Fenfluramine challenge in unipolar depression with and without anger attacks

Baixiangdan capsule and Shuyu capsule regulate anger-out and anger-in, respectively: GB1–mediated GABA can regulate 5-HT levels in multiple brain regions

The identity of the mechanism by which the Baixiangdan capsule (BXD) and the Shuyu capsule (SY) control anger-out (AO) and anger-in (AI) in rodents is unclear. The current study clarified the intervention role of BXD and SY on AO and AI male rats. We further explored the differences between BXD and SY in the treatment of AO and AI rats. Social isolation combined with the resident-intruder paradigm was used to establish the anger-out and AI rats models. On this basis, GABA content in the dorsal raphe nucleus (DRN) and serotonin (5-HT) contents in these brain regions were detected using ELISA after various time courses (0, 1, 3, 5, and 7 days) treated with BXD and SY. Co-expression of 5-HT and GB1 in the DRN was detected. GB1-specific agonist baclofen and GB1-specific inhibitor CGP35348 were injected into the DRN. Changes in 5-HT levels in these brain regions were then detected. After treatment, rats in the BXD group exhibited lower aggressive behavior scores, longer latencies of aggression, lower total distances in the open field test, and a higher sucrose preference coefficient. Meanwhile, rats in the SY group exhibited higher aggressive behavior scores, shorter latencies of aggression, higher total distances in the open field test, and higher sucrose preference coefficients. With increasing medication duration, 5-HT levels in these brain regions were increased gradually, whereas GABA levels in the DRN were decreased gradually, and all recovered to normal levels by the 7th day. A large number of 5-HT-positive cells could be found in the immunofluorescence section in the DRN containing GABABR1 (GB1)-positive cells, indicating that 5-HT neurons in the DRN co-expressed with GB1. Furthermore, after the drug intervention, the 5-HT level in the DRN was elevated to a normal level, and the GB1 level in the DRN was decreased to a normal level. After the microinjection of baclofen into the DRN, the 5-HT contents in these brain regions were decreased. By contrast, the 5-HT contents were increased after injection with CGP35348. BXD and SY could effectively improve the abnormal behavior changes of AO and AI rats, and the optimal duration of action was 7 days. The improvement way is as follows: Decreased abnormal increase of GABA and GB1 in the DRN further mediated synaptic inhibition and increased 5-HT level in the DRN, leading to increased 5-HT levels in the PFC, hypothalamus, and hippocampus. Therefore, GB1-mediated GABA in the DRN could regulate 5-HT levels in these brain regions, which may be one of the ways by which BXD and SY treat AO and AI, respectively.

GABABR1 in DRN mediated GABA to regulate 5-HT expression in multiple brain regions in male rats with high and low aggressive behavior

The identity of the mechanism that controls aggressive behavior in rodents is unclear. Serotonin (5-HT) and GABA are associated with aggressive behavior in rodents. However, the regulatory relationship between these chemicals in the different brain regions of rats has not been fully defined. This study aimed to clarify the role of GABABR1 in DRN-mediated GABA to regulate 5-HT expression in multiple brain regions in male rats with high and low aggressive behavior. Rat models of highly and less aggressive behavior were established through social isolation plus resident intruder. On this basis, GABA content in the DRN and 5-HT contents in the PFC, hypothalamus, hippocampus and DRN were detected using ELISA. Co-expression of 5-HT and GB1 in the DRN was detected by immunofluorescence and immunoelectron microscopy at the tissue and subcellular levels, respectively. GB1-specific agonist baclofen and GB1-specific inhibitor CGP35348 were injected into the DRN by stereotaxic injection. Changes in 5-HT levels in the PFC, hypothalamus and hippocampus were detected afterward. After modeling, rats with highly aggressive behavior exhibited higher aggressive behavior scores, shorter latencies of aggression, and higher total distances in the open field test than rats with less aggressive behavior. The contents of 5-HT in the PFC, hypothalamus and hippocampus of rats with high and low aggressive behavior (no difference between the two groups) were significantly decreased, but the change in GABA content in the DRN was the opposite. GB1 granules could be found on synaptic membranes containing 5-HT granules, which indicated that 5-HT neurons in the DRN co-expressed with GB1, which also occurred in double immunofluorescence results. At the same time, we found that the expression of GB1 in the DRN of rats with high and low aggressive behavior was significantly increased, and the expression of GB1 in the DRN of rats with low aggressive behavior was significantly higher than that in rats with high aggressive behavior. Nevertheless, the expression of 5-HT in DRN was opposite in these two groups. After microinjection of baclofen into the DRN, the 5-HT contents in the PFC, hypothalamus and hippocampus of rats in each group decreased significantly. In contrast, the 5-HT contents in the PFC, hypothalamus and hippocampus of rats in each group increased significantly after injection with CGP35348. The significant increase in GABA in the DRN combined with the significant increase in GB1 in the DRN further mediated the synaptic inhibition effect, which reduced the 5-HT level of 5-HT neurons in the DRN, resulting in a significant decrease in 5-HT levels in the PFC, hypothalamus and hippocampus. Therefore, GB1-mediated GABA regulation of 5-HT levels in the PFC, hypothalamus and hippocampus is one of the mechanisms of highly and less aggressive behavior originating in the DRN. The increased GB1 level in the DRN of LA-behavior rats exhibited a greater degree of change than in the HA-group rats, which indicated that differently decreased 5-HT levels in the DRN may be the internal mechanisms of high and low aggression behaviors.

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.

Sertraline hydrochloride for reducing impulsive behaviour in male, repeat-violent offenders (ReINVEST): protocol for a phase IV, double-blind, placebo-controlled, randomised clinical trial

INTRODUCTION

Considerable evidence supports an association between poor impulse control (impulsivity) and violent crime. Furthermore, impulsivity and aggression has been associated with reduced levels of serotonergic activity in the brain. Selective serotonin reuptake inhibitors (SSRIs) are a class of anti-depressants that aim to regulate brain serotonin concentrations. Several small studies in psychiatric populations have administered SSRIs to impulsive--aggressive individuals, resulting in reduced impulsivity, anger, aggression and depression. However, no clinical trial has been undertaken in a criminal justice population. This protocol describes the design and implementation of the first systematic study of the potential benefits of SSRIs in impulsive---violent offenders who are at high risk of reoffending.

METHODS AND ANALYSIS

A randomised, double-blinded, multicentre trial to test the clinical efficacy of an SSRI, sertraline hydrochloride, compared with placebo on recidivism and behavioural measures (including impulsivity, anger, aggression, depression and self-reported offending) over 12 months. 460 participants with histories of violence and screening positive for impulsivity are recruited at several local courts and correctional service offices in New South Wales, Australia.

ETHICS AND DISSEMINATION

Results will be submitted for publication in a peer-reviewed journal. Possible implications of the effectiveness of this pharmacological intervention include economic benefits of reducing prison costs and societal benefits of improving safety. This study has received ethical approval from the University of New South Wales, Aboriginal Health & Medical Research Council, Corrective Services NSW and the NSW Justice Health and Forensic Mental Health Network.

TRIAL REGISTRATION NUMBER

ACTRN12613000442707.

