Current Psychology (2024) 43:4751–4765

https://doi.org/10.1007/s12144-023-04682-2

Early maladaptive schema domains and suicide risk in major

depressive disorder: the mediating role of patients’ illness‑related
self‑regulation processes and symptom severity
Giorgos Mavroeides1 · Maria Basta2 · Alexandros Vgontzas3 · Evangelos Karademas1 · Panagiotis Simos2 ·
Katerina Koutra1

Accepted: 16 April 2023 / Published online: 28 April 2023

© The Author(s) 2023

Abstract
Early maladaptive schemas (EMS), illness representations, and coping are associated with clinical outcomes of patients with
major depressive disorder (MDD). However, the pathways that link these factors are largely unknown. The present prospec-
tive study aimed at investigating the possible mediating role of illness representations and coping in the associations among
schema domains, symptom severity, and suicide risk in MDD. Participants were 135 patients diagnosed with MDD, aged
48.13 ± 14.12 (84.4% females). The Young Schema Questionnaire-Short Form 3 was used to measure schema domains at
baseline. Illness representations and coping were measured at approximately five months later (mean = 5.04 ± 1.16 months)
with the Illness Perception Questionnaire-Mental Health and the Brief COPE Inventory, respectively. MDD outcomes were
measured about 10 months after the baseline assessment (mean = 9.44 ± 2.36 months) with the Beck Depression Inventory
and the Risk Assessment Suicidality Scale. SPSS AMOS 27 was used to conduct path analysis. Serial mediation Structural
Equation Modelling, controlling for age, education, marital status, working status, MDD duration, pharmacotherapy, and
psychotherapy, revealed that Impaired Autonomy and Performance was positively linked to suicide risk. Negative MDD
impact representations and symptom severity serially mediated the aforementioned association. Finally, problem-focused
coping was negatively related to symptom severity and suicide risk. This study’s main limitation was modest sample size.
Representations regarding the impact and severity of MDD mediate the effects of Impaired Autonomy and Performance on
future suicide risk in MDD. Healing Impaired Autonomy and Performance domain of EMS, restructuring patients’ repre-
sentations of high MDD impact, and enhancing problem-focused coping could significantly reduce symptom severity and
suicide risk in Schema Therapy with MDD individuals.

Keywords Early maladaptive schemas · Illness representations · Coping · Suicide risk · Major depressive disorder

Introduction

Major depressive disorder (MDD) is a common mental dis-

order affecting more than 290 million people worldwide
(Ferrari et al., 2013). According to cognitive theories of
psychopathology, maladaptive cognitions play a key role in
* Giorgos Mavroeides the emergence and course of MDD by placing individuals at
[email protected] risk for developing depressive symptoms, particularly when
1 they are under high stress, and by maintaining the depressive
Department of Psychology, School of Social Sciences,
University of Crete, Gallos Campus, 74100 Rethymnon, symptomatology (Abramson et al., 1989; Beck & Haigh,
Crete, Greece 2014; Reilly et al., 2012). Moreover, according to Strauman
2
Department of Psychiatry & Behavioral Sciences, Faculty and Eddington (2017), MDD can be conceptualized as a
of Medicine, University of Crete, Heraklion, Crete, Greece disorder of self-regulation, and maladaptive cognitions play
3
Mobile Mental Health Unit, Psychiatric Clinic, University an essential role in patients’ self-regulation processes.
Hospital of Heraklion, Heraklion, Crete, Greece

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4752 Current Psychology (2024) 43:4751–4765

Early maladaptive schema domains Illness representations are a particular type of illness-
related cognitions organizing patients’ beliefs about their
Early Maladaptive Schemas (EMS) are broad pervasive diagnosis (Leventhal et al., 1980, 2003). The CSM proposes
patterns comprising memories, cognitions, emotions, that patients form cognitive and emotional representations of
and physical sensations (Young, 1999). EMS emerge their illness to deal with it. Cognitive illness representations
during childhood and adolescence in response to the consist of patients’ beliefs about the identity of the disease,
frustration of early core emotional needs and collude namely its label and symptoms, the disease’s causes, time
with temperamental factors to contribute to psycho- frame (acute, chronic, cyclical), consequences on patients’
pathological manifestations. Currently, 18 EMS have lives, and the potential for personal and treatment control.
been identified and grouped into the following five Emotional representations are patients’ emotions in response
broad categories called schema domains: Disconnection to the illness. Patients’ illness representations determine
and Rejection, Impaired Autonomy and Performance, their self-management by guiding the strategies they utilize
Impaired Limits, Other-Directedness, and Overvigi- to cope with the illness, thus affecting clinical outcomes
lance and Inhibition (Young et al., 2003). Moreover, (Leventhal et al., 1980, 2003).
in their recent work, Bach et al. (2018) identified four In MDD, illness representations are linked to vari-
higher-order schema domains instead of the original ous clinical and treatment-related outcomes. According
five: Disconnection & Rejection, Impaired Autonomy to a recent systematic review by Mavroeides and Koutra
& Performance, Excessive Responsibility & Standards, (2021), illness representations are associated with the
and Impaired Limits. severity of depressive symptoms, patients’ anxiety and
Lately, there has been an increasing amount of research perceived stress levels, psychosocial functioning, comor-
concerning the role of EMS in MDD. According to a bidity, medication adherence, and the duration of phar-
recent systematic review and meta-analysis by Bishop macotherapy. Moreover, illness representations are linked
et al. (2021), all EMS are positively associated with the to prominent MDD phenomena, such as rumination (Lu
severity of depressive symptoms in patients with MDD, in et al., 2014) and self-blaming (Brown et al., 2007).
patients with other mental disorders such as bipolar dis- The CSM identifies coping as the second critical ill-
order, obsessive-compulsive disorder, and body dysmor- ness-related self-regulation process that plays a role in
phic disorder, and in the general population. Moreover, adaptation to an illness and determines its course and
patients with MDD report significantly higher maladap- outcome (Leventhal et al., 1980, 2003). Coping refers
tive EMS than the general population (Halvorsen et al., to people’s cognitive and behavioral efforts to manage
2009) and, in some cases, higher than patients with other stress, and based on its function, it can be divided into
severe mental disorders, such as schizophrenia (Jang & problem-focused and emotion-focused (Lazarus & Folk-
Lee, 2020). In addition, EMS in MDD present stability man, 1984). Problem-focused coping consists of efforts to
over time (Halvorsen et al., 2010; Renner et al., 2012; resolve the stressful situation or alter the source of stress,
Wang et al., 2010), thus making them potentially crucial while emotion-focused coping aims at managing one’s
long-term vulnerability factors. emotions that are linked to the stressful situation (Car-
roll, 2013). Carver et al. (1989) specified a third group of
coping strategies, the less useful or maladaptive coping,
Illness representations and coping corresponding to less beneficial strategies such as behav-
ioral disengagement and emotion venting. According to
According to the leading model of illness-related self-reg- the meta-analysis by Hagger et al. (2017), the CSM does
ulation, the Common-Sense Model (CSM; Leventhal et al., not specify particular coping procedures, but previous
1980, 2003), there are two main processes which play a distinctions, such as those of Lazarus and Folkman (1984)
crucial role in how patients adapt to their diagnosis: illness and Carver et al. (1989), are commonly employed.
representations and coping. The CSM was originally used The role of coping in MDD is well-established. Spe-
to describe patients’ self-regulation processes in physi- cifically, individuals with MDD are more often engaged
cal illnesses, such as cardiovascular diseases, cancer, and in maladaptive coping (e.g., denial) than adaptive coping
diabetes (see meta-analyses by Dempster et al., 2015; Hag- (e.g., active coping) (Orzechowska et al., 2013). Moreo-
ger et al., 2017). The model was later used successfully ver, specific coping mechanisms have been linked to
with patients with mental disorders, such as schizophrenia MDD outcomes, such as patient quality of life (Holubova
spectrum disorders and bipolar disorder (for a meta-anal- et al., 2018), suicidal ideation (De Berardis et al., 2020),
ysis, see Cannon et al., 2022), and MDD (for a systematic efficacy of psychotherapy for MDD (Renaud et al., 2014),
review, see Mavroeides & Koutra, 2021). and symptom remission (Rodgers et al., 2017).

