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Risk factors associated with depressive symptoms among undergraduate students Mohammad Ali Besharat a,*, Ali Issazadegan b, Mahin Etemadinia c, Safar Golssanamlou c, Atefe Abdolmanafi d a

Department of Psychology, University of Tehran, P.O. Box 14155-6456, Tehran, Iran Department of Psychology, University of Urmia, Urmia, Iran Counseling Service, Urmia University of Technology, Urmia, Iran d Department of Psychology, University of Tarbiat Modares, Tehran, Iran b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 14 July 2013 Received in revised form 1 February 2014 Accepted 5 February 2014 Available online xxx

The purpose of the present study was to examine the relationship of several cognitive and emotional variables including perfectionism, rumination, and attachment quality with depressive symptoms in a sample of Iranian undergraduate students. Two hundred and ninety nine undergraduate students (144 males, 156 females) from Urmia University of Technology, Urmia University, and Urmia University of Medical Sciences participated in this study. Participants were asked to complete Tehran Multidimensional Perfectionism Scale (TMPS), Ruminative Responses Scale (RRS), Revised Adult Attachment Scale (RAAS), and Center for Epidemiologic Studies Depression Scale (CES-D). The results demonstrated that insecurity of attachment, socially prescribed perfectionism, and rumination could significantly predict the depressive symptoms in undergraduate students. Confirming predictive risk factors of depressive symptoms, results of the present study can produce an empirical basis for designing educational and health programs for people at risk. Accordingly, proper assessment of the risk factors of depressive symptoms in health care settings may provide invaluable information for prevention and management programs. ß 2014 Elsevier B.V. All rights reserved.

Keywords: Perfectionism Rumination Attachment quality Depressive symptom

1. Introduction Park depression is a common mental disorder in both general and clinical populations. Depression is considered as the second cause of life years disability in the age category 15–44 years for both male and female individuals. Many people with a depressive illness never seek treatment. However, the majority of them, even those with the most severe depression, can get better with treatment (WHO, 2001). Among general population, a significant number of students leave university without finishing their studies due to inability to manage psychological conditions such as depression, anxiety, and maladjustment (Porter, 1990). Forty-four percent of American college students report feeling symptoms of depression (MHA, 2007). This data suggests that college aged students may be at high risk for depression or depressive mood. Depressive mood is a primary or associated feature of certain psychiatric syndromes such as clinical depression. Several factors including biological, psychological, and social are considered to

* Corresponding author. Tel.: +9821 220 7450. E-mail address: [email protected] (M.A. Besharat).

have roles in development and perpetuation of depression (e.g., Hyde et al., 2008). Considering long lasting stable and influential factors such as perfectionism, ruminative thoughts, and attachment characteristics provides investigating different risk factors of depressive symptoms together. Results of the present study might shed light on variant impacts of intrapersonal and interpersonal cognitive and emotional risk factors of depression. Building on previous research, the present study might have a useful contribution to understanding youth mental health across cultures. One of these factors includes the standards and efforts related to perfectionism (Hewitt & Flett, 1991a). Perfectionism is characterized by the attempt at being perfect, setting high standards of performance, inclination to utterly critical attitude towards one’s behavior, and oversensitivity with regard to mistakes (Flett & Hewitt, 2002; Stoeber & Childs, 2010). Perfectionism is best conceptualized as a multidimensional characteristic with many adaptive and maladaptive aspects (Hewitt & Flett, 1991a; Yang & Stoeber, 2012). Hewitt and Flett (1991a) described self-oriented perfectionism (critical self-scrutiny and unrealistic self-imposed personal standards), otheroriented perfectionism (the expectation that others should achieve

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Please cite this article in press as: Besharat, M.A., et al., Risk factors associated with depressive symptoms among undergraduate students. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.02.002

