Predictors of suicidal thoughts: Mood instability versus neuroticism

Predictive modeling of neuroticism in depressed and non-depressed cohorts using voice features

BACKGROUND

Neuroticism's impact on psychopathological and physical health issues has significant public health implications. Multiple studies confirm its predictive effect on suicide risk among depressed patients. However, previous research lacks a standardized criterion for assessing neuroticism through speech, often relying on simple features (such as pitch, loudness and MFCCs). This study aims to improve upon this by extracting features using advanced pre-trained speaker embedding models (i-vector and x-vector extractors). Additionally, unlike prior studies utilizing general population data, we explore neuroticism prediction in depressed and non-depressed subgroups.

METHODS

We collected edited discourse data from clinical interviews of 3580 depressed individuals and 4016 healthy individuals from the CONVERGE study. Instead of solely extracting Low-Level Acoustic Descriptors, we incorporated i-vector and x-vector features. We compared the performance of three different features in predicting neuroticism and explored their combination to enhance model accuracy.

RESULTS

The SVR model, combining three speech features with downscaled features to 300, exhibited the highest performance in predicting neuroticism scores. It achieved a coefficient of determination (R-squared) of 0.3 or higher and a correlation of 0.56 between predicted and actual values. The predictive classification accuracy of speech features for neuroticism in specific populations (healthy and depressed) exceeded 60 %.

LIMITATIONS

This study included only women.

CONCLUSION

Combining diverse speech features enhances the predictive capacity of models using speech features to assess neuroticism, particularly in specific populations. This study lays the foundation for future exploration of speech features in neuroticism prediction.

Influence of affective instability on suicidal ideation beyond traumatic brain injury and posttraumatic stress disorder in veterans

OBJECTIVE

Mild traumatic brain injury (TBI) is associated with long-term consequences, including greater risk for posttraumatic stress disorder (PTSD) and suicidal ideation. Affective instability is also independently related to PTSD and suicidality, which may explain why some individuals continue to experience chronic psychiatric complaints following mild TBI. The purpose of the present study was to evaluate affective instability as a key factor for PTSD and suicidal ideation among Veterans with and without TBI.

METHOD

Participants (N = 299 Veterans; 86.96% male) completed the Personality Assessment Inventory (PAI) and structured clinical interviews for TBI and psychiatric diagnoses. Hierarchical linear regression was used to evaluate main and interaction effects.

RESULTS

There were no significant differences in affective instability (p = 0.140) or suicidal ideation (p = 0.453) between Veterans with or without TBI. Individuals with TBI were more likely to have a PTSD diagnosis (p = 0.001). Analyses evaluating PTSD diagnosis as an outcome indicated a main effect of affective instability (p < 0.001), but not TBI (p = 0.619). Analyses evaluating suicidal ideation as an outcome demonstrated an interaction effect between PTSD and affective instability beyond the effects of TBI (p = 0.034).

CONCLUSIONS

Severe Affective instability appears to be a key factor in suicidal ideation among Veterans beyond TBI or PTSD history. PTSD was more strongly associated with suicidality at lower and moderate levels of affective instability. At severe levels of affective instability, however, Veterans with and without PTSD experienced suicidal ideation at similar rates. Findings suggests that high levels of affective instability not better explained by other psychiatric conditions confers similar suicidality risk to that of PTSD in a Veteran population.

A study on the effect of music listening on people with high neurotic tendency as evidenced by negative affective scores and physiological responses

BACKGROUND

Music listening has been found to be effective in reducing stress levels with different participant samples. Relatively little evidence has been obtained from people with high neurotic tendency (HNT), whose dispositional psychological characteristics might dampen the effect of music listening. This study therefore tried to examine the immediate effect of music listening in reducing stressful feelings of participants with either high or low neurotic tendency.

PARTICIPANTS AND PROCEDURE

Seventy-nine undergraduate participants who were identified as having either HNT or low neurotic tendency (LNT) accomplished a stressful task before listening to a comforting music piece. Negative affect (NA) scores and heart rate were measured at different phases.