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Current Psychology (2024) 43:4751–4765 4753

The interplay between EMS, illness representations, are largely culturally-determined (Antoniades et al., 2017;
and coping Reichardt et al., 2018; Sinha & Watson, 2007), increasing
knowledge about Greek MDD patients’ illness representa-
Illness representations are linked to coping in patients with tions, coping, and how they are related to MDD outcomes
MDD. Specifically, current research links positive illness is critical.
representations (e.g., high perceived control over the illness) Hence, the current prospective study aimed to investigate
to more adaptive ways of coping in MDD patients and nega- the impact of EMS and self-regulation processes, indexed by
tive illness representations (e.g., more perceived illness con- illness representations and coping, on two major MDD out-
sequences) to more maladaptive coping (Brown et al., 2001; comes (symptom severity and suicidality). We hypothesized
Kelly et al., 2007; Mavroeides & Koutra, 2022). Moreover, (a) that schema domains are associated with higher MDD
according to Brown et al. (2007), various coping strategies suicide risk and (b) that illness representations, and symp-
mediate or moderate the association between illness repre- tom severity serially mediate the aforementioned associa-
sentations and psychosocial functioning in MDD patients. tion. More specifically, we hypothesized that EMS domains
Research on EMS in association with self-regulation are associated with high MDD impact representations (i.e.,
processes is scarce. Studies employing non-clinical samples identity, consequences, chronicity, cyclicality, and emotional
suggest that specific EMS, such as Vulnerability to Harm or representations) leading to more maladaptive and emotion-
Illness, Punitiveness, and Unrelenting Standards (Babajani focused coping, thus resulting to increased symptom severity
et al., 2014), and Disconnection and Rejection, and Impaired and suicide risk. Furthermore, EMS domains are related to
Autonomy domains (Ke & Barlas, 2020) are associated with low control and coherence representations leading to less
coping in the general population. Moreover, according to the problem-focused coping, thus resulting to increased symp-
findings of a recent study by Mc Donnell et al. (2018), EMS tom severity and suicide risk. Figure 1 schematically illus-
are associated with coping in poly-drug users. trates the hypothesized, conceptual model.

The present study

Methods
To our knowledge, no empirical investigation has examined
whether EMS domains are associated with MDD patients’ Participants
illness representations and coping strategies and whether ill-
ness representations and coping mediate the effect of schema As recommended by MacCallum et al. (1996), Root Mean
domains on MDD outcomes. This topic is critical toward Square Error of Approximation (RMSEA) was used to calcu-
elucidating the degree to which patients’ schemas are linked late the required sample size and the achieved power for our
to MDD outcomes through patients’ self-regulation skills. model. The required sample size was N = 105 for 42 degrees
Identifying modifiable factors contributing to the severity of freedom, a p < 0.05, desired power of 0.80, RMSEA = 0
of depression symptoms has become a national emergency for the null hypothesis and RMSEA = 0.08 for the alternative
given the high frequency of MDD in Greece over a decade- hypothesis. Achieved power based on our final sample size
long economic recession (Basta et al., 2021, 2022; Econo- was 0.92. A total of 234 patients with a clinical diagnosis
mou et al., 2013, 2016; Madianos et al., 2011). However, of MDD were contacted and informed about the purpose of
currently no data exist about Greek MDD patients’ EMS and the present study between May 2019 and November 2020.
the only available data about illness-related self-regulation Participants were recruited from the outpatient department
and its role in MDD outcomes are preliminary and come and the mobile mental health unit (MMHU) of the Psychi-
from validating an illness representations measure (Mav- atric Clinic of the University General Hospital of Heraklion
roeides & Koutra, 2022). Given that illness-related self-reg- in Crete, Greece, and from an online depression peer sup-
ulation processes and their associations with mental health port group. Diagnosis of MDD was assessed by experienced

Illness Representations Coping (T2) MDD symptom severity

(T2) (T3)

Schema Domains (T1) Suicide risk (T3)

Fig. 1  Schema domains, illness representations, coping, symptom severity, and suicide risk in MDD: Hypothesized, conceptual model

