Can Anhedonia Be Considered a Suicide Risk Factor? A Review of the Literature

Anhedonia Links Sleep Problems and Suicidal Thoughts: An Intensive Longitudinal Study in High-Risk Adolescents

Growing research indicates that sleep problems are a robust independent risk factor for suicidal thoughts and behaviors among youth. However, relatively little is known about how this risk is conferred. This study used an intensive longitudinal design to investigate anhedonia as a mechanism linking sleep problems and next-day suicidal thoughts in a clinically high-risk sample of adolescents. Adolescents (N = 48; Mage=14.96; 77.1% white, 64.6% female) completed an ecological momentary assessment (EMA) study design for 28 days following discharge from acute psychiatric care for suicide risk. Daily sleep diaries were used to assess prior night total sleep time and sleep onset latency. Ecological momentary assessment was used to assess anhedonia and suicidal thoughts up to six times per day. A series of multi-level structural equation models were used to examine facets of anhedonia as parallel mediators of the association between sleep problems and next-day suicidal thoughts. Significant direct effects were found between sleep problems and consummatory anhedonia, consummatory anhedonia and suicidal thoughts, and anticipatory anhedonia and suicidal thoughts. There were significant indirect (mediated) effects between sleep problems and next-day suicidal thoughts through consummatory anhedonia, but not anticipatory anhedonia. Findings provide initial evidence as to how sleep problems may confer risk for next-day suicidal thoughts- by increasing consummatory anhedonia. Future research is needed to replicate these findings in larger samples and investigate how modifying anhedonia may mitigate suicide risk in youth.

Anhedonia is associated with a specific depression profile and poor antidepressant response

BACKGROUND

Anhedonic features within major depressive disorder (MDD) have been associated with worse course and outcome and may predict nonresponse to treatment. However, a detailed clinical profile of anhedonia in MDD is still lacking.

MATERIALS AND METHODS

One thousand two hundred ninety-four patients with MDD were selected from the cross-sectional European multicenter Group for the Study of Resistant Depression study. Anhedonia was assessed through the Montgomery-Åsberg Depression Rating Scale anhedonia item "inability to feel." Clinical and demographic features were then analyzed.

RESULTS

The presence of anhedonia related to a distinct demographical (living alone) and clinical profile (thyroid diseases, diabetes, suicide risk, high number of previous depressive episodes, more severe MDD, and more frequent inpatient status). Furthermore, anhedonia was associated with nonresponse to treatment and treatment resistance, even after adjusting for confounding variables.

CONCLUSIONS

Our findings support the role of anhedonia as a modulating feature of MDD, being associated with a more severe depression profile. Moreover, anhedonic features are independent predictors of poor treatment response.

Transdiagnostic alterations in white matter microstructure associated with suicidal thoughts and behaviours in the ENIGMA Suicidal Thoughts and Behaviours consortium

Previous studies have suggested that alterations in white matter (WM) microstructure are implicated in suicidal thoughts and behaviours (STBs). However, findings of diffusion tensor imaging (DTI) studies have been inconsistent. In this large-scale mega-analysis conducted by the ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium, we examined WM alterations associated with STBs. Data processing was standardised across sites, and resulting WM microstructure measures (fractional anisotropy, axial diffusivity, mean diffusivity and radial diffusivity) for 25 WM tracts were pooled across 40 cohorts. We compared these measures among individuals with a psychiatric diagnosis and lifetime history of suicide attempt (n=652; mean age=35.4±14.7; female=71.8%), individuals with a psychiatric diagnosis but no STB (i.e., clinical controls; n=1871; mean age=34±14.8; female=59.8%), and individuals with no mental disorder diagnosis and no STB (i.e., healthy controls; n=642; mean age=29.6±13.1; female=62.9%). We also compared these measures among individuals with recent suicidal ideation (n=714; mean age=36.3±15.3; female=66.1%), clinical controls (n=1184; mean age=36.8±15.6; female=63.1%), and healthy controls (n=1240; mean age= 31.6±15.5; female=61.0%). We found subtle but statistically significant effects, such as lower fractional anisotropy associated with a history of suicide attempt, over and above the effect of psychiatric diagnoses. These effects were strongest in the corona radiata, thalamic radiation, fornix/stria terminalis, corpus callosum and superior longitudinal fasciculus. Effect sizes were small (Cohen's d < 0.25). Recent suicidal ideation was not associated with alterations in WM microstructure. This large-scale coordinated mega-analysis revealed subtle regional and global alterations in WM microstructure in individuals with a history of suicide attempt. Longitudinal studies are needed to confirm whether these alterations are a risk factor for suicidal behaviour.

The Use of Ketamine for the Treatment of Anhedonia in Depression

Anhedonia, a complex symptom rooted in deficits across reward processes, is primarily linked to depression and schizophrenia but transcends diagnostic boundaries across various mental disorders. Its presence correlates with poorer clinical outcomes, including an increased risk of suicide and diminished response to treatment. The neurobiological underpinnings of anhedonia remain incompletely understood despite advancements in biomarkers and imaging that contribute to deeper insights. Ketamine, known for its rapid-acting antidepressant properties, appears to possess antianhedonic effects through a mechanism of action not fully elucidated. This effect appears to be independent of its antidepressant properties. Explorations into alternative antianhedonic treatments have been underway, yet lingering questions persist, underscoring the imperative need for ongoing research to advance the field.

