Association between irritability and suicide-related outcomes across the life-course. Systematic review of both community and clinical studies

An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

OBJECTIVE

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

METHOD

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

RESULTS

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

CONCLUSIONS

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

The effect of bright light therapy on irritability in bipolar depression: a single-blind randomised control trial

OBJECTIVE

The symptom-complex irritability, widely used in descriptions of bipolar patients' manic and mixed states, also represents a common feature in depressive phases. Irritability negatively affects the clinical course of depression, leading to a higher risk of treatment non-adherence, violence, and suicide attempts. Nevertheless, proportional attention from the scientific literature seems to be scarce. We conducted the first randomised controlled trial with the aim of evaluating BLT as a possible therapeutic strategy for irritability in bipolar depression.

METHODS

180 inpatients were randomly assigned to: Group A exposed to bright light therapy (BLT) daily, or Group B treated with pharmacotherapy only. A qualitative assessment of irritability was performed after a 4-week program.

RESULTS

Group A showed about one-third fewer cases of irritability compared to Group B, this reduction was not related to the overall remission of depressive symptoms.

CONCLUSIONS

The present study supports the usefulness of BLT in irritability in bipolar depression.

A cross-sectional analysis of the relationships between anxiety sensitivity and youth irritability: the mediated roles of insomnia and selective attention for threat

BACKGROUND

Irritability is common in multiple psychiatric disorders and is hallmark of disruptive mood dysregulation disorder. Child irritability is associated with higher risk of suicide and adulthood mental health problems. However, the psychological mechanisms of irritability are understudied. This study examined the relationship between anxiety sensitivity and irritability among youth, and further explored three possible mediated factors: selective attention for threat, delayed reward discounting, and insomnia.

METHODS

Participants were 1417 students (51.7% male; mean age 13.83 years, SD = 1.48) recruited from one high school in Hunan province, China. Self-report questionnaires were used to measure irritability (The Affective Reactivity Index and The Brief Irritability Test), anxiety sensitivity (The Childhood Anxiety Sensitivity Index), selective attention for threat (The Davos Assessment of Cognitive Biases Scale-attention for threat bias subscale), insomnia (The Youth Self-Rating Insomnia Scale), and delayed reward discounting (The 27-item Monetary Choice Questionnaire). Structural equation modal (SEM) was performed to examine mediated relations.

RESULTS

Anxiety sensitivity was modestly related to irritability and insomnia (r from 0.25 to 0.54) and slightly correlated with selective attention for threat (r from 0.12 to 0.28). However, there is no significant relationship of delayed rewards discounting with anxiety sensitivity and irritability. The results of SEM showed that selective attention for threat (indirect effect estimate = 0.04) and insomnia (indirect effect estimate = 0.20) partially mediate the relationship between anxiety sensitivity and irritability, which explained 34% variation.

CONCLUSIONS

Anxiety sensitivity is an important susceptibility factor for irritability. Selective attention for threat and insomnia are two mediated mechanisms to understand the relationship between anxiety sensitivity and irritability.

Irritability: A concept analysis

Irritability is a term used to describe feelings of anger, annoyance and impatience, and is commonly experienced by individuals in daily life. However, there are diverse conceptualizations of irritability in public and clinical research, which often result in confusing irritability with anger and other overlapping concepts. This, in turn, leads to a lack of conceptual clarity. Accordingly, the purpose of this concept analysis was to explore the irritability concept, including its definitions, defining characteristics, antecedents, consequences and empirical referents. The findings showed that irritability is predominantly conceptualized as a psychophysiological concept in the literature. We demonstrated that irritability can be differentiated from overlapping concepts like anger by qualities, such as 'unpredictability and lowered emotion control', 'lowered threshold for negative emotional stimuli', 'being manifested in response to frustrative situations or physiological needs' and 'experience of disproportionate and unjustified emotional irritation'. Importantly, severe irritability prospectively predicts psychiatric disorders and greater impairments in health, financial, educational and social functioning in individuals. Taken together, our analysis showed that one should take into account the context, duration, intensity and importantly outcomes, when assessing irritability in an individual. Considering these findings and the presence of irritability in nursing practice, it is crucial for nurses to recognize and successfully identify this concept in the nursing care they provide within the diverse settings and patient populations.

The distinction between irritability and anger and their associations with impulsivity and subjective wellbeing

Irritability, anger, and impulsivity have important associations with psychological well-being. However, studying the internal relationships between such emotional constructs is challenging, largely because of the lack of precise operational definitions and extensively validated measurement tools. The aim of this study was to examine relationships between the above emotional constructs and how they relate to satisfaction with life and perceived negative impact on different life domains. Participants (N = 471) completed a self-report questionnaire online. Correlational analyses showed that higher levels of irritability and trait anger were associated with lower life satisfaction. Impulsivity displayed complex relationships with life satisfaction, with some aspects (sensation seeking) showing a positive relationship and others (urgency, lack of perseverance) showing a negative relationship. A two-factor Confirmatory Factor Analysis treating irritability and anger as separate constructs showed a better fit compared with a one-factor model, indicating that irritability and anger should be treated as separate constructs. An exploratory moderation analysis showed that higher irritability predicted increased anger only for participants scoring average to high on urgency (a facet of impulsivity). Our findings increase the understanding of the relationship between these dispositional constructs and supports the conceptualization of irritability and anger as related but distinct constructs.

Psychometrics of the Concise Health Risk Tracking Self-Report (CHRT-SR16) Assessment of Suicidality in a Sample of Adults with Moderate to Severe Methamphetamine Use Disorder: Findings from the ADAPT-2 Randomized Trial

Background

The co-occurrence of suicidality and substance use disorders has been well established, but rating scales to examine suicidal behavior and risk are sparse among participants with substance use disorders. We examined the psychometric properties of the 16-item Concise Health Risk Tracking Scale - Self Report (CHRT-SR₁₆) to measure suicidality among adults with moderate-to-severe methamphetamine use disorder.

Methods

Participants (n = 403) with moderate-to-severe methamphetamine use disorder completed the CHRT-SR₁₆ as part of a randomized, double-blind, placebo-controlled pharmacotherapy trial. The CHRT-SR₁₆ factor structure was assessed using confirmatory factor analysis (CFA). Internal consistency was estimated with coefficients alpha (α) and omega (ω), test-retest reliability with intraclass correlation coefficient (ICC) and standard error of measurement, and convergent validity using Spearman's ρ rank order correlation coefficient test between CHRT-SR₁₆ factors and the Patient Health Questionnaire (PHQ-9). The analyses utilized baseline and week 1 data (for test-retest reliability only).

Results

CFA revealed a seven-factor model of Pessimism, Helplessness, Social Support, Despair, Impulsivity, Irritability, and Suicidal Thoughts as the best-fitting model. The CHRT-SR₁₆ also exhibited strong internal consistency (α = 0.89; ω = 0.89), test-retest reliability (ICC = 0.78) and convergent validity with the PHQ-9 total score (ρ = 0.62).

Conclusion

The CHRT-SR₁₆ showed strong psychometric properties in a sample of participants with primary methamphetamine use disorder.

Clinicaltrialsgov Identifier

NCT03078075.