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.

Aggressive outbursts among adults with major depressive disorder: Results from the Collaborative Psychiatric Epidemiological Surveys

INTRODUCTION

Little is known about the epidemiology of aggressive outbursts, including physical assault, property destruction, and verbal aggression, among adults with unipolar Major Depressive Disorder (MDD).

METHODS

We examined the prevalence and correlates of aggressive outbursts among adults with primary MDD (N = 2539) from the Collaborative Psychiatric Epidemiological Surveys (N = 20,013) using generalized linear models.

RESULTS

The prevalence estimate of any aggressive outbursts was 58.7% among adults with MDD. MDD was associated with aggressive outbursts independent of other psychiatric diagnoses. The prevalence of aggressive outbursts differed significantly by age, race/ethnicity, sex, education, marital status, and employment status, and psychiatric diagnoses. Aggressive outbursts were associated with greater severity and earlier age of onset for MDD. Positive associations were also found between the frequency of aggressive outbursts and depressive symptoms including weight/appetite change, fatigue, recurrent thoughts of death. Moreover, aggressive outbursts significantly multiplied the odds of experiencing more severe functional impairment, suicidal ideation, suicide plan, and suicide attempt.

CONCLUSION

Aggressive outbursts are much more common than previously recognized among adults with MDD. The significant association of aggressive outbursts with MDD characteristics, increased functional impairment, and suicidal thoughts and behaviors make them an important target for assessment and treatment for adults with MDD.

Kellner's Symptom Questionnaire, a Highly Sensitive Patient-Reported Outcome Measure: Systematic Review of Clinimetric Properties

INTRODUCTION

Patient-reported outcomes (PROs) are of increasing importance in clinical medicine. However, their evaluation by classic psychometric methods carries considerable limitations. The clinimetric approach provides a viable framework for their assessment.

OBJECTIVE

The aim of this paper was to provide a systematic review of clinimetric properties of the Symptom Questionnaire (SQ), a simple, self-rated instrument for the assessment of psychological symptoms (depression, anxiety, hostility, and somatization) and well-being (contentment, relaxation, friendliness, and physical well-being).

METHODS

The PRISMA guidelines were used. Electronic databases were searched from inception up to March 2019. Only original research articles, published in English, reporting data about the clinimetric properties of the SQ, were included.

RESULTS

A total of 284 studies was selected. The SQ has been used in populations of adults, adolescents, and older individuals. The scale significantly discriminated between subgroups of subjects in both clinical and nonclinical settings, and differentiated medical and psychiatric patients from healthy controls. In longitudinal studies and in controlled pharmacological and psychotherapy trials, it was highly sensitive to symptoms and well-being changes and discriminated between the effects of psychotropic drugs and placebo.

CONCLUSIONS

The SQ is a highly sensitive clinimetric index. It may yield clinical information that similar scales would fail to provide and has a unique position among the PROs that are available. Its use in clinical trials is strongly recommended.

Military hazing and suicidal ideation among active duty military personnel: Serial mediation effects of anger and depressive symptoms

BACKGROUND

Military hazing is one of most serious problems affecting suicidal ideation (SI) among active duty personnel, but has received limited research attention. Studies on hazing and SI indicate anger and depressive symptoms as mediators for SI.

METHODS

A sample of active duty military personnel (N = 944) completed an offline survey, consisting of the revised Conflict Tactics Scale-2, Composite International Diagnostic Interview Screening Scale, and revised Columbia Suicide Severity Rating Scale. Frequency, bivariate correlation, and serial mediation analyses were conducted to assess the serial effects of military hazing on SI, mediated via anger and depressive symptoms.

RESULTS

Military hazing, anger, depressive symptoms, and SI were positively related to each other in bivariate analyses. In serial mediation analyses, hazing was found to be a significant predictor of higher levels of anger, consequently triggering depressive symptoms, which, in turn, were associated with greater SI.

LIMITATIONS

Study limitations included the use of cross-sectional data with the use of retrospective self-report.

CONCLUSION

Hazing in the military is prevalent (17.6%), and SI is associated with serial effects of hazing, anger, and depressive symptoms with full mediation path. Findings suggest that policies that address reducing hazing and implementing clinical interventions specifically focused on symptoms of anger and depression may be important for decreasing SI in military personnel.

Searching for neural and behavioral parameters that predict anti-aggressive effects of chronic SSRI treatment in rats

RATIONALE

Only a subset of impulsive aggressive patients benefits from selective serotonin reuptake inhibitor (SSRI) treatment, confirming contradictory results about the association between serotonin (5-hydroxytryptamine, 5-HT) and aggression. This shows the need to define behavioral characteristics within this subgroup to move towards individualized pharmacological treatment of impulsive aggression.

METHODS

Here we submitted an outbred strain of Long Evans rats to a crossover design treatment regimen with the SSRI citalopram, to test its anti-aggressive effect. Behavioral characteristics were baseline aggression, anxiety parameters as measured in the elevated plus maze and open field and cue responsivity as indicated by sign vs. goal tracking behavior. 5-HT_1A receptor densities as measured by ex vivo [¹⁸F]MPPF binding were determined in the dorsal raphe nucleus, dentate gyrus, orbitofrontal cortex, infralimbic cortex and prelimbic cortex, because of the receptors' involvement in the therapeutic delay of SSRIs and aggression.

RESULTS

We found statistically significant increased variance in aggressive behavior after citalopram treatment. However, none of the selected parameters predicted the citalopram treatment effect.

CONCLUSION

Since aggression after citalopram treatment decreased in a subgroup of animals and increased in the other, future research should focus on other possible predictors to support treatment strategies in aggressive patients.

A placebo-controlled crossover study of iloperidone augmentation for residual anger and irritability in major depressive disorder

BACKGROUND

Even when patients experience remission with antidepressants, many continue to report anger attacks and excessive irritability despite continued treatment. Iloperidone antagonizes 5-HT-2a, D2, and alpha-1 receptors, which can have anti-aggressive effects. We examined iloperidone's safety and efficacy as an augmentation agent in outpatients with partially remitted major depressive disorder (MDD) with residual symptoms of anger and irritability.

METHODS

A total of 13 outpatients with partially remitted MDD [currently treated with selective serotonin reuptake inhibitors (SSRIs)] received four weeks of iloperidone or placebo, followed by one week of washout. Patients were then crossed over to the other treatment arm for 4 weeks. Treatment arms were randomized and double blind; and two sites were used for the study. Analyses compared treatment response using the Symptom Questionnaire (SQ) Anger/Hostility Subscale as the primary outcome measure.

RESULTS

There was no significant differential effect of iloperidone × weeks on the SQ Anger/Hostility Subscore over the course of the study, compared with placebo × weeks, regardless of administration order (p = 0.77).

CONCLUSIONS

Iloperidone did not significantly outperform placebo on measures of anger or irritability in patients with partially remitted MDD and residual anger/irritability.