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unrealistic standards, tendency toward dominance and authoritarianism), and socially prescribed perfectionism (the need to achieve standards and goals indicated by others). Perfectionism is generally related to some negative outcomes and mental vulnerabilities (Besharat & Shahidi, 2010; Erozkan et al., 2011; Flett & Hewitt, 2002). Established is the fact that perfectionism is a remarkable cause of depression (Flett & Hewitt, 2002; Rice et al., 2007; Schiena et al., 2012; Wheeler et al., 2011). The three dimensions of perfectionism are potentially related to depressive symptoms. According to studies, the strongest association has been found between socially prescribed perfectionism and depressive symptoms (Hewitt & Flett, 1991a; Wyatt & Gilbert, 1998). Consistent correlations between depressive symptoms and self-oriented perfectionism are also frequently found (Hewitt & Flett, 1991a). Although other-oriented perfectionism is not related to depression itself, Hewitt and Flett (1991b), found that it may contribute to distress in an indirect manner by creating difficult relationships. In addition to perfectionism, there are some other cognitive variables contributing to depression, one of which is rumination. During the last 20 years, persistent, recyclic, and repetitive thoughts manifested as rumination, have received a lot of theoretical and empirical attention (Papageorgiou & Wells, 2004). Nolen-Hoeksema (1991) conceptualized rumination as ‘‘repetitively focusing on the fact that one is depressed, on one’s symptoms of depression, and on the causes, meanings, and consequences of depressive symptoms’‘ (p. 569). There is a bulk of research on depression, investigating the role of repetitive thoughts (rumination) in depression and its symptoms (e.g., Kuyken et al., 2006; Liverant et al., 2011; Nolen-Hoeksema, 1991; Peled & Moretti, 2010). Evidence from studies suggests that the negative implications of rumination are due to cognitive biases, such as memory and attention biases, which predispose ruminators to selectively devote attention to negative stimuli (Joormann et al., 2006). The cognitive model of depression suggests that depression can be intensified due to the interactional cycle of negative thoughts and mood (Beck et al., 1979). One of the emotional variables contributing to depression is the quality of the individual’s attachment. The main result of the mother-child interaction is an affective attachment which displays the emotional relation between the two, and results in child’s seeking comfort from mother, especially in times of fear or insecurity (Crain, 2005). It is thought that the experiences of early loss, separation and rejection by the parent or caregiver (conveying the message that the child is unlovable) may all lead to insecure internal working models (Ma, 2006). The relation between the quality of attachment and psychological disorders has been the subject of a large number of psychological studies which have revealed a significant correlation between insecure patterns of attachment and disorders like depression (Kamkar et al., 2012) and anxiety (Bifulco et al., 2002; Lopez et al., 2001). While a wide variety of studies has upheld the basic tenets of attachment theory, research has been inconclusive as to whether self-reported early attachment and later depression are demonstrably related (Ma, 2006). Research has showed that across many nations, cultures, and ethnicities, women are about twice as likely as men to develop depression (e.g., Nolen-Hoeksema, 2001). Many different explanations for this gender difference in depression have been offered, but none seems to fully explain it. Recent research has focused on gender differences in stress responses, and in exposure to certain stressors (Nolen-Hoeksema, 2001). These studies suggest gender as a factor that moderates the effect of stress on depressive affect. Research shows that interpersonal stressors of all types, including family stressors, peer stressors and romantic stressors, have been associated with increases in depressive symptoms for adolescent females (Hankin, 2006). During the university, social stressors may

