement with any close neighbors that she's had and enjoying the neighborhood where she was located during her marital life and in terms of what we know from the psychosocial literature our social supports the quality of social supports are vital in terms of maintaining and enhancing well-being and for the separation the reasons stemming from the separation of the husband with a close friend that would also create some social awkwardness in her friendship circles and hopefully Melissa would have an extended social network or close relatives and other colleagues at work that she could talk to in terms of looking men at symptom presentation from what we know from the vignette she's got a whole cascade of symptoms that look like potentially adjustment and we'd have to also carefully consider the depression as well because it would determine the treatment plan and also the level of intensity of psychotherapy if referred to a psychologist so the symptom she's displayed so far is low mood the fatigue both mentally and physically a loss of interest the withdrawal behavior the loneliness sleep disturbances as monica had raised the guilt and the particularly around her children and also she's experiencing frequent crying and a loss of pleasure next slide please so looking at diagnostic considerations there are two key diagnostic considerations here it would be adjustment disorder but with the qualifier of depressed mood because she does she does elicit depressed mood at the referral and comparing that to major depressive disorder particularly in terms of a specific episode whether it's acute and then also screening of the chronicity around it just a quick summation here is that both these disorders have common trigger points and in this instance it's significant life stressors so what Melissa has undergone is would qualify for either these disorders now on the left hand column is it just a summation of the adjustment disorder diagnosis according to dsm 5 current criteria so criterion a is if the client elicits emotional and or behavioral symptoms due to an identifiable stressor occurring within three months of stressor onset and in this instance it seems that Melissa does in addition to that there's criterion b for clients to meet one or both of these symptoms which is marked distress as well as significant impairment in functioning and there is some evidence potentially there that monica also talked about with her occupation and impact on concentration as well as her withdrawal from social activities as well criterion c is critical in terms of the differential diagnostic considerations comparing this to adjustment and or depression and any other disorder because according to adjustment disorder with dsm criteria the stress symptoms do not result in not a result of any other disorder or an exacerbation of a pre-existing disorder so that's quite critical as well and then criterion d it's not due to normal bereavement even though there is a grieving process as a result of the separation from a partner criterion e is about the duration once the stressor or its consequences have elapsed the symptoms do not persist for greater than six months but for Mary there's a lot of sorry for Melissa there is a lot of ongoing cascade of stressors including her financial pressures and then the relocation of the family home and as it stands the depressive qualify there's other specifies as well for adjustment disorder there is the anxiety specifies as well but for this case I think the depressed mood specifies the one that I'd closely consider contrasting that to major depressive disorder criteria the criterion a is the one that defines the constellation of symptoms the major depressive disorder episodes that is the clients to meet at least five of nine and of which our clients have to meet at least one of the top two listed here depressed mood and or loss of interest or pleasure for at least most of the days over a two-week period and then there's the other seven criteria that are listed on this slide similar to adjustment disorder criterion b is significant distress or impairment in functioning and c is it's not due to substance use or medical conditions and we don't have evidence of that for the Melissa case at this stage there's another ruling out in criteria d it's not due to a psychosis or a schizophrenia episode and e is another rule out it's not also due to a hypomanic or a mania episode and again we don't have evidence of that for Melissa the specifies for depression is in severity and recurrence and that's something to screen for in a more comprehensive clinical interview next slide please so this is a duplicate of the previous slide but what I've highlighted here in purple coloring is what we know so so far from the Melissa case she does meet all the criteria for adjustment disorder but the key differential diagnostic issue for me is criterion c because if she meets criteria for another disorder then adjustment disorder can't be met why this is important from a psychological perspective in a treatment formulation plan that we're not hooked fixated on diagnosis per se but it's out what I refer to is our GPS navigator in terms of finding an evidence-based treatment program for our clients so with the with Melissa she actually does meet criterion a from what limited information we do have including the essential first two symptoms she meets criterion b and from the lack of information about substances I would be inclined to say she's potentially meeting criterion c in terms of the severity we don't know and this would be screened through our initial assessment and backed up by a validated self-report instrument that would if she agrees to psychotherapy treatment would be used to monitor treatment progress as well such as the ph q9 or the depression subscale from the desk 21 or the bdi2 depending on what people use in their practices next slide please further considerations I would factor in in terms of an assessment treatment formulation is Melissa psychiatric history we do not really