The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication

M Fava, I Hwang, A J Rush, N Sampson, E E Walters, R C Kessler, M Fava, I Hwang, A J Rush, N Sampson, E E Walters, R C Kessler

Abstract

Irritability is a diagnostic symptom of major depressive disorder (MDD) in children and adolescents but not in adults in both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases (ICD-10) systems. We explore the importance of irritability for subtyping adult DSM-IV MDD in the National Comorbidity Survey Replication (NCS-R), a national US adult household survey. The WHO Composite International Diagnostic Interview (CIDI) was used to assess prevalence of many DSM-IV disorders in the lifetime and in the year before interview (12-month prevalence). MDD was assessed conventionally (that is, requiring either persistent sadness or loss of interest), but with irritability included as one of the Criterion A symptoms. We also considered the possibility that irritability might be a diagnostic symptom of adult MDD (that is, detect cases who had neither sad mood nor loss of interest). Twelve-month MDD symptom severity was assessed with the Quick Inventory of Depressive Symptomatology and role impairment with the Sheehan Disability Scale. After excluding bipolar spectrum disorders, irritability during depressive episodes was reported by roughly half of respondents with lifetime DSM-IV MDD. Irritability in the absence of either sad mood or loss of interest, in comparison, was rare. Irritability in MDD was associated with early age of onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes, and disability. Irritability was especially common in MDD among respondents in the age range 18-44 and students. Further investigation is warranted of distinct family aggregation, risk factors and treatment response. Consideration should also be given to including irritability as a nondiagnostic symptom of adult MDD in DSM-V and ICD-11.

Figures

Figure 1
Figure 1
Age of onset for MDE ― Irritable Depression ― Non-Irritable Depression