The Role of Anger/Hostility in Treatment-Resistant Depression: A Secondary Analysis From the ADAPT-A Study

Major depressive disorder is often accompanied by elevated levels of anger, hostility, and irritability, which may contribute to worse outcomes. The present study is a secondary analysis examining the role of anger/hostility in the treatment response to low-dose aripiprazole added to antidepressant therapy in 225 patients with major depressive disorder and inadequate response to antidepressant treatment. Repeated-measures model demonstrated no drug-placebo difference in treatment response across levels of anger/hostility. However, within-group analyses showed significantly lower placebo response rates in patients with high anger/hostility and a trend for lower drug response rates in patients with high anger/hostility. Pooled response rates across phases and treatments revealed a lower response rate among patients with high anger/hostility. Depressed patients with high anger/hostility demonstrate greater illness severity and lower depressive treatment response rates than patients with low anger/hostility, suggesting that patients with high anger/hostility may have poorer outcomes in response to adjunctive treatment.

Correlates of irritability in college students with depressive symptoms

Depression is a prevalent psychiatric disorder associated with significant personal and societal burden. There is accumulating evidence for the presence of a subtype of depression characterized by the presence of irritability that is associated with increased morbidity, risk for suicidal ideation, and functional impairments in adults. Little is known about the features of depressive symptoms with and without irritability among young adults in college. The primary aim of this study was to characterize the presentation of college students with depressive symptoms and irritability. Two-hundred eighty-seven undergraduate college students with depressive symptoms with and without irritability were compared across several psychiatric and functional outcome variables. Independent samples t-tests or logistic regressions were conducted for each outcome variable using the irritability item of the Beck Depression Inventory as a dichotomous grouping variable. Analyses were conducted separately for the men and the women. Both male and female students with depressive symptoms and severe irritability reported a greater severity of depressive symptoms compared with their peers with no or mild irritability. In the women, the presence of irritability was associated with greater symptoms of anxiety, whereas in the men, it was associated with increased likelihood of engaging in risky behaviors, including compulsive use of alcohol, illicit drugs, and prescription drugs. The male and female college students with depressive symptoms with and without irritability did not differ on severity of suicidal ideation, hopelessness, or cognitive functioning. The findings from this study suggest that depressive symptoms and irritability may characterize a subtype of college students who have a greater symptom burden and with the potential need for more aggressive and prompt treatment.

Revisiting the serotonin-aggression relation in humans: a meta-analysis

The inverse relation between serotonin and human aggression is often portrayed as "reliable," "strong," and "well established" despite decades of conflicting reports and widely recognized methodological limitations. In this systematic review and meta-analysis, we evaluate the evidence for and against the serotonin deficiency hypothesis of human aggression across 4 methods of assessing serotonin: (a) cerebrospinal fluid levels of 5-hydroxyindoleacetic acid (CSF 5-HIAA), (b) acute tryptophan depletion, (c) pharmacological challenge, and (d) endocrine challenge. Results across 175 independent samples and over 6,500 total participants were heterogeneous, but, in aggregate, revealed a small, inverse correlation between serotonin functioning and aggression, anger, and hostility (r = -.12). Pharmacological challenge studies had the largest mean weighted effect size (r = -.21), and CSF 5-HIAA studies had the smallest (r = -.06). Potential methodological and demographic moderators largely failed to account for variability in study outcomes. Notable exceptions included year of publication (effect sizes tended to diminish with time) and self- versus other-reported aggression (other-reported aggression was positively correlated to serotonin functioning). We discuss 4 possible explanations for the pattern of findings: unreliable measures, ambient correlational noise, an unidentified higher order interaction, and a selective serotonergic effect. Finally, we provide 4 recommendations for bringing much needed clarity to this important area of research: acknowledge contradictory findings and avoid selective reporting practices; focus on improving the reliability and validity of serotonin and aggression measures; test for interactions involving personality and/or environmental moderators; and revise the serotonin deficiency hypothesis to account for serotonin's functional complexity.

Melancholic features and hostility are associated with suicidality risk in Asian patients with major depressive disorder

BACKGROUND

Suicide rates are higher in East-Asians than other populations, and especially high in Koreans. However, little is known about suicidality risk and melancholic features in Asian patients with major depressive disorder (MDD).

METHOD

Drug-free MDD outpatients were included from 13 centers across five ethnicities consisting of Chinese (n=290), Korean (n=101), Thai (n=102), Indian (n=27), and Malay (n=27). All were interviewed using the Mini-International Neuropsychiatric Interview (M.I.N.I.), the Montgomery-Åsberg Depression Rating Scale (MADRS), and the Symptoms Checklist 90-Revised (SCL-90-R).

RESULTS

Of 547 subjects, 177 MDD patients showed melancholic features (32.4%). These melancholic MDD patients revealed significantly higher suicidality risk (p<0.0001), hostility (p=0.037), and severity of depression (p<0.0001) than those MDD patients without melancholic features. Suicidality risk was significantly higher in MDD with melancholic features than those without in subjects with lower hostility, whereas it showed no difference in higher hostility. Adjusted odds ratios of melancholic features and hostility for moderate to high suicidality risk were 1.79 (95% CI=1.15-2.79) and 2.45 (95% CI=1.37-4.38), after adjusting for age, sex, education years, and depression severity. Post-hoc analyses showed that suicidality risk was higher in Korean and Chinese than that of Thai, Indian and Malay in MDD subjects with melancholic features, although depression severity showed no significant differences among the ethnicities.

CONCLUSIONS

Suicidality risk is associated with both melancholic features and hostility and it shows cross-ethnic differences in Asian MDD patients, independent of depression severity.

Personality and depression: evidence of a possible mediating role for anger trait in the relationship between cooperativeness and depression

BACKGROUND

An increasingly growing area of empirical research has found consistent links between anger, depression, and temperament and character domains of personality, separately. However, precise nature of these relationships remains still unclear, and little is known about its underlying processes.

OBJECTIVES

The aim of our explorative research was to conduct a more detailed investigation into the relationships among depression, anger trait, and personality characteristics based on Cloninger's 7-factor personality theory in healthy individuals.

METHOD

In this preliminary study, 230 Italian undergraduates were investigated by using the Temperament and Character Inventory-Revised, the State-Trait Anger Expression Inventory-2, and the Beck Depression Inventory-II. Depression and cooperativeness were expected to have a negative and significant relationship and separate relationships with the trait-anger. Theoretically, a new hypothesis was that the trait-anger would mediate the relationship between depression and cooperativeness.

RESULTS

Zero-order and partial correlations and a path analysis based on Baron and Kenny's method (J Pers Soc Psychol.1986;51:1173-1182) for calculating multiple regression analyses were calculated. Consistent with the hypotheses, cooperativeness and depression were strongly associated; the trait-anger was significantly associated with both cooperativeness and depression, and the mediation model fit the data.

CONCLUSIONS

Behaviors related to the trait-anger could help to explain how depression and reduced cooperativeness are related each other.