Sex differences in anhedonia in bipolar depression: a resting-state fMRI study

Previous studies about anhedonia symptoms in bipolar depression (BD) ignored the unique role of gender on brain function. This study aims to explore the regional brain neuroimaging features of BD with anhedonia and the sex differences in these patients. The resting-fMRI by applying fractional amplitude of low-frequency fluctuation (fALFF) method was estimated in 263 patients with BD (174 high anhedonia [HA], 89 low anhedonia [LA]) and 213 healthy controls. The effects of two different factors in patients with BD were analyzed using a 3 (group: HA, LA, HC) × 2 (sex: male, female) ANOVA. The fALFF values were higher in the HA group than in the LA group in the right medial cingulate gyrus and supplementary motor area. For the sex-by-group interaction, the fALFF values of the right hippocampus, left medial occipital gyrus, right insula, and bilateral medial cingulate gyrus were significantly higher in HA males than in LA males but not females. These results suggested that the pattern of high activation could be a marker of anhedonia symptoms in BD males, and the sex differences should be considered in future studies of BD with anhedonia symptoms.

Neurological, Metabolic, and Psychopathological Correlates of Lifetime Suicidal Behaviour in Major Depressive Disorder without Current Suicide Ideation

INTRODUCTION

Suicidal behaviour (SB) has a complex aetiology. Although suicidal ideation (SI) is considered the most important risk factor for future attempts, many people who engage in SB do not report it.

METHODS

We investigated neurological, metabolic, and psychopathological correlates of lifetime SB in two independent groups of patients with major depression (sample 1: n = 230; age: 18-65 years; sample 2: n = 258; age >60 years) who did not report SI during an index episode.

RESULTS

Among adults (sample 1), SB was reported by 141 subjects (58.7%) and severe SB by 33 (15%). After controlling for interactions, four risk factors for SB emerged: male gender (OR 2.55; 95% CI: 1.06-6.12), negative self-perception (OR 1.76; 95% CI: 1.08-2.87), subthreshold hypomania (OR 4.50; 95% CI: 1.57-12.85), and sexual abuse (OR 3.09; 95% CI: 1.28-7.48). The presence of at least two of these factors had the best accuracy in predicting SB: sensitivity = 57.6% (39.2-74.5); specificity = 75.1% (68.5-82.0); PPV = 27.9% (20.9-37.2); NPV = 91.4% (87.6-94.1). In older patients (sample 2), 23 subjects (9%) reported previous suicide attempts, which were characterized by earlier onset (25 years: OR 0.95: 0.92-0.98), impaired verbal performance (verbal fluency: OR 0.95: 0.89-0.99), higher HDL cholesterol levels (OR 1.04: 1.00-1.07) and more dyskinesias (OR 2.86: 1.22-6.70).

CONCLUSION

Our findings suggest that SB is common in major depressive disorder, even when SI is not reported. In these individuals it is feasible and recommended to investigate both psychiatric and organic risk factors. The predictive power of models excluding SI is comparable to that of models including SI.

Suicide ideation and male-female differences in major depressive disorder

OBJECTIVE

This study aimed to explore male-female differences in suicide ideation (SI) and suicide risk factors in major depressive disorder (MDD).

METHODS

We analysed 482 adults (sample 1) and 438 elderly outpatients (sample 2) with MDD. Sample 1 was treated with different antidepressant combinations (escitalopram; bupropion plus escitalopram; venlafaxine plus mirtazapine) and assessed by means of the Concise Health Risk Tracking (SI), Quick Inventory of Depressive Symptomatology, Altman Mania Rating Scale and Psychiatric Diagnostic Screening Questionnaire. Sample 2 was treated with venlafaxine and assessed using the Hamilton scale for depression, Anxiety Sensitivity Index and Penn State Worry Questionnaire for anxiety, Beck Scale for Suicide Ideation and Repeatable Battery for the Assessment of Neuropsychological Status.

RESULTS

In sample 1, females had greater depression severity (O.R 0.961 99%CI: 0.929 - 0.995), males reported more alcohol abuse (O.R 1.299 99%CI: 1.118 - 1.509) and active SI (O.R 1.109 99%CI: 1.005 - 1.255). In sample 2 men showed more severe SI (O.R 1.067; 99%CI: 1.014 - 1.122) and weight loss (OR = 5.89 99%CI: 1.01 - 34.19), women more gastrointestinal symptoms.

CONCLUSIONS

In these selected samples, although women had more severe depression, men had more suicide risk factors. Such differences might contribute to men's increased suicide risk.

