Cognitive Emotion Regulation and Mental Health Outcomes among Individuals with Chronic Diseases: Exploring Adaptive and Maladaptive Strategies

Abstract

Chronic diseases place substantial cognitive and emotional demands. Utilizing adaptive strategies can mitigate these challenges and enhance mental health outcomes. However, research is limited among individuals living with chronic conditions, especially in non-western contexts. We examined the relationship between cognitive emotion regulation strategies and mental health outcomes among individuals living with chronic conditions in Ghana. Using cross-sectional data from 801 participants (mean age = 46.61 years, SD = 16.21), we used multiple regression models to estimate associations between specific strategies and symptoms of depression, anxiety, and stress. Positive refocusing, self-blame, refocus on planning, and putting into perspective were found to negatively associated with depression, anxiety, and stress. In contrast, rumination, positive appraisal and blaming others, were positively associated with depression, anxiety and stress. These findings emphasize the need for targeted mental health interventions that promote adaptive emotion regulation strategies to enhance mental health for individuals with chronic conditions.

Keywords

cognitive emotion regulation depression anxiety stress chronic conditions

Get full access to this article

View all access options for this article.

References

Adjei-Banuah

N. Y.

Ayiku

R. N. B.

Reichenberger

Sasu

Mirzoev

Murphy

Agyepong

I. A.

Antwi

(2024). Factors influencing primary care access for common mental health conditions among adults in West Africa: Protocol for a scoping review. JMIR Research Protocols, 13(1), Article e58890. https://doi.org/10.2196/58890

Agyei

Agboso

Addo

Klomega

Affum

Opare

Yabani

P. A.

Banakoma

Oduro

Kondi

Kando

S. B.

(2025). Exploratory study on the role of emotions in influencing dietary behaviour among patients with chronic physical health conditions in Ghana. Discover Public Health, 22(1), 588. https://doi.org/10.1186/s12982-025-00984-x

Agyei

de-Graft Aikins

Osei-Tutu

Annor

(2024). Community social capital and mental health participation: Test of psychosocial mediators in two resource-poor urban communities in Ghana. Journal of Psychology in Africa, 34(3), 299–307. https://doi.org/10.1080/14330237.2024.2363700

Aldao

Nolen-Hoeksema

(2010). Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48(10), 974–983. https://doi.org/10.1016/j.brat.2010.06.002

Aldao

Nolen-Hoeksema

Schweizer

(2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004

Amu

Darteh

E. K. M.

Tarkang

E. E.

Kumi-Kyereme

(2021). Management of chronic non-communicable diseases in Ghana: A qualitative study using the chronic care model. BMC Public Health, 21(1), 1120. https://doi.org/10.1186/s12889-021-11170-4

Beck

A. T.

Haigh

E. A.

(2014). Advances in cognitive theory and therapy: The generic cognitive model. Annual Review of Clinical Psychology, 10(1), 1–24. https://doi.org/10.1146/annurev-clinpsy-032813-153734

Berk

Köhler‐Forsberg

Turner

Penninx

B. W.

Wrobel

Firth

Marx

Reavley

N. J.

McGrath

J. J.

Momen

N. C.

Plana-Ripoll

O'Neil

Siskind

Williams

L. J.

Carvalho

A. F.

Schmaal

Walker

A. J.

Dean

Walder

(2023). Comorbidity between major depressive disorder and physical diseases: A comprehensive review of epidemiology, mechanisms and management. World Psychiatry, 22(3), 366–387. https://doi.org/10.1002/wps.21110

Cerolini

Zagaria

Vacca

Spinhoven

Violani

Lombardo

(2022). Cognitive emotion Regulation Questionnaire—Short: reliability, validity, and Measurement Invariance of the Italian version. Behavioral Sciences, 12(12), 474. https://doi.org/10.3390/bs12120474

10.

Damian

A. J.

Gallo

J. J.

(2018). Models of care for populations with chronic conditions and mental/behavioral health comorbidity. International Review of Psychiatry, 30(6), 157–169. https://doi.org/10.1080/09540261.2019.1568233

11.

de-Graft Aikins

(2003). Living with diabetes in rural and urban Ghana: A critical social psychological examination of illness action and scope for intervention. Journal of Health Psychology, 8(5), 557–572. https://doi.org/10.1177/13591053030085007

12.

de-Graft Aikins

(2006). Reframing applied disease stigma research: A multilevel analysis of diabetes stigma in Ghana. Journal of Community & Applied Social Psychology, 16(6), 426–441. https://doi.org/10.1002/casp.892

13.