The 5-HT deficiency theory of depression: perspectives from a naturalistic 5-HT deficiency model, the tryptophan hydroxylase 2Arg439His knockin mouse

A decreased level of brain 5-hydroxytryptamine (5-HT) has been theorized to be a core pathogenic factor in depression for half a century. The theory arose from clinical observations that drugs enhancing extracellular levels of 5-HT (5-HT(Ext)) have antidepressant effects in many patients. However, whether such drugs indeed correct a primary deficit remains unresolved. Still, a number of anomalies in putative biomarkers of central 5-HT function have been repeatedly reported in depression patients over the past 40 years, collectively indicating that 5-HT deficiency could be present in depression, particularly in severely ill and/or suicidal patients. This body of literature on putative 5-HT biomarker anomalies and depression has recently been corroborated by data demonstrating that such anomalies indeed occur consequent to severely reduced 5-HT(Ext) levels in a mouse model of naturalistic 5-HT deficiency, the tryptophan hydroxylase 2 His(439) knockin (Tph2KI) mouse. In this review, we will critically assess the evidence for 5-HT deficiency in depression and the possible role of polymorphisms in the Tph2 gene as a causal factor in 5-HT deficiency, the latter investigated from a clinical as well as preclinical angle.

Anger attacks in obsessive compulsive disorder

BACKGROUND

Research on anger attacks has been mostly limited to depression, and only a few studies have focused on anger attacks in obsessive compulsive disorder.

MATERIALS AND METHODS

In a cross-sectional study all new obsessive compulsive disorder patients aged 20-60 years attending an outpatient clinic were assessed using the anger attack questionnaire, irritability, depression and anxiety scale (for the direction of the aggressive behavior) and quality of life (QOL).

RESULTS

The sample consisted of 42 consecutive subjects with obsessive compulsive disorder, out of which 21 (50%) had anger attacks. The obsessive compulsive disorder subjects with and without anger attacks did not show significant differences in terms of sociodemographic variables, duration of illness, treatment, and family history. However, subjects with anger attacks had significantly higher prevalence of panic attacks and comorbid depression. Significantly more subjects with anger attacks exhibited aggressive acts toward spouse, parents, children, and other relatives in the form of yelling and threatening to hurt, trying to hurt, and threatening to leave. However, the two groups did not differ significantly in terms of QOL, except for the psychological domain being worse in the subjects with anger attacks.

CONCLUSION

Anger attacks are present in half of the patients with obsessive compulsive disorder, and they correlate with the presence of comorbid depression.

Prevalence of anger attacks in depressive and anxiety disorders: implications for their construct?

AIMS

The present study explores anger attacks in depressive and anxiety disorders for their prevalence and some of the clinical and psychosocial correlates.

METHODS

The sample comprised of patients with ICD-10-diagnosed depressive and anxiety disorders (n=328). All the subjects were given a demographic and clinical profile sheet, the Irritability Depression Anxiety Scale, World Health Organization Quality of Life - BREF Version and the Anger Attack Questionnaire. Using the Anger Attack Questionnaire they were divided into two groups--with anger attacks (n=170) and without anger attacks (n=158)--in order to study the differential profile of the two groups.

RESULTS

Anger attacks were associated with more anxiety and irritability, and poorer quality of life. Frequency of anger attacks had a positive correlation with depression, irritability and aggression, and a negative correlation with education, income, and quality of life. Panic attacks, somatic anxiety and psychological domain of quality of life predicted the categorization of subjects into those with and without anger attacks.

CONCLUSION

Anger attacks are common among depressive and anxiety disorder cases and have a negative impact on quality of life. Status of anger attacks as either linked to anxiety and/or depression, or as an independent syndrome needs further study.

Clinical and physiological correlates of irritability in depression: results from the Netherlands study of depression and anxiety

Objective. Irritable and nonirritable depressed patients differ on demographic and clinical characteristics. We investigated whether this extends to psychological and physiological measures. Method. We compared irritable and nonirritable unipolar depressed patients on symptomatology, personality, and (psycho)physiological measures (cortisol, cholesterol, and heart rate variability). Symptomatology was reassessed after one year, and we also compared depressed patients who were irritable or non-irritable at both time points (Irr++ versus Irr--). Results. Almost half (46%; N = 420) of the sample was classified as irritable. These patients scored higher on depression severity, anxiety, hypomanic symptoms, and psychological variables. No differences were observed on physiological markers after correction for depression severity. The same pattern was found when comparing Irr++ and Irr-- groups. Conclusion. Irritable and non-irritable depressed patients differ on clinical and psychological variables, but not on the currently investigated physiological markers. The clinical relevance of the distinction and the significance of the hypomanic symptoms remain to be demonstrated.

The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication

Irritability is a diagnostic symptom of major depressive disorder (MDD) in children and adolescents but not in adults in both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases (ICD-10) systems. We explore the importance of irritability for subtyping adult DSM-IV MDD in the National Comorbidity Survey Replication (NCS-R), a national US adult household survey. The WHO Composite International Diagnostic Interview (CIDI) was used to assess prevalence of many DSM-IV disorders in the lifetime and in the year before interview (12-month prevalence). MDD was assessed conventionally (that is, requiring either persistent sadness or loss of interest), but with irritability included as one of the Criterion A symptoms. We also considered the possibility that irritability might be a diagnostic symptom of adult MDD (that is, detect cases who had neither sad mood nor loss of interest). Twelve-month MDD symptom severity was assessed with the Quick Inventory of Depressive Symptomatology and role impairment with the Sheehan Disability Scale. After excluding bipolar spectrum disorders, irritability during depressive episodes was reported by roughly half of respondents with lifetime DSM-IV MDD. Irritability in the absence of either sad mood or loss of interest, in comparison, was rare. Irritability in MDD was associated with early age of onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes, and disability. Irritability was especially common in MDD among respondents in the age range 18-44 and students. Further investigation is warranted of distinct family aggregation, risk factors and treatment response. Consideration should also be given to including irritability as a nondiagnostic symptom of adult MDD in DSM-V and ICD-11.

Anger and Depression: Evidence of a Possible Mediating Role for Rumination

Tendency to ruminate may mediate the relationship between anger and depression. In this preliminary study, 353 Italian community participants completed the State-Trait Anger Expression Inventory–2, the Padua Inventory's Tendency to Doubt and to Ruminate subscale, and the Beck Depression Inventory–II. Trait anger and depression were expected to have a positive relationship, and separate relationships with the tendency to ruminate. Theoretically, a new hypothesis was that the tendency to ruminate would mediate the relationship between depression and anger. Zero-order and partial correlations and a path analysis based on Baron and Kenny's method for calculating multiple regression analyses were calculated. Consistent with the hypotheses, anger and depression were strongly associated; the tendency to ruminate was significantly associated with both anger and depression; and the mediation model fit the data. Behaviors related to the tendency to ruminate could help to explain how depression is related to anger.

The interpersonal dimension of borderline personality disorder: toward a neuropeptide model

Borderline personality disorder is characterized by affective instability, impulsivity, identity diffusion, and interpersonal dysfunction. Perceived rejection and loss often serve as triggers to impulsive, suicidal, and self-injurious behavior, affective reactivity, and angry outbursts, suggesting that the attachment and affiliative system may be implicated in the disorder. Neuropeptides, including the opioids, oxytocin, and vasopressin, serve a crucial role in the regulation of affiliative behaviors and thus may be altered in borderline personality disorder. While clinical data are limited, the authors propose alternative neuropeptide models of borderline personality disorder and review relevant preclinical research supporting the role of altered neuropeptide function in this disorder in the hope of stimulating more basic research and the development of new treatment approaches.