know much about her mental health in the past and that's important to factor in particularly her experiences with mental health and allied health services because it will give us an indicator of engagement and whether this is a right fit for her at this time and also if she has had access to treatments even limited whether what was the outcomes and whether what she liked and what she didn't like given there is mood impairment irrespective of whether you opt for the adjustment disorder or mdd we need to screen for suicidal risk in terms of safety and duty of care issues and social supports to get her through this crisis point and between therapy sessions and and not only access to the social supports that I raised earlier on but Melissa's willingness to actually reach out for help particularly during times when she may be plagued by upsetting thoughts and and really feeling out of control moreover I would also be checking in with Melissa in any client in this circumstance about her willingness to engage in psychotherapy files to recommend it because we do really need informed consent from our clients and we know from the evidence based from therapeutic paradigms that I work with that clients motivation and engagement is vital to treatment success as well with that in mind although if she was referred under a mental health care plan even though Medicare covers some of the sessions depending on who she sees including how where I work there is a gap coverage for our clients and we have to factor in financial constraints and this is very relevant for Melissa given the financial pressures because if she can't afford treatment then we'd have to refer on to a provider that can actually may not have that gap coverage and similar to what Monica has raised I always look out for clients strengths and resources to fit into the treatment formulation and one strength is actually for clients actually asking for help that's a strength to begin with and how they've actually coped with the adversity so far and any other adversity that they have gone through in their past including their childhood next slide please so in terms of psychotherapy considerations and mapping out a treatment plan I would summarize the key features and how they fit in so in terms of Melissa's symptomatology we know that the symptoms have been activated by a stress response we also know from the evidence from the literature including some very well controlled studies in Australia and longitudinal studies at unresolved adjustment disorders can actually evolve and morph into more chronic psychopathology including chronic major depression with concurrent other types of anxiety and substance abuse problems so we know that would be helpful to nip it in the bud early and provide options for such clients. Melissa's also displaying the triapatite features of mental health problems including a behavioral response what I mean by that she's eliciting withdrawal avoidance behavior from social connections she's feeling isolated and that is a primary concern which needs to be addressed in therapy she's got a physiological reactivity impacting on asleep and there's fatigue both mentally and physically and her cognitive attributions are evident even at the initial assessment she's got guilt including about her parenting the impact it has on her teenage children as well as her own self-worth so in drawing on the evidence-based practice the evidence for treat psychotherapy treatments for adjustment disorder are in their infancy and this can be modified for adjustment disorder but we also know for major depressive disorder I would be recommending on the basis of the current evidence a behavioral activation therapy plan and integrating some cognitive therapy there because of the cognitive attributions in particular I'd be working with with Melissa in terms of the valued based her values what she values to return to in terms of activities to return a gradually to her normal life while accepting the losses that she's endured with her relationships and the previous partner the treatment would incorporate looking self-attributions who outlook in life because we also know a risk for chronic depression is negative outlook in life and not having any plans in the short term and particularly in the longer term and as I mentioned earlier I'd also make sure bringing in the client's strengths into the treatment plan and using that as a motivational tool tool and highlighting the strengths at the end of the initial assessment to the client because most clients who are depressed don't actually see how strong they are even at the crisis point so thank you I think that brings me to the end of the slides thanks Maria and now I'd like to welcome Curtis to respond from your perspective as a psychiatrist thanks very much Mary and can I say thank you to Monica and Maria for really doing my job in respect of this I would endorse everything that Monica and Maria have said the approaches are from my point of view absolutely bang on and part of me thinks that if I was a psychiatrist receiving the referral from well Monica but if Maria was involved as well there is really not that much more for me to do other than look at the history in the way that both Monica and Maria were outlining and then clarifying whether or not to bring though was maybe looking at this whole issue of adjustment sort from a slightly different perspective firstly look at look to the right of the slide that's a very good book I believe around the concept of sort of medicalising and psychiatricising normal human experience in this case sadness and I believe that's something we need to bear in mind and in fact it was Mary's first question to me tonight and it was a very very good one how do we distinguish the normality and of course Melissa is in a very difficult situation it's not just the marital breakdown she's now facing some workplace challenges she's got a lot of challenges with her friendship group and so her sort of difficulties are sitting in the sort of minnestrone and a