Leveraging genetic overlap between irritability and psychiatric disorders to identify genetic variants of major psychiatric disorders

Irritability is a heritable core mental trait associated with several psychiatric illnesses. However, the genomic basis of irritability is unclear. Therefore, this study aimed to 1) identify the genetic variants associated with irritability and investigate the associated biological pathways, genes, and tissues as well as single-nucleotide polymorphism (SNP)-based heritability; 2) explore the relationships between irritability and various traits, including psychiatric disorders; and 3) identify additional and shared genetic variants for irritability and psychiatric disorders. We conducted a genome-wide association study (GWAS) using 379,506 European samples (105,975 cases and 273,531 controls) from the UK Biobank. We utilized various post-GWAS analyses, including linkage disequilibrium score regression, the bivariate causal mixture model (MiXeR), and conditional and conjunctional false discovery rate approaches. This GWAS identified 15 independent loci associated with irritability; the total SNP heritability estimate was 4.19%. Genetic correlations with psychiatric disorders were most pronounced for major depressive disorder (MDD) and bipolar II disorder (BD II). MiXeR analysis revealed polygenic overlap with schizophrenia (SCZ), bipolar I disorder (BD I), and MDD. Conditional false discovery rate analyses identified additional loci associated with SCZ (number [n] of additional SNPs = 105), BD I (n = 54), MDD (n = 107), and irritability (n = 157). Conjunctional false discovery rate analyses identified 85, 41, and 198 shared loci between irritability and SCZ, BD I, and MDD, respectively. Multiple genetic loci were associated with irritability and three main psychiatric disorders. Given that irritability is a cross-disorder trait, these findings may help to elucidate the genomics of psychiatric disorders.

Irritability in bipolar disorder and unipolar disorder measured daily using smartphone-based data: An exploratory post hoc study

OBJECTIVE

To investigate (i) the proportions of time with irritability and (ii) the association between irritability and affective symptoms and functioning, stress, and quality of life in patients with bipolar disorder (BD) and unipolar depressive disorder (UD).

METHODS

A total of 316 patients with BD and 58 patients with UD provided self-reported once-a-day data on irritability and other affective symptoms using smartphones for a total of 64,129 days with observations. Questionnaires on perceived stress and quality of life and clinical evaluations of functioning were collected multiple times during the study.

RESULTS

During a depressive state, patients with UD spent a significantly higher proportion of time with presence of irritability (83.10%) as compared with patients with BD (70.27%) (p = 0.045). Irritability was associated with lower mood, activity level and sleep duration and with increased stress and anxiety level, in both patient groups (p-values<0.008). Increased irritability was associated with impaired functioning and increased perceived stress (p-values<0.024). In addition, in patients with UD, increased irritability was associated with decreased quality of life (p = 0.002). The results were not altered when adjusting for psychopharmacological treatments.

CONCLUSIONS

Irritability is an important part of the symptomatology in affective disorders. Clinicians could have focus on symptoms of irritability in both patients with BD and UD during their course of illness. Future studies investigating treatment effects on irritability would be interesting.

Psychometric properties of Concise Associated Symptom Tracking (CAST) scale in youths and young adults: Findings from the Texas youth depression and suicide research network (TX-YDSRN)

Symptoms of irritability, anxiety, panic, and insomnia are common in patients with depression, and their worsening after antidepressant treatment initiation is associated with poorer long-term outcomes. The Concise Associated Symptom Tracking (CAST) scale was developed to measure these symptoms in adults with major depressive disorder (MDD). Here, we evaluate the psychometric properties of CAST in an ongoing community-based observational study involving children, adolescents, and young adults. Individuals from the ongoing Texas Youth Depression and Suicide Research Network (TX-YDSRN; N = 952) with CAST data available were included. Fit statistics [Goodness of Fit Index (GFI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)] from confirmatory factor analyses were used to evaluate the five- and four-domain structure of CAST. Item response theory (IRT) analyses were also used. Individuals were grouped based on age (in years) as youths (8-17) and young adults (18-20). Correlations with other clinical measures were used to inform construct validity. Four-domain (irritability, anxiety, panic, and insomnia) 12-item structure of CAST (CAST-12) was optimal for youths (N = 709, GFI = 0.906, CFI = 0.919, RMSEA = 0.095) and young adults (N = 243, GFI = 0.921, CFI = 0.938, RMSEA = 0.0797) with Cronbach's alpha of 0.87 and 0.88, respectively. Slope of each item exceeded 1.0 on IRT analyses suggesting adequate discrimination for each item. Scores on irritability, anxiety, panic, and insomnia were significantly correlated with similar items on other scales. Together these findings suggest that CAST-12 is a valid self-report measure of irritability, anxiety, insomnia, and panic in youths and young adults.

Early reduction in irritability is associated with improved outcomes among youth with depression: Findings from the AMOD study

OBJECTIVES

Evaluate whether early improvement in irritability predicts improvement in depression severity in a naturalistic sample of adolescents undergoing pharmacologic treatment for major depressive disorder.

METHODS

Adolescents (N = 161) aged 13-18 years with a moderate to severe depressive episode were enrolled. Outcome measures included the Children's Depression Rating Scale-Revised (CDRS-R), Quick Inventory of Depressive Symptomatology (QIDS-A₁₇), and Clinical Global Impression scale (CGI). Paired t-tests were used to estimate the change in irritability items from baseline to week-4, and Cohen's d effect sizes were computed. Separate linear regression analyses with CDRS-R, QIDS-A₁₇, and CGI at week-8 as the dependent variables and baseline levels of irritability and baseline-to-week-4 changes in irritability as independent variables of interest were conducted. These analyses were repeated after controlling for overall depression severity (minus the irritability item) at baseline and baseline to week-4 change.

RESULTS

Greater baseline to week-4 reduction in irritability was associated with lower levels of CDRS-R, QIDS-A₁₇, and CGI at week-8. These findings were significant for QIDS-A₁₇ and CGI even after controlling for baseline-to-week-4 changes in other depressive symptoms.

LIMITATIONS

The single item evaluation of irritability reduced assessment reliability in the absence of validated measures of irritability.

CONCLUSIONS

Early reduction in irritability is strongly associated with better outcomes in depressed youths, regardless of baseline depression severity. Further research is needed to quantify the burden of irritability, explore it as a tool for measurement-based care, and to develop targeted treatments for irritability.

Systematic Review and Meta-analysis: Task-based fMRI Studies in Youths With Irritability

OBJECTIVE

Childhood irritability, operationalized as disproportionate and frequent temper tantrums and low frustration tolerance relative to peers, is a transdiagnostic symptom across many pediatric disorders. Studies using task-dependent functional magnetic resonance imaging (fMRI) to probe neural dysfunction in irritability have increased. However, an integrated review summarizing the published methods and synthesized fMRI results remains lacking.

METHOD

We conducted a systematic search using irritability terms and task functional neuroimaging in key databases in March 2021, and identified 30 studies for our systematic review. Sample characteristics and fMRI methods were summarized. A subset of 28 studies met the criteria for extracting coordinate-based data for quantitative meta-analysis. Ten activation-likelihood estimations were performed to examine neural convergence across irritability measures and fMRI task domains.

RESULTS

Systematic review revealed small sample sizes (median = 58, mean age range = 8-16 years) with heterogeneous sample characteristics, irritability measures, tasks, and analytical procedures. Meta-analyses found no evidence for neural activation convergence of irritability across neurocognitive functions related to emotional reactivity, cognitive control, and reward processing, or within each domain. Sensitivity analyses partialing out variances driven by heterogeneous tasks, irritability measures, stimulus types, and developmental ages all yielded null findings. Results were compared with a review on irritability-related structural anomalies from 11 studies.

CONCLUSION

The lack of neural convergence suggests a need for common, standardized irritability assessments and more homogeneous fMRI tasks. Thoughtfully designed fMRI studies probing commonly defined neurocognitive functions may be more fruitful to elucidate the neural mechanisms of irritability. Open science practices, data mining in large neuroscience databases, and standardized analytical methods promote meaningful collaboration in irritability research.