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4754 Current Psychology (2024) 43:4751–4765

attending psychiatrists of the University General Hospital

Contacted for
of Heraklion using standard procedures (clinical evaluation participation
including the Mini International Neuropsychiatric Interview)
based on the DSM-5 criteria (American Psychiatric Asso- (N=234)
ciation, 2013; Sheehan et al., 1998). Participants recruited Declined to
through the online peer support group had received a for- participate
mal diagnosis of MDD by a psychiatrist. In Heraklion, 129 (N=18)
patients were contacted during their visit to the outpatient 1
department, and 88 were contacted during their visit to the
MMHU. Seventeen patients were contacted through the (N=216, response
online peer support group. Finally, 216 patients (response rate = 92.3%)
rate = 92.3%) agreed to participate in the study and returned Not found or
usable data during the baseline assessment (T1) (n = 117 declined to
from the outpatient department, n = 82 from the MMHU, participate
and n = 17 from online peer support). One hundred fifty (N=66)
2
patients (attrition rate: 31.6%) returned usable data during (mean=5.04±1.16
the study’s second wave (T2) (n = 80 from the outpatient months after T1)
department, n = 60 from the MMHU, and n = 10 from online
peer support). Finally, 135 patients (attrition rate from T1: (N=150, attrition
rate: 31.6%)
37.5% and from T2: 10%) returned usable data during the
study’s third wave (T3) (n = 72 from the outpatient depart- Not found or
ment, n = 54 from the MMHU, and n = 9 from online peer declined to
support) (Fig. 2). participate
The criteria for inclusion in the study were: i) being diag- (N=15)
3
nosed by a psychiatrist with MDD according to the Diag-
(mean=4.43±1.44
nostic and Statistical Manual of Mental Disorders (DSM-5) months after T2)
or the International Classification of Disease (ICD-10), ii)
having a good understanding of the Greek language, and iii) (N=135, attrition
aged 18 or older. Participants were excluded if they were rate from T1:
37.5% and from
diagnosed with severe mental disorders other than MDD,
T2: 10%)
substance use disorder, neurological or severe physical ill-
ness, or intellectual disability.
This study was approved by the Research Ethics Com- Fig. 2  Flow diagram for study participants
mittee of the University of Crete (registration number:
44/18.03.2019). Following the presentation of the study’s
aims and methods, all participants provided written informed designed to measure the 18 EMS and the five broad schema
consent to participate in the study, according to the Declara- domains described by Young et al. (2003). The five domains
tion of Helsinki (World Medical Association, 2013). measured by the YSQ-S3 are Disconnection and Rejection,
Impaired Autonomy and Performance, Impaired Limits,
Measures Other-Directedness, and Overvigilance and Inhibition. The
Disconnection and Rejection domain comprises the Aban-
Sociodemographic and clinical characteristics donment/ Instability, Mistrust/ Abuse, Emotional Depriva-
tion, Defectiveness/ Shame, and Social Isolation/ Aliena-
Sociodemographic characteristics (e.g., gender, age, edu- tion EMS. Impaired Autonomy and Performance includes
cational level, marital status, working status) and clinical the Dependence/ Incompetence, Vulnerability to Harm or
characteristics (e.g., illness duration, hospitalizations, phar- Illness, Enmeshment/ Undeveloped Self, and Failure to
macotherapy, psychotherapy) were collected through a struc- Achieve EMS. Impaired Limits comprise the Entitlement/
tured questionnaire. Grandiosity and Insufficient Self-Control/ Self-Discipline
EMS. Other-Directedness domain refers to the Subjugation,
Young Schema Questionnaire‑Short Form Self-Sacrifice, and Approval-Seeking/ Recognition-Seeking
EMS. Finally, Overvigilance and Inhibition domain includes
The Young Schema Questionnaire-Short Form 3 (YSQ- the Negativity/ Pessimism, Emotional Inhibition, Unrelent-
S3; Young, 2005) is a 90-item self-report questionnaire ing Standards/ Hypercriticalness, and Punitiveness EMS.

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Current Psychology (2024) 43:4751–4765 4755

Responses to the YSQ-S3 are made on a 6-point Likert- behavioral disengagement, denial, self-distraction, self-
type scale ranging from 1=“Completely untrue for me” to blame, substance use, and venting into dysfunctional/ mala-
6=“Describes me perfectly.” Since mean scores were used daptive coping (possible range 6-24). Cronbach’s alpha val-
in this study, the possible range for all schema domains sub- ues in the present study were: .77 for problem-focused, .63
scales was 1-6. The YSQ-S3 has been validated for use in for emotion-focused coping, and .67 for maladaptive coping.
the Greek population (Malogiannis et al., 2018). Cronbach’s
alpha values for the five domains in this study were: .94 for Beck Depression Inventory
Disconnection and Rejection, .90 for Impaired Autonomy
and Performance, .75 for Impaired Limits, .84 for Other- Severity of MDD symptoms, indexed by the total score on
Directedness, and .89 for Overvigilance and Inhibition. the Beck Depression Inventory (BDI) served as one of the
two major study outcomes. The BDI is a 21-item multiple-
Illness Perception Questionnaire‑ Mental Health choice self-report questionnaire assessing symptoms such
as low mood, suicidal ideas, and fatigability experienced
The Illness Perception Questionnaire- Mental Health (IPQ- during the past week (Beck et al., 1961). Responses to the
MH; Witteman et al., 2011) is a 67-item self-report assess- BDI are made on a 4-point Likert-type scale ranging from 0
ing various illness representations dimensions of patients to 3 (possible range 0-63). The BDI has been validated for
with mental disorders. Responses to the IPQ-MH are made use in the Greek population (Jemos, 1984). Cronbach’s alpha
on a 5-point Likert-type scale ranging from 1=“Not at all/ value was .92 in the current study.
Strongly disagree” to 5=“Very much/ Strongly agree.” The
IPQ-MH has been validated in the Greek population (Mav- Risk Assessment Suicidality Scale
roeides & Koutra, 2022) and measures 13 distinct illness
representation dimensions. To reduce analyses’ complex- Suicidality risk assessed using the total score on the Risk
ity, we combined illness representations’ dimensions into Assessment Suicidality Scale (RASS; Fountoulakis et al.,
broader illness schemas. This is in line with theory since 2012) served as the second study outcome. The RASS is a
illness representations are parts of broader health schemas, 12-item self-report questionnaire originally developed for
according to Leventhal et al. (1980). Moreover, Skinner the Greek population to measure suicide-related behavior
et al. (2011) argue that combining illness representations and inner experience. Responses to the RASS items are
can be more helpful in understanding patterns of responding made on a 4-point Likert–type scale ranging from 0=“Not
to an illness than investigating illness representations dimen- at all” to 3 = “Very much”, with total scores ranging between
sions separately. Hence, in this study, we combined identity 0 and 1190, and Cronbach’s a = .85.
(felt symptoms), consequences, chronic timeline, cyclical,
and emotional representations into representations about the Procedure
impact of MDD (possible range 28-140), and coherence,
personal control, and treatment control into representations In the current study, we utilized T1 data regarding patients’
of control over MDD (possible range 13-65). Cronbach’s sociodemographic characteristics and schema domains, T2
alpha values in this study for impact and control representa- data regarding patients’ representations of MDD and cop-
tions were .95 and .86, respectively. ing styles, and T3 data regarding MDD symptom severity
and suicide risk. The initial assessment took place in person
Brief Cope Orientation to Problems Experienced during a scheduled appointment with the patients, with a
mean duration of 90 minutes. During the initial assessment,
The Brief Cope Orientation to Problems Experienced (Brief patients were informed about T2 and T3, and those who
COPE; Carver, 1997) is a 28-item self-report questionnaire agreed to participate in them provided a phone number or
assessing 14 strategies for coping with stress. Respondents an email address to the researchers to contact them. The
answer each item on a 4-point Likert-type scale ranging average time interval between T1 and T2 was 5.04 months
from 1=“I haven’t been doing this at all” to 4=“I’ve been (SD = 1.16; range 3-7 months), and the average time inter-
doing this a lot.” The Brief COPE has been validated for val between T2 and T3 was 4.43 months (SD = 1.44; range
use in the Greek population (Kapsou et al., 2010). In line 3-7 months).
with various previous studies (Cooper et al., 2008; Kalait- The package of questionnaires for T1 assessment was
zaki, 2021), in this study, we combined active coping, use of administered to patients by the first author in individual
informational support, and planning into problem-focused sessions at the Psychiatric Clinic or the MMHU of the Uni-
coping (possible range 3-12), acceptance, use of emotional versity Hospital of Heraklion, Crete, Greece. The question-
support, humor, positive reframing, and religious coping naires were also administered online to patients with MDD
into emotion-focused coping (possible range 5-20), and recruited from an online peer support group who completed

