Relevance of anger and irritability in outpatients with major depressive disorder

Does risk-taking or alcohol misuse mediate the association between anger and suicidal ideation in male depression?

Anger is among the core symptoms in male-specific inventories of depression and has consistently been linked with suicidal ideation. In this study, we assessed whether this link may be mediated via other prominent symptoms of depression in men, namely risk-taking and alcohol misuse. We used self-reported data from 322 men responding to a 3-wave survey over 6 months. Regression with mediation analysis was employed to test whether anger at baseline predicted suicidal ideation six months later through the mediating effects of risk-taking or alcohol misuse at 3 months. We found a statistically significant indirect effect (indicating a mediation effect) of anger at baseline on suicidality at 6-months follow-up through risk taking at 3-months follow-up (effect = 0.007, SE = 0.003, 99% Confidence interval = 0.0002 to 0.0161). Anger at baseline was not significantly associated with alcohol misuse at 3-months follow-up (β = .062, t = 0.919, p = .358), thus nullifying alcohol misuse as a possible mediator between anger and suicidal ideation. In conclusion, the results of this study suggest that risk-taking, but not alcohol misuse, may be a mediator between anger and suicidal ideation in the context of male depression. If these results are replicated, assessing anger and risk-taking may inform monitoring of suicidality. Also, anger and risk-taking may be promising targets for treatment aimed at reducing the risk of suicide.

Comparison of latent variable and psychological network models in PROMIS data: output metrics and factor structure

PURPOSE

Much research is still needed to compare traditional latent variable models such as confirmatory factor analysis (CFA) to emerging psychometric models such as the Gaussian graphical model (GGM). Previous comparisons of GGM centrality indices with factor loadings from CFA have discovered redundancies, and investigations into how well a GGM-based alternative to exploratory factor analysis (i.e., exploratory graph analysis, or EGA) is able to recover the hypothesized factor structure show mixed results. Importantly, such comparisons have not typically been examined in real mental and physical health symptom data, despite such data being an excellent candidate for the GGM. Our goal was to extend previous work by comparing the GGM and CFA using data from Wave 1 of the Patient Reported Outcomes Measurement Information System (PROMIS).

METHODS

Models were fit to PROMIS data based on 16 test forms designed to measure 9 mental and physical health domains. Our analyses borrowed a two-stage approach for handling missing data from the structural equation modeling literature.

RESULTS

We found weaker correspondence between centrality indices and factor loadings than found by previous research, but in a similar pattern of correspondence. EGA recommended a factor structure discrepant with PROMIS domains in most cases yet may be taken to provide substantive insight into the dimensionality of PROMIS domains.

CONCLUSION

In real mental and physical health data, the GGM and EGA may provide complementary information to traditional CFA metrics.

The Role of Anger Expression in Unmet Expectations and Depressive Symptoms

Background and Objectives. Depression is associated with unmet relational expectations, but little is known about how both partners experience meeting expectations and how this relates to anger expression and depressive symptoms. The aim of study 1 was to explore the role of anger expression in explaining the link between relational expectations and depression using the actor-partner interdependence mediation model. Additionally, social expectations beyond romantic relationships are associated with societal demands. Study 2 is aimed at investigating the role of anger expression in the relationship between internalized social demands (i.e., outer self-awareness) and depressive symptoms. Design and Methods. Online self-report data were collected from N = 194 romantic partners (97 dyads) in study 1 and N = 407 individuals in study 2. Results. In study 1, unmet expectations were associated with both actor and partner effects on depressive symptoms and anger expression. In particular, inwardly directed anger was linked to depressive symptoms in the case of the individual experiencing unmet expectations, whereas outwardly directed anger predicted such symptoms in the case of the partner's unmet expectations. In study 2, there was a positive association between outer self-awareness and directing anger inwards and outwards, which was linked to higher depressive symptoms. Furthermore, while directing anger inwards seemed to be a universal mechanism underlying the association, the interpersonal mechanism (i.e., directing anger outwards) was found to be dependent on gender.

Emotion regulation strategy correlates with discrete state emotion in major depression

BACKGROUND AND OBJECTIVES

Research has shown that state emotion can affect emotion regulation strategies in healthy samples. Emotion regulation plays an important role in depression. We hypothesized that for depressed individuals, experiencing anxiety or anger affects emotion regulation strategy use differently than experiencing sadness.

DESIGN AND METHODS

Individuals diagnosed with chronic or recurrent depression (N = 386) responded to vignettes of hypothetical stressors and reported their state emotions and emotion regulation strategies in a thought-listing procedure. We modeled the effect of reporting anger or anxiety compared to sadness on the use of seven emotion regulation strategies: avoidance, distraction, other-blame, problem-solving, rumination, self-blame, and social support.

RESULTS

Compared to sadness, anger was associated with a greater likelihood of using other-blame, and a lower likelihood of using avoidance, rumination, or self-blame. Compared to sadness, anxiety was associated with a greater likelihood of using self-blame. Responses with anger or anxiety did not significantly differ from sadness in coder-rated adaptiveness.

CONCLUSIONS

Differences in observed emotion regulation strategy use were correlated with the discrete emotions experienced, and not overall adaptiveness of a response. These results highlight the importance of assessing for emotion type when studying emotion regulation strategy use in depression.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

[Gender-Sensitive Depression Screening (GSDS) - Further Validation of a New Self-Rating Instrument]

OBJECTIVE

To check the validity of the preliminary results with the Gender-Sensitive Depression Screening (GSDS) in two German samples of non-psychiatric outpatients.

METHODS

The psychometric validation of the GSDS-33 was performed in a sample of non-psychiatric outpatients of different clinics belonging to the Ludwig-Maximilians-University of Munich (n = 958) and in a male non-psychiatric sample of the Men's Health Center in Berlin (n = 237).

RESULTS

Findings of the first validation study of the GSDS (Möller-Leimkühler, Mühleck 2020) were largely confirmed. The data also confirmed the factors 'aggressiveness' and 'emotional control' as important components of an increasing depression risk. Compared to a standard screening the GSDS again identified more risk cases among men in the two samples (8 % and 18 %).

CONCLUSIONS

The GSDS-25 is a multidimensional, valid and reliable scale for better identifying men with a risk of depression.