be particularly problematic as females report more social stressors than males (Darling et al., 2007). Sociocultural models (e.g., Ahmed, & Bhugra, 2006; Hammarstro¨m et al., 2009; Karasz, 2005) explain gender differences of vulnerability to psychopathology in terms of familial and cultural factors. For example, it is argued that the interplay of family functioning (Chao & Aque, 2009; Davidov & Khoury-Kassabri, 2013; Ellison et al., 2011; Gunnoe et al., 2006) and gender socialization (Cyranowski et al., 2000) may have an important impact on psychological adjustment and mental health outcomes. Therefore, exploring cultural factors that may be involved in vulnerability to and development of depressive symptoms would be critical. Building on previous research, the present study was conducted with the aim of investigating the association of several cognitive, emotional, and interpersonal variables including perfectionism, rumination, and attachment quality with depressive symptoms in a sample of Iranian undergraduate students. Magnitude of the effect of each of these variables in predicting depressive symptoms for both male and female students was also investigated. 2. Method 2.1. Participants and procedure A sample of 300 male and female Iranian undergraduate students who had not a history of psychiatric disorder or illness requiring medical treatment, participated in the study voluntarily. Participants included 144 males (mean age = 19.78, SD = 1.54) and 156 females (mean age = 19.64, SD = 1.58) from Urmia University, Urmia University of Technology, and Urmia University of Medical Sciences. Participants were asked to take part in a ‘‘study on personality and behavior’‘ via announcements made by relevant lecturer in classrooms. Questionnaires were completed in classes consisting of 30–40 students in the presence of the researchers who gave a brief description of the materials and answered questions. All participants were asked to complete Tehran Multidimensional Perfectionism Scale (TMPS), Ruminative Responses Scale (RRS), Revised Adult Attachment Scale (RAAS), and Center for Epidemiologic Studies Depression Scale (CES-D). The order of the questionnaires was counterbalanced across participants. University of Tehran Department of Psychology approved the protocol. All participants signed an informed consent beforehand. All participants were debriefed upon completion and thanked for their participation. 2.2. Measures 2.2.1. Tehran Multidimensional Perfectionism Scale (TMPS) This scale has 30 questions which was derived from the Multidimensional Perfectionism Scale (Flett & Hewitt, 2002; Hewitt & Flett, 1991a) and the Multidimensional Perfectionism Scale (Frost et al., 1990) and validated for the purpose of measuring dimensions of perfectionism on Iranian population (Besharat, 2011). The TMPS is comprised of three subscales, which measures different sources and foci of perfectionistic standards. The selforiented, other-oriented and socially prescribed perfectionism were assessed using a Likert scale ranging from 1 to 5. Scores in each of the subscales change from 10 to 50 and they have good internal consistency. The test-retest reliability for self-oriented, other-oriented, and socially prescribed perfectionism were .85, .79, and .84, respectively (p < .001). 2.2.2. Ruminative Response Scale (RRS) The RRS is a subscale of the Response Styles Questionnaire (RSA; Nolen-Hoeksema & Morrow, 1991) which consists of 22

Please cite this article in press as: Besharat, M.A., et al., Risk factors associated with depressive symptoms among undergraduate students. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.02.002