Anhedonia in adolescents at transdiagnostic familial risk for severe mental illness: Clustering by symptoms and mechanisms of association with behavior

BACKGROUND

Anhedonia is a transdiagnostic symptom of severe mental illness (SMI) and emerges during adolescence. Possible subphenotypes and neural mechanisms of anhedonia in adolescents at risk for SMI are understudied.

METHODS

Adolescents at familial risk for SMI (N = 81) completed anhedonia (e.g., consummatory, anticipatory, social), demographic, and clinical measures and one year prior, a subsample (N = 46) completed fMRI scanning during a monetary reward task. Profiles were identified using k-means clustering of anhedonia type and differences in demographics, suicidal ideation, impulsivity, and emotional processes were examined. Moderation analyses were conducted to investigate whether levels of brain activation of reward regions moderated the relationships between anhedonia type and behaviors.

RESULTS

Two-clusters emerged: a high anhedonia profile (high-anhedonia), characterized by high levels of all types of anhedonia, (N = 32) and a low anhedonia profile (low-anhedonia), characterized by low levels of anhedonia types (N = 49). Adolescents in the high-anhedonia profile reported more suicidal ideation and negative affect, and less positive affect and desire for emotional closeness than low-anhedonia profile. Furthermore, more suicidal ideation, less positive affect, and less desire for emotional closeness differentiated the familial high-risk, high-anhedonia profile adolescents from the familial high-risk, low-anhedonia profile adolescents. Across anhedonia profiles, moderation analyses revealed that adolescents with high dmPFC neural activation in response to reward had positive relationships between social, anticipatory, and consummatory anhedonia and suicidal ideation.

LIMITATIONS

Small subsample with fMRI data.

CONCLUSION

Profiles of anhedonia emerge transdiagnostically and vary on clinical features. Anhedonia severity and activation in frontostriatal reward areas have value for clinically important outcomes such as suicidal ideation.

The presence of anhedonia in individuals with subacute and chronic stroke: an exploratory cohort study

Background

Anhedonia refers to the diminished capacity to experience pleasure. It has been described both as a symptom of depression and an enduring behavioral trait that contributes its development. Specifically, in stroke patients, anhedonia has been closely linked to depression, resulting in reduced sensitivity to everyday pleasures and intrinsic motivation to engage in rehabilitation programs and maintain a healthy active lifestyle. This condition may hinder patients' recovery, diminishing their autonomy, functioning, and quality of life.

Objective

We aimed to explore the prevalence and level of anhedonia and those variables that might be associated in patients with both ischemic and hemorrhagic stroke at subacute and chronic phases of the disease.

Methods

We conducted an exploratory cohort study with a sample of 125 patients with subacute and chronic stroke presenting upper-limb motor deficits. We measured participants' level of anhedonia with four items from the Beck Depression Inventory-II that describe the symptoms of this condition: loss of pleasure, loss of interest, loss of energy, and loss of interest in sex. We also collected demographic and clinical information and evaluated motor and cognitive functions as well as levels of depression, apathy, and various mood states. The results were compared to a sample of 71 healthy participants of similar age, sex, and level of education.

Results

Stroke patients demonstrated a significantly higher prevalence (18.5-19.7%) and level of anhedonia compared to the healthy controls (4.3%), regardless of stroke phase, level of motor impairment, and other clinical variables. Furthermore, post-stroke anhedonia was associated with lower levels of motivation and higher levels of negative mood states such as fatigue and anger in the long term. Importantly, anhedonia level was superior in stroke patients than in healthy controls while controlling for confounding effects of related emotional conditions.

Conclusion

This study provides novel evidence on the prevalence, level and factors related to anhedonia post-stroke. We emphasize the importance of assessing and treating anhedonia in this population, as well as conducting large-scale cohort and longitudinal studies to test its influence on long-term functional and emotional recovery.

Ecological Momentary Assessment of Social Approach and Avoidance Motivations in Serious Mental Illness: Connections to Suicidal Ideation and Symptoms

AIM

People with serious mental illness (SMI) are at an increased risk for suicide. Social approach and avoidance motivations are linked to social functioning, and social isolation is a risk factor for suicide. This study uses ecological momentary assessment (EMA) to understand social approach and avoidance motivations in relation to symptoms and suicidal ideation (SI).

METHODS

Participants (N = 128) diagnosed with schizophrenia, schizoaffective disorder, or a mood disorder with psychotic features completed assessments of SI and symptoms at baseline. They completed EMA surveys 3×/day for 10 days. EMA surveys included questions about approach and avoidance motivations and psychotic symptoms. Participants were split into four groups based on the median scores of approach and avoidance.

RESULTS

Participants with SI at baseline had higher mean social avoidance motivation, t(126) = 2.84, p = .003, and lower mean social approach motivation, t(126) = -2.44, p = .008, than participants without baseline SI. Greater baseline positive symptoms were related to greater mean avoidance, r = .231, p = .009, but not approach motivation. The low approach/high avoidance group had significantly higher current SI than those with high approach/low avoidance (p < .001). Overall, the low approach/high avoidance group reported more EMA-measured voices than the low approach/low avoidance group (p < .001) and the high approach/low avoidance group (p < .001). Similarly, the low approach/high avoidance group reported more EMA-measured suspiciousness than the low approach/low avoidance (p < .001) and the high approach/low avoidance groups (p < .001).

