Research report Melancholic features and hostility are associated with suicidality risk in Asian patients with major depressive disorder Hong Jin Jeon a,b , Daihui Peng c , Hong Choon Chua d , Manit Srisurapanont e , Maurizio Fava b , Jae-Nam Bae f , Sung Man Chang g , Jin Pyo Hong h,n a Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea b Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA c Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, China d Department of Psychiatry, Institute of Mental Health, Singapore e Department of Psychiatry, Chiang Mai University, Chiang Mai, Thailand f Department of Psychiatry, Inha University College of Medicine, Incheon, South Korea g Department of Psychiatry, Kyungpook National University School of Medicine, Daegu, South Korea h Department of Psychiatry, Asan Medical Center, Ulsan University College of Medicine, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, South Korea article info Article history: Received 22 June 2012 Received in revised form 7 January 2013 Accepted 7 January 2013 Available online 13 February 2013 Keywords: Melancholic Suicidality Hostility Asian Major depressive disorder abstract Background: Suicide rates are higher in East-Asians than other populations, and especially high in Koreans. However, little is known about suicidality risk and melancholic features in Asian patients with major depressive disorder (MDD). Method: Drug-free MDD outpatients were included from 13 centers across five ethnicities consisting of Chinese (n ¼290), Korean (n ¼101), Thai (n ¼102), Indian (n ¼27), and Malay (n ¼27). All were interviewed using the Mini-International Neuropsychiatric Interview (M.I.N.I.), the Montgomery– ˚ Asberg Depression Rating Scale (MADRS), and the Symptoms Checklist 90-Revised (SCL-90-R). Results: Of 547 subjects, 177 MDD patients showed melancholic features (32.4%). These melancholic MDD patients revealed significantly higher suicidality risk (p o0.0001), hostility (p ¼0.037), and severity of depression (p o0.0001) than those MDD patients without melancholic features. Suicidality risk was significantly higher in MDD with melancholic features than those without in subjects with lower hostility, whereas it showed no difference in higher hostility. Adjusted odds ratios of melancholic features and hostility for moderate to high suicidality risk were 1.79 (95% CI ¼1.15–2.79) and 2.45 (95% CI ¼1.37–4.38), after adjusting for age, sex, education years, and depression severity. Post-hoc analyses showed that suicidality risk was higher in Korean and Chinese than that of Thai, Indian and Malay in MDD subjects with melancholic features, although depression severity showed no significant differ- ences among the ethnicities. Conclusions: Suicidality risk is associated with both melancholic features and hostility and it shows cross-ethnic differences in Asian MDD patients, independent of depression severity. & 2013 Elsevier B.V. All rights reserved. 1. Introduction Suicide rates are higher in East-Asian countries, such as Korea, Japan, and China, than in Western and other Asian populations. Suicide rates were greater than 13/100,000 in East-Asian coun- tries, compared with less than 13/100,000 in American and European countries, data presented within the WHO worldwide initiative for the prevention of suicide (SUPRE) in 2011 (WHO Worldwide Initiative for the Prevention of Ssuicide, 2011). Korea was ranked as having the 3rd highest suicide rates, Japan was ranked 9th, and China was the 24th among the 105 worldwide countries examined in 2011. Other Asian countries not in East- Asia were ranked lower; Thailand was the 53rd, India was the 44th, and Singapore was the 45th. Major depressive disorder (MDD) is closely associated with suicidal ideation, plan, attempt and completion, as evidenced by psychological autopsy studies (Hirokawa et al., 2012; McGirr et al., 2008) and nationwide epidemiologic studies (Jeon et al., 2010a; Lee et al., 2007; Nock et al., 2010). MDD is associated with not only planned, but also unplanned suicide attempts (Jeon et al., 2010b). Previous studies have consistently reported that the preva- lence of MDD is lower in the East-Asian countries than those of the Western countries. A large international study carried out by Contents lists available at SciVerse ScienceDirect journal homepage: www.elsevier.com/locate/jad Journal of Affective Disorders 0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.01.001 n Corresponding author. Tel.: þ82 2 3010 3421; fax: þ82 2 485 8381. E-mail address: jphong@amc.seoul.kr (J.P. Hong). Journal of Affective Disorders 148 (2013) 368–374