Asian Journal of Psychiatry 6 (2013) 35–41

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Anger and major depressive disorder: The mediating role of emotion regulation
and anger rumination§
Mohammad Ali Besharat *, Mahin Etemadi Nia, Hojatollah Farahani
Department of Psychology, University of Tehran, P.O. Box 14155-6456, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Article history: Many studies have documented the existence of a close relationship between anger and depression.
Received 7 May 2012 Furthermore, recent literature has emphasized the role of impaired emotion regulation and anger
Received in revised form 27 July 2012 rumination in depression. The aim of this study was to explore the mediating role of emotion regulation
Accepted 30 July 2012
and anger rumination on the relation between anger and major depressive disorder. Eighty-eight
patients with major depressive disorder (20 males, 68 females) completed the Beck Depression
Keywords: Inventory (BDI), the Multidimensional Anger Inventory (MAI), the Cognitive Emotion Regulation
Major depressive disorder
Questionnaire (CERQ), and the Anger Rumination Scale (ARS). Results illustrated that in clinically
Anger
Emotion regulation
depressed people, there are positive relationships between anger, depression, emotion regulation, and
Anger rumination anger rumination. Path analysis revealed that emotion regulation and anger rumination played a
mediating role on the relation between anger and major depression. Anger was associated with
depression via emotion regulation and anger rumination. Findings of the present study suggest that
emotion regulation and anger rumination play an important role on the relation between anger and
depression. The current study implicates the complicated nature of depression, and emphasizes the
understanding and conceptualization of diverse variables that influence depression.
ß 2012 Elsevier B.V. All rights reserved.

1. Introduction Evidence has demonstrated a close relationship between anger

As one of the most common psychological disorders, major
depression is associated with impaired regulation of emotion
(Davidson et al., 2002; Joormann and Gotlib, 2010). Few studies
have attempted to explain the relationship between anger and
depression. Anger is defined as a negative feeling state associated
with specific cognitive appraisals, physiological changes
and action tendencies (Kassinove and Sukhodolsy, 1995). Although
anger could be adaptive especially when it is expressed in a
constructive manner (Taylor and Novaco, 2005), destructive anger,
that causing interrupted interpersonal relationships and excessive
activity of sympathetic nervous system, is generally accounted as
maladaptive (Deffenbacher et al., 1996; Goleman, 2004; Howells,
2004). Apparently, variety in anger expression is associated with
psychological and physiological pathology. Anger arousal, and at
the same time its inhibition, is related to increased diastolic and
systolic blood pressure (Bishop et al., 2008; Bongard and al’Absi,
2005; Goldstein et al., 1988) and heart disease (Depaulo and
Horvitz, 2002; Tennant and McLean, 2001).
§ disturbs definite conclusions (Garnefski et al., 2002). Despite
This study was supported by University of Tehran.
* Corresponding author. Tel.: +98 21 220 7450.
E-mail address: besharat@ut.ac.ir (M.A. Besharat).
and depression both in normal (e.g., Kashdan and Roberts, 2007;
Riley et al., 1989; Robbins and Tanck, 1997) and patient
populations (e.g., Besharat et al., 2011; Brody et al., 1999; Fava
and Rosenbaum, 1998; Novaco, 2010). Depressed people exhibit
more anger suppression than normal people (Bridewell and Chang,
1997; Robbins and Tanck, 1997). Evolutionary theories of
depression suggest that aroused but arrested defenses of fight
(arrested anger) and flight (feelings of entrapment) may be among
the important components of depression (Gilbert et al., 2004).
However, it has been recognized that depressed people also
experience more anger (Cheng et al., 2005). Again, in the case of
treatment, having some residual symptoms such as anger is related
to poor therapeutic outcomes and more relapses in depressed
people (Fava and Rosenbaum, 1998). Depressed people also
percept more hostility than the normal population (Moreno
et al., 1993; Riley et al., 1989).
Psychodynamic theory states that anger is the cause of
depression, but current conceptualizations propose a more
complicated relationship. Finman and Berkowitz (1989) showed
that a little increase in depressed mood led to activation of angry
feelings. Indeed, interaction between different causal mechanisms
various investigations on anger-depression relationship from
clinical and theoretical views, there is insufficient evidence on