CONCLUSION

The results of this study point to the role of social approach and avoidance motivations in relation to SI and psychotic symptoms. Clinically, exposure therapies and cognitive behavioral therapies may help to address these social approach and avoidance processes linked to SI.

A feasibility study of goal-directed network-based real-time fMRI neurofeedback for anhedonic depression

Anhedonia is a hallmark symptom of depression that often lacks adequate interventions. The translational gap remains in clinical treatments based on neural substrates of anhedonia. Our pilot study found that depressed individuals depended less on goal-directed (GD) reward learning (RL), with reduced reward prediction error (RPE) BOLD signal. Previous studies have found that anhedonia is related to abnormal activities and/or functional connectivities of the central executive network (CEN) and salience network (SN), both of which belong to the goal-directed system. In addition, it was found that real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback (NF) could improve the balance between CEN and SN in healthy individuals. Therefore, we speculate that rt-fMRI NF of the CEN and SN associated with the GD system may improve depressive and/or anhedonic symptoms. Therefore, this study (1) will examine individuals with anhedonic depression using GD-RL behavioral task, combined with functional magnetic resonance imaging and computational modeling to explore the role of CEN/SN deficits in anhedonic depression; and (2) will utilize network-based rt-fMRI NF to investigate whether it is feasible to regulate the differential signals of brain CEN/SN of GD system through rt-fMRI NF to alleviate depressive and/or anhedonic symptoms. This study highlights the need to elucidate the intervention effects of rt-fMRI NF and the underlying computational network neural mechanisms.

Relations among symptoms of depression over time in at-risk youth

Depression consists of symptoms that may relate to each other in ways that go beyond simple co-occurrence. For example, some symptoms may precede and possibly contribute to the emergence of others. The present study examined several potential relations among the symptoms of depression. The overarching goals were to better understand how depression may unfold and to identify potential targets for intervention. The sample included 120 offspring of depressed parents. Youths' symptoms of depression were rated across 89 weeks. First, we investigated which symptoms preceded and potentially contributed to other symptoms 1 week later. This model revealed that sleep disturbance predicted the occurrence of other symptoms (e.g., sad mood, fatigue), and the occurrence of sad mood was predicted by other symptoms (e.g., worthlessness/guilt, psychomotor symptoms, sleep disturbance). Second, we investigated the within-person question of which symptoms tended to co-occur at the same time point. This model identified sad mood, irritability, and anhedonia as symptoms that tended to co-occur with each other and with many other depressive symptoms. Third, we investigated the between-person question of which symptoms tended to co-occur when averaged across time. This model identified worthlessness/guilt, fatigue, and anhedonia as symptoms strongly associated with other depressive symptoms across people irrespective of timing. Results indicate that the relations among the symptoms of depression vary, such that some symptoms preceded others by 1 week, some symptoms occurred at the same time, and other symptoms co-occurred in individuals. This more detailed view of the connections among depressive symptoms informs our understanding of depression as a dynamic set of unique indicators. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Anhedonia and Depressive Disorders

Anhedonia is a core symptom of depression and of several psychiatric disorders. Anhedonia has however expanded from its original definition to encompass a spectrum of reward processing deficits that received much interest in the last decades. It is a relevant risk factor for possible suicidal behaviors, and that it may operate as an independent risk factor for suicidality apart from the episode severity. Anhedonia has also been linked to inflammation with a possible reciprocal deleterious effect on depression. Its neurophysiological bases mainly include alterations in striatal and prefrontal areas, with dopamine being the most involved neurotransmitter. Anhedonia is thought to have a significant genetic component and polygenic risk scores are a possible tool for predicting an individual's risk for developing anhedonia. Traditional antidepressants, such as selective serotonin reuptake inhibitors, showed a limited benefit on anhedonia, also considering their potential pro-anhedonic effect in some subjects. Other treatments may be more effective in treating anhedonia, such as agomelatine, vortioxetine, ketamine and transcranial magnetic stimulation. Psychotherapy is also widely supported, with cognitive-behavioral therapy and behavioral activation both showing benefit. In conclusion, a large body of evidence suggests that anhedonia is, at least partially, independent from depression, therefore it needs careful assessment and targeted treatment.

