People with major depression are often irritable and angry as well, and such individuals tend to experience a more severe depression and to have a less favorable long-term outcome than those who are depressed without these accompanying characteristics.
These findings emerged from a 31-year prospective study headed by Lewis Judd, M.D., chair of psychiatry at the University of California, San Diego, and a former APA president, and published online September 11 in JAMA Psychiatry.
Darin Dougherty, M.D., an associate professor of psychiatry at Harvard Medical School who has researched the biological underpinnings of anger plus depression, told Psychiatric News that the new study “supports previous smaller studies reporting a high incidence of anger and irritability during major depressive episodes. Most important, in addition to the additional burden these symptoms place on the patient and those around them during the depressive episode, this study demonstrates that the presence of anger and irritability during major depressive episodes is associated with greater severity and worse long-term outcomes.”
The study included 536 individuals who had been diagnosed with unipolar major depression from 1978 to 1981 at academic medical centers in Boston, Chicago, Iowa City, New York City, and St. Louis. The Schedule for Affective Disorders and Schizophrenia was used to diagnose the subjects for unipolar major depression and to evaluate them for symptoms of irritability and anger independent of manic or hypomanic symptoms.
More than half the subjects had clinically significant irritability or anger at study intake, the researchers found. They were more likely to be younger, male, less well educated, to have more severe depressive symptoms, and to engage in irresponsible, reckless, or antisocial behavior, compared with subjects in the group without irritation and anger.
The researchers then followed the subjects for 16 years on average and compared the outcomes for the two groups.
Compared with the nonirritable group, subjects who had anger and/or irritability in addition to depression took considerably longer to recover from the major depression they had at the start of the study—on average 91 weeks versus 49 weeks.
In addition, during the years of follow-up, the irritable group was significantly more likely to experience affective symptoms, an affective episode, or a major affective episode; to have substance use disorders or anxiety disorders; to have difficulties with their partners or trouble performing at work or school; and to experience a lower quality of life.
Thus it looks as if major depression accompanied by irritability and anger represents a more severe, complex, and chronic illness than major depression without these factors, Judd told Psychiatric News. “And, as such, it deserves careful [clinical] attention,” he stressed.
“The results of our study [also] support the possibility that unipolar depression with overt irritability/anger may be a marker for a distinct subtype of unipolar major depressive disorder,” Judd and his group suggested in their report.
Maurizio Fava, M.D., a professor of psychiatry at Harvard Medical School, is convinced that there is such a subtype, based not just on this study, but on his extensive research during the past several decades, he said in an interview. Several of the findings in this new study also confirm several of his earlier findings, he noted—for example, that anger and irritability are common in depressed patients and that patients who are irritable and angry as well as depressed have a form of unipolar depression, not bipolar disorder.
However, Jan Fawcett, M.D., a professor of psychiatry at the University of New Mexico who headed the DSM-5 Work Group on Mood Disorders, is more skeptical about the combination of anger, irritability, and depression constituting a subtype of major depression, he told Psychiatric News. “To alter major depression criteria as much as major depression has been studied, you need a lot of data to add a subtype,” he explained. “[For example,] we had enough data on the effect anxiety has on outcome to add an anxiety specifier across all mood disorders, but not enough to create a new subtype.” In contrast, he said, a “major depressive episode may represent over 20 subtypes that have not yet been defined.”
The study was funded by the National Institute of Mental Health. ■