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

Evaluating psychological distress associated with life events under the traumatic experience threshold in patients with major depressive and bipolar disorder

Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience psychological distress associated with daily events that do not meet the threshold for traumatic experiences, referred to as event-related psychological distress (ERPD). Recently, we developed an assessment tool for ERPD, the ERPD-24. This tool considers four factors of ERPD: feelings of revenge, rumination, self-denial, and mental paralysis. We conducted a cross-sectional study between March 2021 and October 2022 to identify the differences and clinical features of ERPD among patients with MDD and BD and healthy subjects who did not experience traumatic events. Specifically, we assessed ERPD using the ERPD-24 and anxiety-related symptoms with the State-Trait Anxiety Inventory, Liebowitz Social Anxiety Scale, and anxious-depressive attack. Regarding the ERPD-24 scores among the groups, as the data did not rigorously follow the test of normality, the Kruskal-Wallis test was used to compare the differences among the groups, followed by the Dunn-Bonferroni adjusted post-hoc test. Non-remitted MDD patients and BD patients, regardless of remission/non-remission, presented more severe ERPD than healthy subjects. This study also demonstrated the relationships between all anxiety-related symptoms, including social phobia and anxious-depressive attack and ERPD, in both BD and MDD patients and in healthy subjects. In conclusion, patients with non-remitted MDD and with BD regardless of remission/non-remission experience severe ERPD related to anxiety-related symptoms.

Al Ghazali's Concept of Diseases of the Spiritual Heart and its Significance to the DSM-5-TR Diagnosis

The intertwined relationship between religion and mental health has been accounted for since the earliest recorded history. This study aimed to explore the relationship between the concept of diseases of the spiritual heart (DOTSH) from the Islamic-Sufi perspective and the medical-psychiatric concept of mental disorder. We examined two essential documents as our primary data sources: (1) Al Ghazali's Ihya Ulumuddin (Revivals of Religion Sciences) Volume III entitled the Quarter of the Destructive and (2) The Diagnostic and Statistical Manual, Fifth Version, Text Revision (DSM-5-TR). We employed a document analysis of the qualitative method by applying six steps of data analysis. We reviewed the English version of Al Ghazali's book to identified DOTSH. In this stage, we found six DOTSH categories which comprised of 40 DOTSH. Then, we searched the correspondence of DOTSH's categories to the DSM-5-TR criteria for mental disorders. We found that all DOTSH categories correspond to DSM-5-TR diagnostics criteria, diagnostic features or diagnostic associated features. We concluded that spiritual heart diseases not only present as symptoms but also can be regarded as mental disorder preconditions that require preventive intervention.

Comparison of the effect of hostility on the level of depression of drug addicts and non-addicts and the mediating role of sense of life meaning between them

BACKGROUND

The level of depression among drug addicts is generally higher than normal. Hostility and sense of life meaning may influence depression and become risk factors for depression. This study has three research purposes. First, to analyze whether drug use can aggravate hostility and depression levels. Second, to assess whether the hostility has different effects on depression among drug addicts and non-addicts. Third, to examine whether the sense of life meaning has a mediating role between different groups (drug addicts and non-addicts).

METHODS

This study was conducted from March to June 2022. 415 drug addicts (233 males and 182 females) and 411 non-addicts (174 males and 237 females) were recruited in Chengdu, Sichuan Province. After signing informed consent, their psychometric data were obtained using the Cook-Medley Hostility Scale (CMI), Beck Depression Inventory (BDI) and Meaning in Life Questionnaire (MLQ) questionnaires. Linear regression models were used to assess the impact of hostility and depression among drug addicts and non-addicts. Bootstrap mediation effect tests were used to further test the mediation effect of sense of life meaning between hostility and depression.

RESULTS

The results showed four main outcomes. First, compared with non-addicts, drug addicts had higher levels of depression. Second, hostility exacerbated depression in both drug addicts and non-addicts. Compared with non-addicts, hostile affect had a greater effect on depression in drug addicts. Third, the sense of life meaning among females was higher than males. Fourth, for drug addicts, the sense of life meaning showed a mediating effect between social aversion and depression, while for non-addicts, the sense of life meaning showed a mediating effect between cynicism and depression.

