Predictors of suicidal thoughts: Mood instability versus neuroticism
Highlights
► One of three factors in the Eysenck Neuroticism Scale represented mood instability (MI). ► MI is the only factor that predicts suicidal thoughts. ► MI along with depression (with neuroticism controlled) predicts suicidal thoughts. ► MI mediates the relationship between neuroticism and suicidal thoughts. ► MI may be more directly associated with suicidal thoughts than neuroticism.
Introduction
This study investigates the association between mood instability (MI) and neuroticism and how these traits relate to suicidal thoughts. To borrow an analogy from Ebner-Priemer, Eid, Kleindienst, Stabenow, and Trull (2009), think of the weather as an analogy for moods. Suppose that you go to a resort that has unpredictable rain for half the days over two weeks while your friend goes to a resort that has one week of rain and then a week of sunshine. The holiday experiences will be different for the two of you even though the amount of rainfall might have been the same. Just like reporting the average rainfall, depression is usually evaluated with interview schedules (Sheehan et al., 1998) and scales (Beck, Steer, & Garbin, 1988) that ask patients to mentally average their experience of depression over two weeks. The negative bias to depression tends to outweigh fluctuations in mood (Solhan, Trull, Jahng, & Wood, 2009), resulting in a response that is slanted towards more severe continual depression.
In contrast, studies that incorporate prospective, frequent measurements reveal that the depressive experience varies within the day or every few days (Bowen et al., 2006, Trull et al., 2008). These fluctuations are described as mood instability (MI) that is defined as “extreme and frequent fluctuations of mood over time” (Trull et al., 2008). MI has been described in depression occurring alone or comorbid with other conditions including borderline personality disorder (Ebner-Priemer et al., 2009), alcohol abuse (Bowen, Block, & Baetz, 2008), anxiety (Bowen et al., 2006) or depression with mood swings (MI) (Bowen, Mahmood, Milani, & Baetz, 2011). This literature indicates that MI and depression are separate but related concepts and that current formulations of depression do not adequately account for the MI component.
Frequent, unpredictable, sudden descents in mood are distressing (Craske, Brown, Meadows, & Barlow, 1995) and are associated with suicidal thoughts in patients with depression (Trull et al., 2008). This might occur by affecting how people perceive events, their perceived control over emotions, or their event attributions (DeNeve & Cooper, 1998). MI has been found to be a significant predictor of suicidal acts in university students and in diverse groups of patients with depression, personality disorders and bipolar disorder (MacKinnon et al., 2005, Sampson et al., 2004, Witte et al., 2005, Yen et al., 2004). Conversely, emotional stability that has been conceptualized as the reverse of the Eysenck Neuroticism Scale is an important predictor of happiness (Eysenck and Eysenck, 1985, Hills and Argyle, 2001, Vitterso, 2001), and minor and major depression are associated with higher emotional reactivity (Bowen et al., 2004, Bylsma et al., 2011). These observations suggest that measures of MI may be clinically relevant in studies of depression and suicide (Trull et al., 2008).
Eysenck derived his concept of neuroticism from mathematical clustering studies but interestingly, he used the term to refer to unstable moods (Eysenck & Eysenck, 1985). Cullen in the 1700s first used the term neurosis to mean a class of diseases that could not be explained physiologically (Kendell, 1991) and Freud and his followers later used it as an explanation for symptoms related to unconscious conflicts (Makari, 2008). Neuroticism and similar traits of negative affect or emotional instability are a large first component of most common personality inventories (Costa and McRae, 1992, Trull et al., 2008). More recently the term neuroticism has been used as a superordinate organizing concept linking anxiety and depressive syndromes (Krueger, 1999).
In longitudinal studies it is clear that neuroticism predicts both depression (Caspi et al., 1996, Quilty et al., 2009) and suicidal thoughts (Brezo et al., 2006, ten Have et al., 2009). MI is less well researched than neuroticism, but is also associated with depression (Bowen et al., 2011) and suicidal thoughts (Links, Eynan, Heisel, & Nisenbaum, 2008). Neuroticism has been directly linked to MI but most relevant studies on this topic were done with student or general population samples rather than with patients (Eysenck and Eysenck, 1985, Miller et al., 2009, Murray et al., 2002). Therefore, the question of whether MI forms an essential component of neuroticism in patients with depression has not been addressed.
In this study, we investigated the relationship between MI, neuroticism, depression and suicidal thoughts in a group of depressed patients. We postulated that MI is the essential component of neuroticism accounting for the association between neuroticism and suicidal thoughts, and that MI would predict suicidal thoughts even after controlling for neuroticism.
Section snippets
Participants
Consecutive inpatients and outpatients from two general hospital psychiatric units who complained of depression were screened using the BDI and those with a score greater than 10 were invited to participate. Following written consent, the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) was conducted and participants were provided with a package of self-report questionnaires to complete. We excluded individuals who were involuntary admissions, psychotic,
Results
Depressive symptom severity (BDI) (mean 27.7; SD 10.5) was in the moderate to severe range (suicide question included). The Mood Disorder Questionnaire, Perceived Stress Scale and Eysenck Neuroticism Scale scores (Ormel, Oldehinkel, & Brilman, 2001) were in the range expected for distressed individuals.
Exploratory factor analysis (n = 185; Table 2) of the Eysenck Neuroticism Scale indicated three main factors accounting for 18.70%, 18.53%, and 16.16% of the variance respectively for a total of
Discussion
This study confirms that depression severity (BDI) and MI (ALS) are predictors of suicidal thoughts, even after controlling for other broad and well known predictors such as neuroticism (Eysenck Neuroticism Scale), perceived stress (Perceived Stress Scale) (Ormel et al., 2004, ten Have et al., 2009) and hypomanic symptoms (Mood Disorders Questionnaire) (Judd & Akiskal, 2003). The moderate positive correlation between the BDI and the ALS (r = 0.32, p < 0.001) suggests that, there is an unstable
Conclusions
Our hypothesis that MI and depression would predict suicidal thoughts, even after controlling for neuroticism, was supported. These results indicate that MI is a distinct and salient component of neuroticism and may become a clinically useful concept in the assessment and treatment of patients with depression, particularly when suicidal thoughts are present. Mood instability will undoubtedly be a useful concept for research because it can be easily elicited clinically and is amenable to
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Mood instability/variability.