The role of emotion dysregulation in cognitive behavioural group therapy for perinatal anxiety: Results from a randomized controlled trial and routine clinical care

BACKGROUND

Emotion dysregulation (ED) has been implicated in anxiety disorders and may play an important role in Cognitive Behavioural Therapy (CBT) treatment for perinatal anxiety outcomes although there is a dearth of research in this area. The current study investigated the role of ED in perinatal anxiety treatment outcome to determine whether it impacts CBT treatment outcomes and whether CBT reduces ED.

METHODS

Secondary analyses were run on a sample of N = 75 women participating in a CBT for perinatal anxiety randomized controlled trial (RCT), and N = 47 women who received the treatment as part of routine clinical care. Participants completed measures of anxiety, depression and ED at baseline, post-CBT/post-waitlist and 3-month follow-up (CBT-RCT group only). MANOVAs were conducted to determine if level of ED moderates treatment outcomes and whether CBT reduces ED. Reliable and clinically meaningful change was calculated.

RESULTS

Baseline level of ED did not moderate treatment outcomes. There were significant changes in some ED subscales over time in the CBT group compared to waitlist. Changes were reliable and clinically meaningful in 28.6% (RCT) and 16% (routine clinical care) of participants. Participants with high ED at baseline remained in the high range at post-treatment.

LIMITATIONS

Limitations include low sample size; homogeneity of sample, use of measures not validated in perinatal populations.

CONCLUSIONS

These findings suggest that ED during the perinatal period may be a stand-alone factor that will need to be separately addressed in psychological treatment.

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.

Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states)

Objective

To review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms.

Methods

PubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted.

Results

By classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2–3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms.

Discussion

Categorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.

Depression history and memory bias for specific daily emotions

Reports of emotions experienced over the past week can be influenced by memory bias, which is more pronounced for people with depression. No studies, however, have examined memory bias for specific emotion clusters (e.g., sadness, anxiety, and anger) experienced on a day-to-day basis among people with depression or a history of depression. Participants (N = 1,657) from the Midlife in the United States Study were assessed for depression. Approximately 6 months later, participants reported their emotional experiences for 8 days and recalled these experiences on the final day. Differences in recalled and reported emotion were compared between participants with and without a history of depression. Participants overestimated experience only of negative emotions, particularly anger, and this negativity bias was greatest for participants with a history of depression. Feelings related to anger were prone to greater overestimation than sadness or anxiety. These findings emphasize the role of memory bias in retrospective reports of specific emotions and illustrate the presence of an amplified memory bias among people who are at a greater risk for recurrent depressive episodes.

Prepartum and Postpartum Mothers' and Fathers' Unwanted, Intrusive Thoughts in Response to Infant Crying

BACKGROUND

Unwanted intrusive thoughts of intentionally harming one's infant (intrusive harm thoughts) are common distressing experiences among postpartum mothers and fathers.

AIM

To understand infant crying as a stimulus for intrusive harm thoughts and associated emotional responses in prepartum and postpartum mothers and fathers in response to infant cry.

METHOD

Following completion of self-report measures of negative mood and anger, prepartum (n = 48) and postpartum (n = 44) samples of mother and father pairs completed 10 minutes of listening to audio-recorded infant crying. Post-test questionnaires assessed harm thoughts, negative emotions, urges to comfort and flee, and thoughts of shaking as a soothing or coping strategy.

RESULTS

One quarter of prepartum and 44% of postpartum parents reported intrusive infant-related harm thoughts following crying. Mothers and fathers did not differ in the likelihood of reporting harm thoughts, nor in the number of thoughts reported. Women reported more internalizing emotions compared with men. Hostile emotions were stronger among postpartum parents, and parents reporting harm thoughts. All parents reported strong urges to comfort the infant. Urges to flee were stronger among parents who reported harm thoughts. The likelihood of using infant shaking as a soothing or coping strategy was minimally endorsed, albeit more strongly by fathers and parents who also reported harm thoughts.

CONCLUSIONS

In response to crying, harm thoughts are common and are associated with hostile emotions, urges to flee, and increased thoughts of using infant shaking. Reassuringly, the number of participants considering infant shaking as a strategy for soothing or for coping with a crying infant was low.

Changes in Problematic Anger, Shame, and Disgust in Anxious and Depressed Adults Undergoing Treatment for Emotion Dysregulation

Emotion dysregulation, the pervasive difficulty managing negative emotions, is a core problem across mood and anxiety disorders. Anger, shame, and disgust are particularly problematic emotions, impacting both disorder severity and treatment outcome. We previously found that a 16-week dialectical behavior therapy skills training group (DBT-ST) was superior to an activities-based support group (ASG) in decreasing emotion dysregulation in 44 adults with high emotion dysregulation who met diagnostic criteria for an anxiety or depressive disorder. We presently examine these participants' changes in anger, shame, disgust, and distress using self-reports collected over 6 months during and after treatment. Hierarchical linear modeling analyses show that DBT-ST was superior to ASG in decreasing anger suppression (d = 0.93) and distress (d = 1.04). Both conditions significantly reduced shame, disgust propensity, and disgust sensitivity, but neither was superior for these outcomes. The treatments did not significantly reduce anger expression. Mediation analyses suggest that condition indirectly influenced 4-month anger suppression, shame, and distress through its effect on 2-month emotion dysregulation. These findings suggest that DBT-ST is efficacious for certain problematic emotions and distress in depressed and anxious adults and that common factors may account for some, but not all, of its benefits.

Clinical Insight Into Latent Variables of Psychiatric Questionnaires for Mood Symptom Self-Assessment

BACKGROUND

We recently described a new questionnaire to monitor mood called mood zoom (MZ). MZ comprises 6 items assessing mood symptoms on a 7-point Likert scale; we had previously used standard principal component analysis (PCA) to tentatively understand its properties, but the presence of multiple nonzero loadings obstructed the interpretation of its latent variables.

OBJECTIVE

The aim of this study was to rigorously investigate the internal properties and latent variables of MZ using an algorithmic approach which may lead to more interpretable results than PCA. Additionally, we explored three other widely used psychiatric questionnaires to investigate latent variable structure similarities with MZ: (1) Altman self-rating mania scale (ASRM), assessing mania; (2) quick inventory of depressive symptomatology (QIDS) self-report, assessing depression; and (3) generalized anxiety disorder (7-item) (GAD-7), assessing anxiety.