CONCLUSIONS

Depression is more severe in drug addicts. More attention should be paid to the mental health of drug addicts, because the elimination of negative emotions is conducive to reintegration into society. Our results provide a theoretical basis for reducing depression among drug addicts and non-addicts. As a protective factor, we can reduce their hostility and depression by improving the sense of life meaning.

[Hostility as a manifestation of attachment disorders in depression]

OBJECTIVE

To analyze the relationship between hostility and attachment disorders in endogenous depression.

MATERIAL AND METHODS

The study included 49 patients with a diagnosis of depressive disorder, all of them completed the Simptom Check List-90-Revised (SCL-90R); the Buss-Perry Aggression Questionnaire; the Experiences in Close Relationships-Revised (ECR-R); Ich-Struktur-Test nach Ammon. The patients were assessed using the Hamilton Depression Rating Scale (HDRS-17).

RESULTS

At high levels of depression, the indicators of «hostility» (p=0.046), «destructive aggression» (p=0.04) and «deficit aggression» (p=0.005) are significantly higher. The severity of depression significantly correlates with the severity of «anxiety» in attachment (close relationships), as well as with pathological «narcissism», «destructive external self-delimitation», «deficient internal self-delimitation» (p<0.05). For the measure of depression, the regression model explains more than 76% of the variance, with the measures of «interpersonal sensitivity», «deficit narcissism», and «avoidance» in attachment making significant contributions. For the «hostility» the regression model explains about 62% of the variance, while, as in the analysis of «depression», a significant contribution is made by the indicators of «interpersonal sensitivity» and «avoidance», however, unlike «depression», the contribution of the «destructive narcissism» is noted in contrast to the «deficit narcissism».

CONCLUSIONS

With severe depressive symptoms, indicator of hostility are increased. Hostility in depression is associated with factors caused by a violation of early interpersonal relationships (anxious attachment) (which causes increased sensitivity in relations with others, building a barrier between oneself and the external environment perceived as hostile), the narcissistic pathology, problems in emotional regulation.

The relationship between father absence and hostility among Chinese depressed youths: A serial mediation model and the role of self-esteem and frustration tolerance

BACKGROUND

While the association between father absence and youth hostility has been well-documented among depressed youths, there is a lack of research on the potential mechanism underlying such an association. This study aimed to test a serial mediation model of self-esteem and frustration tolerance on the link between father absence and youth hostility.

METHODS

A total of 137 Chinese youths with major depressive disorder were recruited from Wuhan Mental Health Center. They completed a survey including the Father Absence Questionnaire to measure father absence, the Chinese Hostility Inventory (CHI) to measure hostility, the Psychological Endurance Questionnaire to measure frustration tolerance, and the Self-esteem Scale (SES) to measure self-esteem. A series of multiple linear regression models were employed to assess the associations among father absence, self-esteem, frustration tolerance, and hostility.

RESULTS

Although father absence was modestly associated with hostility (r = 0.30, p < 0.001), subsequent serial mediation analysis showed that father absence was not directly related to hostility (β = 0.06, p = 0.29) when self-esteem and frustration tolerance were included in the model. High levels of father absence had an adverse effect on levels of self-esteem, which decreased levels of frustration tolerance, and thus higher levels of hostility among depressed youths. The indirect effects of father absence on hostility through self-esteem, frustration tolerance, as well as through self-esteem and frustration tolerance serially accounted for 28%, 24%, and 24% of the total effect, respectively.

CONCLUSION

Our study tested a serial mediation model of self-esteem and frustration tolerance as mediators between father absence and hostility among depressed youths. The findings strengthened our understanding of the potential mechanism underlying the association between self-esteem and frustration tolerance, which may provide useful guidance for future intervention programs.

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.