Antecedents, concomitants and consequences of anger attacks in depression

Anger attacks are episodes of intense anger with autonomic arousal, which occur in response to often trivial provocations. This study explores some of the antecedents, concomitants, and consequences of anger attacks in patients with depression. The sample comprised three groups: depression with anger attacks (n=20), depression without anger attacks (n=20) and normal controls (n=20). Subjects were administered the Mini International Neuropsychiatric Interview, the Anger Attack Questionnaire, Irritability, the Depression Anxiety Scale, the State-Trait Anger Expression Inventory, the Psychoticism Extraversion Neuroticism Inventory, the Hassles Scale, the World Health Organization Quality of Life-BREF Version and the Dysfunctional Analysis Questionnaire. Depressed patients with anger attacks exhibited more suicide-related phenomena and dysfunction scores in comparison to depressed patients without anger attacks. Depressed patients with anger attacks also had higher scores of anxiety, irritability, trait-anger, anger-out, anger expression, psychoticism, hassles, and poor quality of life in comparison to the other two groups. In conclusion, anger attacks adversely affect the lives of depressed patients and their family members and may serve as a qualifier for partially distinct syndrome of depression.

Clinical and genetic dissection of anger expression and CREB1 polymorphisms in major depressive disorder

BACKGROUND

Anger and irritability are prominent in a subset of individuals with major depressive disorder (MDD). Phosphorylation of the transcription factor cyclic adenosine monophosphate (cAMP) Response Element Binding Protein (CREB) has been associated with aggression or reward/aversion in rodents, and markers near CREB1 have been linked to MDD. Therefore, we examined the association between CREB1 polymorphisms and anger expression in MDD.

METHODS

A clinical sample of 94 Caucasian outpatients with MDD (42 male, 52 female) completed the Spielberger State-Trait Anger Expression Inventory. We examined six tagging single nucleotide polymorphisms (SNPs) spanning CREB1 and flanking regions for association with a summary measure of frequency and intensity of anger expression. We also introduced a novel statistical method to dissect the independent effect of individual SNPs and haplotypes.

RESULTS

For the sample as a whole, one of six SNPs tested was significantly associated with anger expression (empirical p = .003). Among the male subsample, this association was particularly marked (empirical p = 8 x 10(-5)). A global haplotype test of the six SNPs was likewise significant (p = 3.7 x 10(-6)). No single SNP or haplotype accounted for all of the association observed.

CONCLUSION

These preliminary results suggest a strong, gender-specific association between variation at the CREB1 locus and anger expression in MDD.

Transtornos de humor refratários a tratamento

OBJETIVOS E MÉTODO: Os transtornos de humor estão entre os transtornos psiquiátricos mais prevalentes. Apesar de novas descobertas e avanços no estudo das bases neurobiológicas e abordagens terapêuticas no transtorno bipolar e depressão recorrente, elevadas taxas de recorrência, sintomas subsindrômicos persistentes e refratariedade terapêutica são aspectos clínicos desafiadores e precisam ser abordados. O objetivo desta revisão da literatura é o de avaliar os conceitos e critérios de resistência e refratariedade ao tratamento, e evidenciar as principais alternativas terapêuticas para transtornos do humor resistentes aos tratamentos disponíveis. RESULTADOS: Fatores genéticos, erro diagnóstico e de tratamento, não-aderência, e estressores biológicos e psicossociais podem levar à perda de mecanismos regulatórios e ao aumento na prevalência de casos de refratariedade nos transtornos de humor. Com relação aos tratamentos disponíveis, o uso de doses apropriadas, seguido por associação com um segundo ou terceiro fármaco, e após, se indicado, a troca de medicação, são etapas necessárias na busca de melhor eficácia. Entretanto, no paradigma de refratariedade terapêutica, tratamentos atuando em sistemas já conhecidos, especialmente monoaminas, freqüentemente apresentam limitada eficácia. Assim, a busca por tratamentos mais eficazes para os transtornos de humor torna-se um aspecto chave para diminuir sua morbidade. CONCLUSÃO: Estratégias focadas na regulação de vias ativadoras de neuroplasticidade, incluindo agentes antiglutamatérgicos, antagonistas de receptor glucocorticóide e neuropeptídeos, podem representar opções terapêuticas promissoras.

Major depressive disorder with anger attacks and cardiovascular risk factors

OBJECTIVE

Depression and anger have been separately associated with cardiovascular risk factors. We investigated if major depressive disorder (MDD) with concomitant anger attacks was associated with cardiovascular risk factors.

METHOD

We measured total serum cholesterol, glycemia, resting blood pressure, and smoking parameters in 333 (52.9% women) MDD nonpsychotic outpatients, mean age of 39.4 years. MDD was diagnosed with the Structured Clinical Interview (SCID) in accordance with the Diagnostic and Statistic Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). The presence of anger attacks was established with the Massachusetts General Hospital Anger Attacks Questionnaire.

RESULTS

In a logistic regression analysis, anger attacks were independently associated with cholesterol levels > or = 200 mg/dL (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.18-3.94) and years of smoking > 11 (OR, 2.59; 95% CI, 1.32-5.04).

CONCLUSIONS

MDD with anger attacks was significantly associated with increased cholesterol levels and years of smoking.

G protein-coupled receptors in major psychiatric disorders

Although the molecular mechanisms underlying psychiatric illnesses such as depression, bipolar disorder and schizophrenia remain incompletely understood, there is increasing clinical, pharmacologic, and genetic evidence that G protein-coupled receptors (GPCRs) play critical roles in these disorders and their treatments. This perspectives paper reviews and synthesizes the available data. Dysfunction of multiple neurotransmitter and neuropeptide GPCRs in frontal cortex and limbic-related regions, such as the hippocampus, hypothalamus and brainstem, likely underlies the complex clinical picture that includes cognitive, perceptual, affective and motoric symptoms. The future development of novel agents targeting GPCR signaling cascades remains an exciting prospect for patients refractory to existing therapeutics.

Anger, depression and personality dimensions in patients with migraine without aura

BACKGROUND

Migraine without aura causes acute and chronic pain and partially compromises patients' social functioning and work performance. Over the past years, psychiatric comorbidities were frequently observed in these patients, together with coping difficulties and typical personality traits. The aim of this study was to identify whether migraine patients and controls share distinctive personality traits.

METHODS

105 consecutive patients suffering from migraine without aura referred to the Headache Center of Turin University were enrolled in the study and compared to a control group of 79 healthy subjects. Patients and controls completed several psychometric questionnaires, including the Temperament and Character Inventory, the Beck Depression Inventory and the State-Trait Anger Expression Inventory.

RESULTS

Patients suffering from migraine show more depressive symptoms, difficult anger management with a tendency to hypercontrol, and a distinctive personality profile with high harm avoidance, high persistence and low self-directedness. When a logistic regression was performed, the only significant predictors of migraine were temperament variables.