de-Graft Aikins

Boynton

Atanga

L. L.

(2010). Developing effective chronic disease interventions in Africa: Insights from Ghana and Cameroon. Globalization and Health, 6(6), 1–15. https://doi.org/10.1186/1744-8603-6-6

14.

de-Graft Aikins

Kushitor

S. B.

Sanuade

Asante

P. Y.

Sakyi

Ogedegbe

(2020). Building cardiovascular disease competence in an urban poor Ghanaian community: A social psychology of participation approach. Journal of Community & Applied Social Psychology, 30(4), 419–440. https://doi.org/10.1002/casp.2447

15.

de-Graft Aikins

Sanuade

Baatiema

Asante

P. Y.

Agyei

Asah-Ayeh

Koram

Osei-Tutu

(2021). COVID-19, chronic conditions and structural poverty: A social psychological assessment of the needs of a marginalized community in Accra, Ghana. Journal of Social and Political Psychology, 9(2), 577–591. https://doi.org/10.5964/jspp.7543

16.

Dzokoto

V. A.

Osei-Tutu

Kyei

J. J.

Twum-Asante

Attah

D. A.

Ahorsu

D. K.

(2018). Emotion norms, display rules, and regulation in the Akan society of Ghana: An exploration using proverbs. Frontiers in Psychology, 9, 1–14, 1916. https://doi.org/10.3389/fpsyg.2018.01916

17.

Essien

Asamoah

M. K.

(2020). Reviewing the common barriers to the mental healthcare delivery in Africa. Journal of Religion and Health, 59(5), 2531–2555. https://doi.org/10.1007/s10943-020-01059-8

18.

Fortin

Leblanc

Elgbeili

Cordova

M. J.

Marin

M. F.

Brunet

(2021). The mental health impacts of receiving a breast cancer diagnosis: A meta-analysis. British Journal of Cancer, 125(11), 1582–1592. https://doi.org/10.1038/s41416-021-01542-3

19.

Fredrickson

B. L.

(2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56(3), 218–226. https://doi.org/10.1037/0003-066X.56.3.218

20.

Gao

Yan

Yuan

(2022). Neural correlations between cognitive deficits and emotion regulation strategies: Understanding emotion dysregulation in depression from the perspective of cognitive control and cognitive biases. Psychoradiology, 2(3), 86–99. https://doi.org/10.1093/psyrad/kkac014

21.

Garnefski

Koopman

Kraaij

ten Cate

(2009). Brief report: Cognitive emotion regulation strategies and psychological adjustment in adolescents with a chronic disease. Journal of Adolescence, 32(2), 449–454. https://doi.org/10.1016/j.adolescence.2008.01.003

22.

Garnefski

Kraaij

(2006). Cognitive emotion regulation questionnaire–development of a short 18-item version (CERQ-short). Personality and Individual Differences, 41(6), 1045–1053. https://doi.org/10.1016/j.paid.2006.04.010

23.

Garnefski

Kraaij

(2018). Specificity of relations between adolescents’ cognitive emotion regulation strategies and symptoms of depression and anxiety. Cognition & Emotion, 32(7), 1401–1408. https://doi.org/10.1080/02699931.2016.1232698

24.

Hussain

Khawar

Amin

Hamdani

Majeed

(2023). Psychological flexibility, cognitive emotion regulation and mental health outcomes among patients with asthma in Pakistan. PeerJ, 11(2), e15506. https://doi.org/10.7717/peerj.15506

25.

Kitayama

Markus

H. R.

Kurokawa

(2000). Culture, emotion, and well-being: Good feelings in Japan and the United States. Cognition & Emotion, 14(1), 93–124. https://doi.org/10.1080/026999300379003

26.

Kitayama

Mesquita

Karasawa

(2006). Cultural affordances and emotional experience: Socially engaging and disengaging emotions in Japan and the United States. Journal of personality and social psychology, 91(5), 890–903. https://doi.org/10.1037/0022-3514.91.5.890

27.

Kitayama

Park

Miyamoto

Date

Boylan

J. M.

Markus

H. R.

… Ryff

C. D.

(2018). Behavioral adjustment moderates the link between neuroticism and biological health risk: A US–Japan comparison study. Personality and Social Psychology Bulletin, 44(6), 809–822. https://doi.org/10.1177/0146167217748603

28.

Lee

A. R. Y. B.

Leong

Lau

Tan

A. W.

R. C. M.

C. S. H.

Chen

M. Z.

(2023). Depression and anxiety in older adults with cancer: Systematic review and meta-summary of risk, protective and exacerbating factors. General Hospital Psychiatry, 81(2), 32–42. https://doi.org/10.1016/j.genhosppsych.2023.01.008

29.

