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Personality and Individual Differences

Manuscript Draft

Manuscript Number: PAID-D-11-00354Rl

Title: Predictors of suicidal thoughts: Mood instability versus neuroticism

Article Type: Research Paper ( <5000 words)

Section/Category: Regular Issue

Keywords: Depression; Mood Instability; Neuroticism; Suicidal Thoughts

Abstract: The personali ty trait neuroticism predicts depression and suicidal thoughts. Neuroticism is

also linked to mood instability (MI) which is common in patients with depression. This study

investigated (a) whether Ml predicts suicidal thoughts in depressed patients and (b) the relationship of

MI to neuroticism. All129 patien ts with Major Depression (MINI interview) were assessed on MI(Affective Lability Scale), neuroticism (Short Eysenck Neurot icism Scale), depression (Beck Depression

Inventory), and suicidal thoughts (Beck Scale for Suicidal Ideation). Participants also completed the

Perceived Stress Scale, Mood Disorder Questionnaire and five questions on mood swings. Factor

analysis of the Neuroticism Scale revealed uns table moods as one of three main factors. Only

depression severity and MI predicted suicidal thoughts once other variables including neuroticism

were controlled. Mediation analyses showed that MI mediated the relationship between neuroticism

and suicidal thoughts. These resul ts suggest that MI as measured by the Affective Lability Scale typifies

the type of depression that predicts suicidal thoughts and that MI may be more directly associated with

suicidal thoughts than neuroticism. This demonstrates the clinical value of assessing MI rather than

neuroticism in the treatment of patients with depression with suicidal thoughts.



to view linked References

Abstract

The personality trait neuroticism predicts depression and suicidal thoughts. Neuroticism

is also linked to mood instability (MI') which is common in patients with depression.

This study investigated (a) whether MI predicts suicidal thoughts in depressed patients

and (b) the relationship ofMI to neuroticism. All 129 patients with Major Depression

(MINI interview) were assessed on MI (Affective Lability Scale), neuroticism (Short

Eysenck Neuroticism Scale), depression (Beck Depression Inventory), and suicidal

thoughts (Beck Scale for Suicidal Ideation). Participants also completed the Perceived

Stress Scale, Mood Disorder Questionnaire and five questions on mood swings. Factor

analysis of the Neuroticism Scale revealed unstable moods as one of three main factors.

Only depression severity and MI predicted suicidal thoughts once other variables

including neuroticism were controlled. Mediation analyses showed that MI mediated the

relationship between neuroticism and suicidal thoughts. These results suggest that MI as

measured by the Affective Lability Scale typifies the type of depression that predicts

suicidal thoughts and that MI may be more directly associated with suicidal thoughts than

neuroticism. This demonstrates the clinical value of assessing MI rather than neuroticism

in the treatment of patients with depression with suicidal thoughts.

Keywords: Depression; Mood Instability; Neuroticism; Suicidal Thoughts

*Mood InstabilityNariability

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First copyedit complete.

1. Introduction

This study investigates the association between mood instability (Ml) and

neuroticism and how these traits relate to suicidal thoughts. To borrow an analogy from

Ebner-Priemer et al, think of moods as the weather (Ebner-Priemer, Eid, Kleindienst,

Stabenow, & Trull, 2009). Suppose that you go to a resort that experiences 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 7L.--- _

of you, even though the amount of rainfall might have been the same. Just like reporting

the average rainfall, depression is typically assessed with interview schedules (Sheehan

et a!., 1998) and scales (Beck, Steer, & Garb in, 1988) that patients to mentally \ \ _ -... . &4r t> rJC(--, i::.t· average their experience of depression over two weeks. Unfortunately, when average

mood is estimated, negatives tend to outweigh positives (Solhan, Trull, Jahng, & Wood,

2009), resulting in a response that is slanted towards more sene depression. ; . A I,.

:{at('aP{to 1'-J c- f-.

Lo,0 ( 1&-1uQ.J

s1-.J:cc;. (}A\

aThis can lead to oversight J=:. h--. , \ ? _ r 1 ).1.-·')./ .r;:. .k.J 7 \ S

In contrast, studies that incorporate prospective, frequent, repeated measurements1

17A

. reveal that the depressive experience varies within the day or every few days (Bowen,

Baetz, Hawkes, & Bowen, 2006; Trull et al., 2008). This is true whether depression

occurs alone or is comorbid with other conditions including borderline personality

disorder (Ebner-Priemer et al., 2007), alcohol abuse (Bowen, Block, & Baetz, 2008),

anxiety (Bowen et al., 2006), or depression with mood swings (Bowen, Mahmood,

Milani, & Baetz, 2011 ). Accordingly, Ml is a critical component of depression in the

patients.