very unpleasant and untasty minnestrone of life for her and it's not surprising that she would be struggling on the other hand we know that she's symptomatic so looking to the left of this slide thinking about in this case depression as what I would call a construct asking a question when when is it an illness and when might it be worthy of treatment and I think one way to look at that is to think of it as a spectrum so either from top to bottom or left to right you could imagine the spectrum starting with obviously reactive types of depression a depressive reaction to something terrible that's happened indeed that's Melissa's situation and then right over at the other end of the spectrum is what we used to call endogenous or probably now would call melancholic depression which is characterized by so PMR means psychomotor retardation which means slowing up of physical and mental faculties and very depressive thinking guilt pessimism self criticism maybe even suicidality and we have a little bit of that going on in Melissa's case and in elderly patients a lot of agitation sometimes in the younger patients but often in elderly patients and then in the middle we would have a mix of reactive to stressors plus maybe some personality vulnerabilities and sort of in the past we we would have called that neurotic depression next slide please so Maria's already put up the diagnostic criteria for adjustment disorder this is a sort of a reinforcement of that and just a reminder of how do you tell the difference between sort of normality and adjustment disorder in fact Maria also made the point about the significance of function and functional impairment and a lot of symptoms in major depressive disorder but in adjustment disorder as I mentioned earlier we look at the stress that's in excess of what you'd expect from exposure to the stress or all this notion of impairment and it doesn't have to be severe impairment but in Melissa's case she's really you know missing out she's withdrawn from a lot of things and so certainly argue that she is to some extent impaired not impaired in the sort of totally impaired notion but at least partly impaired it next slide please so if I was seeing Melissa I'd be thinking about what type of depression is this lady suffering is it really an adjustment disorder or is it more of a melancholic and as I think Maria mentioned sometimes adjustment disorder or adjustment reactions can evolve over time just as things like skin cancer and various other medical conditions can evolve over time so adjustment disorder can evolve into a more severe type of depression usually major depressive disorder but on the left of our slide what what I've tried to capture there and this is taken from the Black Dog Institute which is a significant reference I would recommend to everybody is the sort of trying to capture the percentage of patients that come through all of our doors typically with what type of depression are they suffering being the question and you can see the tiny little circle of psychotic depression I would see much more of that than say most of you guys I think as a psychiatrist because there's a referral sort of bias and then maybe between two and ten percent of all of the depression out there in the community might be melancholic these days we would call that major depression with melancholia a descriptor and then the rest is non-melancholic and that's where the adjustment disorders would sit so just on statistics alone probably most of the depression in the community is not the major depressive disorder type it's much more reactive but we still need to look for that the we look still need to look for major depressive disorder what do we look for so on the right that's a screening instrument again from the Black Dog Institute that is helpful to identify those patients that might have more of a melancholic type of depression those who are sort of slowed up both physically and mentally and that brings me to the value of being able to do a mental state examination so with our materials with Melissa we only have the history and from my point of view I would want to be able to sit down with Melissa and really observe her over a lengthy interview and be able to do a mental state examination identifying whether or not in fact she does have any of these slowed up psychomotor retardation type features that instrument there by the way is not the type of instrument that Maria was talking about which is a she was talking about typical and really helpful screening instruments in clinical practice this one would help more to distinguish on the basis of your observations whether or not somebody might have melancholia and the significance of that is we would just use more medications than psychotherapy next slide please this here is also from the Black Dog Institute and I just wanted to put it out there for you because I think it's a very very useful model I think Monica actually touched on a lot of these factors in her presentation about trying to sort of identify them and then in the as a psychiatrist what we try to come to is what's called a formulation which is really an understanding of an answer to the question why has this particular person presented in this particular way at this particular time and invariably when we're looking at the impact of stressors in the context of a depressive state it'll come back to that thing in the middle the meaning of the events and obviously from Melissa very very meaningful stressors have occurred next slide please just to comment about the course over time of adjustment disorder just look at the black line first and you you know you might think well if a stressor occurs people are going to be feeling sort of bad initially and then over time it's going to settle down in this nice curvy linear way actually the reality is more like the green light things tend to go up and down and of course in Melissa's case we wouldn't be surprised by that because there's a whole bunch of other stressors starting to pile up for her and