The relationship between suicidal behavior and reactive aggression in major depression: The role of testosterone and cortisol reactivity

The Relationship Between Suicidal Behavior and Reactive Aggression in Major Depression: The Role of Testosterone and Cortisol Reactivity Objectives: There are findings that suicidal behavior is associated with reactive aggression. Nevertheless, there is no study conducted on adults investigating the relationship between suicidal behavior and aggression in which aggression is evaluated with a behavioral task. This study aims to investigate the relationship between suicidal ideation and suicide attempt, and behaviorally assessed reactive aggression, anger, impulsivity, perceived burdensomeness, and basal level of testosterone and cortisol, and their response to the behavioral task. Method: Patients diagnosed with major depression according to DSM-5 criteria and with a Hamilton Depression Rating Scale score of 14 and above were included in the study (n=101). Patients were divided into research groups with the Columbia-Suicide Severity Rating Scale. Patients who attempted suicide in the last month constituted "Suicide Attempt" (SA, n=22), patients who had suicidal ideation in the last month and who did not attempt suicide during the last depression episode constituted "Suicidal Ideation" (SI, n=31), patients who did not have suicidal ideation during the episode and did not have lifetime attempt history constituted the "Major Depression" (MD, n=42) group. Point Subtraction Aggression Paradigm (PSAP) was applied for the behavioral assessment of reactive aggression. The State Anger Scale was applied before and after PSAP to evaluate the change in anger. In addition, Trait Anger Expression Scale, Buss-Perry Aggression Scale, and Barratt Impulsivity Scale-11 were administered. Anger attacks in the last month were evaluated with the Anger Attack Questionnaire. Perceived burdensomeness and thwarted belongingness, components of the Interpersonal Theory of Suicide, were evaluated using the Interpersonal Needs Questionnaire, and the other component, capability for suicide, was evaluated using the Acquired Capability for Suicide and Death Fearlessness. Testosterone and cortisol analyses were performed by ELISA in saliva samples collected before and 15 minutes after PSAP. Results: Reactive aggression was higher in the SA group than in the SI and MD groups. Reactive aggression was associated with impulsivity, hostility, perceived burdensomeness, and the presence of anger attacks. There was no difference between the groups in terms of basal hormone levels and their reactivity. In multivariate analysis, reactive aggression, depression severity, motor impulsivity, poor anger control, perceived burdensomeness, and low baseline testosterone level significantly predicted being in the SA group. Perceived burdensomeness was the only variable that had a significant effect on being in the SI group when other variables were controlled for. Conclusion: Reactive aggression as assessed by behavioral task was found to be associated with the presence of recent suicide attempt even when other related variables such as impulsivity, depression severity, and testosterone level were controlled. In addition, our results were largely consistent with the Interpersonal Theory of Suicide, and the relationship between perceived burdensomeness and reactive aggression was demonstrated. Determination of features related to reactive aggression such as anger attacks will be useful in the clinical evaluation of suicide risk.