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mood swings questions, these are the most commonly used tools to assess the particular

qualities in depressed patients.

Major Depression Diagnoses: The Mini-International Neuropsychiatric

Interview (MINI) is a short structured diagnostic interview for DSM-IV and ICD-1 0

psychiatric disorders (Sheehan et al., 1998). This was used to make the diagnosis of

major depression and comorbid psychiatric conditions.

Depression Severity: The Beck Depression Inventory (BDI) (Beck, Steer, &

Garbin, 1988) is a self-report 21-item questionnaire that emphasizes cognitive rather than

somatic symptoms of depression over the past two weeks

Suicidal Ideation: The Beck Scale for Suicidal Ideation (BSI) ( Beck & Steer,

1991) is a 21-item self-report instrument for detecting and measuring the pat ients'

specific attitudes, behaviours, and plans to commit suicide during the past week (suicidal

thoughts).

Mood Instability (MI): The Affective Lability Scale-Short Form (ALS) (Oliver &

Simons, 2004) is an 18-item measure of sudden mood changes between depression, high

mood, anxiety, and anger. Scores correlate highly with those from the longer version (r =

0.94) and the short form has a similar relationship with other scales as the long version.

Neuroticism (N-EPQ) (Eysenck & Eysenck, 1985): We used the 12 items from

the Neuroticism scale of the short Eysenck Personality Questionnaire (Roberts &

Kendler, 1999).G e relationship of the N-EPQ to MI is apparent in the wording of the

questions) q.)17,,

Perceived Stress: The Perceived Stress Scale (PSS) is a I 0-item version of a self-

report scale for measur ing the degree to which situations in one's life are viewed as

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stressful (Cohen, Kamarck, & Mermelstein, 1983). Because it is a global measure of

perceived stress, the scale correlates with depression and anxiety (r = 0.5 to 0.8).

Hypomanic Symptoms: The Mood Disorder Questionnaire (MDQ) is a sensitive

screen for lifetime hypomanic and manic symptoms. We used the sum ofthe 13 symptom

questions as a measure of severity of hypomanic symptoms (Hirschfeld et al., 2000).

Mood Swings: Mood swings were assessed with questions (MS); the

first two were modified from a published report ( B e n a z p Akiskal, 2005). The

remaining three questions were generated from patients' reports of behavioural

consequences ofmood swings. The questions were rated on a visual analogue scale

(VAS) and inquired about "frequent ups and downs in moods", "mood swings that occur

for no reason", "other people complain about my mood swings", "having trouble

following through with plans because of mood swings", and "not making commitments

because moods might change". The sum of the five visual analogue scales was used as an

alternate clinical measure of MI.

2.3 Participant Characteristics

The study sample comprised 185 participants, but only 129 ofthese completed the

Affective Lability Scale that was introduced when we became aware of it. All analyses

included 129 participants that completed the Affective Lability Scale and the other scales,

except for the factor analysis of the Eysenck Neuroticism Scale that included all 185

participants. The characteristics ofthe 129 patients are presented in Table I.

The distribution of the Beck Scale for Suicidal Ideation total was positively

skewed with 36 participants reporting no suicidal thoughts, but the distribution for the

remaining 93 participants with suicidal thoughts was approximately normal. When the

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analyses were repeated with only the 93 participants who reported suicidal thoughts and

compared to the analyses with 129 participants no significant differences were found, so

we used the larger number. The distributions of the other scales including the ALS

(median= 43, std. error of skewness= .213) were approximately normal probably

because this was a fairly ill patient sample.

2. 4 Analysis

To establish the factor structure of the 12-item Eysenck Neuroticism Scale, a

principal components exploratory factor analysis with Varimax rotation was employed

(see Table 2). An Eigenvalue of I was used to determine the factors.

In addition we did partial correlation analyses with age and sex controlled 0between the variables N-EPQ, ALS, PSS, MDQ, !3D! (with the suicide item #9 '

excluded), BSI, and MS (see Table 3).