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items. The RRS measures responses to dysphoric mood that are focused on the self, on symptoms, and on possible causes and consequences of moods. The RRS has three factor-derived subscales including self-focused rumination, symptom-focused rumination, and cause/consequence-focused rumination. Several studies investigated and approved the psychometric properties of the RRS (e.g., Nolen-Hoeksema & Morrow, 1991; Roberts et al., 1998). Adequate psychometric properties of the RRS have reported for Iranian populations (Besharat, 2010). Cronbach’s alpha coefficients for the total score of the RRS and its subscales ranged from .85 to .94 in the present study. 2.2.3. Revised Adult Attachment Scale (RAAS) The RAAS is a modified version of the Adult Attachment Scale developed by Collins and Read (1990). The scale was designed to measure adult attachment in close relationships, specifically the three attachment styles of secure, avoidant, and anxious-ambivalent attachment (Hazan & Shaver, 1987). This 18-item questionnaire asks participants to rate their ‘feelings about romantic relationships’ on a 5-point Likert scale ranging from one (not at all characteristic of me) to five (very characteristic of me). Using the standard procedures, three subscales were computed: comfort with closeness and intimacy in romantic relations (close), feelings about depending on others to be available when needed (depend); and fear of being abandoned or unloved (anxiety). Higher scores indicate greater comfort with closeness, ability to depend and rely on others to be available when needed and higher feelings of anxiety in romantic relationships. The internal consistency, testretest reliability, and correlation of the three subscales with other measures of attachment have been demonstrated (Collins & Read, 1990). The test-retest reliability for the Farsi version of the scale was .97. The reported validity was also proper (Pakdaman, 2001). 2.2.4. Center for Epidemiologic Studies Depression Scale (CES-D) The CES-D (Radloff, 1977) is a 20-item scale designed to measure depressive symptoms experienced during the past week. Responses range from 0 to 3: 0 = Rarely or none of the time (less than 1 day); 1 = Some or a little of the time (1–2 days); 2 = Occasionally or a moderate amount of the time (3–4 days); and 3 = Most or all of the time (5–7 days). The internal consistency for the 20-item measure has been shown to be .85 for the general population (Radloff, 1977). The range of possible scores is 0–60. Higher scores indicate more depressive symptomatology. It has been suggested that scores of 15 or more indicate depression, whereas scores of 22 or more indicate severe depression. Cronbach’s alpha was .87. Cronbach’s alpha coefficient for the present study was .77. 3. Results Mean scores and standard deviations on each scale of perfectionism, rumination, attachment, and depression for the

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Table 1 Means and standard deviations of perfectionism, rumination, attachment, and depression in males and females. Variable/scale

Self-oriented perfectionism Other-oriented perfectionism Socially prescribed perfectionism Rumination Close Depend Anxiety Depression

Male (n = 144)

Female (n = 156)

M

SD

M

SD

31.43 32.09 30.32 25.54 17.65 17.45 15.68 15.79

6.62 6.35 6.70 9.16 2.38 2.90 3.32 9.37

31.83 33.32 31.15 26.93 18.90 17.89 16.49 17.67

7.99 8.41 8.79 10.76 2.62 3.06 3.27 9.34

participants are presented in Table 1. One hundred and sixty six participants (55.3%) scored above the cutoff on the CES-D. Pearson correlation coefficients are shown in Table 2. Based on this data, self-oriented perfectionism (r = .18, p < .01), otheroriented perfectionism (r = .22, p < .01), socially prescribed perfectionism (r = .35, p < .01), rumination (r = .50, p < .01), close (r = .17, p < .01), and anxiety (r = .20, p < .01) are significantly correlated with depression. Simultaneous regression analysis was performed to investigate the relationship among variables. In regression equation, perfectionism, rumination, and attachment were considered as predictor variables and depression as criterion variable. According to Table 3, the observed F was significant (p < .001, F = 8.55) and these variables explained .29 percent of depression variance (R2 = .33). Regression coefficients show that among the variables, socially prescribed perfectionism (t = 3.56, b = .25), rumination (t = 8.15, b = .46) and anxiety in close relationship (t = 2.28, b = .11) can predict the changes of students’ depression. When gender was entered into the regression analysis as a predictor variable, regression coefficient showed that gender (t = 2.74, b = .13) could significantly predict changes of participants’ depression. 4. Discussion The aim of the present study was to examine a number of cognitive, emotional, and interpersonal risk factors of depression symptoms in a sample of Iranian undergraduate students. Analyses of the relationship between dimensions of perfectionism, rumination, and attachment quality with symptoms of depression revealed that all dimensions of perfectionism, rumination, as well as close and anxiety dimensions of attachment were correlated with depressive symptoms. According to the results of regression analyses, socially prescribed perfectionism, rumination, and feeling of anxiety in close relationships predicted symptoms of depression. The findings of the present study are in line with the results of the previous studies on the relation between perfectionism and depression (Flett & Hewitt, 2002; Rice et al., 2007; Schiena et al., 2012; Wheeler et al., 2011), rumination and depression (e.g.,

Table 2 Zero order correlations among perfectionism, rumination, attachment, and depression (n = 300). Variables

1

2

3

4

5

6

7

1. 2. 3. 4. 5. 6. 7. 8.

