Overt Irritability/Anger in Unipolar Major Depressive Episodes Past and Current Characteristics and Implications for Long-term Course
ABSTRACT IMPORTANCE Although symptoms of irritability or anger are not central to the diagnosis of unipolar major depressive episodes (MDEs), these symptoms have been found, in cross-sectional studies, to be highly prevalent and associated with increased comorbidity and depressive illness burden. OBJECTIVE To determine the prevalence of overtly expressed irritability/anger and its effect on intake presentation and the long-term course of illness. DESIGN A prospective, naturalistic investigation of patients with unipolar MDEs, studied systematically at intake and during up to 31 years of follow-up. SETTING Five US academic medical centers. PARTICIPANTS Patients entered the National Institute of Mental Health Collaborative Depression Study during an MDE in 1978, 1979, 1980, or 1981. Patients with unipolar MDE at intake (n = 536) were divided into those with and those without current comorbid overtly expressed irritability/anger. EXPOSURE In this observational, longitudinal study, patients received treatment that was recorded but not controlled. MAIN OUTCOMES AND MEASURES Groups were compared on illness severity and chronicity, psychosocial impairment, quality of life, suicidal behavior, lifetime comorbid diagnoses, impulse control, and measures associated with bipolarity. RESULTS Overt irritability/anger was present in 292 of 536 participants with a unipolar MDE at study intake (54.5%). It was associated with significantly increased depressive severity, longer duration of the index MDE, poorer impulse control, a more chronic and severe long-term course of illness, higher rates of lifetime comorbid substance abuse and anxiety disorder, more antisocial personality disorders, greater psychosocial impairment before intake and during follow-up, reduced life satisfaction, and a higher rate of bipolar II disorder in relatives. No association was found with increased suicidal ideation or behavior. Results were not explained by comorbidity or other manic spectrum symptoms. CONCLUSIONS AND RELEVANCE This study extends results of cross-sectional investigations and indicates that irritability/anger during MDEs is a highly prevalent clinical marker of a more severe, chronic, and complex depressive illness. Findings have important implications for assessment and treatment.
SourceAvailable from: Gustavo Vazquez[Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND: Long-term symptomatic status in persons with major depressive and bipolar disorders treated clinically is not well established, although mood disorders are leading causes of disability worldwide. AIMS: To pool data on long-term morbidity, by type and as a proportion of time-at-risk, based on published studies and previously unreported data. METHODS: We carried out systematic, computerized literature searches for information on percentage of time in specific morbid states in persons treated clinically and diagnosed with recurrent major depressive or bipolar I or II disorders, and incorporated new data from one of our centers. RESULTS: We analyzed data from 25 samples involving 2479 unipolar depressive and 3936 bipolar disorder subjects (total N=6415) treated clinically for 9.4 years. Proportions of time ill were surprisingly and similarly high across diagnoses: unipolar depressive (46.0%), bipolar I (43.7%), and bipolar II (43.2%) disorders, and morbidity was predominantly depressive: unipolar (100%), bipolar-II (81.2%), bipolar-I (69.6%). Percent-time-ill did not differ between UP and BD subjects, but declined significantly with longer exposure times. CONCLUSIONS: The findings indicate that depressive components of all major affective disorders accounted for 86% of the 43-46% of time in affective morbidity that occurred despite availability of effective treatments. These results encourage redoubled efforts to improve treatments for depression and adherence to their long-term useJournal of Affective Disorders 03/2015; 3(178):71-78. DOI:10.1016/j.jad.2015.02.011. · 3.71 Impact Factor
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ABSTRACT: Most measures of depression severity are based on the number of reported symptoms, and threshold scores are often used to classify individuals as healthy or depressed. This method – and research results based on it – are valid if depression is a single condition, and all symptoms are equally good severity indicators. Here, we review a host of studies documenting that specific depressive symptoms like sad mood, insomnia, concentration problems, and suicidal ideation are distinct phenomena that differ from each other in important dimensions such as underlying biology, impact on impairment, and risk factors. Furthermore, specific life events predict increases in particular depression symptoms, and there is evidence for direct causal links among symptoms. We suggest that the pervasive use of sum-scores to estimate depression severity has obfuscated crucial insights and contributed to the lack of progress in key research areas such as identifying biomarkers and more efficacious antidepressants. The analysis of individual symptoms and their causal associations offers a way forward. We offer specific suggestions with practical implications for future research.BMC Medicine 04/2015; 13(72):1-11. DOI:10.1186/s12916-015-0325-4 · 7.28 Impact Factor
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ABSTRACT: Unlike adult major depressive disorder (MDD) which requires anhedonia or depressed mood for diagnosis, adolescent MDD can be sufficiently diagnosed with irritability in the absence of the former symptoms. In addition, the current Diagnostic and Statistical Manual of Mental Disorders (DSM) schema does not account for the interindividual variability of symptom severity among depressed adolescents. This practice has contributed to the high heterogeneity and diagnostic complexity of adolescent MDD. Here, we sought to examine relationships between two core symptoms of adolescent MDD - irritability and anhedonia, assessed both quantitatively and categorically - and other clinical correlates among depressed adolescents. Ninety adolescents with MDD (51 females), ages 12-20, were enrolled. Anhedonia and irritability scores were quantified by summing related items on the Children's Depression Rating Scale-Revised and the Beck Depression Inventory. Extremes of score distribution were defined as high or low irritability/anhedonia subgroups. A significance level of p=0.01 was set to adjust for the five comparisons. Despite all subjects exhibiting moderate to severe MDD, both irritability and anhedonia scores manifested a full and normally distributed severity range including the lowest values possible. However, only anhedonia severity was associated with more severe clinical outcomes, including greater overall illness severity (p<0.001), suicidality scores (p<0.001), episode duration (p=0.006), and number of MDD episodes (p=0.01). Similarly, only the high-anhedonia subgroup manifested more severe outcomes; specifically, greater illness severity (p<0.0001), number of MDD episodes (p=0.01), episode duration (p=0.01), and suicidality scores (p=0.0001). Our findings suggest the significance of anhedonia as a hallmark of adolescent MDD and the need to incorporate dimensional analyses. These data are preliminary, and future prospective studies are needed to better characterize the syndrome of adolescent MDD.Journal of child and adolescent psychopharmacology 03/2015; 25(3). DOI:10.1089/cap.2014.0105 · 3.07 Impact Factor