Epidemiology of Childhood Witnessing Domestic Violence and Exploration of Its Relationships With Affective Lability and Suicide Attempts in Chinese Young Adults

Childhood witnessing domestic violence (CWDV) exerts short- and long-term negative impacts on emotional and behavioral health. The present study investigated the epidemiological features of CWDV, and its negative impact on psychological outcomes in a sample of Chinese college students. The mediating role of emotion regulation strategies on CWDV associations with psychological outcomes and gender differences in these relationships were examined. A total of 3,126 respondents (1,034 males; 2,086 females; 6 missing data in gender) completed the study questionnaire, which included demographic characteristics, CWDV, and suicide attempt history items as well as the Emotion Regulation Questionnaire (ERQ) and Affect Lability Scale-18 (ALS-18). Overall, 43.03% of the respondents reported CWDV, including 44.87% of males and 42.09% of females. Higher frequencies of CWDV were found to be related to the following factors: unstable marital status of parents; not being an only child; being a left-behind child, family financial difficulties, consumption of alcohol in the past year, and being in relatively poor physical condition. Among males, ERQ suppression scores were significantly higher for those men who experienced "often or every day" CWDV than for men who indicated that they did not have any history of CWDV (Bonferroni-corrected p = 0.047). More frequent CWDV was associated with higher ALS-18 scores and increased risk of suicide attempts in males and females (p < 0.05), and emotion regulation (suppression) was found to mediate the association between CWDV and affective lability among males. This study revealed high rates of CWDV, and serious impacts of CWDV on mental health in male and female Chinese college students. In males, but not females, emotion regulation strategy use, use of suppression, was found to act as a mediator in the association of CWDV with affective lability. Our findings suggest that interventions for individuals with CWDV should focus on the emotional regulation, which may help them improve mental health, especially in males.

Clinical correlates and prognostic impact of binge-eating symptoms in major depressive disorder

Binge-eating (BE) symptoms are relatively common in major depressive disorder (MDD), but their prognostic role is not fully understood. This study compared two groups of patients with MDD experiencing or not BE symptoms to ascertain differences in terms of clinical manifestations, presence of bipolar features, and antidepressant treatment outcomes. The study involved 482 outpatients collected within the Combining Medications to Enhance Depression Outcomes (CO-MED) trial, who were assessed with scales for depressive and hypomanic symptomatology, suicidality, comorbid mental disorders, and childhood traumas. BE symptoms were reported in 95 patients (20%). Patients with MDD experiencing BE symptoms were characterized by higher scores of negative self-outlook ( P = 0.0018), negative outlook of future ( P = 0.0014), irritability ( P = 0.0043), comorbid anxiety disorders (generalized anxiety disorder: P = 0.0006; panic disorder: P &lt; 0.0001; social phobia: P &lt; 0.0001), obsessive-compulsive disorder ( P = 0.0053), hypomanic symptoms (increased talkativeness: P = 0.0029; reduced need for sleep: P = 0.0171), and suicidality (suicidal propensity: P = 0.0013; suicidal risk: P = 0.0148; lifetime suicidal behavior: P = 0.0052). BE symptoms (OR = 2.02; 95% CI = 1.06-3.84) and depression severity (OR = 1.04; 95% CI = 1.00-1.08) were independently associated with lifetime attempted suicide. The presence of BE symptoms might indicate higher severity of depressive disorder. Suicidal risk is a major issue in these patients, whereas the association between BE and bipolar features needs further research.

Perinatal adversity profiles and suicide attempt in adolescence and young adulthood: longitudinal analyses from two 20-year birth cohort studies

BACKGROUND

We aimed to identify groups of children presenting distinct perinatal adversity profiles and test the association between profiles and later risk of suicide attempt.

METHODS

Data were from the Québec Longitudinal Study of Child Development (QLSCD, N = 1623), and the Avon Longitudinal Study of Parents and Children (ALSPAC, N = 5734). Exposures to 32 perinatal adversities (e.g. fetal, obstetric, psychosocial, and parental psychopathology) were modeled using latent class analysis, and associations with a self-reported suicide attempt by age 20 were investigated with logistic regression. We investigated to what extent childhood emotional and behavioral problems, victimization, and cognition explained the associations.

RESULTS

In both cohorts, we identified five profiles: No perinatal risk, Poor fetal growth, Socioeconomic adversity, Delivery complications, Parental mental health problems (ALSPAC only). Compared to children with No perinatal risk, children in the Poor fetal growth (pooled estimate QLSCD-ALSPAC, OR 1.89, 95% CI 1.04-3.44), Socioeconomic adversity (pooled-OR 1.42, 95% CI 1.08-1.85), and Parental mental health problems (OR 1.74, 95% CI 1.27-2.40), but not Delivery complications, profiles were more likely to attempt suicide. The proportion of this effect mediated by the putative mediators was larger for the Socioeconomic adversity profile compared to the others.

CONCLUSIONS

Perinatal adversities associated with suicide attempt cluster in distinct profiles. Suicide prevention may begin early in life and requires a multidisciplinary approach targeting a constellation of factors from different domains (psychiatric, obstetric, socioeconomic), rather than a single factor, to effectively reduce suicide vulnerability. The way these factors cluster together also determined the pathways leading to a suicide attempt, which can guide decision-making on personalized suicide prevention strategies.

Irritable Mood and Subthreshold Hypomanic Episodes Correlate with More Severe Major Depression

INTRODUCTION

Irritable mood (IM) and subthreshold hypomanic symptoms are reported in half and two-fifths of major depressed subjects respectively, but their clinical and prognostic meanings remain unclear. The aim of this study was to test the clinical usefulness of 2 specifiers in DSM-IV major depressive disorder (MDD): IM occurring during an index episode (IM+) and lifetime episodes of elated mood or IM with at least 2 concurrent hypomanic symptoms (subthreshold hypomanic episodes [SHEs]).

METHOD

We included 482 outpatients with MDD participating in the Combining Medications to Enhance Depression Outcome study (mean age 43.14 ± 12.46 years, 144 males - 30%). The main aim of the original study was to test whether 2 different medications when given in combination as the first treatment step, compared to 1 medication, would improve antidepressant response.

RESULTS

IM + subjects (N = 349; 70%) were younger and more often females, with a more severe depression, a more marked social impairment, and more psychiatric comorbidities. The IM + group was also characterized by higher levels of suicidal ideation and more cases of emotional abuse. The combination of IM+ and SHEs was associated with an even more severe clinical picture. Limitations include the post hoc method, incomplete assessment of bipolar validators (e.g., family history of bipolar illness), personality disorders and suicide attempts.

CONCLUSIONS

The presence of IM and SHEs in MDD correlate with an overall more severe clinical condition.

Instability of Suicidal Ideation in Patients Hospitalized for Depression: An Exploratory Study Using Smartphone Ecological Momentary Assessment

This study used ecological momentary assessment (EMA) to explore the correlates of suicidal ideation (SI) instability in patients hospitalized for depression and SI. Thirty-nine adult inpatients were given smartphones with visual analogue scales to rate current depressed mood, anger/irritability, feeling socially connected, and SI three times a day throughout hospitalization. Affective Lability Scales (ALS) were also completed at baseline. SI instability was correlated with SI intensity, depressed mood instability, and social connection instability. Social connection instability was not associated with SI instability after controlling for depressed mood instability. ALS scores were not associated with EMA-derived SI instability. Participants with multiple past suicide attempts experienced greater SI instability. More research examining the clinical significance of SI instability is warranted.