We then performed multiple regression analysis with the Beck Scale for Suicidal

Ideation as the dependent variable, and age and sex entered first as control variables (see

Table 4). Hypomania has been associated with suicide (Judd & Akiskal, 2003), but the

correlation of the Mood Disorder Questionnaire with the Beck Scale for Suicidal Ideation

was small (r = 0.18) and the Mood Disorder Questionnaire was not a significant predictor

in a preliminary model, so it was not included in the final regression model. In the next

step we entered the Perceived Stress Scale (r = 0.40), the Eysenck Neuroticism Sca le (r =

0.28) and the BDI (with the suicide item # 9 excluded) (r = 0.57) because recent adverse

events and depression have each been associated with suicidal behaviour (ten Have eta!.,

2009; Judd & Akiskal, 2003). The ALS was entered in the last step based on its

7



correlation with the BSI (r = 0.37) and the association between bipolar spectrum

disorders and suicidal behaviour (Judd & Akiskal, 2003; Angst, I998).

Finally, we tested for mediation between the Eysenck Neuroticism Scale and the

Affective Lability Scale as independent variables and the Beck Scale for Suicidal

Ideation as the dependent variable because the correlation between the Eysenck

Neuroticism Scale and the Affective Lability Scale was the highest that we observed (r =

0.62). Age and sex were controlled in all regressions.

3. Results

Depressive symptom severity (801) (mean 27.7; SO I 0.5) 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%, I8.53%, and 16.16% of the variance

respectively for a total of 53.38%. The first factor consisted of three items related to

nervousness and tension (6, 8, I 0) that are mild symptoms of anxiety. The second factor

consisted of five items ( 4, 7, 9, II , I2) that are symptoms of a mild low mood. The third

factor consisted of four items (I , 2, 3, 5). The first item is a direct question about MI,

similar to the first question of the five questionswe asked about mood swings (MS). The

other items (2, 3, 5) seem to refer to quick changes to negative mood with a tendency to

irritability.

A partial correlation analysis done with age and sex controlled (n = I29; Table 3)

showed that the Beck Scale for Suicidal Ideation correlated with scores from all the other

8



questionnaires (the N-EPQ, ALS, PSS, MOQ, 801 and MS). However, the multi ariate

linear regression analysis (Table 4) showed that only the Scale were significant predictors of suicidal thoughts. The Affective Lability Scale

contributed 2.5% of the variance (adjusted R2

= 0.376, F change= 5.187, df= I, I22, p =

0.024). When the variables that were not significant (age, sex, PSS, N-EPQ) were

dropped from the regression equation the 801 (adjusted R2

= 0.333, F change 64.9, df=

I, 127, p < 0.001) contributed 33.8% of the variance and the Affective Lability Scale

contributed 4.1% ofthe variance (adjusted R2

= 0.370, F change 8.398, df=1J26, p <

-6-0,tJCo<? 0.005). V\.. \ .-:J_/ ? u All ofthe conditions for a mediation analysis were met. The results are shown in

\J (lv>\ Figure I with the unmediated standardized beta first and the mediated beta inside the

brackets. The Affective Lability Scale mediates the relationship between the Eysenck

Scale and Beck Scale tOr Suicidal ideation, but the Eyscnck Neuroticism t' Scale does not mediate the relationship between the Affective Lability Scale and Beck

,\.J);J\ Scale for Suicidal Ideation.

4. Discussion

This study confirms that depression severity (801) and MI as measured by the

Affective Lability Scale are predictors of suicidal thoughts, even after controlling for

other broad and well known predictors such as neuroticism (Eysenck Neuroticism Scale)

(ten Have et al., 2009) and perceived stress (Perceived Stress Scale) (ten Have Metal.,

2009; Ormel, Rosmalen, & Farmer, 2004). The BOI and the Affective Lability Scale are . - : ? moderately (r = 0.32, p < 0.00 I) positively correlated and conceptually we •

interpret the findings as indicating an unstable quality to the depression that predicts

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suicidal thoughts, rather than as two separate predictors. Our findings are consistent with

the literature showing that MI predicts suicidal thoughts (Yen eta!., 2004). In most ofthe

previous research, MI has been seen as the main diagnostic criterion for the borderline

personality disorder (Yen eta!., 2004; Trull eta!. , 2008). The normal distribution ofthe

Affective Lability Scale does not support this point of view, indicating instead that there

are a few patients with low MI, but that the majority of patients with Major Depression

experience it to some degree (Murray eta!., 2002).