Non-canonical pathways in the pathophysiology and therapeutics of bipolar disorder

Bipolar disorder (BD) is characterized by extreme mood swings ranging from manic/hypomanic to depressive episodes. The severity, duration, and frequency of these episodes can vary widely between individuals, significantly impacting quality of life. Individuals with BD spend almost half their lives experiencing mood symptoms, especially depression, as well as associated clinical dimensions such as anhedonia, fatigue, suicidality, anxiety, and neurovegetative symptoms. Persistent mood symptoms have been associated with premature mortality, accelerated aging, and elevated prevalence of treatment-resistant depression. Recent efforts have expanded our understanding of the neurobiology of BD and the downstream targets that may help track clinical outcomes and drug development. However, as a polygenic disorder, the neurobiology of BD is complex and involves biological changes in several organelles and downstream targets (pre-, post-, and extra-synaptic), including mitochondrial dysfunction, oxidative stress, altered monoaminergic and glutamatergic systems, lower neurotrophic factor levels, and changes in immune-inflammatory systems. The field has thus moved toward identifying more precise neurobiological targets that, in turn, may help develop personalized approaches and more reliable biomarkers for treatment prediction. Diverse pharmacological and non-pharmacological approaches targeting neurobiological pathways other than neurotransmission have also been tested in mood disorders. This article reviews different neurobiological targets and pathophysiological findings in non-canonical pathways in BD that may offer opportunities to support drug development and identify new, clinically relevant biological mechanisms. These include: neuroinflammation; mitochondrial function; calcium channels; oxidative stress; the glycogen synthase kinase-3 (GSK3) pathway; protein kinase C (PKC); brain-derived neurotrophic factor (BDNF); histone deacetylase (HDAC); and the purinergic signaling pathway.

Suicidal Ideations in Major Depressed Subjects: Role of the Temporal Dynamics of Anhedonia

Given the limited data available in the literature, the aim of this study was to investigate the potential role played by the temporal dynamics of anhedonia (lifelong anhedonia and recent changes in anhedonia) in the occurrence of suicidal ideations in major depressed subjects. The clinical data of 285 major depressed subjects recruited from the database of the Erasme Hospital Sleep Laboratory were analyzed. A score on item nine of the Beck Depression Inventory (BDI-II) ≥1 and/or an identification during the systematic psychiatric assessment were used to determine the presence of suicidal ideations. The association between anhedonia complaints (lifelong anhedonia and recent change in anhedonia) and suicidal ideations in major depressed subjects was assessed by logistic regression analyzes. The prevalence of suicidal ideations was 39.3% in our sample of major depressed subjects. After adjusting for the main confounding factors, multivariate logistic regression analysis demonstrated that unlike lifelong anhedonia, only recent changes in anhedonia were a risk factor for suicidal ideations in major depressed subjects. Given this potential involvement of the recent change in anhedonia in the occurrence of suicidal ideations in major depressed subjects, it seems essential to better identify and adequately manage this specific form of anhedonia in order to open new perspectives for the prevention of suicide in this particular sub-population.

Anhedonia and suicidal ideation in young people with early psychosis: Further findings from the 2-year follow-up of the ReARMS program

Hedonic deficits have been extensively studied in schizophrenia, but little is known about their association with suicidal ideation in early psychosis. The aim of this research was to examine the relationship between anhedonia and suicidal thoughts across a 2-year follow-up period in people with First Episode Psychosis (FEP) and at Ultra High Risk (UHR) of psychosis. Ninty-six UHR and 146 FEP, aged 13-35 years, completed the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Beck Depression Inventory-II (BDI-II). The BDI-II "Anhedonia" subscale score to assess anhedonia and the CAARMS "Depression" item 7.2 subscore to measure depression were used across the 2 years of follow-up. Hierarchical regression analyses were performed. No difference in anhedonia scores between FEP and UHR individuals was found. In the FEP group, a significant enduring association between anhedonia and suicidal ideation was found at baseline and across the follow-up, independent of clinical depression. In the UHR subgroup, the enduring relationship between anhedonia and suicidal thoughts were not completely independent from depression severity. Anhedonia is relevant in predicting suicidal ideation in early psychosis. Specific pharmacological and/or psychosocial interventions on anhedonia within specialized EIP program could reduce suicide risk overtime.

Longitudinal associations among dimensional symptoms of depression and anxiety and first onset suicidal ideation in adolescents

INTRODUCTION

Depression and anxiety are implicated in suicide risk, but the contributionof specific symptom dimensions within these disorders is not well understood. The present study examined longitudinal associations of transdiagnostic symptoms (General Distress[GD]) and unique symptom dimensions (Anhedonia-Apprehension [AA], Fears, and Narrow Depression [ND]) of depression and anxiety and suicidal ideation (SI).

METHODS

Data from 551 adolescents oversampled on high neuroticism were examined in a series of discrete-time survival analyses to predict first SI onset over an 8-year period.

RESULTS

Results indicate that GD, AA, and ND were independent predictors of increased likelihood of SI onset and remained significant when controlling for effects of fears. Furthermore, AA and GD remained significant when controlling for one another. ND effects reduced by 24% when adjusting for AA and 74% when adjusting for GD. Fears did not significantly predict SI onset.

CONCLUSION

Results suggest that broad levels of distress across depression and anxiety, deficits in positive affect, and elevated negative affect specific to depression increase the likelihood of suicidal thoughts. As such, attention to broader distress and a lack of pleasure, interest, and motivation-potentially more so than negative affect characterizing depression-are particularly important for addressing suicide risk in adolescents.