Using ecological momentary assessment to enhance irritability phenotyping in a transdiagnostic sample of youth

Irritability is a transdiagnostic symptom dimension in developmental psychopathology, closely related to the Research Domain Criteria (RDoC) construct of frustrative nonreward. Consistent with the RDoC framework and calls for transdiagnostic, developmentally-sensitive assessment methods, we report data from a smartphone-based, naturalistic ecological momentary assessment (EMA) study of irritability. We assessed 109 children and adolescents (Mage = 12.55 years; 75.20% male) encompassing several diagnostic groups – disruptive mood dysregulation disorder (DMDD), attention-deficit/hyperactivity disorder (ADHD), anxiety disorders (ANX), healthy volunteers (HV). The participants rated symptoms three times per day for 1 week. Compliance with the EMA protocol was high. As tested using multilevel modeling, EMA ratings of irritability were strongly and consistently associated with in-clinic, gold-standard measures of irritability. Further, EMA ratings of irritability were significantly related to subjective frustration during a laboratory task eliciting frustrative nonreward. Irritability levels exhibited an expected graduated pattern across diagnostic groups, and the different EMA items measuring irritability were significantly associated with one another within all groups, supporting the transdiagnostic phenomenology of irritability. Additional analyses utilized EMA ratings of anxiety as a comparison with respect to convergent validity and transdiagnostic phenomenology. The results support new measurement tools that can be used in future studies of irritability and frustrative nonreward.

Identifying environmental pathways between irritability during childhood and suicidal ideation and attempt in adolescence: findings from a 20-year population-based study

BACKGROUND

Irritable children are at increased risk of suicidal ideation and suicide attempt, but the underlying environmental mechanisms accounting for these associations are largely unknown. We aimed to investigate the mediating role of peer victimization and harsh parenting in the association between childhood irritability and adolescent suicidal ideation and attempt.

METHOD

N = 1,483 participants from the Québec Longitudinal Study of Child Development followed up from 5 months until 20 years of age (2018) with annual or biannual assessments. Irritability was operationalized using assessments of teacher-reported temper tantrums and reactive aggression. Suicidal ideation and suicide attempt at ages 13, 15, 17, and 20 years were self-reported. Peer victimization (self-reported at age 13) and harsh parenting (mothers reported at age 13) were considered as potential mediators.

RESULTS

We identified four trajectories of teacher-reported irritability symptoms from 6 to 12 years: low (74.8%), rising (12.9%), declining (7.3%), and persistent (4.9%). In adjusted models, children in the persistent and rising trajectories had, respectively, 2.81-fold (CI, 1.27-6.22) and 2.14-fold (CI, 1.20-3.81) increased odds of suicide attempt in adolescence, but not suicidal ideation. We found that a significant proportion of the association between irritability trajectories and suicide attempt was mediated by peer victimization (33% and 35% for rising and persistent, respectively), but there was no mediation via harsh parenting.

CONCLUSIONS

Our findings suggest that peer victimization may be a key mechanism explaining the increased suicide attempt risk of children presenting with persistently high or increasing irritability. Interventions to reduce peer victimization may be helpful to reduce suicide risk among irritable children.

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up

BACKGROUND AND AIM

The Suicide Crisis Syndrome (SCS) is an evidence-based pre-suicidal cognitive and affective state predictive of short-term suicide risk. The most recent SCS formulation, proposed as a suicide-specific DSM diagnosis, features a feeling of Entrapment accompanied by four additional symptom clusters: Affective Disturbance; Loss of Cognitive Control; Hyperarousal; and Social Withdrawal. The aim of the present study was to revise the Suicide Crisis Inventory (SCI; Barzilay et al., 2020), a self-report measure assessing the presence of the SCS,in accordance with the current SCS formulation, as well as to assess the psychometric properties and clinical utility of its revised version, the Suicide Crisis Inventory-2 (SCI-2).

METHODS

The SCI-2, a 61-item self-report questionnaire, was administered to 421 psychiatric inpatients and outpatients at baseline. Prospective suicidal outcomes including suicidal ideation, preparatory acts, and suicidal attempts were assessed after one month. Internal structure and consistency were assessed with confirmatory factor analysis, convergent, discriminant, and current criterion validity. Receiver-operating characteristic (ROC) curves with Area under the Curve (AUC) were used to examine the predictive validity of the SCI-2 to prospective outcomes. Exploratory analyses assessed the predictive validity of the five SCI-2 dimensions.

RESULTS

The SCI-2 demonstrated excellent internal consistency (Cronbach's α = 0.971), good convergent, discriminant, and current criterion validity. The SCI-2 significantly predicted all three outcomes, and was the only significant predictor of suicidal attempts with AUC = 0.883.

DISCUSSION

The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness to disclose suicidal ideation.

Novel insights into irritability: the relationship between subjective experience, age and mood

BACKGROUND

The relationship between irritability as a subjective experience and the behavioural indicators typically used to measure the construct are not known. Its links to mood, and contextual relationships, vary with age and are yet to be thoroughly examined.

AIMS

First, to interrogate the relationship between the subjective experience of irritability and mood, and that with its behavioural indicators. Second, to determine how these relationships vary with age and over time.

METHOD

This study examined data from a previous clinical trial of adolescents and young adults (N = 82) with bipolar disorder, who received a psychological intervention over 18 months. Participants completed a battery of questionnaires, which included assessments of irritability. Analyses of covariance were conducted to examine the interaction between mood symptoms, subjective measures of irritability, behavioural measures of irritability and age over time.

RESULTS

Subjective irritability scores differed significantly over time when controlling for manic, but not depressive, symptom scores. Further, subjective irritability significantly differed when controlling for behavioural measures of irritability (temper outbursts and argumentativeness). There were significant interactions between scores of depressive symptoms, temper outbursts and subjective irritability with age, wherein younger participants showed no correlation between depressive symptoms and temper outbursts. In addition, younger participants showed lower correlations between subjective irritability and both depressive and temper outburst scores, than older participants.

CONCLUSIONS

Subjective irritability is linked to mood morbidity and behavioural outbursts, and these relationships are contingent on age. Our novel findings suggest that subjective irritability should be assessed in greater detail in patients with mood disorders.

The association of phasic irritability (aggressive outbursts) and tonic irritability (irritable mood) to depression occurrences, symptoms, and subtypes

BACKGROUND

Research among adults has rarely differentiated between tonic irritability (i.e., irritable mood) and phasic irritability (i.e., aggressive outbursts) with respect to multiple dimensions of depression. The current study explored both tonic and phasic irritability in relation to depression severity, depression chronicity, age of depression onset, individual depressive symptom, and depression subtypes.

METHODS

The study included participants (N = 5692) from the National Comorbidity Survey - Replication (NCS-R) part two. The NCS-R used lay-administered, fully standardized diagnostic interviews. The current study implemented linear models, generalized linear models, Cox proportional hazard model, and latent class regression.

RESULTS

Both types of irritability were significantly associated with greater risk for MDD diagnosis, as well as risk for having at least one depressive symptom, early MDE onset, and MDE chronicity. Both phasic and tonic irritability were associated with greater odds of specific depressive symptoms and were differentially related to distinct depressive symptom constellations. Phasic irritability related only to severe depression. Lastly, both phasic and tonic irritability was associated with suicidal ideation, but only phasic irritability was associated with a suicide plan and attempt, above and beyond depression subtypes.

CONCLUSIONS

Both phasic and tonic irritability differentially related to almost all aspects of depression in adults. Specifically, tonic irritability showed overall stronger associations with various depressive features, whereas phasic irritability marked higher depressive severity.

