Anger and Depression: Addressing the Links Between Them

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, 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 other, resulting in self-reproach, self-criticism, and depressive symptoms.

In a subsequent paper on depression, Rado (1928) added narcissistic vulnerability as a significant contributor to depression, in which individuals react with intense feelings of inadequacy and anger to relatively minor disappointments or rejection. Like Freud and Abraham, in his view, the angry response to narcissistic injury becomes directed toward the self. Subsequent analysts expanded on these conceptions, adding attachment difficulties, and identifying individualized early adverse and traumatic experiences as contributors to depression (see Busch et al., 2016).

Psychodynamic Formulation for Depression

Drawing on theory, clinical observation, and research, my colleagues and I (Busch et al., 2016) proposed a core psychodynamic formulation of depression as a framework for understanding patients and targeting psychotherapeutic interventions. We agreed with Rado’s conception that narcissistic vulnerability, a sensitivity to loss and rejection, increases the likelihood of an individual developing depression. This sensitivity develops from early experiences of rejection, helplessness, or trauma that come to be interpreted as evidence of inadequacy, unlovability, or defectiveness. Individuals with narcissistic vulnerability frequently react to hurt and disappointment with intense anger at the people who trigger these feelings. This anger triggers guilty feelings and defense mechanisms (such as repression and projection) intended to protect the other person. Thus, anger becomes directed toward the self, creating a further reduction in self-esteem, fueling a cycle of rejection sensitivity and anger.

We also proposed a second vicious cycle in which low self-esteem leads to compensatory idealized expectations of oneself and others. Because these idealized expectations are inevitably disappointed, they give way to self-criticism and devaluation, intensifying feelings of hurt and rejection and undermining self-esteem. Additionally, this devaluation triggers angry feelings and fantasies directed toward both the self and others.

How to Use Psychodynamic Understanding of Anger and Depression in Treatment Interventions

As noted above, when depression is identified, patients should be evaluated for the presence of irritability and conflicts with anger. Depending on the assessment and the patient, medication for depression should be strongly considered (see Busch, 2026). Indeed, by reducing depressive symptoms such as low self-esteem and self-criticism, medication can diminish the vicious cycles of depression described above and work synergistically with psychodynamic treatment.

Psychodynamic treatment of depression maintains a focus on depressive symptoms and dynamics, as opposed to a more traditional open-ended psychodynamic psychotherapy (Busch, 2026). The therapist begins by exploring the patient's depressive symptoms to help identify their particular meanings. Attention is directed to the circumstances surrounding the onset of depression, including precipitating events, associated feelings and fantasies, and relevant developmental experiences. As treatment progresses, these experiences are understood in relation to the central dynamics of depression described above, including narcissistic vulnerability, conflicted anger, guilt, and compensatory idealization and devaluation. These themes are explored in the patient's past and current relationships, including how they emerge in the transference. Treatment aims to reduce narcissistic vulnerability, increase the capacity to recognize and tolerate anger without excessive guilt or self-attack, and promote more satisfying engagement in relationships. During termination, heightened sensitivity to loss, rejection, and anger associated with ending treatment provides an opportunity to consolidate these gains through further understanding and intervention with these dynamics.

Depression Essential Reads

Depression Doesn’t Just Affect the Thinking Brain

Could Creatine Improve Mental Health?

Exploration and Addressing of Anger

A central task in the psychodynamic treatment of depression is helping patients recognize and understand angry feelings and fantasies that often remain outside awareness or are experienced as unacceptable. Exploration begins with recent stressors, particularly experiences of actual or perceived loss, rejection, criticism, or disappointment that may have precipitated or exacerbated the depressive episode. Such events commonly evoke angry wishes or fantasies toward the person experienced as responsible for the narcissistic injury.

The angry feelings and fantasies are also linked to developmental experiences, especially traumatic losses, separations, criticism, or chronic disappointments that contributed to narcissistic vulnerability and difficulties tolerating anger. Patients often respond to angry feelings with guilt, anxiety, fears of retaliation or punishment, or by directing anger toward themselves, thereby reinforcing depressive symptoms. Observing these reactions as they emerge in treatment helps clarify the mechanisms through which anger becomes transformed into self-criticism, hopelessness, or withdrawal. Because many depressed patients expect their anger to be condemned, they may anticipate criticism or retaliation from the therapist. Thus, the therapist maintains a consistently curious and nonjudgmental stance, helping patients to feel safer with and less guilty about angry feelings and fantasies.

Working through these reactions enables patients to tolerate and manage anger more effectively and experience relationships with less fear of rejection, guilt, and self-devaluation. Understanding and addressing the sources of irritability can help patients better control angry outbursts that may disrupt relationships. Improved management of anger also enables patients to establish healthier boundaries and limits with others, further strengthening self-esteem.

To find a therapist near you, visit the Psychology Today Therapy Directory.