The Status of Irritability in Psychiatry: A Conceptual and Quantitative Review

Abstract

Objective: Research and clinical interest in irritability have been on the rise in recent years. Yet several questions remain about the status of irritability in psychiatry, including whether irritability can be differentiated from other symptoms, whether it forms a distinct disorder, and whether it is a meaningful predictor of clinical outcomes. In this article, we try to answer these questions by reviewing the evidence on how reliably irritability can be measured and its validity.

Method: We combine a narrative and systematic review and meta-analysis of studies. For the systematic review and meta-analysis, we searched studies in PubMed and Web of Science based on preselected criteria. A total of 163 articles were reviewed, and 24 were included.

Results: We found that irritability forms a distinct dimension with substantial stability across time, and that it is specifically associated with depression and anxiety in longitudinal studies. Evidence from genetic studies reveals that irritability is moderately heritable, and its overlap with depression is explained mainly by genetic factors. Behavioral and neuroimaging studies show that youth with persistent irritability exhibit altered activations in the amygdala, striatum, and frontal regions compared with age-matched healthy volunteers. Most knowledge about the treatment of irritability is based on effects of treatment on related conditions or post hoc analyses of trial data.

Conclusion: We identify a number of research priorities including innovative experimental designs and priorities for treatment studies, and conclude with recommendations for the assessment of irritability for researchers and clinicians.

Keywords: anxiety; conduct; depression; irritability; meta-analysis.

Figure 1

The position of irritability within commonly used terminology. Note: irritability shares a negative valence with anxiety and depression but denotes approach and is therefore linked to elation in mania.

Figure 2

Forest plot of irritability as a predictor of future psychiatric disorders. Note: Points represent the estimated odds ratio of each study; the lines bisecting the point correspond to the 95% CI. Pooled effect sizes are represented by diamonds. Weights for each study are given in the far-right column. ADHD = attention-deficit/hyperactivity disorder; ODD = oppositional defiant disorder.