recognizing and addressing depression presenting as anger

as one of the more common mental illnesses in america, depression is most recognizable in the forms of sadness or apathy. however, depression doesn’t look the same for everyone who experiences it. in many instances, symptoms of depression, such as feelings of unworthiness and helplessness, can translate into anger. this can be particularly difficult for people with depression to navigate, especially if feeling angry is uncharacteristic of their typical behavior.

battling depression on a daily basis is lonely and exhausting to manage. learning how to identify anger in depression in a healthy way can alleviate part of the struggle.

in this article:

how prevalent is anger in depression and what does it look like?

why may depression present as anger?

how to treat depression and anger

major depressive disorder is a common mood disorder that affected more than 17 million u.s. adults in 2017. the prevalence of a major depressive episode (mde) was highest among adults ages 18 to 25 (13.1%) and higher for women (8.7%) than men (5.3%).

the diagnostic and statistical manual of mental disorders, 5th edition (dsm-5) states that an individual must exhibit specific symptoms to be diagnosed with major depression, one of which must be either depressed mood and or loss of interest or pleasure in life activities for at least two weeks. the dsm-5 also requires the majority of the following symptoms that cause clinically significant impairment in social, work or other important areas of functioning almost every day:

though anger isn’t listed by the dsm-5 as one of the diagnostic criteria for adults, irritability is a key diagnostic factor for children and adolescents. in an interview with npr about anger and depression, dr. maurizio fava, a psychiatrist at massachusetts general hospital and a professor at harvard medical school, questioned whether the dsm-5 is getting it right.

“why would someone who happens to be irritable and angry when depressed as an adolescent suddenly stop being angry at age 18?” he said.

fava, who has researched “anger attacks,” noted that about one-third of his patients with depression reported losing their tempers and engaging in behaviors like screaming, slamming doors and throwing objects.

in a jama psychiatry study of patients who experienced major depressive episodes, researchers used the schedule for affective disorders and schizophrenia to assess irritability or anger, counting everything at a 3 or above as clinically significant.

schedule for affective disorders and schizophrenia: levels of anger and irritability

1 – not at all
2 – occasional snappiness
3 – somewhat argumentative or quick to express annoyance
4 – often shouts or loses temper
5 – throws things, breaks windows, or is occasionally assaultive
6 – repeatedly violent against things or people

researchers found that overt irritability or anger, which was present in approximately 54.5% of participants, was associated with:

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the use of ineffective or inappropriate emotional regulation strategies as well an impaired ability to process negative information may play a role in developing depression. authors of a review published in cardiovascular psychiatry and neurology noted that these behaviors can result in:

rumination: repetitive, unwanted, past-oriented negatively inclined thoughts. individuals who ruminate may mentally rehearse past stressful events and worry about future events.

impaired cognitive reappraisal: inability to reframe one’s thoughts about emotion-eliciting occurrences to change their effects.

increased expressive suppression: attempts to hide, inhibit or reduce ongoing emotion-expressive behavior.

but how does that relate to anger? a separate study in the asian journal of psychiatry sought to explain the mediating role of emotional regulation and anger rumination on the relation between anger and major depressive disorder. researchers ultimately found that people with depression were more likely to experience anger and irritability if they lacked the ability to emotionally regulate and ruminated on negative events.

culture can play a significant role in determining whether specific groups of people use maladaptive emotional regulation strategies. the national institute of mental health notes that while both men and women experience depression, men may be less likely to talk about it and instead choose to hide their emotions. this can result in the appearance of irritability, anger and aggressiveness.

similarly, a study in the journal of the society for social work and research indicates that african american patients with depression may culturally express the mood disorder as irritability, increased agitation, increased hostility and internalized anger. they may also be less likely to verbalize feelings of depression.

overlooking these differences can result in dangerous consequences such as underdiagnoses and misdiagnoses, which could lead to ineffective treatment. in a study published in psychiatric services, researchers found that african americans were more likely to screen positive for depression after being diagnosed for schizophrenia, suggesting that racial disparities in schizophrenia diagnoses may in part be the result of clinicians underemphasizing the symptoms of mood disorders.

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in order to treat depression, individuals should first be screened by a medical or mental health professional who can provide an assessment of the history and severity of symptoms. if the screening results in a diagnosis, there are a number of ways to treat depression including medication; psychotherapies, such as cognitive-behavioral therapy (cbt), interpersonal therapy (ipt), and problem-solving therapy; or a combination. fava’s study indicated that anger attacks disappeared in 53% to 71% of depressed patients who used medication.

therapy will focus on the psychological, behavioral, interpersonal and situational causes. the anxiety and depression center explains how therapy can help patients recover from depression:

identifying negative thinking patterns that contribute to feelings of hopelessness and helplessness and developing a more positive outlook.

exploring learned thoughts and behaviors that create problems and contribute to depression.

identifying problems that may contribute to depression and which aspects of those problems they may be able to solve or improve.

regaining a sense of control and pleasure in life.

techniques that therapists may use to help depressed patients cope with anger can include:

• maintaining a diary of anger outbursts that includes the antecedents, behaviors, and consequences of anger.
• progressive muscular relaxation training and deep breathing.
• distraction, which requires an individual to move away from the anger-eliciting situation, keep calm and picture something positive.
• cognitive restructuring, which replaces anger-provoking thoughts with more rational thoughts.

of course, there are coping mechanisms that individuals can practice to regulate mood. in a study published in behaviour research therapy, researchers found that engaging in self-compassion improved the effectiveness of cognitive reappraisal, or restructuring, as an emotional regulation tool to address depression.

authors of the study define self-compassion as a compassionate response toward one’s own suffering, which can interfere with self-criticism likely to be cued during challenging tasks. it can also strengthen the motivation to engage in self-help strategies.

how can a person engage in self-compassion?

researchers encouraged participants in the study to engage in self-compassion and used a more in-depth version of the following prompt:

• visualize yourself from the perspective of a compassionate observer.
• notice from the outside how feelings are upsetting you and how they are reflected in your appearance.
• try to let the warm feeling of compassion and desire to help arise within yourself.
• say to yourself: “it is understandable that you feel that way. you are experiencing a natural response to depressing thoughts. but i am going to help you.”
• encourage yourself by saying: “you can pull yourself out of this mood again. you have already accomplished so much; you will be able to deal with this.”
• visualize putting your hand on your shoulder or hugging yourself to soothe and comfort yourself. give yourself a friendly smile.
• think about if there are other things you want to tell yourself that would energize and encourage you to cheer up.
• take your time to say those things. when you feel it is appropriate, begin saying goodbye to yourself and remind yourself that you can come back every time you want.

remember that anger can often be expressed inwardly. learning how to cope with anger caused by depression is as much a benefit to those who may be on the receiving end of an anger attack as it is to the individual. if you are interested in helping individuals struggling with depression, consider becoming a social worker.

if you or someone you know is suffering from depression and needs help, call the substance abuse and mental health services administration’s 24-hour free and confidential national helpline at 1-800-662-help (4357).

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last updated: april 2020