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4756 Current Psychology (2024) 43:4751–4765

them individually. In this case, after receiving approval from shown to control for Type I error by reducing false discovery
the website’s administrator, we made an announcement rates up to 80% in comparison to analyses conducted with-
about the study on the group’s website and posted a link to out bootstrapping (Meuwissen & Goddard, 2004). Moreover,
a Google Form containing the questionnaires. Patients inter- bootstrapping adequately accounts for Type I error even for
ested in the study could follow the link and participate in the complex SEM models with multiple mediations (Cheung
survey online. Participants were given an information sheet & Lau, 2007; Williams & MacKinnon, 2008). To assess
describing the aims of the study. After answering T1 ques- model fit, we used a series of absolute (Chi-square [χ2],
tionnaires, patients who consented to participate in T2 and Standardized Root Mean Squared Residual [SRMR]), rela-
T3 assessments provided an email address to the researchers tive (Normed Fit Index [NFI], Tucker-Lewis Index [TLI],
to contact them. T2 and T3 data were also collected using Incremental Fit Index [IFI]), and centrality-based fit indi-
Google Forms. If needed, participants could ask a specially ces (Comparative Fit Index [CFI], RMSEA). Cutoff values
trained graduate-level psychologist (the first author) for help. were: NFI ≥0.90 (Byrne, 2010; Hair et al., 1998), TLI, IFI,
and CFI ≥0.90 for acceptable fit and ≥ 0.95 for excellent fit,
Data analysis RMSEA ≤0.06, SRMR ≤0.08, and p for χ2 ≥ 0.05 (Hu &
Bentler, 1999). All statistical analyses were performed using
Homoscedasticity was checked by plotting the predicted SPSS Statistics 27 software (IBM, Armonk, NY, USA) and
values against residuals. Linearity was tested using P-P AMOS 27. Estimated associations are described in terms of
plots. Normality was assessed using skewness and kurtosis β-coefficients (beta) and corresponding 95% CIs.
values, and multicollinearity was assessed using variance
inflation factor (VIF) and tolerance with a cutoff value of
5 and .20, respectively (James et al., 2013; Menard, 1995). Results
Mahalonobis distance was used to test for outliers at p < .001
(Tabachnick & Fidell, 2007). To test for differences between Sample characteristics
patients who participated in T2 and T3 and those who did
not participate in them, as well as between patients from Participants’ socio-demographic and clinical characteris-
peer support and hospital-based patients, we used the t-test tics are presented in Table 1. The final sample comprised
for independent samples for continuous variables and chi- 135 patients, of whom 21 were males (15.6%) and 114
square for categorical variables. To test for possible control were females (84.4%). Patients’ ages ranged from 18 to 73,
variables, a series of MANOVAs were performed. In each with a mean age of 48.13 years (SD = 14.12). Most partici-
MANOVA, schema domains, illness representations, coping, pants were of Greek origin (97%), residents of urban areas
and MDD outcomes were used as the dependent variables. (53.3%), married (60%), and not working (59.3%). Moreo-
Gender (male, female), marital status (married, non-married, ver, most patients were chronic since 120 (80%) had MDD
widowed/divorced), educational level (elementary school, onset longer than two years prior to the assessment. Among
junior high school, high school, vocational training, univer- patients receiving pharmacotherapy (77% of the total sam-
sity degree), working status (working, not working), duration ple), most were treated with selective serotonin reuptake
of MDD (<6 months, 6-12 months, 1-2 years, 3-4 years, inhibitors (34.1%), followed by patients treated with com-
>5 years), pharmacotherapy (no, yes), psychotherapy (no, binations of antidepressants (14.8%), while eight patients
yes), and hospitalization (no, yes) were used separately as (5.9%) received no antidepressants and were treated with
independent variables. The correlations of schema domains, other medications (e.g., anxiolytics and atypical antipsy-
illness representations, coping, MDD outcomes, and age chotics). In general, half of the patients receiving pharma-
were also examined using Pearson’s product-moment cor- cotherapy (36.3% of total sample) were treated with more
relation coefficient. The aforementioned analyses were con- than one medication (e.g., antidepressants and anxiolytics).
ducted assuming a 0.05 significance level. Futhermore, one-third of the patients (34%) were receiving
To investigate the indirect effects of schema domains psychotherapy. Among them, most were receiving support-
on suicide risk through illness representations, coping, and ive therapy (14.1%), followed by Cognitive Analytic (6.7%),
MDD severity we used Structural Equation Modelling. A and Cognitive-Behavioral Therapy (5.2%). Patients who
complete mediation model (Model 1) was tested by assum- participated in T2 and T3 did not differ significantly from
ing only indirect effects between schema domains and sui- those who did not participate in T2 and T3 on gender, age,
cide risk. A partial mediation model (Model 2) alternative to education, working status, marital status, duration of MDD,
Model 1 was also tested by specifying direct effects between pharmacotherapy, and psychotherapy. Patients recruited
schema domains and suicide risk outcomes in addition to the from online peer support presented some differences from
indirect ones. Bootstrapping with 2000 resamples and 95% hospital-based patients. Specifically, patients from online
confidence intervals (CIs) was used. Bootstrapping has been peer support were more often better educated (elementary