1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajp.2012.07.013
36 M.A. Besharat et al. / Asian Journal of Psychiatry 6 (2013) 35–41
the nature and circumstances of this relationship. Depression is
heterogeneous and therefore multiple variables may be operating.
Disturbances in emotional processing or negative bias in
processing emotional information is a key feature of major
depressive disorder (e.g., Gotlib et al., 2004; Koster et al., 2005;
Siegle et al., 2002). Such dysfunctions of emotional information
processing are presented by negative attention biases toward cues
for sadness or dysphoria (Gotlib et al., 2004) and negative
interpretation of neutral or positive information (Gollan et al.,
2008) in patients with major depressive disorder.
Current research has emphasized the importance of emotional
functioning and deficits in emotion regulation for depression and
related psychological disorders (Ehring et al., 2008; Gross and
Munoz, 1995; Joormann and Gotlib, 2010). Although there is no
consensus on the precise nature of these deficits, it is proposed that
depression changes emotional reactivity in some ways (Rottenberg
et al., 2005). Dysfunctions of emotion regulation are associated
with changes in depressive symptoms (Ehring et al., 2008).
Emotion regulation refers to methods that are used to change or
modify the experience and expression of emotions, as well as times
in which emotions occur (Rottenberg and Gross, 2003). Emotions
can be regulated by a range of unconscious or conscious cognitive
processes (Garnefski et al., 2001). This study is limited to self-
regulatory, conscious, and cognitive components of emotion
regulation.
Cognitive emotion regulation consists of two types of coping
strategies: Less adaptive coping strategies such as self-blaming,
blaming others, rumination, and catastrophizing are categorized;
and more adaptive coping strategies including acceptance, refocus
on planning, positive refocusing, positive reappraisal, and putting
into perspective (Garnefski et al., 2001). Garnefski et al. (2002)
have accounted the use of less adaptive cognitive coping strategies
as correlates of depression. Less adaptive coping strategies are
associated with experience of and expression of anger as well
(Martin and Dahlen, 2005). Several of the specific coping strategies
proposed by Garnefski et al. (2001) are theoretically related to
anger (Beck, 1999).
Anger rumination is defined as an unintentional and recurrent
cognitive process that emerges during and continues after an
episode of anger experience (Sukhodolsky et al., 2001). It is
responsible for duration and intensification of anger (Segerstrom
et al., 2003). Sukhodolsky et al. (2001) stated that, ‘‘Generally, if
anger is viewed as an emotion, anger rumination can be defined as
thinking about this emotion’’ (p. 689). Research has demonstrated
a relation between anger rumination and depression (e.g., Gilbert
et al., 2005). Anger rumination is also associated with aggression
and anger (Maxwell, 2004; Maxwell et al., 2005; Peled and Moretti,
2010) and it can partially explain the intensity (Bushman, 2002;
Rusting and Nolen-Hoeksema, 1998) and endurance (Bushman,
2002) of angry feelings.
Rumination is also associated with the tendency for anger
suppression (Martin and Dahlen, 2005). In fact, there is a
complicated relationship between rumination and anger that
Fig. 1. The hypothetical model of the mediating role of emotion regulation and anger rumination on the relation between anger and depression.
needs to be explained. People who use rumination as an emotion
regulation strategy are more likely to experience anger repeatedly
(Martin and Dahlen, 2005). The cognitive model of depression
proposes that depression may intensify by a reciprocal cycle
between negative thoughts and mood (Beck et al., 1979).
Rumination may be a feature of emotion regulation that has
unexpected effects on increasing distress during a long period of
time (Campbell-Sills and Barlow, 2007).
The current study attempted to examine the relationship
among anger, depression, emotion regulation, and anger rumina-
tion in people with major depressive disorder. It was hypothesized
that the relationship between anger and depression in people with
major depressive disorder is mediated by emotion regulation and
anger rumination. The hypothetical model of the research is
illustrated in Fig. 1.
2. Method
2.1. Participants and procedure
A total of 88 participants with major depressive disorder (68
women, 20 men; mean age: 33.61, age range: 18–58, SD: 9.28)
participated in this study. Patients were selected if (i) they met the
DSM-IV-TR (APA, 2000) diagnostic criteria for major depression;
(ii) consulting for the first time in order to control therapeutic
outcomes; and having good physical health. Patients were
excluded from the study if (i) they did not agree to participate
in the study; (ii) they had a current/past medical or psychiatric
disorder in addition to depression (because of high comorbidity of
major depression and anxiety disorders, this criteria was not fully
applied and 16% of the present sample contemporaneously
suffered from general anxiety disorder); (iii) they had a significant
health problem; (iv) they had prior psychiatric treatment.
Participants were asked to complete Beck Depression Inventory
(BDI), Multidimensional Anger Inventory (MAI), Cognitive Emotion
Regulation Questionnaire (CERQ), and Anger Rumination Scale
(ARS). Upon completion, all participants were thanked for their
participation. The protocol was approved by Department of
Psychology, University of Tehran. All participants signed an
informed consent document prior to performing the research
procedure. Participants were primarily drawn from the middle
socioeconomic classes. Participants’ demographic information is
presented in Table 1.
2.2. Measures
2.2.1. Beck Depression Inventory (BDI)
The BDI (Beck et al., 1988) is a 13-item measure of depressive
symptomatology. Each item is rated on a four-point Likert scale
ranging from 0 to 3. The BDI is a widely used measure with
considerable support for its reliability and validity across a variety
of samples (Besharat, 2004; Beck et al., 1979, 1988). Cronbach’s
alpha coefficient was .78 for the present study.
 M.A. Besharat et al. / Asian Journal of Psychiatry 6 (2013) 35–41 37

