Beyond general depression: Premenstrual interpersonal anger as a unique pathway to suicidal ideation in adolescent...

Adolescent females with ADHD exhibit heightened vulnerability to hormonal fluctuations, yet the specific clinical pathways associated with their acute suicide risk remain unclear. This study investigated whether ADHD diagnosis relates to premenstrual "Interpersonal Anger" and examined its sequential linkage to suicidal ideation (SI) alongside general depression.

This retrospective chart review analyzed 392 female psychiatric outpatients (mean age 15.3 years). Premenstrual symptoms were quantified using a validated retrospective scale. Depressive severity was evaluated using a modified QIDS-SR-J (excluding the SI item). Hierarchical linear and logistic regression analyses were conducted to determine the dynamic predictors of premenstrual distress and SI.

ADHD was associated with a significantly higher prevalence of suspected premenstrual dysphoric disorder (22.1% vs. 13.3%; p = .039). Hierarchical linear regression revealed that ADHD diagnosis was a significant independent predictor of the premenstrual "Interpersonal Anger" factor score (β = 0.148, p = .002), even after rigorously controlling for baseline depression. In hierarchical logistic regression predicting the presence of active SI, premenstrual Interpersonal Anger emerged as a robust predictor when entered individually in Step 2 (OR = 1.096, 95% CI [1.046, 1.149], p < .001). However, upon entering baseline depressive severity in Step 3, general depression demonstrated an overwhelming association with SI (OR = 1.281, 95% CI [1.209, 1.357], p < .001), while the direct effect of Interpersonal Anger was fully attenuated (OR = 0.997, 95% CI [0.941, 1.057], p = .923).

Perimenstrual suicidal risk in adolescent females with ADHD does not follow a simple, independent direct pathway; rather, its effect is statistically subsumed by overall depressive severity. The acute premenstrual anger-potentially linked to neurodevelopmental impulsivity-appears to be closely integrated into the broader framework of general depression, which ultimately drives the proximal risk of suicidal distress. Suicide prevention for neurodivergent adolescents warrants phase-aware screening and targeted interventions addressing premenstrual conflict within an integrated care framework.