METHODS

We elicited responses from 131 participants: 48 bipolar disorder (BD), 32 borderline personality disorder (BPD), and 51 healthy controls (HC), collected longitudinally (median [interquartile range, IQR]: 363 [276] days). Participants were requested to complete ASRM, QIDS, and GAD-7 weekly (all 3 questionnaires were completed on the Web) and MZ daily (using a custom-based smartphone app). We applied sparse PCA (SPCA) to determine the latent variables for the four questionnaires, where a small subset of the original items contributes toward each latent variable.

RESULTS

We found that MZ had great consistency across the three cohorts studied. Three main principal components were derived using SPCA, which can be tentatively interpreted as (1) anxiety and sadness, (2) positive affect, and (3) irritability. The MZ principal component comprising anxiety and sadness explains most of the variance in BD and BPD, whereas the positive affect of MZ explains most of the variance in HC. The latent variables in ASRM were identical for the patient groups but different for HC; nevertheless, the latent variables shared common items across both the patient group and HC. On the contrary, QIDS had overall very different principal components across groups; sleep was a key element in HC and BD but was absent in BPD. In GAD-7, nervousness was the principal component explaining most of the variance in BD and HC.

CONCLUSIONS

This study has important implications for understanding self-reported mood. MZ has a consistent, intuitively interpretable latent variable structure and hence may be a good instrument for generic mood assessment. Irritability appears to be the key distinguishing latent variable between BD and BPD and might be useful for differential diagnosis. Anxiety and sadness are closely interlinked, a finding that might inform treatment effects to jointly address these covarying symptoms. Anxiety and nervousness appear to be amongst the cardinal latent variable symptoms in BD and merit close attention in clinical practice.

Social functioning in major depressive disorder

Depression is associated with social risk factors, social impairments and poor social functioning. This paper gives an overview of these social aspects using the NIMH Research and Domain Criteria 'Systems for Social Processes' as a framework. In particular, it describes the bio-psycho-social interplay regarding impaired affiliation and attachment (social anhedonia, hyper-sensitivity to social rejection, competition avoidance, increased altruistic punishment), impaired social communication (impaired emotion recognition, diminished cooperativeness), impaired social perception (reduced empathy, theory-of-mind deficits) and their impact on social networks and the use of social media. It describes these dysfunctional social processes at the behavioural, neuroanatomical, neurochemical and genetic levels, and with respect to animal models of social stress. We discuss the diagnostic specificity of these social deficit constructs for depression and in relation to depression severity. Since social factors are importantly involved in the pathogenesis and the consequences of depression, such research will likely contribute to better diagnostic assessments and concepts, treatments and preventative strategies both at the diagnostic and transdiagnostic level.

Content validity of the Sheehan Irritability Scale in patients with major depressive disorder

The Sheehan Irritability Scale (SIS) measures the frequency, severity, and impairment associated with irritability in psychiatric patients. The content validity of the SIS in patients with major depressive disorder (MDD) has not been evaluated. A cross-sectional, qualitative research study was conducted to assess the content validity of the SIS among patients with MDD. One-on-one interviews were conducted, starting with open-ended questions to evaluate the consistency of the SIS content with patient experiences of irritability. Participants then completed the SIS and cognitive interviews around the comprehension of the SIS content (instructions, items, response options). Participants included 24 patients diagnosed with MDD who had an inadequate response to an antidepressant treatment. The sample was: 50.4 mean years, 66.7% female, and 91.7% white racial background. All concepts on the SIS were spontaneously mentioned by at least one participant, and when probed about the symptoms, the majority of participants (66.7-100%) reported the concepts being part of their experience. The majority of participants (70.8-100%) understood the SIS instructions, items, and response scales. This study provides evidence of content validity of the SIS in patients diagnosed with MDD, supporting the use as a measure of irritability in patients with depression.

The Association of Anger with Symptom Subtypes in Severe Obsessive-Compulsive Disorder Outpatients

BACKGROUND

Despite the theoretical and clinical relevance of psychopathological dimensions in obsessive-compulsive disorder (OCD), no studies to date have investigated their possible association with obsession subtypes. Thus, we aimed to examine whether, in OCD patients, anger and other psychopathological dimensions are associated with specific obsession subtypes.

METHODS

We consecutively recruited 57 first-visit OCD patients (66.7% female, mean age 34 years) at our Psychiatric Outpatient Clinic. We used the point biserial coefficient (rpbi) to measure the correlation between psychopathological dimensions and obsession subtypes.

RESULTS

We found significant correlations (p < 0.05) between the following: (1) anger/aggressiveness dimension and aggressive, contamination, and sexual obsessions; (2) apprehension/fear dimension and contamination, religious, and somatic obsessions; (3) sadness/demoralization dimension and contamination and somatic obsessions; (4) impulsivity dimension and aggressive and sexual obsessions, and (5) somatic concern/somatization dimension and contamination and somatic obsessions. We also found that OCD patients with comorbid obsessive-compulsive personality disorder--but not schizotypal or histrionic disorders--showed higher levels (p < 0.05) of obsessiveness/iterativity and anger/aggressiveness than OCD patients without the personality disorder.

CONCLUSIONS

Anger and other psychopathological dimensions seem to be linked with specific obsession subtypes in OCD patients, suggesting an association between these dimensions and OCD.

The role of self-blame and worthlessness in the psychopathology of major depressive disorder

BACKGROUND

Cognitive models predict that vulnerability to major depressive disorder (MDD) is due to a bias to blame oneself for failure in a global way resulting in excessive self-blaming emotions, decreased self-worth, hopelessness and depressed mood. Clinical studies comparing the consistency and coherence of these symptoms in order to probe the predictions of the model are lacking.

METHODS

132 patients with remitted MDD and no relevant lifetime co-morbid axis-I disorders were assessed using a phenomenological psychopathology-based interview (AMDP) including novel items to assess moral emotions (n=94 patients) and the structured clinical interview-I for DSM-IV-TR. Cluster analysis was employed to identify symptom coherence for the most severe episode.