difficulties as time goes by so just because someone's really bad at week three and is a lot or maybe somewhat better at week six doesn't mean in week eight they're going to be better they might be a bit worse but hopefully by that maybe week 12 16 and so on the general trend is one of improvement with the types of treatments that maria was talking about next slide please this is my last slide just draw your attention to the image on the right first that is my understanding and I think most people's understanding of optimal patient care it's really a shared decision making process between therapists you know doctors ecologists mental health social worker whatever the profession is and and the patient and that will draw on in clinical practice evidence the evidence base so from my point of view as a medical practitioner evidence based medicine on the left what is the evidence base with respect to adjustment disorder well I think as Maria mentioned it's in its infancy but there are three approaches that are potentially going to be helpful one is modifying or removing the stress or the second is facilitating adaptation or adjustment to the stress or using various psychological therapies and the third one is altering the symptomatic response so the depressed mood the sleep disturbance particularly in this case with perhaps behavioral or psychotherapeutic approaches but also at least for me because I can prescribe consideration of medication I would have to say in most cases of adjustment disorder I would be trying to avoid the use of medication but there are some cases that are more severe or where there might be target symptoms that will be very effectively addressed and insomnia might be one of those in the short term although just a plug that cognitive behavior therapy for insomnia is the gold standard the natural history of adjustment disorder I've mentioned before it can more for evolve into a major depressive disorder but sometimes it'll evolve if it's more of an anxiety-based type of condition into something like a generalized anxiety disorder thank you thanks to all of you and we're going to begin our panel discussion very shortly so just a reminder to the audience that you can change your slide and video layout if you want to look at the videos more now than that slide which is going to sit there for a while by clicking on the icon with the two arrows inside a circle on the top right corner of the slide window and we I'm going to start with a question first of all that's just around diagnostic clarification so I think Maria I'm going to ask you this one so a participant called Shay in the audience has asked us a question if clients just to clarify whether if the client meets the criteria for major depressive disorder then does that mean they don't meet the criteria for adjustment and it when you had the comparisons side by side it did look like she met criteria for both in a way so Maria could you just expand on that yes thanks for that and seeking that clarification yes so why I had it side by side is because I had it in red font when I was comparing it and the purple font was what I thought Melissa's case had met and that's the criterion sea line for both so if a disorder is if the stressor symptoms are better accounted for another psychological psychiatric disorder in the DSM then that disorder overrides adjustment disorder so to answer that Shay's question that is correct as long but you can get a comorbid diagnosis if there is a history of depression or another disorder for Melissa and then the stressor has set off another constellation of symptoms so say for example Melissa has a history of generalized anxiety disorder the stressor then sets off these mood symptoms but they don't fully meet major depression then she could have GAD history with concurrent active adjustment disorder but the way that this case has been presented I would be inclined to say Melissa meets major depressive disorder as a result of the stressor onset from the info we have therefore she does not meet adjustment disorder because of the ruling out criterion C of adjustment disorder DSM5 I am going to ask we'll come back to these questions around diagnosis but Monica I was wondering so a couple of people have asked really this is such a sensible question did GP's diagnosed adjustment disorder to prevent depression from marring a patient's employment record and also a similar kind of question what difference does it make for work cover if you're putting adjustment versus depression so I might ask Monica first and I can see Maria's nodding so we'll go to Monica and then Maria yeah no that's a really good question and when I'm feeling in the mental health treatment plan and talking to the person about why I'm choosing either or essentially what I want is the advantage to them so you know some people say even though I've had previous episodes you know I really it's always been in response to something I'm naturally anxious and so I think it's an adjustment disorder and so it's really you know some people have said when they clearly have a diagnosis of depression when they tick all the boxes when they respond brilliantly to the antidepressant that I've prescribed and they still don't want to have a diagnosis of depression then I guess I have to say look you know in order to I'm a stickler for the rules and in order to honour both the treatment of this but also you know everything else I need to put the correct diagnosis down I guess the thing about adjustment disorder is that it's really acknowledging that this person is struggling for lots of different reasons and and that if you put depression it's it's not so much that I don't know whether in this day and age where you can get treatment for depression where it really signifies so much in terms of like it used to be insurance um that it used to have a great impact on your insurance and your ability to get a good premium but it's it's more about how is it how are their employers going to respond in a way that is helpful because if it's an