Hostility and recovery from melancholia

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.

Influence of Genetic Polymorphisms and Concomitant Anxiolytic Doses on Antidepressant Maintenance Doses in Japanese Patients with Depression

To prevent recurrent depression, patients should ideally continue treatment for >6 months with the antidepressant dose that effectively suppressed acute depressive symptoms. However, there are inter-individual differences in the antidepressant doses required to achieve response and maintenance. Therefore, this study was conducted to examine the role of clinical features, including genetic polymorphisms, on the antidepressant dose required for maintenance therapy in 82 Japanese patients with depression. We calculated the antidepressant dose using the imipramine equivalent scale and the dose of concomitant anxiolytics and hypnotics using the diazepam equivalent scale. The 82 participants were classified into two groups based on the median imipramine equivalent dose, and we examined the influence of patient characteristics and the presence of genetic polymorphisms of brain-derived neurotropic factor (BDNF; rs6265) and cyclic adenosine monophosphate responsive element-binding protein 1 (CREB1; rs2253306, rs4675690, rs769963) on the antidepressant maintenance dose. Using a multivariate logistic regression analysis, we found that the concomitant diazepam equivalent dose and presence of the CREB1 rs4675690 polymorphism were significantly associated with the antidepressant maintenance dose. We concluded that these factors influenced the antidepressant dose in maintenance therapy among Japanese patients with depression. However, further research is required in large cohorts.

Genotype distributions and allele frequencies of possible major depressive disorder-associated single nucleotide polymorphisms, cyclic adenosine monophosphate response element binding protein 1 rs4675690 and Piccolo rs2522833, in a Japanese population

It is known that the onset of major depressive disorder (MDD) would be associated with genetic factors. To investigate the susceptibility to psychiatric disorders, e.g. MDD, schizophrenia etc., it is necessary to compare the genetic differences of objective polymorphisms between in patients and in relative contol subjects. Recently, an increasing number of studies focused on the role of cyclic adenosine monophosphate response element binding protein 1 (CREB1) and Piccolo (PCLO) on MDD. However, there was no report about genetic characterization of polymorphisms in between MDD patients and healthy subjects in Japanese population. We analized genotype distributions and allele frequencies of CREB1 rs4675690 and PCLO rs2522833 polymorphisms in 267 Japanese subjects, respectively. In CREB1 rs4675690, C allele frequency (0.41) was lower than T allele (0.59). While in PCLO rs2522833, A allele frequency (0.45) was lower than C allele (0.55). Our findings may be useful for investigating the genetic factors concerning the susceptibility to MDD in Japanese population.

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.

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.

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

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

Dimensional psychopathology of depression: detection of an 'activation' dimension in unipolar depressed outpatients

BACKGROUND

Despite the high prevalence of bipolar spectrum disorders, most instruments currently available for the assessment of depression do not explore symptoms of 'activation' such as anger, irritability, aggressiveness, hostility, and psychomotor activation.

METHODS

Two samples of adults with unipolar depression were studied. They had no comorbid DSM-IV disorder, and they were free from antidepressant drugs. The first sample (n = 380) was assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. The second sample (n = 143) was assessed with the MMPI-2. Factor analysis was performed on SVARAD items and MMPI-2 clinical scales.

RESULTS

In both samples, we obtained a three-factor solution with factors interpreted as a depressive dimension, an anxious dimension, and an activation dimension. The latter dimension appeared to be clinically relevant in 20-27% of patients.

LIMITATIONS

The presence of a comorbid disorder may have been missed in some cases. Also, some bipolar II patients might have been misdiagnosed as unipolar and included in the study. Further, our findings apply only to a selected psychiatric population, and it should be tested whether they generalize to other settings of care and other countries.

CONCLUSIONS

Our results suggest that depressive mixed states are not rare even in patients diagnosed as unipolar, and that some unipolar patients might actually be 'pseudounipolar' and belong to the bipolar spectrum. More in general, our findings suggest that some depressed patients have prominent symptoms of activation that can easily go unnoticed using instruments that do not explore such symptoms. Detecting these symptoms has important treatment implications.

Relevance of anger and irritability in outpatients with major depressive disorder

INTRODUCTION

Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder.

METHODS

A total of 222 newly admitted consecutive outpatients with major depressive disorder (mean age 48.9 years, 64.4% females) were enrolled in the study. They had no comorbid axis I or II DSM-IV disorder, and they received no treatment with antidepressants in the preceding 2 months. They were assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. Principal component analysis was performed on SVARAD items.