RESULTS

Feelings of inadequacy, depressed mood, and hopelessness emerged as the most closely co-occurring and consistent symptoms (≥90% of patients). Self-blaming emotions occurred in most patients (>80%) with self-disgust/contempt being more frequent than guilt, followed by shame. Anger or disgust towards others was experienced by only 26% of patients. 85% of patients reported feelings of inadequacy and self-blaming emotions as the most bothering symptoms compared with 10% being more distressed by negative emotions towards others.

LIMITATIONS

Symptom assessment was retrospective, but this is unlikely to have biased patients towards particular emotions relative to others.

CONCLUSIONS

As predicted, feelings of inadequacy and hopelessness were part of the core depressive syndrome, closely co-occurring with depressed mood. Self-blaming emotions were highly frequent and bothering but not restricted to guilt. This calls for a refined assessment of self-blaming emotions to improve the diagnosis and stratification of MDD.

Predictors of inpatient psychiatric admission in patients presenting to the emergency department: the role of dimensional assessment

OBJECTIVE

To identify which patient factors predict psychiatric hospitalization in patients presenting to the emergency department and to examine the role of the dimensional approach to psychopathology in predicting hospitalization.

METHODS

We consecutively recruited 312 patients undergoing psychiatric evaluation in the emergency room of a hospital in Rome over a 6-month period. Patients were rated on the SVARAD (Scala per la Valutazione Rapida Dimensionale), a scale designed for the rapid assessment of the main psychopathological dimensions. Information about patient history, as well as sociodemographic and clinical variables, was also collected. Univariate analysis was performed to detect the variables associated with recommendation of psychiatric hospitalization. Multiple logistic regression analysis was used to identify independent predictors of hospitalization and compare their strength. A replication study was performed in another hospital on a random sample of 118 patients.

RESULTS

In both studies, patients who were recommended for psychiatric hospitalization showed significantly higher levels of anger/aggressiveness, apathy, impulsivity, reality distortion, thought disorganization and activation. Multivariate analysis identified psychopathological dimensions (reality distortion, impulsivity, apathy), diagnosis of psychotic or mood disorders and proposal for compulsory admission as independent predictors of psychiatric hospitalization. Hierarchical regression analysis revealed that the dimensional evaluation was the strongest predictor.

CONCLUSIONS

Our findings suggest that, in emergency setting, a systematic dimensional assessment may usefully complement the categorical assessment. Future research should aim at developing an operational assessment model, including both categorical and dimensional approaches to psychopathology.

Suicidal ideation and sex differences in relation to 18 major psychiatric disorders in college and university students: anonymous web-based assessment

College/university students are at high risk for psychiatric disorder and suicide secondary to age, campus stressors, and social pressures. We therefore report frequencies of 18 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision disorders and suicidal ideation (SI) acquired anonymously from a Web site receiving 113,181 visits from more than 1,500 predominantly US colleges/universities. Depression was foremost, followed by social phobia and eating disorders. Substance-related disorders were less frequent than expected. SI occurred in 47.1% of students, with women evidencing somewhat stronger findings than men. SI was more associated with substance, bipolar, and panic disorders than depression. Self-reported emotional volatility exceeded thoughts of self-harm for all disorders. The results support two subtypes of suicide risk: dysphoric premeditators and those primarily angry and/or impulsive. Clinicians and researchers should therefore consider suicide as an independent psychopathological phenomenon that includes emotional volatility as a risk factor and thoroughly evaluate psychiatric disorders potentially conferring greater suicidal propensity than depression.

Clinical characteristics and temperament influences on 'happy' euphoric and 'snappy' irritable bipolar hypo/manic mood states

BACKGROUND

While mood elevation and euphoria are the most commonly described phenotypic descriptors of hypo/mania, irritability and anger may dominate. This study was designed to pursue possible determinants of such differing states.

METHODS

Patients with bipolar I or II disorder were assigned to an 'irritable/snappy' or 'euphoric/happy' sub-set on the basis of their dominant hypo/manic symptoms. Group differences were examined across clinical, personality, lifestyle and illness impact measures.

RESULTS

The two sub-sets did not differ on age of depression onset, family history of mood disorders, or depression severity and impairment. The snappy sub-set reported higher levels of irritability in depressed phases and were more likely to have a comorbid anxiety disorder. Their hypo/manic episodes were shorter and they were more likely to be hospitalized at such times. On a temperament measure they scored as more irritable and self-focussed and as less cooperative and effective - indicative of higher levels of disordered personality functioning.

LIMITATIONS

Some comparison analyses were undertaken on a reduced sample size, giving rise to power issues. Our bipolar I and II diagnoses deviated to some extent from DSM-5 criteria in not imposing duration criteria for hypo/manic episodes.

CONCLUSIONS

Findings support a spectrum model for the bipolar disorders linking temperament to bipolar symptomatic state and which may have treatment implications.

An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide

Research has implicated a relationship between anger and suicidality, though underlying mechanisms remain unclear. The current study examined this relationship through the lens of the interpersonal theory of suicide (ITS). According to the ITS, individuals who experience thwarted belongingness, perceived burdensomeness, and elevated acquired capability for suicide are at increased risk for death by suicide. The relationships between anger and these variables were examined and these variables were examined as potential mediators between anger and suicidal ideation and behavior. Additionally, exposure to painful and provocative events was examined as a potential mediator between anger and acquired capability. As part of intake at a community mental health clinic, 215 outpatients completed questionnaires assessing depression, suicidal ideation, anger, perceived burdensomeness, thwarted belongingness, and acquired capability. Regression analyses revealed unique relationships between anger and both thwarted belongingness and perceived burdensomeness, covarying for depression. The association between anger and acquired capability trended toward significance. The links between anger and suicidal ideation and behavior were fully mediated by thwarted belongingness and perceived burdensomeness, but this effect was driven by perceived burdensomeness. Additionally, the link between anger and acquired capability was fully mediated by experience with painful and provocative events. In conclusion, results suggest that anger is uniquely associated with perceived burdensomeness and thwarted belongingness. Anger is associated with suicidal ideation and behavior via perceived burdensomeness and with greater acquired capability for suicide via experiences with painful and provocative events. Treatment for problematic anger may be beneficial to decrease risk for suicide.

A psychoeducational intervention (SWEEP) for depressed women with diabetes

BACKGROUND

Clinically significant depression is present in 25 % of individuals with type 2 diabetes, its risk being doubled in women.