RESULTS

Results in a within-subjects analysis showed that the stressor and music listening could significantly alter the stressful feeling of both participant groups. Although the percentage changes in heart rate were similar between the groups, the changes of NA score which were measured after either the stressful task or the music listening session were consistently lower in the HNT group than the LNT group.

CONCLUSIONS

The divergence revealed a loose connection between the subjective feelings and the bodily changes in the HNT group, which could be important for clinicians and practitioners to take into consideration in psychology when evaluating the stressful feelings for their clients with HNT.

The role of clinical and Personological features in predicting high lethality suicide attempts: A study among mood disorder patients

Suicidal attempts (SA) represent heterogeneous behaviours ranging in their seriousness from fatal and near-fatal (high-lethality) cases to those that do not require medical attention (low lethality). These considerations stress the need to identify high-risk individuals for high lethality SA in order to target suicide preventive interventions. The present study aims at evaluating the role of sociodemographic and clinical variables and examining personality pathological features in predicting high lethality SA. The sample was composed by 94 patients who were consecutively admitted to the Mood Disorders Unit of the San Raffaele Turro Hospital in Milan. The results of binary logistic regression analyses showed that previous SA and current suicide ideation play a role in predicting serious SA. Considering the DSM-5 personality dysfunctional domains assessed by the Personality Inventory for DSM-5, our logistic regression analyses suggested that high lethality SA was associated with Detachment PID-5 domain. Finally, binary hierarchical regression analysis showed that Detachment domain remained a significant predictor of serious SA over and above the effect of previous SA and suicide ideation. As a whole, our results highlight the importance of a multidimensional approach to develop adequate assessment, effective treatments and prevention of high lethality SA risk.

Mood instability, depression, and anxiety in pregnancy and adverse neonatal outcomes

Background

Antenatal women experience an increased level of mood and anxiety symptoms, which have negative effects on mothers’ mental and physical health as well as the health of their newborns. The relation of maternal depression and anxiety in pregnancy with neonate outcomes is well-studied with inconsistent findings. However, the association between antenatal mood instability (MI) and neonatal outcomes has not been investigated even though antenatal women experience an elevated level of MI. We sought to address this gap and to contribute to the literature about pregnancy neonate outcomes by examining the relationship among antenatal MI, depression, and anxiety and neonatal outcomes.

Methods

A prospective cohort of women (n = 555) participated in this study at early pregnancy (T1, 17.4 ± 4.9 weeks) and late pregnancy (T2, 30.6 ± 2.7 weeks). The Edinburgh Postnatal Depression Scale (EPDS) was used to assess antenatal depressive symptoms, anxiety was measured by the EPDS anxiety subscale, and mood instability was measured by a visual analogue scale with five questions. These mood states together with stress, social support, as well as lifestyle were also examined in relation to neonatal outcomes using chi-square tests and logistic regression models.

Results

Mood instability, depression, and anxiety were unrelated to adverse neonatal outcomes. Only primiparous status was associated with small for gestational age after Bonferroni correction.

Conclusions

We report no associations between antenatal mood symptoms including MI, depression, and anxiety and neonatal outcomes. More studies are required to further explore the relationship between antenatal mood instability, depression, and anxiety and neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04021-y.

Perinatal depression: Data-driven subtypes derived from life history and mindfulness and personality

BACKGROUND

Perinatal depression is the most prevalent mental disorder during the perinatal period, and research suggests that it presents heterogeneously. We aimed to explore how subtypes of perinatal depression present in terms of multivariate patterns of stable characteristics.

METHODS

A cohort study was conducted from March 2016 to March 2018 with Chinese women in the prenatal period (n = 3186). Of the participants, 682 (21.41%) women with Edinburgh Postnatal Depression Scale scores ≥10, indicating probable depression, were included, with the remaining 2504 (78.59%) representing the control group. We assessed mood distress, cognition, life history, emotional regulation, and personality, and used latent class analysis and latent transition analysis to identify perinatal depression subtypes. Of the 682 women with probable depression, only 598 were included in the full analyses, as they completed at least 10 questionnaires. A second, non-overlapping sample and a follow-up cohort were used.