A Clinically Useful Anger Outcome Scale

In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Clinically Useful Anger Outcome Scale (CUANGOS). Current anger measures vary in their psychometric quality, clinical utility, and clinically relevant content coverage, and no one scale addresses all three of these key considerations. We aimed to develop a brief, clinically useful anger scale that (a) assesses clinically relevant aspects of anger, (b) performs well across different patient populations, and (c) is brief, accessible, and easy to use in routine clinical practice either as a stand-alone measure or as part of an assessment battery. Analyses included data from 2710 psychiatric outpatients and 1397 partial hospitalization patients. We used data from randomly drawn subsamples to select items with good psychometric properties and sufficient distinction from measurements of other emotional dysfunction, resulting in a 5-item scale. In reliability and validity analyses using the remaining participants, CUANGOS scores showed high internal consistency and appropriate test-retest reliability, as well as excellent discriminant validity from measurements of depression and anxiety. CUANGOS scores converged strongly with clinician ratings of subjective and overt anger and differentiated across all or almost all levels of clinician-rated anger severity. CUANGOS scores were also significantly higher in patients with anger-related disorders versus patients with other psychiatric disorders. Results provide promising evidence for the CUANGOS as a reliable and valid measurement of anger in clinical populations. Moreover, the CUANGOS is brief and feasible to incorporate into routine clinical practice.

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.

Trait anger and anger attacks in relation to depressive and anxiety disorders

BACKGROUND

Patients with various psychiatric disorders may suffer from feelings of anger, sometimes leading to maladaptive (e.g., aggressive) behaviors. We examined to what extent depressive and anxiety disorders, relevant clinical correlates, and sociodemographics determined the level of trait anger and the prevalence of recent anger attacks.

METHODS

In the Netherlands Study of Depression and Anxiety (NESDA), the Spielberger Trait Anger Subscale and the Anger Attacks Questionnaire were analyzed in patients with depressive (n = 204), anxiety (n = 288), comorbid (n = 222), and remitted disorders (n = 1,107), as well as in healthy controls (n = 470) based on DSM-IV criteria.

RESULTS

On average, participants were 46.2 years old (SD = 13.1) and 66.3% were female. Trait anger and anger attacks were most prevalent in the comorbid group (M = 18.5, SD = 5.9, and prevalence 22.1%), followed by anxiety disorder, depressive disorder, remitted disorder, and controls (M = 12.7; SD = 2.9, and prevalence 1.3%). Major depressive disorder, social phobia, panic disorder, and generalized anxiety disorder were most strongly associated to trait anger and anger attacks.

LIMITATIONS

Due to a cross-sectional design, it was not possible to provide evidence for temporal or causal relationships between anger and depressive and anxiety disorders.

CONCLUSIONS

Trait anger and anger attacks are linked to depressive and anxiety disorders, although the strength of the relationship differed among both anger constructs.

Irritability and Its Clinical Utility in Major Depressive Disorder: Prediction of Individual-Level Acute-Phase Outcomes Using Early Changes in Irritability and Depression Severity

OBJECTIVE

The authors evaluated improvement in irritability with antidepressant treatment and its prognostic utility in treatment-seeking adult outpatients with major depressive disorder.

METHODS

Mixed-model analyses were used to assess changes in irritability (as measured with the five-item irritability domain of the Concise Associated Symptom Tracking [CAST-IRR] scale) from baseline to week 4 after controlling for depression severity (as measured with the 16-item Quick Inventory of Depressive Symptomatology-Clinician Rated [QIDS-C]) in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial (N=664). An interactive calculator for remission (QIDS-C score ≤5) and no meaningful benefit (<30% reduction in QIDS-C score from baseline) at week 8 was developed with logistic regression analyses in the CO-MED trial using participants with complete data (N=431) and independently replicated in the Suicide Assessment and Methodology Study (SAMS) (N=163).

RESULTS

In the CO-MED trial, irritability was significantly reduced (effect size=1.06) from baseline to week 4, and this reduction remained significant after adjusting for QIDS-C change (adjusted effect size=0.36). A one-standard-deviation greater reduction in CAST-IRR score from baseline to week 4 predicted a 1.73 times higher likelihood of remission and a 0.72 times lower likelihood of no meaningful benefit at week 8, independent of baseline QIDS-C and CAST-IRR scores and reduction in QIDS-C score from baseline to week 4. The model estimates for remission (area under the curve [AUC]=0.79) and no meaningful benefit (AUC=0.76) in the CO-MED trial were used to predict remission (AUC=0.80) and no meaningful benefit (AUC=0.84) in SAMS and to develop an interactive calculator.