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Current Psychology (2024) 43:4751–4765 4757

Table 1  Participants’ socio-demographic and clinical characteristics (N = 135)

Socio-demographic characteristics Clinical characteristics
N % N %

Gender MDD onset

Male 21 15.6 <6 months 3 2.2
Female 114 84.4 6-12 months 3 2.2
Nationality 1-2 years 21 15.6
Greek 131 97 3-4 years 19 14.1
Other 4 3 >5 years 89 65.9
Origin Hospitalization
Urban 72 53.3 None 104 77
Rural 63 46.7 1 20 14.8
Residence 2 or more 11 8.1
Urban 72 53.3 Duration of longest hospitalization
Rural 63 46.7 Up to 10 days 4 3
Marital status 11-20 days 12 8.9
Unmarried 81 60 21-30 days 11 8.1
Married 23 17 31+ days 3 2.2
Divorced/Widowed 31 23 No hospitalization 104 77
Education Missing 1 .7
Elementary school 38 28.1 Last hospitalization
Junior high school 13 9.6 Within the last 6 months 4 3
High school 44 32.6 6-12 months 12 8.9
Vocational training 13 9.6 1-2 years 11 8.1
University degree 27 20 3+ years 3 2.2
Employment status No hospitalization 104 77
Working 55 40.7 Missing 1 .7
Not working 80 59.3 Pharmacotherapy
Monthly income Yes 104 77
No individual income 39 28.9 No 31 23
1-650 € 54 40 Medication class
651-1000 € 31 23 Selective Serotonin Reuptake Inhibitors 46 34.1
  > 1000 € 11 8.1 Selective Norepinephrine Reuptake Inhibitors 11 8.1
Living Atypical Antidepressants 12 8.9
Alone 21 15.6 Antidepressants combination 20 14.8
With family/ partner/ others 114 84.4 Other, non-antidepressant (e.g., anxiolytics) 8 5.9
Min-Max Mean (SD) No medication 31 23
Age (years) 18-73 48.13 (14.12) Missing 7 5.2
Monotherapy
Yes 48 35.6
No 49 36.3
Missing 7 5.2
Antidepressants frequency
Once per day 74 54.8
Twice per day 12 8.9
Three+ times a day 3 2.2
No medication 31 23
Missing 7 5.2
Psychotherapy
Yes 46 34.1
No 89 65.9

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4758 Current Psychology (2024) 43:4751–4765

Table 1  (continued)
Socio-demographic characteristics Clinical characteristics
N % N %

Type of psychotherapy
Supportive 19 14.1
Cognitive-Behavioral 7 5.2
Psychodynamic 2 1.5
Cognitive Analytic 9 6.7
Systemic/ Family therapy 2 1.5
Group therapy 2 1.5
No psychotherapy 89 65.9
Missing 5 3.7

school 0% vs. 30.15%, junior high school 11.11% vs. coping styles and MDD outcomes. All coping styles were
9.52%, high school 22.22% vs. 33.33%, vocational training correlated with MDD outcomes as well. In general, schema
33.33% vs. 7.93%, university degree 33.33% vs. 19.04%, domains were linked to lower control and higher impact
χ2(4,N = 135) = 9.92, p = .042). Moreover, online peer sup- representations, and worse MDD outcomes. High control
port patients were more likely to be working (77.77% vs. representations were associated with more problem-focused
38.09% two-tailed p = .031) and receiving psychotherapy and emotion-focused coping, less maladaptive coping, and
(88.88% vs. 30.15% two-tailed p = .001). better MDD outcomes. High impact representations were
linked to less problem-focused and emotion-focused cop-
Bivariate correlations between the study variables ing, more maladaptive coping and worse MDD outcomes.
Finally, problem-focused and emotion-focused coping were
The five schema domains were significantly correlated with linked to better MDD outcomes, and maladaptive coping was
impact and control representations, maladaptive coping, and linked to worse MDD outcomes. Intercorrelations, means,
MDD outcomes. Illness representations were linked to all and standard deviations are presented in Table 2.

Table 2  Means, standard deviations, and inter-correlations between main variables

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

1. D&R-Τ1 1
2. IA-Τ1 .79** 1
3. IL-Τ1 .65** .63** 1
4. OD-Τ1 .65** .68** .53** 1
5. O&I-Τ1 .80** .78** .65** .70** 1
6. CR-Τ2 −.43** −.48** −.28** −.29** −.35** 1
7. IR-Τ2 .54** .60** .39** .39** .51** .70** 1
8. PFC-Τ2 −.09 −.14 −.06 −.06 −.005 .43** −.35** 1
9. EFC-Τ2 −.12 −.13 −.06 −.05 −.10 .25** −.23** .53** 1
10. MC-Τ2 .45** .49** .34** .38** .37** −.38** .60** −.01 .07 1
11. BDI-Τ3 .39** .43** .30** .31** .38** −.53** .58** −.43** −.28** .38** 1
12. RASS-Τ3 .52** .52** .40** .29** .44** −.45** .57** −.27** −.26** .44** .73** 1
Mean 2.74 2.44 2.60 3.09 2.91 45.51 84.47 16.19 26.23 26.22 18.24 346.44
SD 1.02 .91 .81 .86 .88 8.68 23.08 4.36 5.24 5.72 13.39 305.53

Abbreviations: BDI Beck Depression Inventory, CR Control Representations, D&R Disconnection and Rejection, EFC Emotion-Focused Cop-
ing, IA Impaired Autonomy and Performance, IL Impaired Limits, IR Impact Representations, MC Maladaptive Coping, O&I Overvigilance and
Inhibition, OD Other-Directedness, PFC Problem-Focused Coping, RASS Risk Assessment Suicidality Scale
**p < .01

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Current Psychology (2024) 43:4751–4765 4759

