| Abstract |
Background: Major depressive disorder (MDD) is a common and debilitating mental illness
and the processes by which patients self-regulate to adjust to their diagnosis appear to have a
critical role in MDD progression. However, there is scant research on the impact of personality
and Early Maladaptive Schemas (EMS) on patients’ self-regulation, and on their role in MDD
clinical outcomes.
Aim: The first main aim of this study was to investigate the applicability of the Common-Sense
Model of illness-related self-regulation (CSM) in MDD with the following objectives: 1) to
systematically review the literature on the role of illness representations, 2) to culturally adapt
the Illness Perception Questionnaire-Mental Health (IPQ-MH), and 3) to assess concurrent and
prospective relationships of illness-related self-regulation with clinical outcomes. The second
main aim was to investigate the mediating role of self-regulation between EMS, personality,
and MDD outcomes with the following objectives:1) to investigate the serial mediating role of
illness representations, coping, and symptom severity in the relationship between EMS and
suicide risk, 2) to investigate the relationship of personality traits with symptom severity and
the potential mediating role of illness representations in this association.
Method: The study involved three measurement waves: At baseline (T1), 222 patients with a
clinical diagnosis of MDD were enrolled, with 154 and 141 patients retested at T2 and T3.
Assessments; T1: socio-demographic and clinical profiles, personality traits and EMS (Traits
Personality Questionnaire, Young Schema Questionnaire-Short Form 3). T2: illness
representations (IPQ-MH)., coping strategies (Brief Cope Orientation to Problems
Experienced), emotion dysregulation (Difficulties in Emotion Regulation Scale), as well as
symptom severity (Beck Depression Inventory) and suicidality (Risk Assessment Suicidality
Scale) as interim outcomes. T3: symptom severity, patients’ functioning level, quality of life,
life satisfaction (WHO Disability Assessment Schedule 2. 0, WHO Quality of Life-BREF,
Satisfaction with Life Scale), melancholic features (MINI), and suicidality as end points.
Analyses included Exploratory and Confirmatory Factor Analysis, hierarchical multiple
regression, and mediation analysis using Structural Equation Modeling, with SPSS and AMOS.
Results: The literature corroborated associations between representations of MDD with clinical
outcomes and treatment-related outcomes. The factor structure of the Greek IPQ-MH was
similar to the original IPQ-MH and displayed good reliability, convergent, discriminant, and
concurrent validity. Representations of identity, consequences, chronicity, psychosocial causes of MDD, and maladaptive coping were associated with worse outcomes, while personal control,
cyclicality, and problem-focused coping was associated with better outcomes. Stress as a cause
of MDD was linked both to better and worse outcomes. Impact-threat representations of MDD
(including the dimensions of identity, chronicity, cyclicality, consequences, and emotional
representations) and depressive symptom severity serially mediated the relationship between
the schema domain of Impaired Autonomy and Performance and suicide risk. Finally, high
Neuroticism and low Extraversion led to higher MDD severity. In addition, high Neuroticism
was associated with higher impact representations and poorer control representations, while
high Extraversion was associated with poorer impact representations. Finally, impact
representations fully mediated the relationship between Neuroticism, Extraversion, and MDD
severity.
Conclusions: The CSM is a theoretical framework that can effectively describe the selfregulation
processes of patients with MDD. In addition, patients' self-regulation is significantly
linked to their EMS and personality dimensions. Finally, the relationships of specific EMS
domains (Impaired Autonomy and Performance), Neuroticism, and Extraversion, with MDD
outcomes are mediated by patients' representations of MDD impact-threat. Focusing on
personality, EMS, and self-regulation processes of patients with MDD can significantly
enhance all stages of their care, from treatment planning to relapse prevention.
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