CONCLUSIONS

Irritability is an important symptom domain of major depressive disorder that is not fully reflected in depressive symptom severity measures. Early reductions in irritability, when combined with changes in depressive symptom severity, provide a robust estimate of likelihood of remission or no meaningful benefit in outpatients with major depression.

Psychometric parameters of the subscale of hostility from the Symptom Checklist 90 (SCL-90)

Abstract The present study aimed to know the psychometric parameters of the SCL-90 hostility scale. For this, two studies were traced; In Study 1, 209 students, mean age 16 years (SD = 1.29), who responded to the Scale of Hostility and a sociodemographic questionnaire. The exploratory factorial analysis indicated a unidimensional structure, whose Cronbach’s alpha was.71. In Study 2, we sought to find additional evidence of validity and reliability counting with 212 students with a mean age of 16 years (SD = 1.19). The confirmatory factorial analysis tested the unifactorial structure and pointed to good adjustment indexes; good internal consistency and composite reliability were also observed. In general, the Scale of Hostility provided evidence of satisfactory validity and reliability.

The neural basis of hostility-related dimensions in schizophrenia

Hostility and related dimensions like anger, urgency, impulsivity and aggressiveness have been described in non-clinical populations and various serious mental illnesses including schizophrenia. Although representing a mental healthcare challenge, the investigation of such constructs is often limited by the presence of complex and multi-factorial causes and lack of agreement in their conceptualisation and measurement. In this review, we aim to clarify the anatomical basis of hostility-related dimensions in schizophrenia. Imaging studies suggest malfunctioning of a neural circuitry including amygdala, striatum, prefrontal cortex, anterior cingulate cortex, insula and hippocampus to modulate hostile thoughts and behaviours, at least in the subgroup of patients with schizophrenia who exhibit high levels of urgency, impulsivity and aggressiveness.

Stability of Cortical Thinning in Persons at Increased Familial Risk for Major Depressive Disorder Across 8 Years

BACKGROUND

A biological marker of vulnerability should precede onset of illness and be independent of disease course. We previously reported that cortical thinning may serve as a potential biomarker for risk for familial depression. We now test stability of the cortical thinning across 8 years, and whether thinning mediates associations between familial risk and depressive traits.

METHOD

Participants were from a 3-generation family study of depression, where 2nd and 3rd generation offspring were characterized as being at high- or low-risk for depression based on the presence/absence of major depression in the 1st generation. The analysis includes 82 offspring with anatomical MRI scans across two assessment waves, 7.8 (S.D.1.3, range: 5.2-10.9) years apart.

RESULTS

High-risk offspring had thinner bilateral superior and middle frontal gyri, and left inferior parietal lobule, at both time-points. High intra-subject correlation (0.60<r<0.91) and intra-class correlation (0.72-0.78) of thickness measures across time points was detected within the above regions; rank order by effect size and region was also preserved across time. The thinning was stable despite changes in scanning platform (Siemens Sonata vs. GE Signa), field-strength (1.5 vs. 3T), and participant age and clinical course. Thinning at the first time-point predicted anger and hostility at the second, and mediated the relationship between familial risk and these traits.

CONCLUSION

The study provides evidence for cortical thinning as a stable biomarker for familial vulnerability for depressive illness, which supports the ability to detect persistent and clinically relevant anatomical findings irrespective of MRI platform.

Lurasidone for major depressive disorder with mixed features and irritability: a post-hoc analysis

OBJECTIVE

The aim of this post-hoc analysis was to evaluate the efficacy of lurasidone in treating major depressive disorder (MDD) with mixed features including irritability.