Confounding variables Discussion

No significant differences in schema domains, illness The present study aimed to investigate the associations
representations, coping, and MDD outcomes were found among MDD patients’ schema domains, symptom severity,
with respect to gender Wilks’ λ = .881, F(12, 122) = 1.37, and suicide risk, as well as the possible mediating role of
p > .05, partial η 2 = .119 and hospitalizations Wilks’ illness representations and coping in the aforementioned
λ = .852, F(12, 122) = 1.76, p > .05, partial η2 = .148. Sig- relationships. To the best of our knowledge, this is the
nificant differences in schema domains, illness represen- first study examining the role of EMS domains, one of the
tations, coping, and MDD outcomes were observed with main concepts of Schema Therapy, and illness representa-
respect to marital status Wilks’ λ = .575, F(24, 242) = 3.21, tions and coping, two key illness-related self-regulation
p = .000, partial η 2 = .242, educational level Wilks’ processes in symptom severity and suicide risk in MDD.
λ = .572, F(48, 460) = 1.49, p = .021, partial η 2 = .130, Results suggest that representations about MDD’s impact
working status Wilks’ λ = .839, F(12, 122) = 1.95, p = .034, and depressive symptom severity serially mediate the
partial η2 = .161, duration of MDD Wilks’ λ = .565, F(48, association between Impaired Autonomy and Performance
460) = 1.53, p = .016, partial η 2 = .133, pharmacother- and suicide risk in MDD, while problem-focused coping is
apy Wilks’ λ = .735, F(12, 122) = 3.66, p = .000, par- also linked to suicide risk through MDD severity.
tial η2 = .265, and psychotherapy Wilks’ λ = .768, F(12, The first significant finding of this study is that
122) = 3.07, p = .001, partial η2 = .223. Age was signifi- Impaired Autonomy and Performance appeared to con-
cantly correlated with all schema domains except Other- tribute to negative representations about MDD’s impact,
Directedness, and it was also significantly correlated with thus leading to higher symptom severity, and ultimately
problem-focused coping and suicide risk. Hence, age, to higher suicide risk. It seems that MDD patients’ dif-
marital status, educational level, working status, duration ficulties in differentiating themselves from significant
of MDD, pharmacotherapy, and psychotherapy were used others and functioning independently are associated with
as control variables in the path analytical models. perceiving MDD as more impactful (e.g., as having more
detrimental consequences). In turn, patients’ representa-
tions of MDD’s impact lead to higher symptom severity,
Path analytical models and increased suicide risk. To the best of our knowledge,
there are no previous data concerning the role of schema
The originally hypothesized complete mediation model domains in illness representations and coping in MDD.
(Model 1) provided very good fit to the data (χ2 = 49.811, However, current literature links illness representations
df = 42, p = .190, χ 2/ df = 1.186, CFI = .99, NFI = .96, to MDD patients’ coping strategies (Brown et al., 2001,
IFI = .99, TLI = .97, RMSEA = .37, SRMR = .042). The cor- 2007; Kelly et al., 2007; Mavroeides & Koutra, 2022),
responding partial mediation model (Model 2) allowing, in and suggests that coping mediates the association between
addition, direct paths from schema domains to suicide risk, illness representations and MDD outcomes (Brown et al.,
provided good fit to the data as well (χ2 = 44.378, df = 37, 2007). In our study, illness representations were linked to
p = .189, χ 2/ df = 1.199, CFI = .99, NFI = .96, IFI = .99, coping in a predictable way. Specifically, control represen-
TLI = .97, RMSEA = .039, SRMR = .041). A test of the dif- tations were linked to more adaptive problem-focused cop-
ference between Models 1 and 2 indicated that the two models ing and impact representations were linked to more mala-
fit the data equally well (Δχ2 = 5.433, df = 5, p = .36). Since daptive coping in line with current literature and theory
the two models had an equivalently good fit, following estab- (Hagger et al., 2017; Leventhal et al., 1980, 2003). Moreo-
lished procedures (Keith, 2006), the full mediation model ver, results suggest that MDD severity acts as a mediator
was favored as more parsimonious (df = 42 vs. 37). In addi- between schema domains, illness representations, and sui-
tion, examination of the critical ratios of the direct paths from cide risk. This finding is not surprising, since depressive
schema domains to suicide risk did not reveal any significant symptom severity is consistently considered a risk factor
path. In Model 1, the total effects of Impaired Autonomy and for suicide in MDD (Handley et al., 2018; Moller et al.,
Performance on impact representations, control representa- 2021; Wang et al., 2015).
tions, maladaptive coping, and suicide risk were significant. In our study, Impaired Autonomy and Performance was
Moreover, the effect of Impaired Autonomy and Performance the only schema domain which was found to contribute to
on suicide risk was significantly mediated by impact represen- increased suicide risk. Concerning the role of autonomy
tations and MDD severity. Finally, problem-focused coping in MDD, Beeker et al. (2017) argue that MDD patients
was linked to suicide risk through MDD symptom severity. are characterized by a particular kind of autonomy defi-
Total, direct, and indirect effects are presented in Table 3. cits since they may be capable of thinking rationally, but

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4760 Current Psychology (2024) 43:4751–4765

Table 3  Schema domains, illness representations, coping, MDD severity, and suicide risk: Total, Direct, and Indirect effects
Path Total Effect Direct Effect Indirect Effect
B SE CI B SE CI B SE CI