Table 1 2.2.4. The Farsi version of the Anger Rumination Scale (ARS)
Demographic information (N = 88).
This is a 19-item self-report measure of the tendency to think
Variable Mean (S.D.) Frequency Percentage about current anger-provoking situations and to recall anger
Age (year) 33.61 (9.28) episodes from the past (Sukhodolsky et al., 2001). Each item is
Duration of illness (month) 42.14 (37.60) rated on a four-point Likert scale ranging from 1 (almost never) to 4
Sex (almost always). The scale also provides a total anger rumination
Female 68 77.3 score. It includes four subscales: anger afterthoughts, thoughts of
Male 20 22.7
revenge, angry memories, and understanding of causes. Adequate
Marital status
Married 54 61.4 psychometric properties of the scale have been reported for the
Single 32 36.4 English (Sukhodolsky et al., 2001) and the Farsi (Besharat, 2011;
Divorced 2 2.3 Besharat and Mohammad Mehr, 2009) versions.
Highest education level
9th to 12th grade 48 54.6
Bachelor level 34 38.6 3. Results
Master level 6 6.8
A multivariate analysis of variance (MANOVA) was performed
between measures of anger, anger rumination, and emotion
regulation and the categorical variable of gender in order to
2.2.2. The Farsi version of the Multidimensional Anger Inventory examine gender differences. The use of Wilks’ criterion analysis
(MAI) revealed that there was no multivariate main effect for gender
The MAI is a 30-item scale rated on a five-point Likert scale F(3,84) = 0.84, P > 0.05. So subsequent analyses were collapsed
ranging from 1 (completely undisruptive) to 5 (completely across gender.
descriptive). Items measure five dimensions of anger including Descriptive statistics and Pearson’s correlation coefficients
anger arousal, anger-eliciting situations, hostile outlook, anger- between variables are shown in Table 2. Correlation coefficients
out, and anger-in. Psychometric properties of the MAI have been between variables showed that depression was positively corre-
confirmed across several studies (e.g., Siegel, 1986). Psychometric lated with four dimensions of anger as well as anger rumination
properties of the Farsi version of the scale indicated sufficient and less adaptive emotion regulation strategies. Less adaptive
internal consistency and test-retest reliability (Besharat, 2007). emotion regulation strategies were positively associated with
Cronbach’s alpha coefficient was .80 for the present study. anger arousal and anger-eliciting situations. It was also shown that
anger rumination was positively correlated with four dimensions
2.2.3. Cognitive Emotion Regulation Questionnaire (CERQ) of anger including anger arousal, anger-eliciting situations, hostile
The CERQ is a 18-item questionnaire validated for measuring outlook, and anger-in.
individual differences in coping across nine subscales: Self-blame, Variance–covariance matrices were used as input data in order
blaming others, acceptance, refocusing on planning, positive to examine the hypothesized model of the study (Fig. 1). Since
refocusing, rumination, positive reappraisal, putting into perspec- distribution of the data was normal, the maximum likelihood (ML)
tive, and catastrophizing (Garnefski and Kraaij, 2006). Items are method was conducted. The results showed that the model is
rated on a five-point Likert scale ranging from 1 (almost never) to 5 significant for anger arousal, anger-eliciting situations, and hostile
(almost always) so that higher scores represent greater use of the outlook; and insignificant for anger-in and anger-out.
coping strategy. Adequate psychometric properties of the scale Fig. 2 displays standardized path coefficients on the mediating
have been reported for the English version (Garnefski and Kraaij, role of emotion regulation and anger rumination on the relation of
2006; Garnefski et al., 2001). Preliminary findings on the Farsi anger arousal to depression. Direct effects of variables are shown
version of the CERQ have confirmed the internal consistency and on the arrows pointing to relationships of variables in the model.
the test-retest reliability of the scale (Besharat, 2010). As can be seen from Fig. 2, anger arousal explained 35% of