Irritability as an independent predictor of concurrent and future suicidal ideation in adults with stimulant use disorder: Findings from the STRIDE study

BACKGROUND

This report evaluated whether irritability in adults with stimulant use disorder is associated with suicidal ideation (SI) at the same visit (i.e., concurrently) and whether early changes in irritability predict subsequent levels of SI.

METHODS

Adults with stimulant use disorder (n=302) from nine residential addiction treatment programs were included. Participants were randomized to augmentation of usual care with dosed exercise or health education intervention. Irritability, SI, and depression were measured every week with 5-item irritability domain of Concise Associated Symptom Tracking scale, 3-item suicidal thoughts factor of Concise Health Risk Tracking scale, and 16-item Quick Inventory of Depressive Symptomatology Clinician-Rated version (excluding the suicide-related item) respectively during acute-(baseline-to-week-12) and continuation-(week-12-to-week-36) phase. Covariates included age, sex, race, ethnicity, treatment arm, type of substance(s) used, and comorbid psychiatric and medical disorders.

RESULTS

Higher irritability was associated with higher SI concurrently both in the acute-phase: r=0.28 (p<0.0001) and in the continuation-phase: r=0.33 (p<0.0001). Irritability was associated with concurrent SI after controlling for depression [acute-phase: β=0.17 (p<0.0001); continuation-phase: β=0.18 (p<0.0001)]. Greater baseline-to-week-2 reductions in irritability predicted lower levels of SI from week-2-to-week-12 (β=-0.11, p=0.003) and from week-12-to-week-36 (β=-0.22, p<0.0001) after controlling for baseline levels of depression and SI and baseline-to-week-2 changes in depression and SI.

LIMITATIONS

Secondary analyses, self-report measures of irritability and SI, limited generalizability.

CONCLUSIONS

Irritability is associated with SI concurrently, and greater reductions in irritability earlier in treatment are associated with lower levels of subsequent SI. Therefore, targeting irritability may reduce suicidality in adults with stimulant use disorder.

Differential associations of phasic and tonic irritability to suicidality among U.S. adults

Research on the relations between irritability and suicidality among adults has rarely compared or differentiated between tonic versus phasic irritability. The current cross-sectional study investigated the role of both tonic and phasic irritability in relation to lifetime suicidal ideation, plans, and attempts. The study included adult participants who completed the suicidality module from the National Comorbidity Survey - Replication (NCS-R) (N = 7683 for suicidal ideation and N = 1223 for suicidal plan and attempt). The NCS-R used lay-administered, standardized diagnostic interviews. Phasic and tonic irritability were assessed with individual screener items from the World Health Organization Composite International Diagnostic Interviews (CIDI). The current study used logistic regression, weighted Cox proportional hazard model, and multinomial logit regression, adjusting for sex, race/ethnicity, age, education, and marital status. Both types of irritability were included simultaneously in the models. Results indicated that both types of irritability were significantly associated with increased odds of suicidal ideation (phasic: Odds Ratio 2.72 [2.35,3.14]); tonic: OR 2.34 [2.04,2.68]), age of first-time suicidal ideation (phasic: Adjusted Hazard Ratio 2.87 [2.27, 3.63]; tonic: AHR 2.12 [1.76,2.54]), and suicide attempt (phasic: OR 1.53 [1.13,2.07]); tonic: OR 1.44 [1.11,1.89]). Only tonic but not phasic irritability was associated with suicide plans (OR 1.39 [1.08,1.79]). When suicide attempts were divided into those that were impulsive versus planned and compared them to no suicide attempt, both types of irritability were associated planned attempts, (phasic: OR 1.53 [1.13,2.07]); tonic: OR 1.44 [1.11,1.89]) but only phasic irritability was related to impulsive attempts (OR 1.70 [1.10,2.64]). Phasic and tonic irritability show differential relations to and can serve as differential markers for suicide-related outcomes in adults.

The Irritable and Oppositional Dimensions of Oppositional Defiant Disorder: Integral Factors in the Explanation of Affective and Behavioral Psychopathology

Oppositional defiant disorder includes distinct but inseparable dimensions of chronic irritability and oppositional behavior. The dimensions have been identified in early childhood to adulthood, and show discriminant associations with internalizing and externalizing psychopathology. The introduction of disruptive mood dysregulation disorders and the requirements that it take precedence over oppositional defiant disorder diagnostically are not supported by evidence and introduce confusion about the structure and linkages of irritability and oppositional behavior, and obscure the importance of the behavioral dimension in explaining and predicting poor outcomes. A dimensional framework with irritability, oppositionality, callous-unemotional traits, and aggression may more fully describe antisocial outcomes.

Anger attacks are associated with persistently elevated irritability in MDD: findings from the EMBARC study

BACKGROUND

This report tests the association of self-reported symptoms of irritability with overt behavior of anger attacks (uncharacteristic sudden bouts of anger that are disproportionate to situation and associated with autonomic activation).

METHODS

Participants of the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care study who completed Massachusetts General Hospital Anger Attacks questionnaire were included (n = 293). At each visit, the 17-item Hamilton Depression Rating Scale and the 16-item Concise Associated Symptom Tracking scale were used to measure depression, anxiety, and irritability. In those with anger attacks present v. those without anger attacks, separate t tests and mixed model analyses compared afore-mentioned symptoms at baseline and changes with treatment respectively. As anger attacks may occur without aggressive behaviors, analyses were repeated based only on the presence of aggressive behaviors.

RESULTS

At baseline, those with anger attacks (n = 109) v. those without anger attacks (n = 184) had similar levels of depression but higher levels of irritability [effect size (d) = 0.80] and anxiety (d = 0.32). With acute-phase treatment, participants with anger attacks experienced a greater reduction in irritability (p < 0.001) but not in depression (p = 0.813) or anxiety (p = 0.771) as compared to those without anger attacks. Yet, irritability levels at week-8 were higher in those with anger attacks (d = 0.32) than those without anger attacks. Similar results were found in participants with aggressive behaviors.

CONCLUSIONS

The presence of anger attacks in outpatients with major depressive disorder may identify a sub-group of patients with persistently elevated irritability.

Suicidal ideation and attempt in adolescents exposed to maternal smoking across pregnancy and childhood: A 20-year prospective cohort study

BACKGROUND

Few studies investigated the association between maternal smoking during pregnancy and offspring suicide risk, none considering postnatal smoking exposure. We investigated associations between maternal smoking patterns during the pre- and postnatal periods and adolescent suicidal ideation and attempt.

METHODS

We identified longitudinal patterns of maternal smoking from the prenatal period to the end of childhood (children's age 12 years, 10 assessments) among participants in the Québec Longitudinal Study of Child Development (N = 1623). We estimated associations between maternal smoking patterns and offspring self-reported suicidal ideation and attempt (ages 13-20). Background confounding factors (e.g., socioeconomic, familial, mental health) were controlled using propensity score inverse-probability weighting (IPW).

RESULTS

Participants reporting suicidal ideation and attempt were 9.3% and 8.4%, respectively. We identified four maternal smoking patterns: non-smoking (66.5%), increasing (5.5%), decreasing (9.3%), persistent (18.5%). Children exposed to persistent (OR=2.92, CI=1.99-4.30) and increasing (OR=2.06, CI=1.13-3.74) maternal smoking were more likely to attempt suicide, compared to non-exposed children. Accounting for confounding factors using IPW fully explained the association between increasing smoking and suicide attempt (OR=0.95, CI=0.39-2.09) but only reduced the association between persistent exposure and suicide attempt (OR=2.30, CI=1.04-4.99). No increased suicide attempt risk was found for children of mothers with a decreased smoking pattern. We found no associations for suicidal ideation.

