Depression, demoralisation or adjustment disorder? Understanding emotional distress in the severely medically ill

As emotional distress is often seen as an understandable reaction to a severe or life-threatening illness, clinicians are reluctant to make a diagnosis of depression and resort to alternative diagnoses such as adjustment disorder (AD) or demoralisation. This paper introduces these concepts and critically examines their clinical utility. It concludes that neither AD nor demoralisation can be clearly distinguished from depression on variables such as clinical symptoms, outcome or treatment response. Since AD and demoralisation are considered transient or understandable reactions, the risk of using these diagnoses as alternatives to depression in a clinical setting is that a simplistic approach of psychological therapies for the former and antidepressants for the latter will be adopted. Instead, a working diagnosis of a general distress syndrome complemented by a personalised formulation is advocated. This would lead to the generation of a problem list and a pragmatic management plan.