RESULTS

We identified four subtypes: 1) a highly distressed type characterized by distress across all domains, high levels of rumination and neuroticism, and reduced trait mindfulness; 2) two moderately distressed types: one with high trauma and low perceived social support, and another with low trauma, high perceived social support, and expressive suppression; and 3) a slightly distressed subtype.

LIMITATIONS

We only collected cost and time spent in hospital from medical records. We only had a small follow-up sample.

CONCLUSIONS

This multidimensional subtyping of women with perinatal depression could help reduce the apparent heterogeneity of perinatal depression. Distinguishing the subtype characteristics facilitates identifying underlying causes of perinatal depression.

Suicidal ideation and affect lability in single and multiple suicidal attempters with Major Depressive Disorder: An exploratory network analysis

INTRODUCTION

A better understanding of the specific contribution of risk factors to suicidal behavior could arise from analyzing suicidal ideation (SI) in clinical samples, and comparing single versus multiple suicide attempters through contemporary methods allowing complex and dynamical analyses of multiple and simultaneously interacting suicide risk factors.

METHOD

We explored associations among suicidal ideation (SI), affect lability and other suicide risk factors in 323 suicidal attempters diagnosed with major depressive disorder (MDD). We analyzed the network structure and centrality of the total sample, and compared single versus multiple attempters and subjects with low and high suicidal ideation.

RESULTS

SI was connected with anxiety (trait) and hopelessness. Central nodes for global and specific groups were affect lability (from anxiety to depression), anxiety as a trait, and harm avoidance. We observed some specific differences between clinical profiles of repeaters and non-repeaters and significant network density between high and low SI.

LIMITATIONS

Because our cross-sectional design, we cannot establish casual relationships among variables. We only examined associations at group level but not at single subject level.

CONCLUSIONS

Affect lability (mainly the shifts from anxiety to depression) and trait anxiety were central in each estimated network. These symptoms might be suitable targets for early detecting and treating suicidal patients.

Mood instability during pregnancy and postpartum: a systematic review

Perinatal mood instability (MI) is a common clinical observation in perinatal women, and existing research indicates that MI is strongly associated with a variety of mental disorders. The purpose of this study is to review the evidence of perinatal MI systematically, with a focus on perinatal MI, its relation to perinatal depression, and its effects on children. A systematic search of the literature using PRISMA guidelines was conducted on seven academic health databases to identify any peer-reviewed articles published in English from 1985 to July 2017. Studies were screened, data were extracted, and quality of the selected studies was assessed. A total of 1927 abstracts were returned from the search, with 1063 remaining for abstract screening after duplicate removal, and 4 quantitative studies were selected for final analysis. The selected studies addressed perinatal MI (n = 2), the relation of perinatal MI to perinatal depression (n = 1), and the effects of perinatal MI on children (n = 1). The selected studies identified that perinatal women experienced a significantly higher level of MI than non-perinatal women, MI is a prominent feature in perinatal women with and without depression, mood lability during the early postpartum predicts psychopathology up to 14 months postpartum, and maternal emotion dysregulation, rather than maternal psychopathology, increases the risk of heightened facial affect synchrony in mother-infant interaction. The study reveals a significant gap in the literature of perinatal MI.

Neuroticism and suicide in a general population cohort: results from the UK Biobank Project

BACKGROUND

Neuroticism has often been linked to suicidal thoughts and behaviour.

AIMS

To examine whether neuroticism is associated with suicide deaths after adjusting for known risks.

METHOD

UK Biobank participants (n = 389 365) were assessed for neuroticism as well as social, demographic and health-related variables at study entry and followed for up to 10 years. Suicide risk was modelled using Cox regression stratified by gender.

RESULTS

Neuroticism increased the risk of suicide in both men (hazard ratio (HR) = 1.15, 95% CI 1.09-1.22) and women (HR = 1.16, 95% CI 1.06-1.27). In a subsample who were assessed for mood disorders, neuroticism remained a significant predictor for women (HR 1.25, 95% CI 1.03-1.51) but not for men.

CONCLUSIONS

Screening and therapeutic interventions for neuroticism may be important for early suicide prevention.

DECLARATION OF INTEREST

None.