)uroticism (Eysenck Neuroticism Scale) is associated with suicidal

thoughtsfour results show that it is no longer predictive after the Aftl:ctive Lability Scale

is entered into the equation. On factor analysis, the third factor of the Eysenck \S

Neuroticism Scale refers to frequent, unpredictable changes in mood. The other two VauJT

factors represent mild symptoms of anxiety and depression and it seems tautological to suggest that they predict later more severe symptoms that develop during the course of

the disorder (Ormel et al., 2004). Furthermore, the Affective Lability Scale is as highly

correlated with the other scales as is the Eysenck Neuroticism Scale, particularly with the

five questions on mood swings. The test for mediation suggests that the Affective

Lability Scale mediates the relationship between the Neuroticism scale and Beck Scale

for Suicidal Ideation, but not vice versa.

This indicates that MI is the distinct feature of neuroticism, and is more clinically

and empirically useful than neuroticism because symptoms can be elicited by askin

about mood swings, or with questionnaires like the Affective Lability Seal or the mean

square successive difference statistic applied to repeated visual analogue scale

measurements (Ebner-Priemer et a!., 2009). nother study has shown an

\()qtt M_( '10

of.-



between MI and the angry hostility and impulsiveness facets in the neuroticism domain

of the NEO personality inventory, and also a negative correlation with facets of the

agreeableness domain (Miller et aL 2009). A critical question for clinical applications is

whether MI is treatable. Current research suggests that there may be a relatively invariant

component, but there is also a component that improves with pharmacological treatment

ofmood disorders (Tang et al., 2009; Bowen et al., 2011 ).

The main implication of these findings is in the prediction and prevention of

suicide. Overall, 85-90% of people who commit suicide can be diagnosed retrospectively

""' with a psychiatric disorder, the vast majority with a mood disorder (Arsenault-Lapierre,

Kim, & Turecki, 2004). The majority ofthe rest without a formal psychiatric disorder

..-JJ' have psychiatric symptoms (Ernst et al., 2004). About 50% ofyoung people who have

suicidal thoughts do not fulfill criteria for major depression and have not come to the

attention ofmental health services (Rhodes & Bethell, 2008). Detection and treatment of

mood problems that might lead to suicide could be improved by the recognition ofMl as

a trait/symptom that requires attention in patients, apart from their formal psychiatric

diagnosis.

In the clinic, some patients do minimize "mood swings" in reporting their

affective symptoms, possibly because they are inclined to report the prevailing low mood,

or they fear being diagnosed as '"bipolar" or "borderline". Our results show that MI as

measured by the Affective Lability Scale is correlated with patients' reports ofmood

swings and a history of hypomanic symptoms (Mood Disorder Questionnaire) but the

exact relationship between these factors remains to be clarified (Koenigsberg, 201 0).

Clinical and epidemiological studies have shown that at least 40% of people who meet

11



the criteria for Major Depression report symptoms consistent with the Bipolar I or II

disorders; consistent with our diagnostic data (Angst & Cassano, 2005). Clearly, the

boundaries of the bipolar and borderline syndromes and the overlap with Ml require more

clarification through research (Angst & Cassano, 2005; Koenigsberg, 201 0).

Research with twins has shown that neuroticism is the most salient of the

0 1999). Neuroticism is also associated with hypothalamic-pituitary-adrenocortical axis

dysfunction (Zobel et al., 2004) and decreased brain volume (Knutson, Momenan,

Rawlings, Fong, & Hom mer, 2001 ). However, little is known about the biological bases

ofMl and so it may be fruitful to examine biological correlates, including the

development of animal models of MI. As in research with patients, current animal models

ofmood disorders typically assess behavioral changes at only one or two points in time.

The main limitation of this study is that this is relatively small and from one

centre; the results will need to be replicated and confirmed. Because of the cross-

sectional design, causality cannot be inferred from statistical associations. It is also

apparent that the variables that we studied accounted for only a relatively small part of

the risk for suicidal thoughts (ten Have et al., 2009; Judd & Akiskal, 2003; Angst, 1998).

It is possible that neuroticism conveys a dimension of affect that is not captured by MI, but examination of the Eysenck and NEO neuroticism scales suggest that most of this G',w:_ J.....

.::A../ "Ei

predictive ability consists ofmilder symptoms of negative affect (Onncl , Rosmalen, & \

<t:lFarmer, 2004; Miller et al., 2009). The percentage of the total variance contributed by the .</_ );-CkJ0

1'7..; Affective Lability Scale appears small (4.1 %) compared with the BDI (16.5%) but this 'F

study cannot isolate true variance because ofmulticollinearity between the Affective 12



acceptable for the regression analysis (Licht, 1995).