Suicide ideation and anhedonia among clinically stable adolescents with the recurrent depressive disorder during the COVID-19 pandemic: A network perspective

BACKGROUND

Anhedonia is a suicide risk factor among adolescent patients with recurrent depressive disorder (depression hereafter). This study examined associations between suicidal ideation (SI) and residual depressive symptoms (RSD), including anhedonia, among clinically stable adolescents with depression.

METHOD

A network analysis was performed to examine the association between RDS and SI among adolescents with depression. Node-specific predictive betweenness was computed to examine short paths between anhedonia and SI. Additionally, a Network Comparison Test (NCT) was conducted to examine gender differences in derived network model characteristics.

RESULTS

The network analysis identified close associations of PHQ9 ("Suicide ideation") with PHQ1 ("Anhedonia") as well as some other RDS including PHQ6 ("Guilt"), PHQ2 ("Sad mood") and PHQ8 ("Motor disturbances"). Additionally, PHQ2 ("Sad mood") and PHQ4 ("Fatigue") were the main bridge nodes linking anhedonia and SI. Comparisons of network models did not find significant differences in network global strength or edge weights.

LIMITATION

Causal relations between anhedonia and SI could not be determined due to the cross-sectional study design.

CONCLUSIONS

SI was directly related to Anhedonia in addition to Guilt, Sad mood and Motor disturbances. Sad mood and Fatigue were the main bridge nodes linking Anhedonia and SI. To reduce the risk of SI among clinically stable adolescents with depression during the COVID-19 pandemic, specific RDS including Anhedonia, Guilt, Sad mood, Motor disturbances and Fatigue should be targeted in interventions.

Evaluating Anhedonia as a risk factor in suicidality: A meta-analysis

Previous studies have evaluated the relationship between anhedonia and suicidality; however, to our knowledge, there has been no quantitative synthesis evaluating the foregoing association to date. Herein, this meta-analysis aims to provide a quantitative synthesis of the extant literature reporting on the association between levels of anhedonia across all dimensions (e.g., anticipatory, consummatory) amongst individuals endorsing suicidality. Online databases (i.e., PubMed, PsycINFO, Google Scholar) were searched from inception to 13 June 2022. Studies which assessed an aspect of suicidality (i.e., ideation, attempts) and a validated anhedonia scale were included. The risk of bias was assessed using the ROBINS-1 tool, and the quality of the sources was evaluated using GRADE criteria. The results of the studies were quantitatively synthesized using Pearson's r effect sizes via a random-effects meta-analysis. A total of 20 studies and 11,212 individuals were included in the final quantitative synthesis. Overall, results indicate that anhedonia has a significant and moderate correlation with suicidality in general and psychiatric populations (r = 0.31, p < 0.001 and r = 0.32, p < 0.001 respectively). Sub-analysis suggests a larger effect of anticipatory and consummatory interpersonal anhedonia (r = 0.40, p < 0.001). The identification of increased levels of anhedonia in individuals with suicidality indicates that anhedonia may be a core risk factor for suicidal ideation and behaviours. Future studies should endeavour to develop a comprehensive risk assessment encompassing all domains of anhedonia which can be utilized in a primary care setting as a potential prevention strategy for suicidal behaviours and outcomes.

Sucrose Preference Test as a Measure of Anhedonic Behavior in a Chronic Unpredictable Mild Stress Model of Depression: Outstanding Issues

Despite numerous studies on the neurobiology of depression, the etiological and pathophysiological mechanisms of this disorder remain poorly understood. A large number of animal models and tests to evaluate depressive-like behavior have been developed. Chronic unpredictable mild stress (CUMS) is the most common and frequently used model of depression, and the sucrose preference test (SPT) is one of the most common tests for assessing anhedonia. However, not all laboratories can reproduce the main effects of CUMS, especially when this refers to a decrease in sucrose preference. It is also unknown how the state of anhedonia, assessed by the SPT, relates to the state of anhedonia in patients with depression. We analyzed the literature available in the PubMed database using keywords relevant to the topic of this narrative review. We hypothesize that the poor reproducibility of the CUMS model may be due to differences in sucrose consumption, which may be influenced by such factors as differences in sucrose preference concentration threshold, water and food deprivation, and differences in animals’ susceptibility to stress. We also believe that comparisons between animal and human states of anhedonia should be made with caution because there are many inconsistencies between the two, including in assessment methods. We also tried to offer some recommendations that should improve the reproducibility of the CUMS model and provide a framework for future research.

Negative Allosteric Modulation of Gamma-Aminobutyric Acid A Receptors at α5 Subunit-Containing Benzodiazepine Sites Reverses Stress-Induced Anhedonia and Weakened Synaptic Function in Mice

BACKGROUND

Abnormal reward processing, typically anhedonia, is a hallmark of human depression and is accompanied by altered functional connectivity in reward circuits. Negative allosteric modulators of GABA_A (gamma-aminobutyric acid A) receptors (GABA-NAMs) have rapid antidepressant-like properties in rodents and exert few adverse effects, but molecular targets underlying their behavioral and synaptic effects remain undetermined. We hypothesized that GABA-NAMs act at the benzodiazepine site of GABA_A receptors containing α5 subunits to increase gamma oscillatory activity, strengthen synapses in reward circuits, and reverse anhedonia.