PURPOSE

To examine the effectiveness of the Study of Women's Emotions and Evaluation of a Psychoeducational (SWEEP), a group therapy for depression treatment based on cognitive behavioral therapy principles that was developed for women with type 2 diabetes was conducted.

METHODS

Women with significantly elevated depression symptoms (Center for Epidemiologic Studies Depression Scale ≥16) were randomized to SWEEP (n = 38) or usual care (UC, n = 36).

RESULTS

Multilevel modeling indicated that SWEEP was more effective than UC in reducing depression (mean difference of -15 vs. -7, p < .01), decreasing trait anxiety (mean difference of -15 vs. -5, p < .01), and improving anger expression (mean difference of -12 vs. -5, p < .05). Although SWEEP and UC had improvements in fasting glucose (mean difference of -24 vs. -1 mg/dl) and HbA1c (mean difference of -0.4 vs. -0.1 %), there were no statistically significant differences between groups.

CONCLUSIONS

SWEEP was more effective than UC for treating depressed women with type 2 diabetes. Addition of group therapy for depression meaningfully expands the armamentarium of evidence-based treatment options for women with diabetes.

Does glycemic variability impact mood and quality of life?

BACKGROUND

Diabetes is a chronic condition that significantly impacts quality of life. Poor glycemic control is associated with more diabetes complications, depression, and worse quality of life. The impact of glycemic variability on mood and quality of life has not been studied.

METHODS

A descriptive exploratory design was used. Twenty-three women with type 2 diabetes wore a continuous glucose monitoring system for 72 h and completed a series of questionnaires. Measurements included (1) glycemic control shown by glycated hemoglobin and 24-h mean glucose, (2) glycemic variability shown by 24-h SD of the glucose readings, continuous overall net glycemic action (CONGA), and Fourier statistical models to generate smoothed curves to assess rate of change defined as "energy," and (3) mood (depression, anxiety, anger) and quality of life by questionnaires.

RESULTS

Women with diabetes and co-morbid depression had higher anxiety, more anger, and lower quality of life than those without depression. Certain glycemic variability measures were associated with mood and quality of life. The 24-h SD of the glucose readings and the CONGA measures were significantly associated with health-related quality of life after adjusting for age and weight. Fourier models indicated that certain energy components were significantly associated with depression, trait anxiety, and overall quality of life. Finally, subjects with higher trait anxiety tended to have steeper glucose excursions.

CONCLUSIONS

Data suggest that greater glycemic variability may be associated with lower quality of life and negative moods. Implications include replication of the study in a larger sample for the assessment of blood glucose fluctuations as they impact mood and quality of life.

Anger, spiritual meaning and support from the religious community in dementia caregiving

This study explores the relationships between spiritual meaning and social support from the religious community and problem behaviors, anger and depression in 128 dementia caregivers. The results suggest a mediating role of anger in the relationship between the appraisal of problem behaviors and depression. Support from the religious community is directly and negatively associated with anger, but the relationship between spiritual meaning and anger is mediated by caregivers' appraisals of problem behaviors, suggesting that spiritual beliefs might help caregivers to find meaning in caregiving experiences and thus appraise care recipients' behavioral problems as less stressful.

Distinguishing symptom dimensions of depression and anxiety: an integrative approach

BACKGROUND

Clark and Watson developed the tripartite model in which a symptom dimension of 'negative affect' covers common psychological distress that is typically seen in anxious and depressed patients. The 'positive affect' and 'somatic arousal' dimensions cover more specific symptoms. Although the model has met much support, it does not cover all relevant anxiety symptoms and its negative affect dimension is rather unspecific. Therefore, we aimed to extend the tripartite model in order to describe more specific symptom patterns with unidimensional measurement scales.

METHOD

1333 outpatients provided self report data. To develop an extended factor model, exploratory factor analysis (EFA) was conducted in one part of the data (n=578). Confirmatory factor analysis (CFA) was conducted in the second part (n=755), to assess model-fit and comparison with other models. Rasch analyses were done to investigate the unidimensionality of the factors.

RESULTS

EFA resulted in a 6-factor model: feelings of worthlessness, fatigue, somatic arousal, anxious apprehension, phobic fear and tension. CFA in the second sample showed that a 6-factor model with a hierarchical common severity factor fits the data better than alternative 1- and 3-factor models. Rasch analyses showed that each of the factors and the total of factors can be regarded as unidimensional measurement scales.

LIMITATIONS

The model is based on a restricted symptom-pool: more dimensions are likely to exist.

CONCLUSION

The extended tripartite model describes the clinical state of patients more specifically. This is relevant for both clinical practice and research.

Subtyping depression in the medically ill by cluster analysis

BACKGROUND

There is increasing awareness of the need of subtyping major depressive disorder, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing depression in the medically ill.

METHODS

1700 patients were recruited from 8 medical centers in the Italian Health System and 1560 agreed to participate. They all underwent a cross-sectional assessment with DSM-IV and DCPR structured interviews. 198 patients (12.7%) received a diagnosis of major depressive disorder. Data were submitted to cluster analysis.

RESULTS

Two clusters were identified: depressed somatizers and irritable/anxious depression. The somatizer cluster included 58.6% of the cases and was characterized by DCPR somatization syndromes (persistent somatization, functional somatic symptoms secondary to a psychiatric disorder, conversion symptoms, and anniversary reactions) and DCPR alexithymia. The anxious/irritable cluster had 41.4% of the total sample and included DCPR irritable mood and type A behavior and DSM-IV anxiety disorders.

LIMITATIONS

The study has limitations due to its cross-sectional nature. Further, these findings require additional validation in another sample.

CONCLUSIONS

The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, irritable mood, type A behavior and alexithymia, as encompassed by the DCPR. Subtyping major depressive disorder may yield improved targets for psychosomatic research and treatment trials.

Factor structure of the Brief Psychiatric Rating Scale in unipolar depression

BACKGROUND

In clinical practice patients with unipolar depression present with a variety of symptom clusters that may combine together in many different ways. However, only few factor analytic studies used general psychopathology scales to investigate the symptom structure of unipolar depression.