RESULTS

We obtained a three-factor solution accounting for 47.4% of total variance. The factors were interpreted as 'anger/irritability', 'depression', and 'anxiety', respectively. The anger/irritability dimension was clinically relevant in 23% of patients. Anger/aggressiveness was especially frequent (21.6%), whereas psychomotor activation was infrequent (0.9%).

DISCUSSION

In depressive disorders, there are psychopathological dimensions other than depressed mood and anxiety that deserve greater clinical recognition and research. Our study suggests that one of these symptom clusters includes anger, irritability, aggressiveness, and hostility. The relevance of this dimension was not related to concurrent pharmacological treatment. Misdiagnosis of bipolar II disorder is also unlikely to explain our findings. Possibly, personality factors might at least partly explain the occurrence of anger and aggressiveness in several depressed patients. Attachment theory suggests that anger might also be conceived as part of the protest-despair-detachment reaction to a loss, either actual or symbolic.

Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common and impairing disorder. However, little is known about non-BDD symptoms and well-being in patients with this disorder. Seventy-five outpatients with DSM-IV BDD completed the Symptom Questionnaire, a validated self-report measure with four scales: depression, anxiety, somatic/somatization, and anger-hostility. Scores were compared to published norms for normal subjects and psychiatric outpatients. Participants in an open-label fluvoxamine trial completed the Symptom Questionnaire at baseline and endpoint. Compared to normal controls, BDD subjects had markedly elevated scores on all four scales, indicating severe distress and psychopathology. Compared to psychiatric patients, BDD subjects had higher scores on the depression, anxiety, and anger/hostility scales but not on the somatic/somatization scale. Scores on all scales significantly decreased with fluvoxamine. In conclusion, patients with BDD have markedly high levels of distress, are highly symptomatic, and have poor well-being in the domains of depression, anxiety, somatic symptoms, and anger-hostility. All of these symptoms significantly improved with fluvoxamine.

A theoretical reappraisal of mixed states: dysphoria as a third dimension

Mixed states are heterogeneous clinical entities difficult to define precisely. The stringent actual DSM IV criteria are unsatisfactory for current clinical use. Many frequently encountered mixed patients benefit without an accurate diagnosis from biological therapeutic interventions such as the introduction of mood stabilizers. We propose a brief review of the definition and characteristics of mixed states and propose a new approach to the typology of mixed states. Based on recent literature data, we add to the depressive and manic syndrome the concept of dysphoria as a third dimension. Integrating this three dimensional approach with recent factor analysis, we describe in addition to the DSM IV mixed state (type I) two new subtypes of mixed states (type IIM and IID). This new typology can give the clinician a more accurate understanding of the complex and polymorphous reality of mixed states and help him make more specific therapeutic interventions. These subtypes of mixed states will need validation through prospective clinical studies. Biological differences, differential outcome over time, and differential response to treatment will be important validation criteria.

Relation between myocardial infarction, depression, hostility, and death

OBJECTIVE

To examine the independent impact of major depression and hostility on mortality rate at 6 months and 12 months after discharge from the hospital in patients with a myocardial infarction.

METHOD

Three hundred thirty-one patients were prospectively evaluated for depression with a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. The Cook Medley Hostility Scale data were analyzed by chi(2) procedures for nominal and categoric data, and Student t test was used for continuous data types.

RESULTS

Depression was a significant predictor of death at 12 months (P =. 04) but not at 6 months (P =.08). Hostility was not found to be a predictor of death at 6 months or 12 months.

CONCLUSIONS

Major depression in patients hospitalized after myocardial infarction is a significant univariable predictor of death at 12 months, although it was not a statistically significant predictor after adjusting for other variables. Hostility is not a predictor of death. Prospective studies are needed to determine the impact of aggressive treatment of depression on post-myocardial infarction survival.

Anger and depressed affect: interindividual and intraindividual perspectives

The relation between anger and depressed affect was examined with both interindividual and intraindividual analyses. Seventy-seven undergraduate students completed the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and kept a psychological diary for 10 consecutive days. The diary included questions dealing with felt anger and expressed anger, and several measures of depressed affect. Only one of four correlational analyses between the number of days on which students reported feeling angry and aggregate measures of depression was significant. However, intraindividual analyses revealed that days on which students reported feeling angry were also days on which they reported higher levels of depressed affect. The tendency to attribute the cause of angry feelings to one's own actions was positively related to depressed affect. The tendency to inhibit expression of anger was positively related to the measure of depression.