Disconnection and Rejection-T1 ➔Impact Representations-T2 .20 .12 −.009, .41 .20 .12 −.009, .41 – – –
Disconnection and Rejection-T1 ➔Control representations-T2 −.25 .13 −.48, −.05 −.25 .13 −.48, −.05 – – –
Disconnection and Rejection-T1 ➔Maladaptive coping-T2 .21 .13 −.02, .41 .12 .11 −.06, .32 .08 .07 −.02, .20
Disconnection and Rejection-T1 ➔Problem-focused coping-T2 −.09 .17 −.40, .17 .01 .15 −.26, .25 −.10 .06 −.24, −.02
Disconnection and Rejection-T1 ➔Emotion-focused coping-T2 −.13 .16 −.42, .12 −.05 .15 −.32, .19 −.08 .05 −.19, −.01
Disconnection and Rejection-T1 ➔ MDD severity-T3 .08 .13 −.12, .32 −.03 .11 −.23, .16 .11 .07 .006, .25
Disconnection and Rejection-T1 ➔Suicide risk-T3 .10 .10 −.06, .27 – – – .10 .10 −.06, .27
Impaired Autonomy & Performance-T1 ➔Impact Representations- .43 .13 .20.64 .43 .13 .20, .64 – – –
T2
Impaired Autonomy & Performance-T1 ➔Control representations- −.39 .15 −.64, −.11 −.39 .15 −.64, −.11 – – –
T2
Impaired Autonomy & Performance-T1 ➔Maladaptive coping-T2 .35 .14 .09, .58 .14 .13 −.06, .37 .20 .07 .09, .32
Impaired Autonomy & Performance-T1 ➔Problem-focused coping- −.25 .16 −.52, .02 −.05 .15 −.33, .19 −.19 .07 −.34, −.08
T2
Impaired Autonomy & Performance-T1 ➔Emotion-focused coping- −.11 .16 −.36, .16 .03 .15 −.22, .29 −.14 .06 −.27, −.04
T2
Impaired Autonomy & Performance-T1 ➔ MDD severity-T3 .16 .13 −.07, .37 −.06 .11 −.24, .12 .22 .09 .08, .38
Impaired Autonomy & Performance-T1 ➔Suicide risk-T3 .19 .10 .01, .35 – – – .19 .10 .01, .35
Impaired Limits-T1 ➔Impact Representations-T2 .03 .09 −.13, .17 .03 .09 −.13, .17 – – –
Impaired Limits-T1 ➔Control representations-T2 −.02 .09 −.19, .13 −.02 .09 −.19, .13 – – –
Impaired Limits-T1 ➔Maladaptive coping-T2 .05 .12 −.14, .24 .03 .10 −.13, .20 .01 .05 −.06, .09
Impaired Limits -T1 ➔Problem-focused coping-T2 −.08 .10 −.25, .09 −.06 .09 −.22, .10 −.01 .04 −.08, .04
Impaired Limits-T1 ➔Emotion-focused coping-T2 .05 .12 −.15, .26 .06 .12 −.14, .26 −.01 .03 −.06, .03
Impaired Limits-T1 ➔ MDD severity-T3 .06 .10 −.10, .22 .04 .08 −.10, .17 .02 .05 −.05, .11
Impaired Limits-T1 ➔Suicide risk-T3 .04 .07 −.09, .16 – – – .04 .07 −.09, .16
Other-Directedness-T1 ➔Impact Representations-T2 −.08 .09 −.24, .06 −.08 .09 −.22, .06 – – –
Other-Directedness-T1 ➔Control representations-T2 .05 .10 −.12, .21 .05 .10 −.12, .21 – – –
Other-Directedness-T1 ➔Maladaptive coping-T2 .10 .11 −.09, .29 .14 .10 −.04, .31 −.04 .04 −.12, .03
Other-Directedness-T1 ➔Problem-focused coping-T2 −.02 .12 −.22, .27 −.05 .11 −.25, .13 .03 .04 −.03, .10
Other-Directedness-T1 ➔Emotion-focused coping-T2 .06 .12 −.13, .27 .04 .12 −.16, .25 .02 .03 −.02, .09
Other-Directedness-T1 ➔ MDD severity-T3 .03 .10 −.13, .20 .05 .09 −.11, .20 −.01 .05 −.09, .07
Other-Directedness-T1 ➔Suicide risk-T3 .006 .07 −.11, .13 – – – .006 .07 −.11, .13
Overvigilance & Inhibition-T1 ➔Impact Representations-T2 .06 .11 −.14, .25 .06 .11 −.14, .25 – – –
Overvigilance & Inhibition-T1 ➔Control representations-T2 .09 .15 −.16, .35 .09 .15 −.16, .35 – – –
Overvigilance & Inhibition-T1 ➔Maladaptive coping-T2 −.18 .12 −.37, .02 −.23 .11 −.40, −.04 .04 .06 −.05, .15
Overvigilance & Inhibition-T1 ➔Problem-focused coping-T2 .28 .17 −.008, .55 .26 .15 −.004, .51 .01 .06 −.07, .13
Overvigilance & Inhibition-T1 ➔Emotion-focused coping-T2 .03 .18 −.28, .33 .02 .18 −.26, .33 .008 .05 −.06, .09
Overvigilance & Inhibition-T1 ➔ MDD severity-T3 .22 .15 −.03, .48 .29 .14 .07, .54 −.06 .07 −.19, .05
Overvigilance & Inhibition-T1 ➔Suicide risk-T3 .14 .11 −.04, .35 – – – .11 .12 −.04, .35
Impact representations-T2 ➔Maladaptive coping-T2 .57 .10 .39, .73 .57 .10 .39, .73 – – –
Impact representations-T2 ➔Problem-focused coping-T2 −.19 .13 −.43, .02 −.19 .13 −.43, .02 – – –
Impact representations-T2 ➔Emotion-focused coping-T2 −.16 .14 −.40, .06 −.16 .14 −.40, .06 – – –
Impact representations-T2 ➔ MDD severity-T3 .32 .10 .15, .49 .22 .10 .05, .39 .10 .06 .01, .22
Impact representations-T2 ➔Suicide risk-T3 .40 .08 .26, .54 .17 .07 .04, .30 .22 .07 .10, .35
Control representations-T2 ➔Maladaptive coping-T2 .11 .11 −.07, .29 .11 .11 −.07, .29 – – –
Control representations-T2 ➔Problem-focused coping-T2 .27 .13 .04, .48 .27 .13 .04, .48 – – –
Control representations-T2 ➔Emotion-focused coping-T2 .18 .12 −.01, .37 .18 .12 −.01, .37 – – –
Control representations-T2 ➔ MDD severity-T3 −.14 .10 −.33, .02 −.09 .11 −.28, .08 −.05 .04 −.14, .006
Control representations-T2 ➔Suicide risk-T3 -.10 .08 −.25, .03 −.008 .07 −.12, .11 −.09 .07 −.22, .02

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Table 3  (continued)
Path Total Effect Direct Effect Indirect Effect
B SE CI B SE CI B SE CI