METHODS

The study included 163 consecutive inpatients with an ICD-10 diagnosis of depressive disorder (ICD-10 codes F32 to F33). All patients were assessed with the 18-item version of the Brief Psychiatric Rating Scale (BPRS) within 3days from admission. Exploratory factor analysis with Varimax rotation was performed on BPRS items.

RESULTS

Four factors were extracted, explaining 52% of total variance. They were interpreted as Apathy, Dysphoria, Depression and Psychoticism. The distribution of factor scores was approximately normal for Apathy, while it displayed a slight negative skewness for Depression, a slight positive skewness for Dysphoria, and a marked positive skewness for Psychoticism. Patient sex, family history of depression, lifetime history of suicide attempt, and recent serious family conflict were not associated with any factor. Occupational status, age, and age at onset displayed a positive correlation with Apathy. Duration of illness and number of previous admissions were positively correlated with Dysphoria.

LIMITATIONS

Patients were not administered a structured diagnostic interview, and no detailed assessment of personality disorders was performed; also, patients were recruited only at a single site, which reduces the generalizability of the results.

CONCLUSIONS

Our findings suggest that in depressive disorders there are psychopathological dimensions other than depressed mood that are worthy of greater clinical attention and research. Dimensions such as apathy and dysphoria may play an important part in the clinical phenomenology of unipolar depression and deserve systematic and careful assessment in order to provide patients with the best possible treatment and improve clinical outcomes.

Distinguishing between depression and anxiety: a proposal for an extension of the tripartite model

AIM

The aim of the current study was to develop scales that assess symptoms of depression and anxiety and can adequately differentiate between depression and anxiety disorders, and also can distinguish within anxiety disorders. As point of departure, we used the tripartite model of Clark and Watson that discerns three dimensions: negative affect, positive affect and physiological hyperarousal.

METHODS

Analyses were performed on the data of 1449 patients, who completed the Mood and Anxiety Symptoms Questionnaire (MASQ) and the Brief Symptom Inventory (BSI). From this, 1434 patients were assessed with a standardized diagnostic interview.

RESULTS

A model with five dimensions was found: depressed mood, lack of positive affect, somatic arousal, phobic fear and hostility. The scales appear capable to differentiate between patients with a mood and with an anxiety disorder. Within the anxiety disorders, somatic arousal was specific for patients with panic disorder. Phobic fear was associated with panic disorder, simple phobia and social anxiety disorder, but not with generalized anxiety disorder.

CONCLUSIONS

We present a five-factor model as an extension of the tripartite model. Through the addition of phobic fear, anxiety is better represented than in the tripartite model. The new scales are capable to accurately differentiate between depression and anxiety disorders, as well as between several anxiety disorders.

Comparison of Clinical Features and Personality Dimensions between Patients with Major Depressive Disorder and Normal Control

OBJECTIVE

Personality dimension is considered as a risk factor of depression. This study was to compare aggression, impulsivity, hopelessness, and TCI (temperament and character dimensions) between patients with major depressive disorder (MDD) and normal controls.

METHODS

A total of 56 MDD patients and the same number of normal controls who were matched for age, gender, and education were recruited. All subjects completed the following questionnaires; Aggression Questionnaire (AQ), Beck Hopelessness Scale (BHS), Barratt Impulsiveness Scale, 11th Version (BIS-11), and Temperament and Character Inventory (TCI).

RESULTS

MDD patients were significantly higher scores in anger, hostility of AQ, BHS, motor impulsivity of BIS-11, and Harm Avoidances (HA) of TCI with all subscales of HA than normal controls, whereas novelty seeking 1 (NS1) (Exploratory of NS), Reward Dependence (RD) with RD3 (Attachment) . RD4 (Dependence), Self-Directedness (SD) with most subscales of SD, Cooperativeness (CO), and ST3 (Spiritual Acceptance) showed lower scores than normal controls. Moreover, BHS and HA, BIS and NS showed moderate positive correlation in MDD patients, while BHS and SD, HA and SD were negatively correlated.

CONCLUSION

The present study showed unique clinical features, especially personality dimensions of patients with MDD. Our results could be applicable to suggest treatment process and to predict one's prognosis for depression in that psychological properties are important for drug compliance and treatment response.

Anger potentiates the reporting of threatening interpretations: an experimental study

This paper reports the results of an experiment investigating the effect of induced anger on interpretational bias using the homophone spelling task. Four groups of participants experienced anger, anxiety, happy or neutral mood inductions and then completed the homophone spelling task. Participants who experienced anger and anxiety inductions reported significantly more threat/neutral homophones as threats compared to control participants; moods had an emotion-congruent effect on threat reporting, with negative moods increasing the tendency to report threat/neutral homophones as threats and positive moods increasing the tendency to report positive/neutral homophones as positive. The findings provide evidence that anger potentiates the reporting of threatening interpretations and does so independently of any effect of concurrent levels of state and trait anxiety. The mechanism mediating this effect is unclear, but the results do lend support to those theories of psychopathology--and especially of PTSD--that see a causal role for anger in the maintenance of symptoms.

Screening for maternal depression in the neonatal ICU

Postpartum depression is common in women with infants in the neonatal ICU. Maternal depression can affect infant health and development adversely. A screening program for depression in the neonatal ICU could identify women who have depressive symptoms and facilitate their referral for follow-up services.

Posttraumatic embitterment disorder in comparison to other mental disorders

BACKGROUND

The term 'posttraumatic embitterment disorder' (PTED) was recently introduced to describe a subtype of adjustment disorders, characterized by prolonged embitterment, severe additional psychopathological symptoms and great impairment in most areas of life in reaction to a severe negative but not life threatening life event. The aim of this study is an empirical description and validation of the clinical concept of PTED, by comparing clinically defined PTED patients with patients suffering from other mental disorders on measures of posttraumatic stress and psychopathological distress.

METHODS

Fifty inpatients, suffering from PTED according to previously defined clinical diagnostic criteria, were compared with another 50 patients, matched by age and gender, who did not meet clinical criteria for PTED but for other mental disorders. Psychiatric diagnoses were assessed by the Mini International Neuropsychiatric Interview. Self-report measures included the Bern Embitterment Scale, the Impact of Event Scale, the PTED Self-Rating Scale and the SCL-90.