Lempesis

I. G.

Georgakopoulou

V. E.

Papalexis

Chrousos

G. P.

Spandidos

D. A.

(2023). Role of stress in the pathogenesis of cancer. International Journal of Oncology, 63(5), 1–14. https://doi.org/10.3892/ijo.2023.5572

30.

Liu

Wang

Zhu

Wang

Pan

Sun

(2024). Association of both depressive symptoms scores and specific depressive symptoms with all-cause and cardiovascular disease mortality. Annals of General Psychiatry, 23(1), 25. https://doi.org/10.1186/s12991-024-00509-x

31.

Lorig

Holman

Sobel

(2013). Living a healthy life with chronic conditions: For ongoing physical and mental health conditions. Bull Publishing Company.

32.

Lovibond

P. F.

Lovibond

S. H.

(1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-u

33.

Markus

H. R.

(1991). Cultural variation in the self-concept. In The self: Interdisplinary approaches. Springer.

34.

Markus

H. R.

Kitayama

(1991). Cultural variation in the self-concept. In The self: Interdisciplinary approaches (pp. 18–48). New York, NY: Springer. https://doi.org/10.1007/978-1-4684-8264-5_2

35.

Markus

H. R.

Kitayama

(2014). Culture and the self: Implications for cognition, emotion, and motivation. In College student development and academic life (pp. 264–293). Routledge.

36.

Megreya

A. M.

Al-Attiyah

A. A.

Moustafa

A. A.

Hassanein

E. E.

(2020). Cognitive emotion regulation strategies, anxiety, and depression in mothers of children with or without neurodevelopmental disorders. Research in Autism Spectrum Disorders, 76(1), 1–9, 1101600. https://doi.org/10.1016/j.rasd.2020.101600

37.

Mesquita

Walker

(2003). Cultural differences in emotions: A context for interpreting emotional experiences. Behaviour Research and Therapy, 41(7), 777–793. https://doi.org/10.1016/s0005-7967(02)00189-4

38.

Min

J. A.

J. J.

Lee

C. U.

Chae

J. H.

(2013). Cognitive emotion regulation strategies contributing to resilience in patients with depression and/or anxiety disorders. Comprehensive Psychiatry, 54(8), 1190–1197. https://doi.org/10.1016/j.comppsych.2013.05.008

39.

Myers

Lund

Lombard

Joska

Levitt

Butler

Sorsdahl

Naledi

Milligan

Stein

D. J.

(2018). Comparing dedicated and designated models of integrating mental health into chronic disease care: Study protocol for a cluster randomized controlled trial. Trials, 19(1), 1–13. https://doi.org/10.1186/s13063-018-2568-9

40.

Nolen-Hoeksema

(2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109(3), 504–511. https://doi.org/10.1037/0021-843X.109.3.504

41.

Nolen-Hoeksema

Wisco

B. E.

Lyubomirsky

(2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400–424. https://doi.org/10.1111/j.1745-6924.2008.00088.x

42.

Nyarko

Peltonen

Kangaslampi

Punamäki

R. L.

(2020). Emotional intelligence and cognitive skills protecting mental health from stress and violence among Ghanaian youth. Heliyon, 6(5), e03878. https://doi.org/10.1016/j.heliyon.2020.e03878

43.

Ofori-Atta

Read

U. M.

Lund

(2010). A situation analysis of mental health services and legislation in Ghana: Challenges for transformation. African Journal of Psychiatry, 13(2), 99–108. https://doi.org/10.4314/ajpsy.v13i2.54353

44.

Petersen

Fairall

Bhana

Kathree

Selohilwe

Brooke-Sumner

Patel

Breuer

Sibanyoni

Lund

(2016). Integrating mental health into chronic care in South Africa: The development of a district mental healthcare plan. The British journal of psychiatry, 208(s56), s29–s39. https://doi.org/10.1192/bjp.bp.114.153726

45.

Pinquart

Duberstein

(2010). Depression and cancer mortality: A meta-analysis. Psychological medicine, 40(11), 1797–1810. https://doi.org/10.1017/S0033291709992285

46.

Riepenhausen

Wackerhagen

Reppmann

Z. C.

Deter

H. C.

Kalisch

Veer

I. M.

Walter

(2022). Positive cognitive reappraisal in stress resilience, mental health, and well-being: A comprehensive systematic review. Emotion Review, 14(4), 310–331. https://doi.org/10.1177/17540739221114642

47.