CONCLUSIONS

The results suggest that the personality traits and psychosomatic mechanisms of migraine patients may make them vulnerable to stress and less skilled in coping with pain. These traits correlate with dysregulated neurotransmitter systems which may also be part of the psychobiological components of personality, depressive disorders and migraine itself.

The effect of buspirone on normal and hypoarousal-driven abnormal aggression in rats

Aggressiveness is associated with decreased glucocorticoid production, autonomic hypoarousal, and social deficits in antisocial personality disorder and its childhood antecedent conduct disorder. We showed previously that experimentally induced chronic glucocorticoid deficiency leads to abnormal forms of attack, autonomic hypoarousal, and social deficits in rats. We also showed that serotonergic neurotransmission, which downregulates aggressiveness in normal rats appears to lose its aggression-controlling role in glucocorticoid-deficient rats. We suggested that abnormal aggression develops in such rats as a consequence of serotonergic disturbances that result from chronic glucocorticoid deficiency. Here we assessed the effects of the serotonergic anxiolytic buspirone on aggressive behavior in normal and glucocorticoid-deficient rats. Noteworthy, this compound is frequently used in the clinic to control moderate aggression problems. As expected, buspirone dose-dependently reduced the duration of agonistic behaviors in normal rats exposed to resident/intruder conflicts. Similar to earlier experiments, glucocorticoid deficiency dramatically increased the share of attacks directed towards vulnerable body parts of the opponents (head, throat and belly). Surprisingly, 1 and 5 mg/kg buspirone dramatically increased the frequency of biting attacks in glucocorticoid-deficient rats. The share of vulnerable attacks remained as high as in vehicle-treated glucocorticoid-deficient rats. These data show that chronic glucocorticoid deficiency disturbs serotonergic neurotransmission, which reverses the aggression-related effects of the serotonergic agent buspirone. This finding is in line with disparate human findings on the effects of serotonergic agents on aggression in antisocial personality disordered people.

Covariation of psychological attributes and incident coronary heart disease in U.S. Air Force veterans of the Vietnam war

OBJECTIVE

The purpose of the present investigation was to examine the prospective associations of hostility, anger, depression, and anxiety, alone and in combination, to incident coronary heart disease (CHD).

METHODS

Subjects were 2105 men who participated in the Air Force Health Study, a 20-year study designed to evaluate the effects of herbicide exposure on various health outcomes in Air Force veterans of Operation Ranch Hand. Psychological attributes were assessed in 1985 using scales constructed from the Minnesota Multiphasic Personality Inventory. Participants were followed for an average of 15 years for evidence of ischemic heart disease (International Classification of Diseases codes 410-414, 428.4, or 36). The relation between psychological attributes and CHD was examined with Cox proportional hazard models.

RESULTS

Adjusting for CHD risk factors, depression, anxiety, hostility, and trait anger were significant predictors of incident CHD. In addition, a factor analytically derived psychological risk factor composite score was the strongest predictor of CHD.

CONCLUSIONS

These results suggest that the covariation of hostility, anger, depression, and anxiety accounts for the increased risk of CHD associated with each individual factor. The results of this study challenge the conventional approach of examining these psychological attributes in isolation.

Relations of serotonin function to personality: current views and a key methodological issue

Studies of biological underpinnings of personality suggest that serotonergic functioning relates to certain personality traits. However, how to interpret the findings depends partly on assumptions about how personality is organized. These assumptions are reflected in the assessment devices used and also in how the data are examined. Review of evidence to date appears to link serotonin function to impulsivity and, to some extent, to hostility. The relation of serotonin function to anxiety proneness is far more questionable. Indeed, when such a relation occurs, it often takes a form opposite to the direction argued by theory. It is recommended that research use measures that discriminate adequately among personality qualities reflecting incentive sensitivity, threat sensitivity, and impulsiveness. Indeed, it is highly desirable to examine facets of each of these qualities separately.

Anger attacks in major depressive disorder and serum levels of homocysteine

BACKGROUND

Increased levels of homocysteine have been associated with anger and depression separately. We investigated the association of anger attacks in major depressive disorder (MDD) with serum levels of homocysteine.

METHODS

Homocysteine serum levels were measured in 192 outpatients with nonpsychotic MDD, mean age 39.9 +/- 10.7 (range 19-65), 53% women, at baseline of an open-trial antidepressant treatment. We used the Massachusetts General Hospital Anger Attacks Questionnaire to evaluate anger attacks, the Structured Clinical Interview for DSM-III-R Axis I Disorders-Patient Edition (SCID-I/P) to diagnose MDD and the 17-item Hamilton Rating Scale for Depression to measure depression severity.

RESULTS

In the multiple regression analysis split by anger attacks adjusted for parameters of depression, creatinine, vitamin B(12), folate, age, smoking, and alcohol consumption, serum levels of homocysteine were positively correlated with length of current major depressive episode (t value, 3.01; 95% confidence interval [CI], .09 to .43; p = .004) and HAM-D-17 scores (t value, 2.48; 95% CI, .07 to 0.64; p = .016) in patients with anger attacks but not in those without anger attacks.

CONCLUSIONS

Anger attacks in MDD may moderate the relationship of homocysteine serum levels with the severity and length of the depressive episode. Future studies are warranted to confirm and clarify the nature of this moderating effect.

Normal and abnormal aggression: human disorders and novel laboratory models

We review here aggression-related human psychopathologies and propose that human aggressiveness is mainly due to three major factors: (i) brain dysfunction affecting aggression-controlling brain centers (e.g. in certain types of brain lesions, epilepsy, Alzheimer disease, etc.); (ii) hypoarousal associated with chronically low plasma glucocorticoids, which foster violence by diminishing emotional barriers that limit such behaviors (e.g. in conduct disorder and antisocial personality disorder); (iii) hyperarousal which leads to irritability and outbursts (e.g. in depression, intermittent explosive disorder, chronic fatigue, etc.). Different disorders are associated with different types of aggressiveness; e.g. hypoarousal is often associated with instrumental aggression, whereas hyperarousal is associated with uncontrollable outbursts. Many psychological disorders have been simulated in laboratory models, which were used to assess aggressiveness. Little effort was invested, however, in assessing the abnormal dimension of such aggressiveness. We present here three models that appear especially suitable to assess abnormal aspects of rodent aggression: (i) abnormal attack targeting (head, throat, and belly) that is induced by hypoarousal in rats and models violence in hypoarousal-driven human aggression (ii) 'escalated' aggression (increased aggressive response due to frustration or instigation), which models irritability and hyperarousal-driven aggressiveness; and (iii) context-independent attacks induced by hypothalamic stimulation or genetic manipulations. These three models address different aspects of abnormal aggressiveness, and can become extremely useful in three areas: in evaluating and assessing models of human psychopathologies, in studying transgenic animals, and in developing new treatment strategies. Research based on these or similar models do not address aggressiveness in quantitative terms, but follows the development of abnormal aspects, and the possibilities of their specific treatment.