adjustment disorder that's really a call out to the manager that this person perhaps hasn't had good boundaries and requires some support and that's up to the manager to do that um so that you know as an employer they maintain their their duty of care to the um to the employee so as a you know when I'm doing this in general practice I'm thinking of like what is actually when I'm talking to this person what's going to be helpful for them so that's how I choose it and you know sometimes people don't want me to put down that they've got epilepsy on their medication history well I have to so it's the same with with this it's really what's going to be more accurate um and in the long run not getting not cause a problem for them so that's really how I'm thinking about it so I'll come to Maria's response in a second and there is a comment from Joanne um I think he's a social worker that that exclusion criteria so because it this is a good example actually so Melissa actually meets criteria for major depression so we have to say that but in fact um is that something that we could critique about the DSM that in fact it may be more helpful for her if we could say she had adjustment disorder I don't really that's something that's come from the audience yeah because I'm a GP I can see people in a week's time and I might have a chat to her having her grief acknowledged and her feelings acknowledged and yeah it's awful you know sometimes just talking about things can improve the mood of a person and then it's not depression and so I'll be able to reassess it um so that's one of the luxuries of being a GP that I can it's an evolving picture and I've got a week to decide I don't have to decide right there right there that's a really good point and Maria did you want to respond to that distinction between the two as well yeah just following on I think Monica you've wrapped that up eloquently in a good segue because I think by the time I get the referral it is set in and the GPs are more convinced that the individual does need psychotherapy and and the depressive symptoms have set in so uh this is why I tend to have used adjustment disorder it's really more with the anxiety related conditions by the time I get to see them I've rarely had an adjustment disorder with depressive specifier it's more an acute episode of major depressed major depression but building on that question I think our role or my role as a psychologist is in terms of enhancing mental health literacy in the community and part of that is uh reducing the stigma around these disorders we're getting caught up with semantics so part of the psychoeducation news this is a better fit um but you're not alone we know the statistics there's a you know it's one of the most prevalent disorders in the community and it's going to be one of the dominant disorders by 2030 that's what the statistics is showing us um one good thing about knowing about the symptomatology is that there is help out there and just because you've got an acute episode does not mean that you'll have a chronic history of it if um you are motivated to to sort of change and also seek help and reach out for help even when you experience lapses so I think just that honest upfront discussion um and if the clients do feel bad about the the labelling then I think that is a definite valid point to address in uh therapy before even moving on to a treatment plan thank you Curtis I'm going to ask you a question and this is a little bit coming back to um your reference to the the um loss of sadness book I guess along the same theme so there's a question from joe um so the the criterion that says mark distress that's in excess of what would be expected from from exposure to the stressor so her comment is that isn't isn't this really a value judgment about what would be an expected response because this client is going through an extremely difficult situation and so is her response not proportional to the situation so Curtis did you could you respond to that one it's a terrific question joe um I think there's a lot of merit in in the issue that you've raised the um I don't know if it's a value judgment so much because we're not really making a value judgment about Melissa but we are making a judgment about whether or not um what where what she's describing and what we're seeing is sort of expectable and I think in the case of Melissa on the basis of what we've um on the base of the information that we've had um I I'm probably um you know it's hard to be sort of binary in in these types of situations but if I had to be I would probably be in the camp of saying I think you know a lot of what she's describing and her difficulties are understandable and are reasonable in the circumstances on the other hand and this is why I think it's important to have a number of perspectives on a case at any one time which is sort of a bit of a theme that we were just talking about patient acceptability versus organizational requirements and so on um I would be thinking from the perspective of what is this lady suffering I think it is a major depressed disorder um she does have five of the nine criteria that are required and her you know her struggle is quite significant she's only just hanging in there at work um she's really not having much of a social life anymore and there's that guilt stuff and there's that you know have you know have a sort of have been a bad wife type thing and I think they're all pointers to really looking at this case as major depressed disorder so I think what you've said is probably right but I also think in this case it may be a bit of a red hearing in that Melissa's probably developed a major depressive disorder I'll say one other thing about major depressive disorder though it is a five of nine criteria and anybody who wants to heart back to mathematics maybe I don't know grade eight how many ways can you configure nine objects in the groups of five the answer is a more than 1500 what that means is you can get major depressive disorder in more than 1500 ways