References

    1. Crowe M, Ward N, Dunnachie B, Roberts M. Characteristics of adolescent depression. Int J Ment Health Nurs. 2006;15:10–18.
    1. Ryan ND, Puig-Antich J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, et al. The clinical picture of major depression in children and adolescents. Arch Gen Psychiatry. 1987;44:854–861.
    1. Fava GA, Grandi S, Canestrari R, Molnar G. Prodromal symptoms in primary major depressive disorder. J Affect Disord. 1990;19:149–152.
    1. Perlis RH, Fraguas R, Fava M, Trivedi MH, Luther JF, Wisniewski SR, et al. Prevalence and clinical correlates of irritability in major depressive disorder: a preliminary report from the Sequenced Treatment Alternatives to Relieve Depression study. J Clin Psychiatry. 2005;66:159–166.
    1. Snaith RP, Taylor CM. Irritability: definition, assessment and associated factors. Br J Psychiatry. 1985;147:127–136.
    1. Fava M, Alpert J, Nierenberg AA, Ghaemi N, O’Sullivan R, Tedlow J, et al. Fluoxetine treatment of anger attacks: a replication study. Ann Clin Psychiatry. 1996;8:7–10.
    1. Fava M, Nierenberg AA, Quitkin FM, Zisook S, Pearlstein T, Stone A, et al. A preliminary study on the efficacy of sertraline and imipramine on anger attacks in atypical depression and dysthymia. Psychopharmacol Bull. 1997;33:101–103.
    1. Fava M, Rosenbaum JF, Pava JA, McCarthy MK, Steingard RJ, Bouffides E. Anger attacks in unipolar depression, Part 1: Clinical correlates and response to fluoxetine treatment. Am J Psychiatry. 1993;150:1158–1163.
    1. Kessler RC, Merikangas KR. The National Comorbidity Survey Replication (NCS-R): background and aims. Int J Methods Psychiatr Res. 2004;13:60–68.
    1. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.
    1. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-Patient Edition (SCID-I/NP) Biometrics Research, New York State Psychiatric Institute; New York, NY: 2002.
    1. Kessler RC, Berglund P, Chiu WT, Demler O, Heeringa S, Hiripi E, et al. The US National Comorbidity Survey Replication (NCS-R): design and field procedures. Int J Methods Psychiatr Res. 2004;13:69–92.
    1. Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) Int J Methods Psychiatr Res. 2004;13:93–121.
    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV) 4. American Psychiatric Association; Washington, DC: 1994.
    1. Rush AJ, Carmody T, Reimitz PE. The inventory of depressive symptomatology (IDS): Clinician (IDS-C) and self-report (IDS-SR) ratings of depressive symptoms. International Journal of Methods in Psychiatric Research. 2000;9:45–59.
    1. Rush AJ, Gullion CM, Basco MR, Jarrett RB, Trivedi MH. The Inventory of Depressive Symptomatology (IDS): psychometric properties. Psychol Med. 1996;26:477–486.
    1. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62.
    1. Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, Klein DN, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573–583.
    1. Leon AC, Olfson M, Portera L, Farber L, Sheehan DV. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27:93–105.
    1. SAS Institute. SAS 9.1.3 Help and Documentation. SAS Publishing; Cary, NC: 2002.
    1. Wolter KM. Introduction to Variance Estimation. Springer-Verlag; New York: 1985.
    1. Research Triangle Institute. SUDAAN: Professional Software for Survey Data Analysis. 8.01. Research Triangle Institute; Research Triangle Park, NC: 2002.
    1. Fava GA, Pilowsky I, Pierfederici A, Bernardi M, Pathak D. Depressive symptoms and abnormal illness behavior in general hospital patients. Gen Hosp Psychiatry. 1982;4:171–178.
    1. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64:543–552.
    1. Benazzi F. Major depressive disorder with anger: a bipolar spectrum disorder? Psychother Psychosom. 2003;72:300–306.
    1. Akiskal HS. The Emergence of the Bipolar Spectrum:Validation along Clinical-Epidemiologic and Familial-Genetic Lines. Psychopharmacol Bull. 2007;40:99–115.
    1. Bauer M, Pfennig A. Epidemiology of bipolar disorders. Epilepsia. 2005;46 (Suppl 4):8–13.
    1. Benazzi F. Possible bipolar nature of irritability in major depressive disorder. J Clin Psychiatry. 2005;66:1072. author reply 1073.
    1. Benazzi F, Akiskal H. Irritable-hostile depression: further validation as a bipolar depressive mixed state. J Affect Disord. 2005;84:197–207.
    1. Alpert JE, Petersen T, Roffi PA, Papakostas GI, Freed R, Smith MM, et al. Behavioral and emotional disturbances in the offspring of depressed parents with anger attacks. Psychother Psychosom. 2003;72:102–106.
    1. Perris C. The distinction between unipolar and bipolar mood disorders. A 25-years perspective. Encephale. 1992;18(Spec No 1):9–13.
    1. Yoshimasu K, Sugahara H, Tokunaga S, Akamine M, Kondo T, Fujisawa K, et al. Gender differences in psychiatric symptoms related to suicidal ideation in Japanese patients with depression. Psychiatry Clin Neurosci. 2006;60:563–569.
    1. Fava M, Rush AJ, Alpert JE, Carmin CN, Balasubramani GK, Wisniewski SR, et al. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension. Can J Psychiatry. 2006;51:823–835.
    1. Swanson JW, Holzer CE, 3rd, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the Epidemiologic Catchment Area surveys. Hosp Community Psychiatry. 1990;41:761–770.
    1. Sher L, Oquendo MA, Li S, Ellis S, Brodsky BS, Malone KM, et al. Prolactin response to fenfluramine administration in patients with unipolar and bipolar depression and healthy controls. Psychoneuroendocrinology. 2003;28:559–573.
    1. Davis LL, Clark DM, Kramer GL, Moeller FG, Petty F. D-fenfluramine challenge in posttraumatic stress disorder. Biol Psychiatry. 1999;45:928–930.
    1. New AS, Trestman RF, Mitropoulou V, Goodman M, Koenigsberg HH, Silverman J, et al. Low prolactin response to fenfluramine in impulsive aggression. J Psychiatr Res. 2004;38:223–230.
    1. Fava M, Vuolo RD, Wright EC, Nierenberg AA, Alpert JE, Rosenbaum JF. Fenfluramine challenge in unipolar depression with and without anger attacks. Psychiatry Res. 2000;94:9–18.
    1. Dougherty DD, Rauch SL, Deckersbach T, Marci C, Loh R, Shin LM, et al. Ventromedial prefrontal cortex and amygdala dysfunction during an anger induction positron emission tomography study in patients with major depressive disorder with anger attacks. Arch Gen Psychiatry. 2004;61:795–804.

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