Association of anger attacks with suicidal ideation in adults with major depressive disorder: Findings from the EMBARC study

Background This report evaluates whether anger attacks (sudden uncharacteristic bouts of anger that are associated with autonomic arousal and/or aggression) in patients with major depressive disorder (MDD) are associated with elevated suicidal ideation (SI; active suicidal thoughts and plans). Methods Participants of Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study who completed Massachusetts General Hospital Anger Attack Questionnaire (AAQ) at baseline were included (n = 293). Levels of SI (suicidal thoughts factor of Concise Health Risk Tracking) were compared at baseline with generalized linear models, and during Stage 1 (baseline-to-week-8) and Stage 2 (week-8-to-week-16) with repeated-measures mixed model analyses. Covariates included age, sex, race, ethnicity, site, and treatment arm. Results At baseline, participants with (n = 109) versus without anger attacks (n = 184) had higher levels of SI (Cohen'sdeffect size [d] = 1.20). Those with >= 9 anger attacks in the past month had significantly higher SI than those with 1-2 (d = 1.21), 3-4 (d = 1.48), and 5-8 (d = 0.94) anger attacks in the past month. Furthermore, participants with anger attacks at baseline reported higher SI at each post-baseline visit (both Stages 1 and 2) of EMBARC study (d = 0.39-0.77; allp < .05). Associations between anger attacks and SI were significant even after controlling for irritability, hostility, anxious arousal, depression, suicide propensity, and self-reported pain at baseline and lifetime suicidal tendencies. Similar results were found in participants with aggressive behaviors. Conclusion Anger attacks in outpatients with MDD may be associated with chronically elevated SI. Clinical Trials Registration: Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC); NCT01407094; .