METHODS

Anhedonia was induced by chronic stress in male mice and assayed by preferences for sucrose and female urine (n = 5-7 mice/group). Hippocampal slices were then prepared for electrophysiological recording (n = 1-6 slices/mouse, 4-6 mice/group). Electroencephalography power was quantified in response to GABA-NAM and ketamine administration (n = 7-9 mice/group).

RESULTS

Chronic stress reduced sucrose and female urine preferences and hippocampal temporoammonic-CA1 synaptic strength. A peripheral injection of the GABA-NAM MRK-016 restored hedonic behavior and AMPA-to-NMDA ratios in wild-type mice. These actions were prevented by pretreatment with the benzodiazepine site antagonist flumazenil. MRK-016 administration increased gamma power over the prefrontal cortex in wild-type mice but not α5 knockout mice, whereas ketamine promoted gamma power in both genotypes. Hedonic behavior and AMPA-to-NMDA ratios were only restored by MRK-016 in stressed wild-type mice but not α5 knockout mice.

CONCLUSIONS

α5-Selective GABA-NAMs exert rapid anti-anhedonic actions and restore the strength of synapses in reward regions by acting at the benzodiazepine site of α5-containing GABA_A receptors. These results encourage human studies using GABA-NAMs to treat depression by providing readily translatable measures of target engagement.

Suicidal Depression in Ancient Egypt

OBJECTIVE

To evaluate the oldest record of a depressed individual contemplating suicide.

METHOD

A directed review of ancient Egyptology literature of translations and discussion regarding a papyrus that is approximately 4,000 years old.

RESULTS

The content of the document is consistent with a man going through a severe depression and is contemplating suicide. However, this does not appear to be a suicide note, but more of an ancient example of 'journaling' or working through the thoughts of suicide and its possible consequences to the man's eternal life in the afterworld.

CONCLUSIONS

Presentation of depression, the reasons for considering suicide, and the process by which an individual works through those thoughts have not varied significantly over the past 4,000 years.

The effect of ketamine on anhedonia: improvements in dimensions of anticipatory, consummatory, and motivation-related reward deficits

Anhedonia is a common, persistent, and disabling condition. However, available therapeutics primarily focus on the reduction of depressive and negative symptoms rather than amelioration of deficits in positive affect. As such, extant drug treatments remain largely ineffective in treating symptoms of anhedonia. Ketamine is a rapid-acting and novel therapeutic treatment for treatment-resistant depression, which has also been demonstrated to attenuate symptoms of anhedonia. However, the literature on the anti-anhedonic effects of ketamine is limited-especially within independent dimensions of this symptom domain. Herein, this review examined the impact of ketamine treatment on anhedonia and its dimensions on anticipatory, consummatory, and motivation-related reward deficits. Overall, the findings have shown a trend towards symptom reduction and/or improvements in anhedonia and their respective subdomains, in both human and preclinical studies, as well as its potential to provide additional benefit in reducing suicidality and improving quality-of-life. Although further research is required in understanding the long-term efficacy and mechanism, ketamine may provide an effective and rapid-acting therapeutic in an otherwise unmet domain.

Effects of stress on endophenotypes of suicide across species: A role for ketamine in risk mitigation

Suicide is a leading cause of death and morbidity worldwide, yet few interventions are available to mitigate its risk. Barriers to effective treatments involve a limited understanding of factors that predict the onset of suicidal thoughts and behaviors. In the context of suicide risk, stress is a precipitating factor that is largely overlooked in the literature. Indeed, the pathophysiology of stress and suicide are heavily interconnected, underscoring the need to target the stress system in suicide prevention. In this review, we integrate findings from the preclinical and clinical literature that links stress and suicide. We focus specifically on the effects of stress on underlying biological functions and processes associated with suicide, allowing for the review of research using animal models. Owing to the rapid anti-suicidal effects of (R,S)-ketamine, we discuss its ability to modulate various stress-related endophenotypes of suicide, as well as its potential role in preventing suicide in those with a history of chronic life stress (e.g., early life adversity). We highlight future research directions that could advance our understanding of stress-related effects on suicide risk, advocating a dimensional, endophenotype approach to suicide research.

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Suicide and chronic stress pathophysiology are interconnected.

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Chronic stress has profound impacts on several endophenotypes of suicide.

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Animal and human research points to stress as a precipitating factor in suicide.

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Ketamine modulates specific biological processes associated with stress and suicide.

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Suicide research into endophenotypes can help inform risk-mitigation strategies.