Suicidality in People With Obsessive-Compulsive Symptoms or Personality Traits

Objective: Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Personality Disorder (OCPD) have been reported to be associated with mood instability (MI), depression and suicide-related outcomes. We examined whether obsessive-compulsive symptoms and personality traits as well as obsessional thoughts of death, are associated with suicidal thoughts, non-suicidal self-injury and attempted suicide. Methods: We used data from 7,839 people from the 2000 British Adult Psychiatric Morbidity Survey that elicited symptoms of OCD with a computerized version of the Clinical Interview Schedule-Revised (CIS-R) and traits of OCPD with a self-completed version of the SCID-II. We created a series of logistic regression models, first entering only OCD symptoms and OCPD traits in separate models, to which depression and mood instability (MI) were added. We also examined the relation of obsessional thoughts about death with self-harm in a network analysis model that included the main symptoms of mood instability and depression. Results: OCD symptoms were associated with suicidal thoughts (OR: 1.23, 95% CI: 1.14-1.32), and suicide attempts (OR: 1.13, 95% CI: 1.04-1.24) in the fully-adjusted model. OCPD traits were associated with suicidal thoughts (OR: 1.14, 95% CI: 1.10-1.19), non-suicidal self-injury (OR: 1.14 95% CI: 1.03-1.26), and suicide attempts (OR: 1.09; 1.01-1.17). Depression and MI were both associated with all three suicide-related outcomes. In the network analysis, MI was the most prominent correlate of suicide-related outcomes, being associated with suicidal ideas (partial r = 0.15) and non-suicidal self-injury (partial r = 0.07). Limitation: This was a cross-sectional study that used a single-item measure for mood instability. Conclusions: Obsessive-compulsive symptoms and personality traits are related to suicide-related outcomes independently of depressive symptoms and mood instability. This relationship is not accounted for by obsessional thoughts of death alone.

Personality traits and suicide attempts with and without psychiatric disorders: analysis of impulsivity and neuroticism

BACKGROUND

There is a critical need for empirical data concerning the association of personality traits and attempted suicide with and without psychiatric disorders in mainland China. The objective of the present study is to provide such data by determining the prevalence of psychiatric disorders and analyzing the levels of impulsivity and neuroticism among people who have attempted suicide, and to examine the association between these personality traits and suicide attempt in people with or without psychiatric disorders.

METHODS

We administered self-reported tests and clinical interviews to 196 people who have attempted suicide who were admitted to a hospital emergency room or our psychiatric settings after a suicide attempt.

RESULTS

One hundred and fifty-six subjects (79.6%) met the criteria for Axis I disorders and eleven (6.6%) met the criteria Axis II personality disorders. Those who have attempted suicide who did not have psychiatric disorders exhibited a greater degree of background characteristics (e.g., high lethality, more interpersonal conflicts and more alcohol use), lower levels of suicidality (suicide risk, depressive symptoms) and differences of personality traits (e.g., more impulsive and less neuroticism) as compared to those who do have psychiatric disorders. Profile differences existed even after control for the stressful life event.

CONCLUSION

Our findings suggest that some personality traits differ between people who have attempted suicide depending on whether or not they have psychiatric disorders. Based on these findings, investigating the impact of personality traits on suicidal behavior in therapeutic settings would provide critical data to improve patient treatment and outcomes.

Moods in Clinical Depression Are More Unstable than Severe Normal Sadness

OBJECTIVE

Current descriptions in psychiatry and psychology suggest that depressed mood in clinical depression is similar to mild sadness experienced in everyday life, but more intense and persistent. We evaluated this concept using measures of average mood and mood instability (MI).

METHOD

We prospectively measured low and high moods using separate visual analog scales twice a day for seven consecutive days in 137 participants from four published studies. Participants were divided into a non-depressed group with a Beck Depression Inventory score of ≤10 (n = 59) and a depressed group with a Beck Depression Inventory score of ≥18 (n = 78). MI was determined by the mean square successive difference statistic.

RESULTS

Mean low and high moods were not correlated in the non-depressed group but were strongly positively correlated in the depressed group. This difference between correlations was significant. Low MI and high MI were weakly positively correlated in the non-depressed group and strongly positively correlated in the depressed group. This difference in correlations was also significant.