LIMITATIONS

Propensity score cannot account for unmeasured confounding factors; attrition limits generalizability.

CONCLUSIONS

Offspring of mothers who smoked persistently and heavily prenatally and postnatally were at increased risk of suicide attempt in adolescence. Future studies should elucidate biological and psychosocial mechanisms potentially at play in these associations.

Cohort Profile: Quebec Longitudinal Study of Child Development (QLSCD)

PURPOSE

The Quebec Longitudinal Study of Child Development (QLSCD) was designed to examine the long-term associations of preschool physical, cognitive, social, and emotional development with biopsychosocial development across childhood, adolescence, and young adulthood.

METHODS

QLSCD is an ongoing prospective cohort including 2120 singletons born in 1997/1998 in the Canadian province of Quebec. So far, data have been collected annually or every 2 years from child ages 5 months to 21 years. The cohort currently includes 1245 participants. Data available include a range of environmental (e.g., family characteristics, child behaviour, educational attainment, mental health), biological (e.g., hair cortisol, genetic, epigenetic), and administrative data.

RESULTS

QLSCD has contributed to the understanding of children's psychosocial development, including the development of physical aggression and anxiety. QLSCD articles have advanced scientific knowledge on the influence of early childhood factors on childhood, adolescent, and young adult mental health, including the effect of participation in early childcare on cognitive and behavioural development, the developmental origins of adolescent and young adult mental health problems and suicide risk, and the development of interpersonal difficulties (e.g., peer victimisation) from preschool years to adolescence.

CONCLUSION

QLSCD has given major contributions to our understanding of the link between different aspects of child development and biopsychosocial development during the first two decades of life. Unique features include the presence of environmental, biological, and administrative data, long-term follow-up with frequent data collections, and use of data from multiple informants, including teachers, mothers, fathers, and the children themselves.

Irritability and mood symptoms in adolescent girls: Trait anxiety and emotion dysregulation as mediators

BACKGROUND

Irritability is a common symptom in youth that is thought to be predictive of mood disorders. Its effects on mood are likely to be age-dependent, with direct and indirect mediators. We assessed age-related effects and mediators of irritability in adolescent girls with subthreshold depressive and manic symptoms.

METHODS

We analysed the irritability item from the Mood Disorder Questionnaire in 3 cohorts of girls aged 12-18years (N=229); 12-13years (N=82); 14-15years (N=68); and 16-18years (N=79). They also completed mood, anxiety and emotion regulation questionnaires. MANOVA, correlations and bootstrapped mediation analyses were performed with SPSS®v25 and Hayes Processv3.5®.

RESULTS

Overall, irritable girls had higher depressive and manic symptoms, trait anxiety and emotion dysregulation than those who were not irritable. Significantly higher rates of irritability were observed in mid-adolescents (aged 14-15years; p = 0.001). Notably, irritability exerted effects on depressive symptoms via trait anxiety, non-acceptance of emotions and dysregulation in emotion clarity throughout adolescence. However, irritability directly exerted effects on manic symptoms in mid-adolescence but in older adolescents, their relationship was indirect via impulse control dysregulation.

LIMITATIONS

The cross-sectional design and non-clinical sample limit generalisability of our findings.

CONCLUSIONS

Irritability is involved in subthreshold depressive symptoms, via trait anxiety and perceptual emotion dysregulation. On the other hand, irritability is directly and indirectly associated with subthreshold manic symptoms via dysregulated impulse control depending on age. Therefore, screening for irritability, trait anxiety and emotion dysregulation throughout adolescence may facilitate the early detection of subthreshold depressive and manic symptoms, and the implementation of preventive strategies.

Latent class analysis of bipolar disorder symptoms and suicidal ideation and behaviors

Individuals with bipolar disorder are at increased risk of dying by suicide compared to healthy controls and those with unipolar depression. Previous studies show that depressive symptoms and mixed episodes of mania and depression are related to suicide. However, most of these studies adopt a variable-centered approach to understanding how specific symptoms relate to suicidal ideation, without addressing how these symptoms and symptom profiles relate to suicidal behaviors.

OBJECTIVES

Using latent class analysis, this study adopts a person-centered approach to examine whether subtypes of patients with bipolar disorder differ in their levels of suicidal ideation and behaviors.

METHODS

A total of 150 patients from a behavioral health outpatient clinic were recruited. Latent classes were generated based on self reports of their depressive and manic symptoms.

RESULTS

Five classes of patients with bipolar disorder were identified, namely, a minimal symptom, mania, moderately depressed, severely depressed, and mixed depression-mania subtypes. Those in the severely depressed and mixed depression-mania groups reported significantly higher levels of suicidal ideation and behaviors compared to the other groups.

CONCLUSIONS

Our findings provide further support for the strong relationship between depressive symptoms and suicidality. These findings are significant as they shed light on the different suicide risk profiles among a heterogenous group of patients with bipolar disorder. Name of clinical trial: Suicidal Behavior in Patients Diagnosed with Bipolar Disorder: The Roles of Biological and Childhood and Adult Environmental Risk Factors. ClinicalTrials.gov Identifier: NCT02604277.

Developmental profiles of childhood attention-deficit/hyperactivity disorder and irritability: association with adolescent mental health, functional impairment, and suicidal outcomes

BACKGROUND

Irritability is frequently comorbid with ADHD. Although irritability alone has been linked to deleterious mental health and adaptive issues, the joint developmental course of ADHD and irritability symptoms during childhood as well as its association with later mental health and suicidal outcomes is not fully understood. We aimed to describe the developmental trajectories of childhood ADHD and irritability symptoms and to quantify their association with adolescent mental health and suicidal outcomes.

METHODS

The Quebec Longitudinal Study of Child Development (QLSCD) included 1407 participants from the general population followed up from age 5 months to 17 years. We used a multitrajectory approach to identify developmental trajectories of childhood (6-12 years) ADHD and irritability symptoms. Outcome measures were adolescent (13-17 years) mental health (psychiatric symptoms/functional impairment) and suicidal outcomes.

RESULTS

We identified distinct developmental profiles: combined absent or very low ADHD and absent or very low irritability (940 [66.8%]; reference group), moderately high irritability and low ADHD (158 [11.2%]), moderately high ADHD and low irritability (198 [14.1%]), and combined high ADHD and high irritability (111 [7.9%]). Multivariate modeling showed that, compared to children in the reference group, those in the combined high ADHD and high irritability profile showed higher levels of ADHD continuity (d ranges = 0.40-0.50), externalizing (d ranges = 0.25-0.59), internalizing (d ranges = 0.20-0.29), and functional impairments (d ranges = 0.17-0.48) and suicidal behaviors (odds ratio (OR) = 2.12, confidence interval (CI) = 1.47-3.06) in adolescence.

CONCLUSIONS

The presence of persistently high levels of irritability along with ADHD symptoms during childhood significantly predicts adolescent ADHD continuity, externalizing, internalizing, and suicidal outcomes. Systematic consideration of irritability when assessing and treating ADHD may improve long-term mental health outcomes.

Association of anger attacks with suicidal ideation in adults with major depressive disorder: Findings from the EMBARC study

BACKGROUND

This report evaluates whether anger attacks (sudden uncharacteristic bouts of anger that are associated with autonomic arousal and/or aggression) in patients with major depressive disorder (MDD) are associated with elevated suicidal ideation (SI; active suicidal thoughts and plans).