Self-oriented perfectionism Other-oriented perfectionism Socially prescribed perfectionism Rumination Close Depend Anxiety Depression

1 .14* .20** .21** .05 .03 .07 .18**

1 .68** .43** .09* .08 .19** .22**

1 .48** .09* .04 .20** .35**

1 .08 .04 .13** .50**

1 .03 .05 .17**

1 .02 .07

1 .20**

*

p < .05. p < .01.

**

Please cite this article in press as: Besharat, M.A., et al., Risk factors associated with depressive symptoms among undergraduate students. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.02.002

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Table 3 Summary of simultaneous regression analysis of variables predicting depression. Variable Fixed Self-oriented perfectionism Other-oriented perfectionism Socially prescribed perfectionism Rumination Close Depend Anxiety Gender

B

SE B 8.74 .09 .16 .30 .43 .18 .02 .32 2.54

5.93 .06 .08 .08 .05 .18 .15 .14 .92

b

t .07 .13 .25 .46 .05 .007 .11 .13

p 1.47 1.51 1.96 3.56 8.15 1.04 .14 2.28 2.74

.14 .13 .05 .001 .001 .29 .88 .02 .006

Kuyken et al., 2006; Liverant et al., 2011; Nolen-Hoeksema, 1991; Peled & Moretti, 2010), and attachment and depression (Besharat et al., 2014; Kamkar et al., 2012). According to the results, all dimensions of perfectionism were related to symptoms of depression. To explain the relation of selforiented and other-oriented perfectionism with depression, one can point at cognitive components they share with depression. Self-oriented perfectionism is characterized by some negative cognitive features like self-blaming, self-criticism, feelings of guilt and neuroticism (Hewitt & Flett, 1991a, 1991b; Shafran et al., 2002). These components can somehow be traced in schemas of individuals prone to depression. The same explanation can be considered for the relationship between socially prescribed perfectionism and symptoms of depression. Socially prescribed perfectionism also shares some cognitive indicators of depressive disorders such as needs for other’s approval, fear of negative evaluation, external locus of control, over generalization of failure, self-criticism, self-blaming, psychological incompatibility, and passive aggression (Flett & Hewitt, 2002). These qualities might make people vulnerable to depression. The evidence of relation between other-oriented perfectionism and depression is rarely available in research literature. However, it can be argued that if the expectation that others should achieve unrealistic standards (Flet & Hewitt, 2002; Yang & Stoeber, 2012) are not fulfilled, it might be perceived as a grate frustration. One possible consequence of such frustration is interpersonal problems (Besharat, 2004). Disturbed interpersonal relationships has been reported as a risk factor of depressive symptoms (Besharat et al., 2014). The results of the present study provided evidence that socially prescribed perfectionism predicted depressive symptoms in both male and female students. This is in line with previous findings (Flett & Hewitt, 2002; Rice et al., 2007; Schiena et al., 2012; Wheeler et al., 2011). The need to achieve standards and goals indicated by others in socially prescribed perfectionist individuals provides them with both intrapersonal and interpersonal problems. Significant others’ expectations as well as one attempts for satisfying others through effort for being perfect (Hewitt & Flett, 1993) impose serious pressures on one. This is likely to produce distress and negative affect (Molnar et al., 2006) that may provoke symptoms of depression. Unachievable goals of accomplishment and productivity imposed by significant others undermine one’s self-worth. Low self-worth may vulnerable individual to emotional distress and depressive symptoms. It is also possible that significant others’ expectations increase the predisposition to experience failure through low self-worth as well as low self-confidence. When encountering interpersonal expectations as the main characteristic of socially prescribed perfectionism, perfectionists may become depressed because of interpersonal sensitivity, lack of control, and strong needs to gain approval (Hewitt & Flett, 1993). Perfectionist students unable to fulfill the demands of significant others and to get their full approval, may feel worthless and incompetent. Such feelings can result in depression in students.