Hostility changes following antidepressant treatment: relationship to stress and negative thinking

It is unclear whether changes in hostility following treatment are primarily related to improvement in depressive symptoms or are also closely associated with reductions in negative thinking or perceived stress. We evaluated 94 outpatients with major depression before and after eight weeks of fluoxetine treatment by administering the Symptom Questionnaire (SQ) Hostility Scale, the Hamilton Rating Scale for Depression (HAM-D), the Cognitions Questionnaire (CQ) and the Perceived Stress Scale (PSS). We observed significant elevations in scores on these questionnaires in depressed patients as compared to normal controls. Following treatment with fluoxetine, there was a statistically significant reduction in scores on all four questionnaires. We observed that changes in SQ Hostility were significantly positively related to changes in both depression severity and perceived stress, with these relationships remaining significant after adjusting for gender and baseline SQ Hostility. The relationship between SQ Hostility changes and reductions in negative thinking became significant only after adjusting for gender and baseline SQ hostility. Our results suggest that the marked decrease in hostility following antidepressant treatment is related to a reduction in depressive symptoms, stress levels and negative thinking.

Hostility and irritable mood in panic disorder with agoraphobia

Twenty patients suffering from panic disorder with agoraphobia were administered the hostility subscale of Kellner's Symptom Questionnaire and the irritability scales of Paykel's Clinical Interview for Depression and of Kellner's Anxiety Rating Scale before and after behavioral treatment of agoraphobia. A matched control group of normal subjects had the same assessments at two similar points in time. Hostility and irritable mood decreased and friendliness increased in patients with panic disorder after treatment; upon recovery, there were no significant differences in hostility between patients and controls, whereas such differences were striking during the illness. The results suggest that increased hostility and irritable mood may be symptoms of panic disorder and improve with the treatment of agoraphobia.

Anger and irritability

Although there have been many studies of violent behaviour, anger has been neglected as a subject of scientific and clinical investigation. Anger can be defined as an affective state experienced as the motivation to act in ways that warn, intimidate or attack those who are perceived as challenging or threatening. Anger is associated with sensitivity to the perception of challenges or heightened awareness of threats. Anger is likely to be closely associated with fear. Although anger is common in mental illnesses it is largely neglected, perhaps because of the social stigma attached to its expression.

Identifying the specific clinical actions of amitriptyline: interrelationships of behaviour, affect and plasma levels in depression

Despite increasing knowledge of the neurochemical bases of the action of the tricyclic drugs, little is known about the sequence of psychological effects which precede recovery in drug-responsive patients. This research was aimed at identifying the specific behavioural effects associated with the therapeutic action of amitriptyline in depression. The design involved measurement (post-hoc) of weekly changes in a severely depressed placebo-resistant group who recovered with drug treatment, compared with a group of similar patients treated for the equivalent four weeks, who showed minimal to no clinical response. The research strategy, in accordance with a dose-response paradigm, was to determine which of the early changes in emotion and behaviour found in treatment responders were systematically associated with plasma concentrations of amitriptyline or its major metabolite. Amitriptyline was found to act within seven days on the components of anxiety and on hostility in the responders, and on sleep disorder in all patients. After 12 to 14 days of treatment these effects increased, with improvements in other significant components distinguishing the responders from the non-responders. At the 12th to 14th treatment days when a steady state concentration of drug in plasma was approached, reductions in anxiety and hostility and in certain somatic components correlated significantly with plasma concentrations of amitriptyline. Implications of the findings for clarifying the specificity of clinical actions of the tricyclic drugs, and for understanding the psychobiological dynamics underlying rapid drug-induced recovery in depression, were explored.

Prodromal symptoms in primary major depressive disorder

Prodromal symptomatology was investigated, by means of a modified version of Paykel's Clinical Interview for Depression, in 15 outpatients at their first episode of primary major depressive disorder. Compared to normals, generalized anxiety and irritability were significantly more frequent. Impaired work and interests, fatigue, initial and delayed insomnia were also reported. Four patients who relapsed upon discontinuation of antidepressant treatment displayed the same prodromal symptomatology as in the initial episode.

Nonpsychotic patients referred to a consultation service

In order to examine characteristics of nondangerous and nonpsychotic patients referred to a consultation service, the authors administered self-rating scales and questionnaires to fifty referred medical patients and nonreferred controls. Recalled abuse in childhood appeared a stronger predictor for referral than some other commonly researched ones such as parental death, divorce or separation in childhood or recent losses. Anxiety, hostility and depression were significantly higher in referred patients, whereas hypochondriacal attitudes did not differ between the two groups. The findings appear to have implications for treatment.