METHODS

Participants of Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study who completed Massachusetts General Hospital Anger Attack Questionnaire (AAQ) at baseline were included (n = 293). Levels of SI (suicidal thoughts factor of Concise Health Risk Tracking) were compared at baseline with generalized linear models, and during Stage 1 (baseline-to-week-8) and Stage 2 (week-8-to-week-16) with repeated-measures mixed model analyses. Covariates included age, sex, race, ethnicity, site, and treatment arm.

RESULTS

At baseline, participants with (n = 109) versus without anger attacks (n = 184) had higher levels of SI (Cohen's d effect size [d] = 1.20). Those with ≥9 anger attacks in the past month had significantly higher SI than those with 1-2 (d = 1.21), 3-4 (d = 1.48), and 5-8 (d = 0.94) anger attacks in the past month. Furthermore, participants with anger attacks at baseline reported higher SI at each post-baseline visit (both Stages 1 and 2) of EMBARC study (d = 0.39-0.77; all p < .05). Associations between anger attacks and SI were significant even after controlling for irritability, hostility, anxious arousal, depression, suicide propensity, and self-reported pain at baseline and lifetime suicidal tendencies. Similar results were found in participants with aggressive behaviors.

CONCLUSION

Anger attacks in outpatients with MDD may be associated with chronically elevated SI.   Clinical Trials Registration: Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC); NCT01407094; https://clinicaltrials.gov/ct2/show/NCT01407094.

Hostility in cancer patients as an underexplored facet of distress

OBJECTIVE

In the present study, we aimed to assess hostility and to examine its association with formal psychiatric diagnosis, coping, cancer worries, and quality of life in cancer patients.

METHODS

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to make an ICD-10 (International Classification of Disease) psychiatric diagnosis was applied to 516 cancer outpatients. The patients also completed the Brief Symptom Inventory-53 to assess hostility (BSI-HOS), and the Mini-Mental Adjustment to cancer scale (Mini-MAC). A subset of patients completed the Cancer Worries Inventory (CWI), the Openness Scale, and the Quality of Life Index.

RESULTS

By analyzing the distribution of the responses 25% of the patients had moderate and 11% high levels of hostility, with about 20% being BSI-HOS "cases." Hostility was higher in patients with a formal ICD-10 psychiatric diagnosis (mainly major depression, other depressive disorders, anxiety disorders) than patients without ICD-10 diagnosis. However, about 25% of ICD-10-non cases also had moderate-to-high hostility levels. Hostility was associated with Mini-MAC hopelessness and anxious preoccupation, poorer quality of life, worries (mainly problems sin interpersonal relationships), and inability to openly discuss these problems within the family.

CONCLUSIONS

Hostility and its components should be considered as dimensions to be more carefully explored in screening for distress in cancer clinical settings for its implications in negatively impacting on quality of life, coping and relationships with the family, and possibly the health care system.

Suicide behavior is associated with childhood emotion dysregulation but not trait impulsivity in first episode psychosis

Historically, research on suicide behavior has not included those experiencing first episode psychosis (FEP), hindering prevention efforts for this population. Emotion dysregulation and impulsivity represent two mechanisms that contribute to suicide, but these have not been examined in FEP. We hypothesize that the combination of trait impulsivity and childhood emotion dysregulation are associated with suicide behavior (SB) and ideation (SI) in those experiencing FEP. Participants were recruited from an Early Psychosis Program (N=80, ages 12-32, 65% male). Clinician ratings of symptoms and history of SI and SB were obtained at baseline. Participants also completed self-report measures of childhood emotion dysregulation and trait impulsivity. Regression analyses examined whether childhood emotion dysregulation and trait impulsivity individually or in combination were associated with SI and SB, and the severity of SI and SB. Childhood emotion dysregulation was significantly associated with a history of SB and its severity, but not SI. Attention impulsivity was associated with the severity of SI. However, other impulsivity types, and interactions were not associated with a history of SI or SB. This suggests childhood emotion dysregulation is a potential target for prevention of SB in FEP, while trait impulsivity may be less important in this effort.

Association between irritability and suicidal ideation in three clinical trials of adults with major depressive disorder

Irritability in pediatric samples is associated with higher rates of subsequent suicide-related outcomes. No study, to date, has evaluated the longitudinal association between irritability and suicidal ideation (SI) in adults with major depressive disorder (MDD). This report evaluated whether irritability is associated with SI at the same visit (i.e., concurrently) and whether early changes in irritability with antidepressant treatment predict subsequent levels of SI. Participants of Combining Medications to Enhance Depression Outcomes (CO-MED, n = 665), Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC, n = 296), and Suicide Assessment Methodology Study (SAMS, n = 266) were included. Repeated-measures mixed model analyses evaluated concurrent association throughout the trial between irritability (five-item irritability domain of Concise Associated Symptom Tracking scale) and SI (three-item suicidal thoughts factor of Concise Health Risk Tracking scale) after controlling for overall depression (excluding suicidality-related item), and predicted subsequent levels of SI (repeated observations from week-2-to-week-8) based on early (baseline-to-week-2) changes in irritability after controlling for early changes in overall depression. Higher irritability was associated with higher SI concurrently; estimates (standard error) were 0.18 (0.02, p < 0.0001), 0.64 (0.02, p < 0.0001), and 0.26 (0.04, p < 0.0001) in CO-MED, EMBARC, and SAMS respectively. Greater baseline-to-week-2 reductions in irritability predicted lower levels of subsequent SI; estimates (standard errors) were -0.08 (0.03, p = 0.023), -0.50 (0.05, p < 0.0001), and -0.12 (0.05, p = 0.024) in CO-MED, EMBARC, and SAMS, respectively. Controlling for anxiety or insomnia produced similar results. In conclusion, irritability and SI were consistently linked in adults with MDD. These findings support careful assessment of irritability in suicide risk assessment.

A Latent Class Analysis of Manic and Psychotic Symptoms

Bipolar spectrum disorders encompass heterogeneous clinical manifestations and comorbidities. A latent class analysis (LCA) was performed in 1846 subjects who experienced an episode of abnormally elevated or irritable mood to identify homogeneous groups of subjects, based on the distribution of 11 manic and 7 psychotic symptoms. LCA identified five classes: 1) two classes with irritability and with low and high level of psychosis (respectively "irritable," 29.1% of the sample, and "irritable-psychotic," 16.2%); 2) a class with expansive mood and hyperactivity ("expansive-hyperactive," 12.7%); and 3) two classes with manic symptoms and high and low level of psychosis ("manic-psychotic," 15.0%, and "manic," 27.2%). "Irritable" displayed lower rates of depressive episode, panic, and substance use disorders. Manic-psychotic displayed higher rates of depressive episode, panic, generalized anxiety, and substance use disorders. Use of mental health treatment more frequent in manic-psychotic and manic classes. Five classes of bipolar spectrum disorders were characterized by different sociodemographic and clinical patterns.

Contribution of genes and environment to the longitudinal association between childhood impulsive-aggression and suicidality in adolescence

BACKGROUND

Population-based and family studies showed that impulsive-aggression predicts suicidality; however, the underlying etiological nature of this association is poorly understood. The objective was to determine the contribution of genes and environment to the association between childhood impulsive-aggression and serious suicidal ideation/attempt in young adulthood.

METHODS

N = 862 twins (435 families) from the Quebec Newborn Twin Study were followed up from birth to 20 years. Repeated measures of teacher-assessed impulsive-aggression were modeled using a genetically informed latent growth model including intercept and slope parameters reflecting individual differences in the baseline level (age 6 years) and in the change (increase/decrease) of impulsive-aggression during childhood (6 to 12 years), respectively. Lifetime suicidality (serious suicidal ideation/attempt) was self-reported at 20 years. Associations of impulsive-aggression intercept and slope with suicidality were decomposed into additive genetic (A) and unique environmental (E) components.