which is which makes it a bit of a problematic entity we could talk about that until the cows come home but that's why it would be important to see Melissa and have that mental state examination and be able to sort of get that feel for just how reactive is her affect for example when you're talking to her how shakeable are these ideas of being you know having done something to make her husband have an affair you know the guilt stuff because if that stuff was sort of relatively unshakable and she's very flat without reactivity I'm definitely saying she's got a major depressive disorder and the whole notion of adjustment disorder becomes irrelevant because at the end of the day the DSM allows what is hierarchical and it allows major depression to basically trump adjustment disorder so I think someone called Sumitra in the chat box has also commented I think what you're all saying really is that you're probably going to start with biological and psychosocial treatments if that's if that's what is needed so it's not necessarily an and either or it's probably both and now I there was a really good question so there's been a lot of both in the registration questions and in during the webinar around grief and and you know adjustment to loss so I wonder if anyone would like any of you would like to comment a little bit more because I mean there is a big loss here there's a number of losses actually and so again I guess how much of this is a normal grief process and indeed someone's commented about a history of trauma and loss and perhaps unacknowledged grief or unprocessed grief even from past things or trauma from the past how do we keep that in mind when we're seeing someone now I know that's an extremely broad question it's really for discussion rather than an answer who wants to say something can I just start with a brief comment because I'd like to hear Maria and Monica more on this one but but I think that's right in the Melissa case I think there is a place for both biological and psychological therapy clearly the psychological therapy is going to be looking at loss and adjustment the biological therapy has to address I think in her case the insomnia by the way we didn't get any history I think about alcohol or drugs I'm going to presume that it's probably not a factor I think both Monica and Maria mentioned it but let's presume that our Melissa is not drinking so it would be good to have her sleeping better because then she's able to going to be able to do her psychotherapy better if she's not sleep deprived and you know struggling with insomnia yeah that's probably where I'd stop I could go on but I won't okay Maria perhaps your comment about the grief kind of questions um I I agree with this questioning there is a lot of loss for Melissa and it's and and hence dare I say the term there is the adjustment to loss um there's yeah the grieving of the loss of the marital relationship the family network the social network and it's going to be in the neighborhood network um and as you can see this is a slippery slope because if she's not continuing to perform this could put pressure on her work we don't know how she's getting on with her colleagues so as Curtis even raised the loss issues is something that would be addressed in psychotherapy and particularly when both from the behavioral perspective of getting her to assess her values and how she wants to live her life moving forward and when it comes to the cognitive elements of the therapy it's to do with her attributions in terms of her own self-worth and putting them into perspective of what she's gone through so in the first instance when when working with people with eliciting signs of depression it is about acknowledging and making space for that loss but also then how can you then pick up the pieces and move forward and that's what we need to build on the client's strengths as well in terms of the other related question that was asked about past loss that's important because that's that would give me a good indicator of what natural resiliency skills clients are coming to psychotherapy with how have they overcome previous adversity and have they actually given themselves credit for that but if they've got unresolved trauma and loss I think such a key stressor of the marital breakdown can reactivate old wounds and resurrect old grief and it can then overlap with the current grief and that has to probably be addressed in therapy which I would do sequentially initially and and and and it's easier said than done but there is going to be overlaps as well but both would have to be addressed at some point through the psychotherapy plan Monica did you want to add anything to those comments just from my perspective and I you know it's almost all being said but just from my perspective the idea of it's not so much what happens to us because we're we have grief and loss all the time um you know it's just stages of life these transitions that we go through it's more about whether we have the resources to cope with it whether we have the inner resources and the outer resources and that's really what we're trying to help melissa with um to to connect to her own strength to connect to her resources and those ones outside and perhaps to develop you know to be to be one of those resources as a GP but then to develop any of the other ways that she can help herself and grief is a process it's not a yeah you know you can't just get through it just because you know what you're grieving about and you know what you're going to do okay well it's over it's like you're still going to go through it and just normalizing that that's okay and we yeah it's crappy I think we are um we've mostly addressed the questions from the chat box tonight but there's a really interesting one that's just come in from melissa around how you might factor the patient's sense of self into the treatment because I guess these disruptions that have just happened are the kinds of things that might shake your view of yourself um perhaps Curtis do you want to respond