Table 2
Mean scores, standard deviations, and correlations between depression and measures of anger, anger rumination and emotion regulation.

Variable M S.D. Anger rumination Less adaptive Depression

emotion regulation

Anger arousal 40.69 12.08 .25* .28** .67**

Anger-eliciting situations 33.72 7.89 .22* .23* .53**
Hostile outlook 41.67 7.44 .31** .16 .44**
Anger-out 13.16 2.43 .03 .14 .11
Anger-in 21.68 4.32 .32** .19 .38**
Depression 21.70 6.90 .31** .44**
Less adaptive emotion regulation 26.48 12.72 .37**
Anger rumination 55.05 12.72
*
p < .05.
**
p < .01.

Fig. 2. Standardized path coefficients on the mediating role of emotion regulation and anger rumination on the relation of anger arousal to depression.
38 M.A. Besharat et al. / Asian Journal of Psychiatry 6 (2013) 35–41

Fig. 3. Standardized path coefficients on the mediating role of emotion regulation and anger rumination on the relation of anger-eliciting situations to depression.

Fig. 4. Standardized path coefficients on the mediating role of emotion regulation and anger rumination on the relation of hostile outlook to depression.

depression variance by the path coefficient of .59. On the other
paths, anger arousal explained 6% of less adaptive emotion
regulation variance by the path coefficient of .25, and 8% of anger
rumination by the path coefficient of .29. Less adaptive emotion
regulation explained 8% of depression variance by the path
coefficient of .28, and anger rumination explained 6% of depression
variance by the path coefficient of .25. All of these direct
coefficients were significant at p < .05.
Fig. 3 displays standardized path coefficients on the mediating
role of emotion regulation and anger rumination on the relation of
anger-eliciting situations to depression. All of these direct
coefficients were significant at p < .05.
Fig. 4 displays standardized path coefficients on the mediating
role of emotion regulation and anger rumination on the relation of
hostile outlook to depression. All of these direct coefficients were
significant (p < .05).
Table 3 shows standardized and non standardized coefficients
of direct paths for anger arousal, anger-eliciting situations, and
hostile outlook.
One of the structural equations modeling aims is to detect
indirect effects of independent variables (exogenous variables) on
dependant variables (endogenous variables); so indirect effects of
independent variables are displayed in Table 4. These indirect
coefficients were significant at p < .05.
The Fit indices related to models of anger arousal, anger-
eliciting situations, and hostile outlook are presented in Table 5.
Absolute fit of each model was adequate. Comparative indices of
the models were superior to independent models. Expected cross-
validation index (ECV) indicated the validity of the models.
The results showed that three dimensions of anger including
anger arousal, anger eliciting-situations, and hostile outlook were
related to depression through the mediating role of emotion

Table 3
Standardized and non standardized coefficients of direct paths for anger arousal, anger-eliciting situations, and hostile outlook.