5. Conclusions

Our hypothesis that Ml would predict suicidal thoughts even after controlling for

neuroticism was supported. These results indicate that Ml 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 those patients with suicidal

thoughts. Mood instability will undoubtedly be a useful concept for research because it

can be easily elicited clinically and is amenable to empirical analysis.

13



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Table 1.

Sample characteristics (N= 129)

Table 2.

Eysenck Neuroticism Scale factor analysis matrix.

Table 3.

Partial correlation matrix (age and sex controlled; N=129). MS is the sum of five

questions on mood swings; see Table I for other abbreviations.

Table 4.

Regression results for predicting the Beck Scale for Suicidal Ideation (N= 129). See Table

I for abbreviations.

Figure 1.

Mediation ofAffective Lability (ALS) on Suicidal Thoughts (BSI) with the Eysenck

Neuroticism Questionnaire (N-EPQ). The numbers are unmediated Beta values of the

regression equations outside ofthe brackets and the mediated values inside of the

brackets.

20



Table 1.

Sample characteristics (N= 129)

Characteristic Mean SD Range Median

Beck Depression Inventory (BDI) 28.98 10.67 10-61 28

Mood Disorder Questionnaire (MDQ) 6.83 3.76 0-13 7

Perceived Stress Scale (PSS) 26.78 7.12 7-40 28

Eysenck Neuroticism Scale (N-EPQ) 8.27 2.91 0-12 9

Affective Lability Scale (ALS) 41.56 13.07 18-69 43

Age (Years) 40.07 11.86 19-76 40

n o;o

Female 86 67

Married/common-law 51 40

Widowed 2 2

Single/separated/divorced 76 59

Inpatient 74 57

Outpatient 55 43

Major depression 129 100

Bipolar Spectrum Disorder 48 37

One Anxiety Disorder 101 78

>I Anxiety Disorders 57 44

Past suicide attempt 80 62



able(s)

Table 2.

Eysenck Neuroticism Scale factor analysis matrix.

Factor I Factor 2 Factor 3

Would you call yourself a nervous person? .774 .185 .028

Would you call yourself tense, or highly strung? .779 .103 .225

Do you suffer from nerves? .785 .233 .043

Does your mood often go up and down? .017 .293 .653

Do you ever feel just miserable for no reason? -.015 .199 .684

Are you an irritable person? .315 -.157 .631

Do you often feel fed up? .058 .1 07 .670

Are your feelings easily hurt? .144 .537 .327

Are you a worrier? .263 .669 .049

Do you worry too long after an embarrassing experience? .463 .590 -.021

Do you often feel lonely? .029 .544 .163

Are you often troubled about feelings of guilt? .112 .764 .090

Variance Explained: 18.70 18.53 16.16

Total variance explained by the three factors: 53.38%



-- - ---

Table 3.

Partial correlation matrix (age and sex controlled; N=l29). MS is the sum of five questions on

mood swings; see Table 1 for other abbreviations.

BSI BDI ALS MDQ PSS N-EPQ MS

BSI 1.00

BDI .57*** 1.00

' '

ALS .38*** . MDQ .19* . *** .53*** 1.00

PSS .41 *** .51*** .38*** .26** 1.00

N-EPQ 6 .32*** .62*** .40*** .46*** 1.00

MS .25** .30** .50*** .40*** .23** .49*** 1.00

*p<.05

**p<.OI

***p<.OOI



- - -Table 4.

Regression results for predicting the Beck Scale for Suicidal Ideation (N= 129). See Table I for

abbreviations.

Unstandardized Standardized

Coefficients Coefficients

B Std. Error Beta t p

(Constant) -5.082 5.412 -.939 .350

Age -.045 .062 -.052 -.722 .471

Sex -2.459 1.545 -.113 -1.592 .114

PSS .161 .130 . I l l 1.242 .216

N-EPQ -.149 .333 -.042 -.448 .655

BDI .461 .084 .456 5.518 <.001

ALS .165 .072 .209 2.278 .024



-- - ---- - · - - - - - -

Figure 1.

Mediation ofAffective Lability (ALS) on Suicidal Thoughts (BSI) with the Eysenck

Neuroticism Questionnaire (N-EPQ). The numbers are unmediated Beta values ofthe regression

equations outside ofthe brackets and the mediated values inside ofthe brackets.

N-EPQ

0.626***0.280**

(0.083)

ALS • BSI

0.370***

(0.318**)

**p<.Ol

***p<.OOI

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