to that well I've got a couple of thoughts about that it again a great question because um um I think to try to answer it briefly if it what if there's a case of adjustment disorder by and large it's probably going to be easier to incorporate that into the psychological therapy in the way that Maria and Monica were talking about looking at values and basically the sort of you know bloated the sense of self that the person would have had in a situation like melissa's in the case of a major depressive disorder they can be mild moderate severe sometimes psychotic as I mentioned before just a quick point the more severe cases might you may observe a sort of a self denigration and a self criticism because of the illness itself and that's potentially a biological thing so just be mindful of that because that's probably not going to respond to psychotherapy and may just resolve without psychotherapy with robust medication treatment in the much more severe cases but it is a bit of a it's a tricky one sometimes because people will end up sometimes having very negative self concepts in the throes of a more severe depression and that won't respond to psychotherapy well I'd be interesting to see what Maria and Monica would say too perhaps Monica you're nodding so I'll go to you next I'm I'm nodding because it's it's true that in severe depression people are just so you know it sucks the air out of the room but I I think you know one of the things as a GP that sometimes we get people and we think is it adjustment disorder is it depression and sometimes you really have to factor in as this person ever coped well with other things in their lives do they have you know are they on on the sliding scale of someone with a personality disorder like do they have some personality disorder traits or a full-blown personality disorder sometimes we're only you know having that concept of you know how much can we improve the the life of someone by working with them rather than thinking that we're going to get them to some sort of imaginary wonderful level that both they and and we want for them and this idea of the sense of self is just being curious and asking them questions about you know what would you say to someone who was your friend about what's just happened and what sort of a person they are what would you say to your children if this had happened to them and they can sometimes give them the perspective and help them to to see themselves as going through grief and going through a very difficult situation and you know they're before the grace of God go I kind of thing rather than being extra hard on themselves so that's a perspective that are of course so good yeah Maria did you want to add something yeah I just like to echo what Curtis and Monica has said I do think that with depressed cases and I think it can be across the continuum it can fluctuate the self-deprecating and self-denigrating schemas do arise and I'm very mindful of that and that's why I did recommend even with Melissa's case to consider integrating it with cognitive therapy because there are already signs that that could go down that that path so the sense of self is really important for any client irrespective of disorder to make to check in with that and to actually address it with depression it's particularly important and even with adjustment with significant stressors and as Monica has said perspective taking is a very vital and powerful I think therapeutic tool and it sounds like GPs are obviously doing it but in psychotherapy we definitely do it even through the different components of cognitive types of therapy so getting and in my experience with depressed clients are very good at giving advice about to close friends and colleagues and then when you ask them but why can't you also take on board the same advice for yourself that's where the plot thickens in psychotherapy because I call it then you get the yes buts or I call it the but eyes in questions and then that's a significant component of therapy why are they making special rules for themselves so we are then tackling core sense of self issues with the client and I'm grateful to hear Curtis's comments about then the need probably to work in tandem with psychiatrist and or GPs the pharmacotherapy arm of treatment as well so we're approaching the end and I'm really conscious that we have not been able to answer everybody's questions but there was one more which I think Curtis you can just answer quickly before we start summing up so someone has pointed out that and I you did as well that there's mild moderate and severe depressive disorders and that medication is not the first line treat for mild to moderate depressive disorder so you were specifically talking about people with a significant you know severe range or melancholic depression would be needing biological treatment as in medication first up and in fact the biological treatment you thought would be appropriate for Melissa Woods round sleep so just to confirm the antidepressants don't have the evidence in mild to moderate yeah there's there's a lot of evidence for a lot of other things and I think well conducted psychotherapy and a good treatment relationship is is just gold really for the milder to moderate ones the more severe ones yes the biological treatment but it doesn't mean that at some point in their recovery psychotherapy is irrelevant I think the evidence is very clear actually that for major depressive disorder the best outcomes come from a combination of antidepressant medication and some form of psychological therapy tailored to the patient thank you Curtis um so we're just coming to your final wrap up so I'm just going to go around the three of you and ask for a final message that you'd like to leave the audience with or a reflection from the discussion I think we'll go in the order that we started with so Monica I might go to you first any final thoughts yeah well I've learned a lot tonight so thank you but one thing that I think as a GP when I'm working with someone and and I