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Research suggests anger and irritability are common in depression but may be overlooked during assessment.

Early experiences of rejection or criticism can contribute to sensitivity to later losses and disappointments.

Anger directed toward the self can intensify self-criticism, guilt, low self-esteem, and depression.

Studies suggest that up to 50 percent of patients with depression experience problems with anger and irritability (Fava et al., 2010; Kovess-Masfety et al., 2013). However, the prevalence may well be higher than that, as many patients are inhibited about experiencing or expressing angry feelings toward others (Busch, 2009). Anger can exacerbate depression in several ways; for example, irritability can lead to disruptions in relationships, causing increased feelings of loss and isolation. Additionally, anger can be directed toward the self, leading to intense self-criticism and guilt (Abraham, 1911; Busch et al., 2016; Freud, 1917).

Despite the frequency of these difficulties, anger is not part of the standardized diagnostic criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (American Psychiatric Association, 2022). Several of the most widely used clinician-rated measures of depression, including the Hamilton Depression Rating Scale (Hamilton, 1960) and the Montgomery-Åsberg Depression Rating Scale (Montgomery & Asberg, 1979), do not directly assess anger or irritability. Nevertheless, it is important that clinicians inquire about anger and its management in their exploration of a patient’s depressive symptoms.

Psychoanalysts have long believed that anger directed toward the self contributes to depression (Busch et al., 2016). Abraham (1911), an early psychoanalyst, suggested that temperamental issues or traumatic experiences led some individuals to develop a hostility toward others that created a vulnerability to depression. These angry feelings trigger guilt and anxiety, leading them to be pushed out of awareness (the defense of repression) and experienced as coming from others (the defense of projection). The individual believes this hostility from others indicates that they are somehow inadequate or bad, causing a drop in self-esteem.

Freud (1917) modified Abraham’s view in his paper "Mourning and Melancholia" but kept anger directed inward as a central component. In Freud’s view, depression results from a fantasized or actual loss of a person toward whom the depressed patient experienced ambivalent feelings. To deal with the loss, the patient internalizes an aspect of that individual. As a consequence, the anger originally directed toward that person is redirected against the part of the self identified with the lost........

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