RESULTS

According to the Mini International Neuropsychiatric Interview both groups fulfilled the criteria for many disorders with a significantly higher occurrence of major depression and chronic adjustment disorder but less generalized anxiety disorder lifetime in PTED patients. Patients with PTED scored significantly higher on the global scores and on most subdimensions of the SCL-90, the Impact of Event Scale, the Bern Embitterment Scale and the PTED Self-Rating Scale.

CONCLUSIONS

Clear differences were found between PTED patients and patients with other mental disorders in regard to the quality and intensity of psychopathological as well as posttraumatic stress symptoms. PTED can help further subclassify and specify adjustment and reactive disorders.

Frequency of dysphoria and mixed states

BACKGROUND

Mixed states are a complex entity in the field of mood disorders. Dysphoria has been advocated as an important clinical dimension of mixed states. The objective of this work is to study the frequency of dysphoria within a population of patients with DSM-IV major depressive and/or manic episodes and to determine if it may help establish diagnostic criteria for subthreshold cases of depressive or manic mixed states.

SAMPLING AND METHODS

A total of 165 patients were assessed using the Mini International Neuropsychiatric Interview complemented by a section defining dysphoria as a constellation of 3 among 4 symptoms (inner tension, irritability, aggressive behavior and hostility).

RESULTS

When classifying patients according to the number of symptoms of the opposite polarity, changes in the frequency of dysphoria revealed a clear contrast between the 2 opposite manic and depressive poles and the full mixed state (DSM-IV definition). The frequency of dysphoria was 17.5% in pure depression, 22.7% in pure mania and 73.3% in full mixed state. Two threshold effects were identified: (1) the frequency of dysphoria increased from 17.5 to 61.1% (p = 0.002) when the number of manic symptoms in DSM-IV depressed patients increased from 0 to 1, and (2) dysphoria increased from 14.3 to 69.2% (p = 0.057) when the number of depressive symptoms increased from 2 to 3 in DSM-IV manic patients.

CONCLUSION

Dysphoria is strongly but not necessarily associated with mixed states. When used as a clinical marker for mixed states, dysphoria confirms the modern delimitations of sub-threshold mixed states by specifying the required number of symptoms of the opposite polarity (which could be lower for depressive mixed states than for manic mixed states). The study has limitations related to the inclusion of patients who are not drug-free, to the definition of dysphoria and to the sample size.

The psychological impact of living with diabetes: women's day-to-day experiences

PURPOSE

The purpose of this study is to understand the feelings of depression, anxiety, and anger experienced by women with type 2 diabetes and the impact these feelings have on their overall quality of life.

METHODS

Four focus groups (2 white, 2 African American) were conducted by ethnically matched professional moderators. Sessions were audiotaped, and transcriptions were analyzed using an inductive approach. Forty-one women (mean age, 55.6 years; SD = 7.9) who had type 2 diabetes for an average of 8.7 years (SD = 6.3) participated. Forty-two percent of the sample was African American.

RESULTS

The themes generated directly from the focus group data are (1) struggling with the changing health situation; (2) encountering challenges in relationships with self, family, and others; (3) worrying about the present and future; (4) bearing multiple responsibilities for self and others; and (5) choosing to take a break. Women also expressed feelings of depression, anxiety, and anger, which were primarily related to having diabetes as well as managing the multiple responsibilities of being a caregiver. There were more similarities than differences noted by race.

CONCLUSIONS

Women with type 2 diabetes experience feelings of depression, anxiety, and anger, which affect their health and overall quality of life. The findings suggest that health care providers should assess the psychological health of women with type 2 diabetes when developing plans of care. By understanding and addressing the emotional health of women with type 2 diabetes, the relationships between the patient, family, and health care provider may improve, allowing for more successful diabetes management.

Detection and treatment of depressive and anxiety disorders among cancer patients: feasibility and preliminary findings from a liaison service in an oncology division

Our aim in this observational study was to evaluate the feasibility of a multiphasic screening project for the detection and treatment of mood and anxiety disorders among cancer patients in a natural setting. One hundred sixty-five patients with cancer, consecutively admitted to the Oncology Division of San Camillo-Forlanini Hospital, were recruited to the study. All patients had solid tumors; the majority of them were colon, breast, and lung cancers. All patients completed the Hospital Anxiety and Depression Scale (HADS). Patients screened as positive were administered the following instruments by a psychiatrist: the Structured Clinical Interview for DSM-IV (SCID-I), the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), and a validated scale for the rapid dimensional assessment of psychopathology (SVARAD). The BDI, HARS, and SVARAD were administered again at 4 and 10 weeks to all treated patients. Out of 45 patients administered the SCID-I, 37 had a mood or anxiety disorder. Adjustment disorders were identified in 20 patients, depressive disorders in 14, and anxiety disorders in three patients. Most patients were prescribed psychotropic medications: mirtazapine was prescribed to 15 patients, citalopram to 13 patients, and escitalopram to four patients. A significant improvement in symptoms of depression and anxiety was observed on all measures (P<.001). Although the design of the study prevents any firm conclusions about effectiveness, this study suggests that including psychiatric expertise in an oncology division is feasible and may lead to improved detection and treatment of psychiatric disorders among cancer patients. Further randomized trials are needed to elaborate on our findings.

Depression in cancer patients: a critical review

Cancer patients experience several stressors and emotional upheavals. Fear of death, interruption of life plans, changes in body image and self-esteem, changes in social role and lifestyle are all important issues to be faced. Moreover, Depressive Disorders may impact the course of the disease and compliance. The cost and prevalence, the impairment caused, and the diagnostic and therapeutic uncertainty surrounding depressive symptoms among cancer patients make these conditions a priority for research. In this article we discuss recent data, focusing on detection of Depressive Disorders, biological correlates, treatments and unmet needs of depressed cancer patients.

Combining an SSRI with an anticonvulsant in depressed patients with dysphoric mood: an open study

Background

Several patients with unipolar depression present with prominent dysphoric mood. We aimed at examining the effectiveness of the combination of an SSRI with an anticonvulsant in such patients.

Methods

Thirty-five newly admitted outpatients with substantial anger, irritability, aggressiveness or hostility who were diagnosed a DSM-IV unipolar depressive disorder were rated on the Hamilton Depression Rating Scale (HDRS), the Clinical Global Improvement (CGI) scale, and a scale for the rapid dimensional assessment (SVARAD), were prescribed an SSRI and an anticonvulsant (usually valproate), and were followed up for 12 weeks. Repeated measures analysis of variance was used to test for within-subject changes in scale scores over time.