Paths B b t p

Anger arousal The effect of anger arousal on depression .34 .59 7.36 .001
The effect of anger arousal on less adaptive emotion regulation .14 .28 2.55 .03
The effect of anger arousal on anger rumination .26 .25 2.39 .04
The effect of less adaptive emotion regulation on depression .28 .25 3.25 .01
The effect of anger rumination on depression .44 .29 6.25 .001

Anger-eliciting situations The effect of anger-eliciting situations on depression .36 .44 4.91 .001
The effect of anger-eliciting situations on less adaptive emotion regulation .18 .23 2.23 .03
The effect of anger-eliciting situations on anger rumination .35 .22 2.09 .03
The effect of less adaptive emotion regulation on depression .34 .30 3.46 .01
The effect of anger rumination on depression .26 .12 2.21 .03

Hostile outlook The effect of hostile outlook on depression .34 .44 3.93 .01
The effect of hostile outlook on less adaptive emotion regulation .33 .23 4.11 .001
The effect of hostile outlook on anger rumination .54 .22 3.09 .001
The effect of less adaptive emotion regulation on depression .40 .30 4.01 .001
The effect of anger rumination on depression .23 .12 4.91 .001

Table 4
Standardized coefficients of indirect paths for dimensions of anger arousal, anger-eliciting situations, and hostile outlook.

Paths b Zsobel

Anger arousal The effect of anger arousal on depression mediated by less adaptive emotion regulation .07 2.01*
The effect of anger arousal on depression mediated by anger rumination .07 2.11*

Anger-eliciting situations The effect of Anger-eliciting situations on depression mediated by less adaptive emotion regulation .07 2.11*
The effect of Anger-eliciting situations on depression mediated by anger rumination .03 2.03*