Maladaptive coping-T2 ➔ MDD severity-T3 .09 .07 −.03, .22 .09 .07 −.03, .22 – – –
Maladaptive coping-T2 ➔Suicide risk-T3 .09 .07 −.02, .22 .03 .06 −.07, .15 .05 .05 −.021, .14
Problem-focused coping-T2 ➔ MDD severity-T3 −.18 .07 −.31, −.06 −.18 .07 −.31, −.06 – – –
Problem-focused coping-T2 ➔Suicide risk-T3 −.09 .07 −.21, .04 .02 .06 −.07, .13 −.11 .04 −.20, −.03
Emotion-focused coping-T2 ➔ MDD severity-T3 −.06 .06 −.17, .04 −.06 .06 −.17, .04 – – –
Emotion-focused coping-T2 ➔Suicide risk-T3 −.09 .07 −.21, .01 −.05 .06 −.16, .05 −.02 .04 −.11, .02
MDD severity-T3 ➔ Suicide risk-T3 .61 .06 .49, .69 .61 .06 .49, .69 – – –

Bold font indicates significant paths (95% CΙs not containing 0)

at the same time, they may be unable to behave the way well (Di Marco et al., 2017; McWilliams et al., 2003; Suciu
they want to. Indeed, previous studies investigating the et al., 2021). In our study, coping styles were linked to out-
role of schema domains in MDD highlight the associa- comes in the bivariate analyses, but not in the SEM model.
tions of Impaired Autonomy and Performance with MDD Given the purported role of cognitions in MDD (Abramson
outcomes (Halvorsen et al., 2010; Renner et al., 2012). et al., 1989; Beck & Haigh, 2014; Reilly et al., 2012), it is
However, our findings differ from studies which investi- likely that illness representations take up most of the explan-
gated specific EMS, not schema domains, in association atory variance in MDD severity and suicide risk, when both
with suicide risk in MDD. Flink et al. (2017) found that representations and coping are included in the same model.
MDD patients with suicidal ideation scored higher than From a cultural perspective, Greek MDD patients’
MDD patients without suicidal ideation on various EMS. autonomy deficits could be associated with social attitudes
Specifically, patients with suicidal ideation scored higher towards relationships and cohesion. According to Young
on four EMS of the Disconnection and Rejection domain et al. (2003), the origins of the Impaired Autonomy and
(Mistrust/Abuse, Emotional Deprivation, Defectiveness/ Performance domain EMS lie in enmeshed and overprotec-
Shame, Social Isolation/ Alienation), three EMS of the tive families. Indeed Greek families are characterized by a
Impaired Autonomy domain (Dependence/ Incompetence, high degree of enmeshment (Tsamparli & Kounenou, 2004;
Vulnerability to Harm or Illness, Failure), two EMS of the Tsibidaki & Tsamparli, 2009) and in some cases consider
Other-Directedness domain (Subjugation, Self-sacrifice), enmeshment as the ideal way of family functioning in terms
and two EMS of the Overvigilance and Inhibition domain of cohesion (Tsamparli et al., 2011; Tsibidaki & Tsamparli,
(Negativity/ Pessimism, Punitiveness). However, after 2009). Social emphasis on tight connections, especially
controlling for MDD symptom severity and hopelessness, inside the family context, may be responsible for deficient
only Vulnerability to Harm or Illness remained a signifi- growth of autonomy during early childhood, which in turn
cant predictor of suicidal ideation. Moreover, according appear to play a critical role in impairing self-regulation and
to Ahmadpanah et al. (2017), various EMS are linked to leading to higher symptom severity and suicide risk during
history of suicide attempts in MDD. Specifically, suicide an MDD episode in adult life.
attempters diagnosed with MDD had higher scores than
non-attempters on all EMS of the Disconnection and Strengths and limitations
Rejection domain, on the Dependence/ Incompetence,
Vulnerability to Harm or Illness, and Failure EMS from This study’s major strength was its prospective design
the Impaired Autonomy and Performance domain, and on that permits conclusions regarding causality between the
Emotional Inhibition and Punitiveness from Overvigilance observed associations. Moreover, the sample was relatively
and Inhibition. homogeneous and naturalistic since we included individuals
Another significant, rather surprising finding was that clinically diagnosed with MDD who did not just screen posi-
problem-focused coping was the only coping style linked tive for depression, and most of whom were treated in the
to MDD clinical outcomes in this study. Specifically, prob- same psychiatric facility, using similar procedures and proto-
lem-focused coping was linked to lower suicide risk through cols. Finally, validated instruments were used to measure the
lower depressive symptom severity. Although previous stud- main variables. Nevertheless, certain limitations of our study
ies found a negative association between problem-focused need to be acknowledged, too. First, we used self-report
coping and MDD outcomes, there have been several reports questionnaires, which can be subject to social desirability
on the role of maladaptive and emotion-focused coping as response bias and may inflate associations due to shared

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4762 Current Psychology (2024) 43:4751–4765

variance. Moreover, although this was a prospective study problem-focused coping could be promising for reducing
with a satisfactory time interval between its three phases, suicide risk in MDD.
studies with more repeated measurements would establish
Acknowledgments The authors wish to thank all patients who partici-
more robust mediating effects. Additionally, diagnostic pro- pated in this study.
cedures may have not been identical between hospital-based
and online peer support patients, however a clinical diagno- Funding Open access funding provided by HEAL-Link Greece. This
sis was available in both cases. Furthermore, the majority of work was supported by the University of Crete’s Special Account for
Research Grants [grant number 4203].
our sample consisted of women and the size of our sample
was considered modest. Finally, our sample can be consid- Data Availability The datasets generated during and/or analysed dur-
ered selective, since it comprised patients diagnosed with ing the current study are available from the corresponding author upon
MDD without other psychiatric comorbidities. reasonable request.

Declarations
Clinical implications
Competing interests The authors declare that they have no conflicts
of interest.
This study’s findings have significant implications at a theo-
retical and practical level. At a theoretical level, this study
Open Access This article is licensed under a Creative Commons Attri-
sheds some light on the relationship between patients’ EMS, bution 4.0 International License, which permits use, sharing, adapta-
self-regulation processes and clinical outcomes in the con- tion, distribution and reproduction in any medium or format, as long
text of MDD, thus underlining the need to examine further as you give appropriate credit to the original author(s) and the source,
the effect of EMS on the course and outcome of MDD and provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
the intrapersonal mechanisms through which these effects included in the article's Creative Commons licence, unless indicated
may be exerted. Although various studies identify signifi- otherwise in a credit line to the material. If material is not included in
cant associations between EMS and MDD symptoms and the article's Creative Commons licence and your intended use is not
outcomes, the role of patients’ self-regulation processes in permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
this relationship is largely unknown. Future studies should copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
further examine the 18 specific EMS in association with
illness representations and coping, as well as in association
with other self-regulation skills, such as emotion regulation
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