Results

Thirty-two and 23 patients attended the follow-up visits 4 and 12 weeks later, respectively. Significant decreases (p < .001) were observed in HDRS total score, HDRS and SVARAD anxiety factors, HDRS and SVARAD core depression factors, and SVARAD anger/irritability factor. Adjusting for age or gender did not change the results. Most patients (82%) were rated as improved or much improved on the CGI.

Conclusion

Although our study has several limitations, we observed a remarkable improvement in most unipolar depressed outpatients with dysphoric mood treated with an SSRI and an anticonvulsant. The effectiveness of anticonvulsants might be linked to their action on symptoms of aggression and behavioural activation.

The psychopathology of posttraumatic embitterment disorders

BACKGROUND

The posttraumatic embitterment disorder (PTED) was introduced as a new subgroup of adjustment disorders. The trigger event in PTED is an exceptional, though normal negative life event that is experienced as a violation of basic beliefs and values. The predominant emotion in PTED is embitterment. This study presents first data on the psychopathological profile of PTED.

METHOD

48 inpatients were diagnosed by clinical judgment as suffering from PTED. Patients were then interviewed with the standardized Mini International Neuropsychiatric Interview (MINI) and an additional interview section on the diagnostic criteria for PTED. Patients also filled in the Symptom Checklist-90-Revision (SCL-90-R), and the Impact of Event Scale (IES-R).

RESULTS

According to the MINI68.8% of the patients fulfilled the criteria for adjustment disorders, 52.1% for major depression, 41.7% for dysthymia, and 35.4% for generalized anxiety disorders. 100% of patients reported that they were suffering from intrusive thoughts about the event. 97.9% of the patients complained about persistent negative mood, 91.7% about restlessness, 83.3% inhibition of drive and loss of interest, 77.1% phobic avoidance of places related to the event, and 75% resignation, but 91.7% reported normal mood when distracted. The SCL-90-R indicated a high load of general psychopathological complaints with an average positive symptom total score of 52.26. Characteristic were feelings of injustice (100%), embitterment (97.7%), and rage (91.7%). The IES-R scale indicated a high prevalence of posttraumatic stress, with an average total score of 3.23. The average duration of illness was 31.7 months.

CONCLUSIONS

The PTED patients are suffering from severe, multiform, and disabling symptoms. Their clinical features pose difficult diagnostic problems. The predominant complaints about feelings of injustice, embitterment, and rage and the results of the IES speak for the importance of the critical event for the development and understanding of such disorders.

Types of depression more frequent in bipolar than in unipolar affective illness: results of the Polish DEP-BI study

BACKGROUND

The aim of the study was to assess the relative frequency of various kinds of depression in patients with bipolar and unipolar affective illness. The study was performed in the framework of the DEP-BI project aimed at assessing the prevalence of bipolar disorders among depressive outpatients treated by psychiatrists in Poland.

METHODS

Eight-hundred and eighty patients (237 male, 643 female) participated in the study. The patients were classified into the following diagnostic categories: bipolar affective illness type I, type II, bipolar spectrum disorder and unipolar affective illness. The various kinds of depression in each group were assessed by means of a semistructured questionnaire added to the diagnostic interview.

RESULTS

In the group of bipolar patients, a significantly higher frequency of psychotic depression in male compared to female patients was observed. Male bipolar patients compared with unipolar depressed ones had significantly more episodes of psychotic depression (odds ratio, OR, 4.29) and atypical depression (hypersomnia and hyperphagia; OR 2.82), and those with bipolar spectrum had more episodes of treatment-resistant depression (OR 2.56). Female bipolar patients compared with unipolar depressed ones had significantly more frequently an early onset of depression (before 25 years; OR 2.95) and postpartum depression (OR 2.48). On the other hand, the percentage of agitation, irritability, distractibility, thought racing and panic attacks during depression was not different in patients with bipolar and unipolar affective illness either in males or females.

CONCLUSIONS

Some kinds of depression occur with a higher frequency in patients with bipolar compared to unipolar affective illness. The occurrence of a given type of depression may constitute an aid for the diagnosis of bipolar illness. The results of this study did not confirm the concept of bipolar mixed depression based on the presence of anxiety symptoms occurring during the depressive episode. The limitation of our study may be the lack of formal criteria or a structured interview to assess the symptoms occurring during depressive episodes.

Arousal of negative emotions and symptom-specific reactivity in chronic low back pain patients

Anger may have greater effects on chronic pain severity than other negative emotions and may do so by increasing muscle tension near the site of injury (symptom-specific reactivity). For patients with chronic low back pain (CLBP), relevant muscles are lower paraspinals (LP). Ninety-four CLBP patients and 79 controls underwent anger and sadness recall interviews. EMG and cardiovascular activity were recorded. Patients exhibited greater LP tension increases during anger and slower recovery than controls. Only patients showed greater LP reactivity during anger than sadness. For both groups, trapezius reactivity during anger and sadness did not differ. LP reactivity to anger correlated with everyday pain severity for patients. Anger-induced symptom-specific LP reactivity may be linked to chronic pain aggravation among CLBP patients.

Diagnosing major depressive disorder VIII: are some symptoms better than others?

The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.

Antidepressant treatments and human aggression

Aggressive behaviour is associated with negative mood and poor impulse control. Serotonin has been specifically associated with impulse regulation and deficiencies in serotonin have been linked to impulsive aggression. However, aggression occurs in a social context and noradrenaline has been implicated in social motivation. Both serotonergic and noradrenergic antidepressants may therefore be effective in reducing aggression. The evidence for the effects of antidepressants on aggression comes from a wide range of sources but there are few controlled trials or experimental studies. Current findings point to decreases in negative mood and anger attacks and positive changes in personality traits after antidepressant treatment. Clinical studies in personality disorder patients have shown some efficacy for serotonergic antidepressants in reducing irritability and impulsive aggression. Experimental work in healthy volunteers has shown both serotonergic and noradrenergic antidepressants to increase assertiveness and affiliative behaviour. Both may therefore decrease aggression through different routes.