Anhedonia and Suicide

Suicide is a leading cause of death, and presently, there is no definitive clinical indicator of future suicide behaviors. Anhedonia, a transdiagnostic symptom reflecting diminished ability to experience pleasure, has recently emerged as a risk factor for suicidal thoughts and behaviors (STBs). This overview, therefore, has the following aims. First, prior research relating anhedonia to STBs will be reviewed, with a particular focus on clarifying whether anhedonia is more closely associated with suicidal thoughts versus behaviors. Second, the National Institute of Mental Health's Research Domain Criteria Positive Valence Systems provide a useful heuristic to probe anhedonia across different units of analysis, including clinical symptoms, behaviors, neural mechanisms, and molecular targets. Accordingly, anhedonia-related constructs linked to STBs will be detailed as well as promising next steps for future research. Third, although anhedonia is not directly addressed in leading suicide theories, this review will provide potential inroads to explore anhedonia within diathesis-stress and interpersonal suicide frameworks. Last, novel approaches to treat anhedonia as a means of reducing STBs will be examined.

Toward a Quantification of Anhedonia: Unified Matching Law and Signal Detection for Clinical Assessment and Drug Development

Anhedonia, the loss of pleasure from previously rewarding activities, is a core symptom of several neuropsychiatric conditions, including major depressive disorder (MDD). Despite its transdiagnostic relevance, no effective therapeutics exist to treat anhedonia. This is due, in part, to inconsistent assays across clinical populations and laboratory animals, which hamper treatment development. To bridge this gap, recent work has capitalized on two long-standing research domains dedicated to quantifying responsivity to antecedents and consequences across species: the generalized matching law and signal detection theory. This review traces the integration of these quantitative frameworks, which yielded two empirically derived metrics: response bias (log b) and task discriminability (log d). These metrics serve as primary dependent variables in the Probabilistic Reward Task (PRT). In this computerized task, subjects make visual discriminations and probabilistic contingencies are arranged such that correct responses to one alternative are rewarded more often (rich) than correct responses to the other (lean). Under these conditions, healthy participants consistently develop a response bias in favor of the rich alternative, whereas participants with MDD exhibit blunted biases, which correlate with current and predict future anhedonia. Given the correspondence between anhedonic phenotypes and response bias, the PRT has been reverse-translated for rodents and nonhuman primates. Orderly log b and log d values have been observed across diverse clinical populations and laboratory animals. In addition, pharmacological challenges have produced similar outcomes across species. Taken together, this quantitative framework offers a highly translational approach to assaying reward responsiveness to accelerate treatment development for neuropsychiatric disorders involving anhedonia.

Effects of transcranial magnetic stimulation on anhedonia in treatment resistant major depressive disorder

BACKGROUND

Anhedonia is one of the defining features of depression but it remains difficult to target and treat. Transcranial magnetic stimulation (TMS) is a proven treatment for depression, but its effects on anhedonia and whether anhedonia can be used as a predictive biomarker of response is not well known.

METHODS

Snaith-Hamilton Pleasure Scale was administered to patients with depression before and after a standard course of TMS in a naturalistic outpatient setting.

RESULTS

144 patients were analyzed. There was an overall significant improvement in anhedonia from pre- to post-treatment (7.69 ± 3.88 vs. 2.96 ± 3.45; p < .001). Significant correlations between improvements in anhedonia and other depressive symptoms were present (r = 0.55, p < .001). Logistic regression revealed that baseline anhedonia severity was not a significant predictor of clinical outcome.

CONCLUSION

This is the first large, naturalistic study examining the effects of standard, non-research TMS on anhedonia. Among depressed patients, TMS resulted in significant improvements in anhedonia. Patients with severe baseline anhedonia had an equal chance of achieving clinical response/remission. Patients with anhedonia should not be excluded from treatment if they are safe for outpatient care and otherwise appropriate candidates for treatment.

Translational Assessments of Reward Responsiveness in the Marmoset

BACKGROUND

Anhedonia, the loss of pleasure in previously rewarding activities, is a prominent feature of major depressive disorder and often resistant to first-line antidepressant treatment. A paucity of translatable cross-species tasks to assess subdomains of anhedonia, including reward learning, presents a major obstacle to the development of effective therapeutics. One assay of reward learning characterized by orderly behavioral and pharmacological findings in both humans and rats is the probabilistic reward task. In this computerized task, subjects make discriminations across numerous trials in which correct responses to one alternative are rewarded more often (rich) than correct responses to the other (lean). Healthy control subjects reliably develop a response bias to the rich alternative. However, participants with major depressive disorder as well as rats exposed to chronic stress typically exhibit a blunted response bias.

METHODS

The present studies validated a touchscreen-based probabilistic reward task for the marmoset, a small nonhuman primate with considerable translational value. First, probabilistic reinforcement contingencies were parametrically examined. Next, the effects of ketamine (1.0-10.0 mg/kg), a US Food and Drug Administration-approved rapid-acting antidepressant, and phencyclidine (0.01-0.1 mg/kg), a pharmacologically similar N-methyl-D-aspartate receptor antagonist with no known antidepressant efficacy, were evaluated.

RESULTS

Increases in the asymmetry of rich:lean probabilistic contingencies produced orderly increases in response bias. Consistent with their respective clinical profiles, ketamine but not phencyclidine produced dose-related increases in response bias at doses that did not reduce task discriminability.

CONCLUSIONS

Collectively, these findings confirm task and pharmacological sensitivity in the marmoset, which may be useful in developing medications to counter anhedonia across neuropsychiatric disorders.