CONCLUSION

The results show that low and high moods, and low and high MI, are highly correlated in people with depression compared with those who are not depressed. Current psychiatric practice does not assess or treat MI or brief high mood episodes in patients with depression. New models of mood that also focus on MI will need to be developed to address the pattern of mood disturbance in people with depression.

Mood Instability Is a Precursor of Relationship and Marital Difficulties: Results from Prospective Data from the British Health and Lifestyle Surveys

The DSM system implies that affective instability is caused by reactivity to interpersonal events. We used the British Health and Lifestyle Survey that surveyed community residents in 1984 and again in 1991 to study competing hypotheses: that mood instability (MI) leads to interpersonal difficulties or vice versa. We analyzed data from 5,352 persons who participated in both waves of the survey. Factor analysis of the Eysenck Personality Inventory neuroticism scale was used to derive a 4-item scale for MI. We used depression measures that were previously derived by factor analyzing the General Health Questionnaire. We tested the competing hypotheses by regressing variables at follow-up against baseline variables. The results showed that MI in 1984 clearly predicted the development of interpersonal problems in 1991. After adjusting for depression, depression becomes the main predictor of spousal difficulties, but MI remains a predictor of interpersonal difficulties with family and friends. Attempts to investigate the reverse hypothesis were ambiguous. The clinical implication is that when MI and interpersonal problems are reported, the MI should be treated first, or at least concurrently.

Mood instability and impulsivity as trait predictors of suicidal thoughts

OBJECTIVES

Impulsivity, the tendency to act quickly without adequate planning or concern for consequences, is a commonly cited risk factor for suicidal thoughts and behaviour. There are many definitions of impulsivity and how it relates to suicidality is not well understood. Mood instability, which describes frequent fluctuations of mood over time, is a concept related to impulsivity that may help explain this relationship. The purpose of this study was to determine whether impulsivity could predict suicidal thoughts after controlling for mood instability.

METHODS

This study utilized longitudinal data from the 2000 Adult Psychiatric Morbidity Survey (N = 2,406). There was a time interval of 18 months between the two waves of the study. Trait impulsivity and mood instability were measured with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Logistic regression analyses were used to evaluate baseline impulsivity and mood instability as predictors of future suicidal thoughts.

RESULTS

Impulsivity significantly predicted the presence of suicidal thoughts, but this effect became non-significant with mood instability included in the same model.

CONCLUSIONS

Impulsivity may be a redundant concept when predicting future suicidal thoughts if mood instability is considered. The significance is that research and therapy focusing on mood instability along with impulsivity may be useful in treating the suicidal patient.

PRACTITIONER POINTS

Mood instability and impulsivity both predict future suicidal thoughts. Impulsivity does not predict suicidal thoughts after controlling for mood instability. Assessing and treating mood instability could be important aspects of suicide prevention and risk management.

The dimensional structure of cycling mood disorders

This study examines whether mood disorders differ fundamentally in terms of phase duration. Most clinically significant mood disorders are recurrent and cyclical. The phase duration of these cycles is part of the diagnostic criteria. Specifically, we determined whether a dimensional or taxonic latent structure better captures cycling mood disorders. 319 patients recruited from 5 psychiatrists and a psychoeducational program completed three questionnaires assessing aspects of mood cycling. These were the Affective Lability Scale-Short Form (ALS-SF), Mood Disorders Questionnaire (MDQ), and the Eysenck Neuroticism scale. Patient scores on these instruments were submitted to three taxometric procedures (MAMBAC, MAXEIG, and L-Mode). Comparison curve fit indices (CCFIs) were calculated to distinguish taxonic versus dimensional latent structure. In addition, graphs were produced for each procedure and compared with those of categorical or dimensional prototypes. The CCFIs of the three procedures ranged from 0.25 to 0.27, consistent with dimensional structure. The graphs closely resembled dimensional prototypes. Mood instability and other types of cycling moods probably conform to a dimensional latent structure. Patients with disorders featuring mood cycling might benefit from common treatments.

How is affective instability defined and measured? A systematic review

BACKGROUND

Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations.

METHOD

This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed.

RESULTS

A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation.

CONCLUSIONS

A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.