Smith

E. M.

Reynolds

Orchard

Whalley

H. C.

Chan

S. W.

(2018). Cognitive biases predict symptoms of depression, anxiety and wellbeing above and beyond neuroticism in adolescence. Journal of affective disorders, 241, 446–453. https://doi.org/10.1016/j.jad.2018.08.051

48.

Sorsdahl

Naledi

Lund

Levitt

N. S.

Joska

J. A.

Stein

D. J.

Myers

(2021). Integration of mental health counselling into chronic disease services at the primary health care level: Formative research on dedicated versus designated strategies in the Western Cape, South Africa. Journal of health services research & policy, 26(3), 172–179. https://doi.org/10.1177/1355819620954232

49.

Tamayo Martínez

Gómez-Restrepo

Ramírez

Rodríguez

M. N.

(2016). Prevalence of mood and anxiety disorders on people with chronic conditions. results from the national mental health survey in Colombia 2015. Revista Colombiana de Psiquiatria, 45(1), 141–146. https://doi.org/10.1016/j.rcp.2016.06.001

50.

Triandis

H. C.

(2018). Individualism and collectivism. Routledge.

51.

Ursu

Măirean

(2022). Cognitive emotion regulation strategies as mediators between resilience and stress during COVID-19 pandemic. International Journal of Environmental Research and Public Health, 19(19), 12631. https://doi.org/10.3390/ijerph191912631

52.

Vanderlind

W. M.

Millgram

Baskin-Sommers

A. R.

Clark

M. S.

Joormann

(2020). Understanding positive emotion deficits in depression: From emotion preferences to emotion regulation. Clinical Psychology Review, 76(2), 101826. https://doi.org/10.1016/j.cpr.2020.101826

53.

Venkatesan

(2021). Ama de-Graft Aikins: Unravelling the complexities of chronic illness experiences in African communities. The Lancet Psychiatry, 8(12), 1038. https://doi.org/10.1016/S2215-0366(21)00442-9

54.

Wang

Q. Q.

Fang

Y. Y.

Huang

H. L.

W. J.

Wang

X. X.

Yang

T. T.

Zhang

Y. H.

Gao

Qian

R. L.

(2021). Anxiety, depression and cognitive emotion regulation strategies in Chinese nurses during the COVID‐19 outbreak. Journal of Nursing Management, 29(5), 1263–1274. https://doi.org/10.1111/jonm.13265

55.

Wang

Zhong

Wang

Zheng

Yang

Wang

Lin

(2020). Prognostic value of depression and anxiety on breast cancer recurrence and mortality: A systematic review and meta-analysis of 282,203 patients. Molecular Psychiatry, 25(12), 3186–3197. https://doi.org/10.1038/s41380-020-00865-6

56.

Ward-Smith

Sorsdahl

van der Westhuizen

(2024). An investigation into symptoms of depression and anxiety and emotion regulation among older adolescents from low-income settings in South Africa. Comprehensive Psychiatry, 132(2), 1–9, 152476. https://doi.org/10.1016/j.comppsych.2024.152476

57.

Watkins

E. R.

(2016). Rumination-focused cognitive-behavioural therapy for depression. New York, N.Y: The Guilford Press.

58.

Watkins

E. R.

Roberts

(2020). Reflecting on rumination: Consequences, causes, mechanisms and treatment of rumination. Behaviour research and therapy, 127, 103573. https://doi.org/10.1016/j.brat.2020.103573

59.

Williams

Jenkins

D. A.

Ashcroft

D. M.

Brown

Campbell

Carr

M. J.

Peek

Kapur

Thomas

Webb

R. T.

(2020). Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: A retrospective cohort study. The Lancet Public Health, 5(10), e543–e550. https://doi.org/10.1016/S2468-2667(20)30201-2

60.

Xue

Cong

(2023). Cognitive emotion regulation for improved mental health: A chain mediation study of Chinese high school students. Frontiers in Psychology, 13(1), 1–9, 1041969. https://doi.org/10.3389/fpsyg.2022.1041969

61.

Yalçınkaya-Alkar

Ö.

(2020). Is self-esteem mediating the relationship between cognitive emotion regulation strategies and depression? Current Psychology, 39(1), 220–228. https://doi.org/10.1007/s12144-017-9755-9

62.

Yano

Oishi

(2024). Individual differences in environmental sensitivity: Associations between cognitive emotion regulation and mental health. Frontiers in Psychology, 15(1), 1–12, 1322544. https://doi.org/10.3389/fpsyg.2024.1322544