guess you know from years of general practice is this idea of the yes but person and they can give advice to someone else and not so much of themselves and you know there are about half of the population who find it very difficult to meet out her expectations and so in the resources I've put a link to a writer called Gretchen Rubin and her quiz where she actually talks about strategies to actually help people who find it very difficult to meet their own near and expectations like of self-care doing exercise going to sleep on time doing meditation if they so choose and that you know when we help our patients know themselves better that we can actually that's actually connecting them to their resources as well so as a GP we can be a support for them but we can actually actually help them to get to know themselves better so that's all I think for tonight thanks Monica Maria I think I probably reiterate a couple of points that I mentioned earlier I think we need informed consent from our clients and to get that I think we need to provide a really good educational summary as to you know what what are the constellation of symptoms they're experiencing it's just a label to guide our treatment hence why use that GPS navigator and then even if they don't want whether it's biological or psychotherapy options and even as Monica said there's lifestyle options available and growing evidence base for that so I'm well aware and I do collaborate with exercise scientists as well so for some clients it's just even changing lifestyle and a wait and watch component but from a psychotherapy perspective I think my role is also to facilitate even clients in terms of a further de-stigmatising mental health even though they've asked the help that they could still be conflicted thanks and Curtis okay so not to sort of overlap on what Monica and Maria have said but just a couple of things my reference is the Black Dog Institute it's got a fantastic website both for professionals and for laypeople members of the general community it's great for therapists and and patients as well in respect to the topic of depression and I suppose I would just encourage people to be on the lookout for the more severe melancholic types of depression because they're the ones that are probably going to need you know robust medication before the therapy but therapy along the way the rest are probably going to be well managed by very competent non-psychiatrist I'm talking from the perspective of a psychiatrist very competent non-psychiatrist professionals with well-conducted therapy Maria hinted at schema therapy which is terrific cognitive behavior therapy there's a couple of other types and so where would you where would you find that evidence of melancholy you might get it in the history but look forward in the mental state examination in your observation and my last tip develop the collaborative networks it's you know it's just fantastic to be able to work as a team and now Maria was talking about it I know Monica does as well but you know most of us have got our favorite psychologists and our you know gps who will refer to us maybe even exercise physiologists these days dieticians if there's eating disorder issues it's just terrific so yeah do develop those collaborative networks thank you all very much and I just someone was very pleased Curtis when you mentioned mental health social workers and I do just want to acknowledge that there are a number of different professions who do do psychotherapy really well and the MHPN is um was set up to support the practitioners who are working under Medicare to collaborate with each other and I also recognize that there will be other people in the audience who don't come from that background who are still doing really important work with people so I just wanted to finish on the note that it's um that collaboration point from Curtis is fantastic and um there are many many people who can be helpful to people so thank you all so much for your contributions tonight and a really interesting discussion and uh I'd really like to encourage the audience thank you all for your participation in your questions and I hope you've had good chats in the chat box which I can't see other than the questions so please make sure you complete the exit survey before you log out so you can click the pie chart icon in the lower right corner of your screen or you can wait for a message to pop up but please give us feedback it does inform future webinars and you will receive a statement of attendance within four weeks and you will also be sent a link to the resources from the webinar and I would like to thank all of our participants for providing such great resources tonight this has been a really rich one in terms of resources um just to let you know about MHPN presents so this is um the podcast arm uh and the series is transitions and Monica co-hosts a number of the podcasts so there's five new episodes on the series um that have been released and um the final one will be available on the 30th of June and you can find that by going to the website um or search for MHPN presents wherever you like to get your podcasts now would you like to continue this discussion with um local practitioners or perhaps start discussing issues of relevance in your local areas MHPN has project officers who can help you establish and support interdisciplinary mental health networks across Australia metropolitan regional rural and remote and some networks are online so we can um include remote people as well and there are currently 373 networks around the country so if you'd like to join one or start one please contact MHPN and I would uh before we go I do want to acknowledge uh people who have lived experience of mental illness and also their um family and carers who've lived with mental illness in the past and those who continue to do so in the present and I thank everyone the panellists and the audience very much for your participation this evening and we look forward to seeing you at another MHPN event good night