Maintaining sleep and physical activity alleviate mood instability

OBJECTIVE

Building on previous work indicating that mood instability is the hallmark of neuroticism, our aim was to examine whether changes in exercise, sleep duration and leisure predicted decreases in mood instability with time.

METHODS

We used data from 3374 participants of the British Health and Lifestyle Study who answered the Eysenck Personality Inventory-Neuroticism subscale (EPI-N) and the General Health Questionnaire on two occasions 7 years apart. We predicted mood instability scores derived from the EPI-N at follow-up using self-reported changes in exercise, sleep duration and leisure hours between the two time points as independent variables.

RESULTS

We confirmed the observation that mood instability decreases with age. Maintaining one's exercise at baseline level decreased mood instability (beta=-0.21) while sleeping less increased mood instability (beta=0.14). Change in leisure time was not independently related to mood instability after accounting for the two other lifestyle factors.

CONCLUSION

Personality, at least with regard to mood instability, can be modified by lifestyle factors. Exercise and sleep support mood stability and could be important components of preventative mental health (as well as physical health) benefits.

The relationship between mood instability and depression: implications for studying and treating depression

BACKGROUND

Most individuals with depressed mood report mood fluctuations (Mood Instability) within hours or days. This is not recognized in diagnostic criteria or standard rating scales for depression.

HYPOTHESIS

That mood instability is a distinct component of the development of depression that has been omitted from criteria for depression because of reliance on retrospective recall and structured interviews. The inclusion of Mood Instability would enhance research into causes and treatment of depression.

STUDIES

We examined three datasets that used retrospective and prospective measures of depressed symptom ratings and mood instability to determine the relationship between the two. Study 1 used data from the 1991 UK Health and Lifestyle Surveys (HALS). Studies 2 and 3 used clinical samples. The scales used to assess mood instability were the mood instability factor from the Eysenck Personality Inventory Neuroticism Scale, the Affective Lability Scale (ALS), and the Visual Analogue Depression Scale (VAS). The depression scales (depressive symptoms) were the General Health Questionnaire (GHQ) depression factor, the Beck Depression Inventory IA (BDI) and the mean from the Visual Analogue Depression Scale (VAS). We used partial correlation analysis to assess the association between mood instability and depression and exploratory factor analysis to determine the factor structure of items pooled from the mood instability and depression scales from studies 1 and 2.

RESULTS

Mood Instability was found to be moderately associated with depressive symptoms. The Pearson's r-values ranged from 0.49 to 0.57. The correlation was lower when recalling mood in the past. The factor analytic solution supported the hypothesis that MI and depressive symptoms are related but distinct constructs.

CONCLUSIONS

Reliance exclusively on the retrospective assessment of depressive symptoms has occluded the widespread occurrence of mood instability. Including Mood Instability in diagnostic and assessment criteria would enhance causal and treatment research in depression.

Does unstable mood increase risk of suicide? Theory, research and practice

BACKGROUND

Suicide represents a substantial problem, with significant societal and personal impact. The identification of factors influencing suicide risk is an important step in preventing self-harming behaviour. In this article the authors explore whether emotional instability increases risk of suicide, beyond that of mood intensity.

METHOD

This article provides a summary of existing theory and indirect evidence in support of an association between emotional instability and suicidality. A systematic literature search (Embase, Medline, PsychInfo) was carried out on literature conducted up to October, 2011. Meta-analysis was used to assess the strength of the proposed association.

RESULTS

The systematic search identified 20 journal articles meeting the inclusion criteria, including retrospective questionnaire design studies and research conducted across several time-points. Meta-analysis revealed a moderate association, which remained statistically significant even when only including studies conducted over multiple time-points. This effect was attenuated, but remained significant, when controlling for study selection bias.

LIMITATIONS

Retrospective questionnaire studies failed to adequately control for mood level. Little is still currently understood about the types of emotional instability (e.g., dysoria, anxiety) most associated with suicidality.

CONCLUSIONS

Future avenues of investigation include micro- to macro-longitudinal research and the differentiation of emotion subtypes and instability metrics. Momentary assessment techniques may help to detect subtle fluctuations in mood leading to more effective and immediate intervention. Psychosocial intervention strategies for treating unstable emotions are discussed.