Mechanisms differentiating normal from abnormal aggression: glucocorticoids and serotonin

Psychopathology-associated human aggression types are induced by a variety of conditions, are behaviorally variable, and show a differential pharmacological responsiveness. Thus, there are several types of abnormal human aggression. This diversity was not reflected by conventional laboratory approaches that focused on the quantitative aspects of aggressive behavior. Recently, several laboratory models of abnormal aggression were proposed, which mainly model hyperarousal-driven aggressiveness (characteristic to intermittent explosive disorder, post-traumatic stress disorder, depression, chronic burnout, etc.) and hypoarousal-driven aggressiveness (characteristic mainly to antisocial personality disorder and its childhood antecedent conduct disorder). Findings obtained with these models suggest that hyperarousal-driven aggressiveness has at its roots an excessive acute glucocorticoid stress response (and probably an exaggerated response of other stress-related systems), whereas chronic hypoarousal-associated aggressiveness is due to glucocorticoid deficits that affect brain function on the long term. In hypoarousal-driven aggressiveness, serotonergic neurotransmission appears to lose its impact on aggression (which it has in normal aggression), certain prefrontal neurons are weakly activated, whereas the central amygdala (no, or weakly involved in the control of normal aggression) acquires important roles. We suggest that the specific study of abnormal aspects of aggressive behavior would lead to important developments in understanding the specific mechanisms underlying different forms of aggression, and may ultimately lead to the development of better treatment approaches.

Relationship of anger and anger attacks with depression: a brief review

Anger is a common and potentially destructive emotion that has considerable social and public health importance. The occurrence of anger, irritability and hostility in depression have been known for many years, but the prevalence, significance for treatment and prognosis and the mechanisms involved remain poorly understood. More recently, anger attacks have been proposed as a specific form of anger in depression. They are characterized by a rapid onset of intense anger and a crescendo of autonomic arousal occurring in response to trivial provocations. Though the presence or absence of hostility, anger and aggression in depression has been a matter of controversy, anger attacks have been found to occur more often in depressed patients in comparison to healthy controls. Some studies have reported that depressed patients with anger attacks differ from those without such attacks in terms of clinical profile, comorbid personality disorders and certain biological variables. Serotonergic dysfunction may characterize this distinct subtype of depression - depression with anger attacks.

Hypothalamus-pituitary-adrenal system regulation and suicidal behavior in depression

BACKGROUND

One of the most demanding tasks in psychiatry is to protect patients from suicidal attempts. Preventive strategies could be improved by increasing our knowledge on the pathophysiologic disturbances underlying this behavior. More than 70-80% of suicides occur in the context of depressive disorders, in which dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis is one of the most prominent neurobiological findings. So far data on the involvement of the HPA axis in the pathophysiology of suicidal behavior in depressed patients are controversial.

METHODS

In this retrospective study, we administered the combined dexamethasone-suppression/CRH stimulation (Dex/CRH) test to 310 patients with a depressive syndrome characterized at admission for acute and past suicidal behavior within the first 10 days after hospitalization.

RESULTS

Suicidal behavior in depressed patients, including past and recent suicide attempts as well as suicidal ideation, was associated with a lower adrenocorticotropin and cortisol response in the combined Dex/CRH test, with lowest hormone levels observed in patients with a recent suicide attempt.

DISCUSSION

The findings suggest that suicidal behavior may alter HPA axis regulation in depressed patients. Large-scale prospective studies assessing neuroendocrine changes may help to develop predictors for an early identification of patients at risk for committing suicide.

From galactorrhea to osteopenia: rethinking serotonin-prolactin interactions

The widespread use of the selective serotonin reuptake inhibitors (SSRIs) has been accompanied by numerous reports describing a potential association with hyperprolactinemia. Antipsychotics are commonly known to elevate serum prolactin (PRL) through blockade of dopamine receptors in the pituitary. However, there is little awareness of the mechanisms by which SSRIs stimulate PRL release. Hyperprolactinemia may result in overt symptoms such as galactorrhea, which may be accompanied by impaired fertility. Long-term clinical sequelae include decreased bone density and the possibility of an increased risk of breast cancer. Through literature review, we explore the possible pathways involved in serotonin-induced PRL release. While the classic mechanism of antipsychotic-induced hyperprolactinemia directly involves dopamine cells in the tuberoinfundibular pathway, SSRIs may act on this system indirectly through GABAergic neurons. Alternate pathways involve serotonin stimulation of vasoactive intestinal peptide (VIP) and oxytocin (OT) release. We conclude with a comprehensive review of clinical sequelae associated with hyperprolactinemia, and the potential role of SSRIs in this phenomenon.

The relationship between anger and depression in a clinical sample of young men: the role of insecure attachment

BACKGROUND

Even though the relevance of insecure attachment in the etiology of dysfunctional anger is indicated by a number of findings, few studies have examined the relationship between anger and depression from the perspective of attachment theory.

METHODS

Self-reported measures of trait anger, depression, and adult attachment style were simultaneously administered to 87 young men with clinically significant depressive symptoms.

RESULTS

Higher levels of trait anger were associated with an insecure style of attachment. Such an association remained significant after controlling for the severity of depressive symptoms. In a multiple regression model, both a measure of anxious attachment and a measure of avoidant attachment emerged as independent predictors of trait anger.

LIMITATIONS

The study was cross-sectional and the sample did not include women.

CONCLUSIONS

Insecure attachment is a useful predictor of anger experience among patients with depressive symptoms.

The prevalence and clinical correlates of anger attacks during depressive episodes in bipolar disorder

BACKGROUND

Anger attacks, characterized by sudden episodes of intense anger with autonomic arousal, have been described in patients with major depressive disorder (MDD). This study compared the prevalence and clinical significance of anger attacks in unipolar versus bipolar depression.

METHODS

Using the questionnaire of Fava et al. [Psychopharmacol. Bull. 27(3) (1991) 275-279], we assessed rates of anger attacks among outpatients with MDD (n=50) or bipolar disorder (BPD) (n=29) who were currently in a pure depressive episode.

RESULTS

Anger attacks were significantly more common among bipolar (62%) than unipolar (26%) depressed individuals. In a multiple logistic regression, the presence of anger attacks emerged as a significant predictor of bipolarity.

LIMITATIONS

This preliminary finding should be confirmed in a larger sample.

CONCLUSIONS

These results suggest that anger attacks may be a common feature of bipolar depression.

Cholesterol in mood and anxiety disorders: review of the literature and new hypotheses

Cholesterol plays an integral role in the structure and function of the cell membrane and may also affect neurotransmission in the central nervous system. Previous work has identified abnormalities in serum cholesterol levels in patients with mood and anxiety disorders as well as in suicidal patients. However, the biological significance of these abnormalities remains to be clarified. An understanding of how serum cholesterol relates to the pathophysiology of mood disorders may generate biological markers that predict treatment response as well as targets for novel therapeutic strategies. In this article, we review the literature studying the significance of cholesterol in mood and anxiety disorders, with an emphasis on new studies focusing on the adverse impact of hypercholesterolemia on the treatment of major depressive disorder (MDD). We then propose possible mechanisms that would account for the relationship between elevated cholesterol and treatment non-response in MDD.

Depression in premenopausal women: gonadal hormones and serotonergic system assessed by D-fenfluramine challenge test

PURPOSE

The aim of the study was to compare the activity of gonadal hormones and serotonergic system in premenopausal women with or without depression in relation to clinical and hormonal indices of menopause.