Hostile outlook The effect of hostile outlook on depression mediated by less adaptive emotion regulation .09 2.07*
The effect of hostile outlook on depression mediated by anger rumination .08 2.21*
*
p < .05.
 M.A. Besharat et al. / Asian Journal of Psychiatry 6 (2013) 35–41
Table 5
Fit indices related to models of anger arousal, anger-eliciting situations, and hostile outlook.
Model X2 df p X2/df
Anger arousal 3.34 1 .224
Anger-eliciting situations 3.06 1 .152
Hostile outlook 4.35 1 .130
Fig. 5. Proposed model of the study on the mediating role of emotion regulation and anger rumination on the relation between anger dimensions and depression.
regulation and anger rumination. Thus, proposed model of the
research is presented in Fig. 5.
4. Disscusion
This study presented a hypothetical model to examine the
relationships between anger, depression, emotion regulation, and
anger rumination in a sample of patients with major depressive
disorder. Results of the present study revealed positive relation-
ships between anger, depression, emotion regulation, and anger
rumination. As predicted, emotion regulation and anger rumina-
tion played a mediating role on the relation between anger and
major depression. Results of the present study confirmed the
hypothetical model about three dimensions of anger including
anger arousal, anger-eliciting situations, and hostile outlook. These
findings are consistent with existing evidence of a robust
relationship between anger, depression, emotion regulation, and
anger rumination (e.g., Besharat et al., 2011; Campbell-Sills and
Barlow, 2007; Cheng et al., 2005; Davidson et al., 2002; Ehring
et al., 2008; Gilbert et al., 2005; Gollan et al., 2008; Gotlib et al.,
2004; Joormann and Gotlib, 2010; Koster et al., 2005; Novaco,
2010; Rottenberg et al., 2005; Siegle et al., 2002).
Through information processing, people lead their attention to
positive or negative events in order to adapt the events with their
previous experiences. Because of the negative bias in information
processing, depressed people tend to perceive cues for sadness or
dysphoria (Gotlib et al., 2004) and interpret neutral or positive
information negatively (Gollan et al., 2008). In fact, negative bias in
information processing is a feature of major depression (Gotlib
et al., 2004; Koster et al., 2005; Siegle et al., 2002). Dysfunctional
schemas and consequently dysfunctional attitudes lead people
with major depression to have failures in evaluating life events
(Scher et al., 2005). On the whole, these people experience more
negative and destructive emotions such as anger than nonde-
pressed individuals. Obviously, simple and usual experiences of
anger cannot explain quality and quantity of this emotion in
depressed people. This study showed that emotion regulation
mechanisms are effective in this relationship. Confronting negative
events, people use different coping strategies. These cognitive
strategies have a crucial role in the relationship between
experiencing negative life events and reporting depression and
anxiety symptoms.
According to a self-regulatory executive functional model
(Wells and Matthews, 1994), failure in cognitive mechanisms of
emotional self-regulation (a type of emotion regulation) leads
to emotional maladjustment and persistence in depression
39
RMSEA GFI AGFI CFI ECV
3.34 .011 .95 .93 .89 .02
3.06 .032 .95 .92 .93 .02
4.35 .030 .96 .94 .89 .07
symptoms. In the present study, we investigated conscious and
cognitive processes such as self-blame, blaming others, and
rumination. Depressive symptoms may indicate the existence of
less adaptive cognitive coping strategies. On the other hand, the
existence of multiple causal mechanisms in depression makes the
final conclusion impossible. Indeed, anger initiates depression
through these less adaptive regulation strategies. On the other side,
depressive mood elicits negative feelings such as anger, and
consequently the feelings accompanied with failures in regulation
worsen the depressed mood. Anger rumination as a coping strategy
in the presence of anger is effective in depression. When anger
feelings are elicited, depressive mood makes a connection between
the feelings and past memories and activates automatic thoughts.
These thoughts have a close relationship with central self-concept.
These thoughts include anger rumination as well. In this situation,
individuals may have hostile feelings toward others, and a
tendency for revenge or other components of rumination might
be started off.
From the metacognitive perspective (Papageorgiou and Wells,
2004), positive beliefs about the rumination benefits and
advantages could make them last. When ruminative thoughts
are activated, people perceive them as uncontrollable and harmful
phenomena that could produce detrimental interpersonal and
social consequences. Arousal of negative thoughts and subse-
quently appraisal on rumination participate in depression. So,
through a number of vicious cycles, depression and metacognitive
beliefs may be involved in depression persistency. Mood disorders
are characterized by another figure of negative cognition, known as
rumination. Therefore, rumination includes negative events of past
and present, and tries to regulate negative emotions; so it elicits
negative emotions.
Campbell-Sills and Barlow (2007) suggested that people who
ruminate deliberately seek negative outcomes. In contrary, active
mechanisms such as negative reinforcement or belief in the
usefulness of rumination probably reinforce this cognitive model.
Accordingly, rumination may be a kind of emotion regulation that
has an unpredictable effect on increasing distress over long periods
of time.
On the basis of the results of the present study, it can be
concluded that anger and depression are related through the
mediating role of emotion regulation and anger rumination.
Accordingly, this knowledge would provide benefits for the
understanding of the relations between anger and depression,
for both theoretical and clinical applications. Therefore, the proper
assessment of anger, dysfunctions of emotion regulation, and
anger rumination in patients with major depressive disorder may
40 M.A. Besharat et al. / Asian Journal of Psychiatry 6 (2013) 35–41
provide useful information for intervention and management
programs. It has been shown that rumination in response to
depressive symptoms predicts new onsets of major depressive
episodes (Nolen-Hoeksema, 2000; Spasojevic and Alloy, 2001).
Hence it may be argued that reductions in rumination would
reduce the risk of new onsets of major depressive episodes. There is
evidence to suggest that mindfulness-based cognitive therapy may
be effective in reducing rumination (Segal et al., 2002; Teasdale
et al., 2000). The results of the present study support using
mindfulness-based cognitive therapy in order to help reduce
rumination and the risk of new onsets of major depressive
episodes.
There are several limitations to the current study. First, the
present study was cross-sectional and utilized self-report mea-
sures. Although this study provides evidence for the mediating role
of emotion regulation and anger rumination on the relation
between anger and major depressive disorder, the cross-sectional
design prevents an understanding of the exact nature of the
relationships, particularly with respect to directionality. Second,
this study did not include a normal control group. It would be of
value to compare the scores of anger, depression, emotion
regulation, and anger rumination between normal controls and
depressive patients. Such a study may lead to a better understand-
ing of the role of dysfunctions of emotion regulation in the
development and or perpetuation of the condition. Third,
differences of personality characteristics were not investigated
in this study. It is possible that personality factors may interact
with emotion regulation to produce positive or negative con-
sequences. Future studies need to be pursued to address this issue.
Finally, the present study focused on two mediating factors,
emotion regulation and anger rumination. Consequently, it is
important that future studies employ different variables which
may have potential to play a mediating role, in order to lead to a
better understanding of the role of emotional and cognitive factors
in the development and perpetuation of depression.
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