RESULTS

Additive genetic factors accounted for an important part of individual differences in impulsive-aggression intercept (A = 90%, E = 10%) and slope (A = 65%, E = 35%). Genetic (50%) and unique environmental (50%) factors equally contributed to suicidality. We found that 38% of the genetic factors accounting for suicidality were shared with those underlying impulsive-aggression slope, whereas 40% of the environmental factors accounting for suicidality were shared with those associated with impulsive-aggression intercept. The genetic correlation between impulsive-aggression slope and suicidality was 0.60, p = .027.

CONCLUSIONS

Genetic and unique environmental factors underlying suicidality significantly overlap with those underlying childhood impulsive-aggression. Future studies should identify putative genetic and environmental factors to inform prevention.

Measurement of Irritability in Cancer Patients

BACKGROUND

Irritability is common among people who are physically ill, but a physical underpinning of irritability is not assessed by existing measures. A measure that assesses multidimensionality of irritability can help nurses and clinicians provide better care for people with cancer and, thus, reduce a risk for developing depression during cancer treatment.

OBJECTIVES

We pilot tested a new measure, The Irritability Scale-Initial Version (TISi), for assessing irritability of cancer patients on three dimensions: physical, affective, and behavioral.

METHODS

We conducted thee pilot studies to develop the 35-item TISi on a 5-point Likert scale. TISi was tested in 48 early-stage, nonmetastasized breast cancer patients at baseline (before) and 3 months (during chemotherapy). Of these patients, 62.5% received neoadjuvant and 37.5% received adjuvant chemotherapy, but none received hormonal treatment before or during the study. Measures of other correlates, including depression, anxiety, symptom distress, and social disconnectedness, were also administered, and biomarkers of hsCRP, TNF-α, IL-6, and BDNF were obtained from blood draws at both assessments.

RESULTS

TISi has a high internal consistency (Cronbach's α = .97), satisfactory test-retest reliability (retest r = .69, intraclass correlation coefficient = .86), and moderate correlation with other constructs over time (r ≈ .40-.70). Its physical subscale significantly correlated with hsCRP (r = .32, p = .025) at baseline and TNF-α (r = .44, p = .002) at 3 months. A confirmatory factor analysis yields three factor loadings that are in line with conceptualization of the subscales.

DISCUSSION

The findings support psychometric properties of TISi and its application for assessing cancer patients' irritability in multiple dimensions. Further investigation using a large study sample is necessary for improving construct and criterion validity and reducing item redundancy.

CONCLUSION

TISi can be used to measure the level of irritability in cancer patients.

Developmental trajectories of childhood symptoms of hyperactivity/inattention and suicidal behavior during adolescence

Hyperactive/inattentive symptoms (ADHD symptoms) are associated with suicidal behavior in clinical studies, but there is still a lack of population-based longitudinal investigations on the developmental aspects of this association. Additionally, it is unclear whether the association is similar for boys and girls. The objectives of the study were to test the association between the ADHD symptoms during childhood and suicidal ideation and attempt during adolescence, and to investigate sex differences. 1407 children from the Québec Longitudinal Study of Child Development were followed up from 5 months to 17 years of age. We used teacher-reports of ADHD symptoms from 6 to 12 years, and self-report of suicidal ideation and attempt at 13, 15, and 17 years. We identified three ADHD symptoms trajectories: low (boys: 32.2%, girls: 48.7%), moderate (boys: 44.6%; girls: 42.2%) and high (boys: 23.2%; girls: 9.1%). Compared to boys on a low trajectory, boys on a moderate trajectory were at higher risk for suicidal ideation (OR 4.2, 95% CI 1.2-14.8), and boys on a high trajectory were at higher risk for suicide attempts (OR 4.5, 95% CI 1.1-17.9). Girls on moderate or high ADHD symptoms trajectories were not at higher risk for suicidal ideation or attempts than girls on low trajectories. For boys, but not for girls, moderate-to-high ADHD symptoms increased the suicidal risk in adolescence. Interventions with boys showing ADHD symptoms should include a suicide prevention component.

Candidate Biomarkers of Suicide Crisis Syndrome: What to Test Next? A Concept Paper

BACKGROUND

There has been increasing interest in both suicide-specific diagnoses within the psychiatric nomenclature and related biomarkers. Because the Suicide Crisis Syndrome-an emotional crescendo of several interrelated symptoms-seems to be promising for the identification of individuals at risk of suicide, the aim of the present paper is to review the putative biological underpinnings of the Suicide Crisis Syndrome symptoms (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal).

METHODS

A PubMed literature search was performed to identify studies reporting a link between each of the 5 Suicide Crisis Syndrome symptoms and biomarkers previously reported to be associated with suicidal outcomes.

RESULTS

Disturbances in the hypothalamic-pituitary-adrenal axis, with dysregulated corticotropin-releasing hormone and cortisol levels, may be linked to a sense of entrapment. Affective disturbance is likely mediated by alterations in dopaminergic circuits involved in reward and antireward systems as well as endogenous opioids. Loss of cognitive control is linked to altered neurocognitive function in the areas of executive function, attention, and decision-making. Hyperarousal is linked to autonomic dysregulation, which may be characterized by a reduction in both heart rate variability and electrodermal activity. Social withdrawal has been associated with oxytocin availability. There is also evidence that inflammatory processes may contribute to individual Suicide Crisis Syndrome symptoms.

CONCLUSION

The Suicide Crisis Syndrome is a complex syndrome that is likely the consequence of distinct changes in interconnected neural, neuroendocrine, and autonomic systems. Available clinical and research data allow for development of empirically testable hypotheses and experimental paradigms to scrutinize the biological substrates of the Suicide Crisis Syndrome.

Relating irritability and suicidal ideation using mood and anxiety

BACKGROUND

Suicide is common in the context of depression and bipolar disorders, but there remains a lack of understanding as to how suicide ideation, a common symptom of mood disorders, progresses to suicidal behaviour. Irritability, a feature of some types of depression, is thought to contribute to the development of suicidal behaviour, but these associations are not well established.

OBJECTIVE

To examine the relationship between irritability and suicide ideation according to the subtype of depression expressed in patients with mood disorder.

METHODS

75 patients with mood disorders seen at the CADE (Clinical Assessment Diagnostic Evaluation) Clinic underwent clinical assessment for suicidal ideation (Paykel Suicide Scale), symptom severity (Young Mania Rating Scale (YMRS), Hamilton Rating Scale for Depression (HAM-D) (anxious depression), Montgomery-Åsberg Depression Rating Scale (MADRS) (melancholic depression)) and irritability (item 5 of the YMRS).

FINDINGS

Interestingly, irritability correlated with mania (r=0.734, p<0.001 (YMRS)) and depressive symptom scores (r=0.369, p<0.001 (MADRS); r=0.477, p<0.001 (HAM-D)), which in turn correlated with suicide ideation scores (r=0.364, p<0.01 (MADRS); r=0.275, p=0.017 (HAM-D)). However, despite this indirect association, there was no direct correlation between irritability and suicide ideation (r=0.050, p>0.05).

CONCLUSIONS

The nature of the relationship between irritability and suicidal ideation is determined by the emotional context within which irritability operates.

CLINICAL IMPLICATIONS

Findings suggest that rather than examining irritability alone, consideration of the subtype of depression, especially that of anxious depression, should be paramount in assessing suicide risk.