METHODS

The sample included 60 women with single or recurrent major depressive episode with disease onset after 38 year of age (mean age 43 years) and 30 healthy control women (mean age 41 years). Psychometric assessment was done by means of 17-item Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI). The presence of menopausal symptoms was assessed by Kupperman Menopause Index (KMI). Activity of gonadal axis was measured by estimating estradiol and follicle-stimulating hormone (FSH) levels. For the assessment of central serotonergic activity, the D-fenfluramine test was used.

RESULTS

Depressed women had higher intensity of menopausal symptoms, significantly lower concentration of estradiol, and higher of FSH than control women. Severity of depression correlated with both the intensity of menopausal symptoms and the concentration of FSH. Baseline levels of prolactin were not different in both groups. Following D-fenfluramine administration, there was a significant increase in prolactin concentration in healthy women and a transient decrease in depressed ones. Baseline cortisol level was significantly higher in depressed women and correlated with the severity of depression. D-Fenfluramine challenge caused a significant increase of cortisol secretion in healthy women and a significant decrease in depressed ones. A relationship was observed between baseline estradiol, FSH, and cortisol level and the magnitude of prolactin and cortisol response to D-fenfluramine.

CONCLUSIONS

In premenopausal women, a high degree of interconnections was demonstrated between symptoms of depression and symptoms of menopause on both clinical and hormonal level. The results confirm the association between depressive and menopausal symptoms as well as an involvement of gonadal hormones, cortisol, and serotonin deficiency in this process.

Serum cholesterol and serotonergic function in major depressive disorder

Studies have revealed a relationship between serum cholesterol levels and serotonergic (5HT) function in healthy young adults. Patients with major depressive disorder (MDD) may have significant differences in cholesterol levels compared with healthy adults, while MDD patients with elevated cholesterol have a poorer prognosis for treatment response. The goal of the present study is to examine (1) the relationship between serum cholesterol levels and central 5HT function by way of the cortisol and prolactin response to the 5HT-selective agonist DL-fenfluramine in MDD patients and (2) differences in 5HT-function between MDD patients who present with and without elevated cholesterol. Fasting serum cholesterol levels were measured in 21 outpatients with MDD. After oral administration of 60 mg of DL-fenfluramine in these patients, cortisol and prolactin responses were measured to test whether cholesterol levels predicted the degree of cortisol or prolactin response. Cortisol and prolactin responses were compared between patients with and without elevated cholesterol levels, defined as >/=200 mg/dl. MDD patients with elevated cholesterol levels were more likely to demonstrate an attenuated cortisol response. There was no relationship between cholesterol levels and cortisol or prolactin response. Excess cholesterol may adversely affect the function of membrane-bound serotonergic structures, and this may explain why MDD patients with elevated cholesterol are more likely to exhibit attenuated neuroendocrine responses, less likely to respond to treatment and more likely to relapse.

Prolactin response to fenfluramine administration in patients with unipolar and bipolar depression and healthy controls

The hormonal response to the serotonin releasing agent/uptake inhibitor fenfluramine has been used as an indicator of central serotonin system function. The serotonergic system plays an important role in the etiology and pathogenesis of mood disorders. We compared the prolactin response to fenfluramine administration in unipolar depressed patients (major depressive disorder), depressed patients with bipolar disorder, and healthy controls. We found a trend towards a blunted prolactin response in depressed patients compared to healthy controls, after controlling for sex, family history, family history-by-gender interaction, and baseline levels. There was no significant difference between unipolar and bipolar patients in the baseline prolactin levels or the response to the fenfluramine administration. We also found a negative correlation between aggression and impulsivity scores and prolactin responses in subgroup with unipolar but not bipolar depression. Female patients with unipolar depression who had first-degree relatives with unipolar depression and normal controls had significantly higher prolactin responses than female patients with unipolar depression who did not have first-degree relatives with unipolar depression. The lack of difference in the response to fenfluramine administration between unipolar and bipolar depressed patients may indicate that overall serotonergic function in unipolar and bipolar depressed patients is similarly impaired.

The prolactin response to fenfluramine in depression: effects of melancholia and baseline cortisol

Depression may be associated with a hypofunction of central serotonergic systems. The prolactin response to fenfluramine, an indicator of serotonergic activity, has been reported to be blunted in depressed patients compared to controls. It has also been suggested that blunting is more likely in melancholic depression. Baseline cortisol, prolactin and tryptophan availability have also been suggested to affect this response. Forty-eight men and 61 women with a major depressive episode, and who were drug free, and 20 healthy control men underwent clinical evaluation and fenfluramine challenge with dl-fenfluramine 1 mg/kg. When baseline variables were covaried, there was no difference in prolactin response to fenfluramine between males with depression and age-matched controls. Amongst all the depressed patients, body mass index showed a significant association with prolactin response to fenfluramine. There was an interaction between baseline cortisol and DSM-III-R melancholic subtype of depression whereby non-melancholic patients appeared more likely to increase prolactin response to fenfluramine in response to higher cortisol levels. Prolactin response to fenfluramine was not blunted in major depression and there was no difference between melancholic and non-melancholic depression. However, the relationship between prolactin response to fenfluramine and baseline cortisol levels appeared to differ between these two subtypes of depression.

An open pilot study of nefazodone in depression with anger attacks: relationship between clinical response and receptor binding

Nefazodone has been widely used as an antidepressant, but it has not been tested for depression with anger attacks. In an open study, we administered nefazodone (maximum 600 mg/day) for 12 weeks to 16 outpatients who had major depression with anger attacks. Assessment instruments comprised the Structured Clinical Interview for DSM-IV (SCID), Anger Attacks Questionnaire (AAQ), 17-item Hamilton Rating Scale for Depression (HAM-D-17), Clinician Global Impression Scale (CGI), Symptom Questionnaire (SQ), Modified Overt Aggression Scale (MOAS), and MOAS-Self-Rated. Three subjects underwent positron emission tomography (PET) with [18F]-setoperone for 5-HT2 binding potential (BP) and [11C]-SCH-23,390 for D1 BP, both at baseline and after 6 weeks of treatment. Eight subjects underwent PET with [18F]-setoperone and with [11C]-SCH-23,390 at baseline only. In an examination of whether D1 and 5HT2 (data available in six subjects) receptor BP predicted treatment response, we found significant decreases in the HAM-D-17, CGI-S, weighted MOAS, MOAS verbal scale, OAS Self-Rated verbal, SQ Depression and Anger/Hostility scales after nefazodone; 50% responded to nefazodone (defined as >or=50% decrease in HAM-D-17 score), and 44% reported disappearance of anger attacks. A statistically significant percentage decrease in 5HT2 BP was observed for the right mesial frontal and left parietal regions after 6 weeks of treatment. No significant change was observed in D1 BP in any region. Although CGI-I scores correlated significantly with D1 BP in the left thalamic region, the correlation was not significant after Bonferroni correction. The effectiveness of nefazodone for depression with anger attacks may be related to widespread changes in 5HT2 receptor BP.