METHODS

The data in this analysis were derived from a study of patients meeting DSM-IV-TR criteria for unipolar MDD, with a Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥26, presenting with two or three protocol-defined manic symptoms, and who were randomized to 6 weeks of double-blind treatment with either lurasidone 20-60 mg/d (n=109) or placebo (n=100). We defined "irritability" as a score ≥2 on both the Young Mania Rating Scale (YMRS) irritability item (#5) and the disruptive-aggressive item (#9). Endpoint change in the MADRS and YMRS items 5 and 9 were analyzed using a mixed model for repeated measures for patients with and without irritability.

RESULTS

Some 20.7% of patients met the criteria for irritability. Treatment with lurasidone was associated with a significant week 6 change vs. placebo in MADRS score in both patients with (-22.6 vs. -9.5, p<0.0001, effect size [ES]=1.4) and without (-19.9 vs. -13.8, p<0.0001, ES=0.7) irritability. In patients with irritable features, treatment with lurasidone was associated with significant week 6 changes vs. placebo in both the YMRS irritability item (-1.4 vs. -0.3, p=0.0012, ES=1.0) and the YMRS disruptive-aggressive item (-1.0 vs. -0.3, p=0.0002, ES=1.2).

CONCLUSIONS

In our post-hoc analysis of a randomized, placebo-controlled, 6-week trial, treatment with lurasidone significantly improved depressive symptoms in MDD patients with mixed features including irritability. In addition, irritability symptoms significantly improved in patients treated with lurasidone.

Is nonverbal behavior in patients and interviewers relevant to the assessment of depression and its recovery? A study with Dutch and Brazilian patients

Nonverbal behaviors exhibited by patients with depression in their interactions with others may reflect social maladjustment and depression maintenance. Investigations of associations between unipolar depression and both patients' and interviewers' behaviors have been scarce and restricted to European samples. This study examined whether nonverbal behavior in patients and their interviewers is associated with depression severity and recovery. Cultural differences were explored. Seventy-eight depressed outpatients (28 Brazilians, 50 Dutch) were evaluated before and after 8-week pharmacological treatment. Patients were videotaped during the Hamilton Depression Scale interview before treatment, and the Brazilians were also videotaped after treatment. Nonverbal behaviors (patients' speaking effort and interviewers' encouragement) were analyzed using a two-factor ethogram. Results revealed that speaking effort was associated with encouragement and both are not influenced by baseline depression severity. However, from before to after treatment, whereas encouragement remained unchanged, speaking effort increased among unrecovered patients. Speaking effort was associated with patients' culture: Brazilians exhibited higher speaking effort than Dutch. These findings highlight that whereas the supportive nonverbal behavior of the interviewer may be stable, the set of nonverbal behaviors composed by head movements, eye contact and gestures displayed by the patients during their speaking in clinical interviews reflects depression persistence after treatment.

The role of affect in predicting depressive symptomatology in remitted recurrently depressed patients

BACKGROUND

Major depressive disorder is an emotional disorder. It is important to improve our understanding of the role of affect in relapse/recurrence of depression. Therefore, this study examines whether affect plays a role in prospectively predicting depressive symptomatology and if there are indications for emotional scarring as a consequence of undergoing depressive episodes.

METHODS

In 107 patients remitted from recurrent depression affect was examined in predicting depressive symptomatology as measured with the Inventory of Depressive Symptomatology - Self Report. Affect was measured with the Positive and Negative Affect Schedule and with a one item Visual Analogue Mood Scale. Indication of emotional scarring was examined by comparing number of previous depressive episodes to levels of affect.

RESULTS

Less positive affect as assessed after remission predicted increased depressive symptomatology six months later, even after we controlled for baseline symptomatology. Negative affect also predicted depressive symptomatology six months later, but not after controlling for baseline depressive symptomatology. No relationship was found between affect and number of previous episodes.

LIMITATIONS

All participants in this study had two or more previous depressive episodes and received CBT during the acute phase of their depression. The instruments that measured mood and affect were administered within 4 weeks of each other.

CONCLUSIONS

Positive affect and negative affect as assessed after remission in recurrent depression can predict depressive symptomatology. Especially positive affect seems to play an independent role in predicting depressive symptomatology. Directly targeting positive affect in relapse prevention during remission might be a way to enhance treatment effects.