Results of the present study revealed that rumination predicted depressive symptoms. This is in line with previous findings (e.g., Kuyken et al., 2006; Liverant et al., 2011; Nolen-Hoeksema, 1991; Peled & Moretti, 2010). There are a number of possible reasons why there might be an association between rumination and symptoms of depression. One is that ruminators characteristics such as memory and attention biases, may predispose them to selectively devote attention to negative stimuli (Joormann et al., 2006). Unavoidable repetitive process of thinking about past experiences, the main characteristic of rumination (Nolen-Hoeksema, 1991; Sukhodolosky et al., 2001; Langloiset al., 2000a, 2000b; Watkins, 2004), may have a crucial role in the development and perpetuation of negative thoughts, which in turn produce depressive symptoms. The cognitive model of depression suggests that depression can be intensified due to the interactional cycle of negative thoughts and mood (Beck et al., 1979). Another possible reason is that ruminative thoughts of the past experiences may increases negative affect and psychological distress through flaming anger (Besharat & Mohammad Mehr, 2009; Besharat & Shahidi, 2010; Bushman, 2002). Anger rumination is shown to be associated with seriousness, onset, relapse, duration, and continuation of depression (Besharat & Mohammad Mehr, 2009; Besharat & Shahidi, 2010; NolenHoeksema, 2000; Watkins, 2004). Moreover, it may be argued that in a vicious circle rumination increases negative affects and vice versa. Research evidence about the link between rumination and mental health components (e.g., Besharat & Mohammad Mehr, 2009; Besharat & Shahidi, 2002, 2010; Kuyken et al., 2006; Liverant et al., 2011; Nolen-Hoeksema, 2000; Peled & Moretti, 2010; Roberts et al., 1998; Rusting & Nolen-Hoeksema, 1998; Watkins, 2004) supports this explanation. As showed in the present study, it may also be possible that ruminative thoughts are intensified by characteristics of socially prescribed perfectionism in an individual. Pressures imposed by significant others’ expectations may increase the predisposition to experience repetitive negative thinking that is the main characteristic of rumination (Nolen-Hoeksema, 1991; Sukhodolsky et al., 2001; Langlois et al., 2000a, 2000b; Watkins, 2004). Having characteristics of both socially prescribed perfectionism and ruminative thoughts make individuals even more susceptible to depression. Results of the present study showed that feeling anxiety in close relationship could predict depressive symptoms in students. This finding is in line with a growing body of research suggesting a strong link between adult attachment insecurity and depressive symptoms (e.g., Besharat et al., 2014; Besser & Priel, 2003; Wei et al., 2004). Concerns and anxieties about one’s close relationships can affect psychological well-being in various ways. For example, according to Jaremka et al. (2013) individuals who are on the high end of the attachment anxiety spectrum are excessively concerned about being rejected, have a tendency to constantly seek reassurance that they are loved, and are more likely to interpret ambiguous events in a relationship as negative. These conditions altogether make individuals more prone to depression. From an information processing point of view, it can be argued that people lead their attention to positive or negative events in order to adapt the events with their previous experiences (Gotlib et al., 2004). Feeling anxiety in close relationship imposes negative bias in information processing. Because of the negative bias in information processing, those who are anxious in their close relationships tend to perceive cues for sadness or dysphoria (Gotlib et al., 2004) and interpret neutral or positive information negatively (Gollan et al., 2008). Negative internal working models of self and others developed in insecure people are showed to be related to negative thoughts (Orth et al., 2008), low self-esteem (Park et al., 2004), and interpersonal problems (Besharat et al., 2014). These are all confirmed as risk factors for depression (Beck et al., 1979; Besharat et al., 2014; Orth et al., 2008).

Please cite this article in press as: Besharat, M.A., et al., Risk factors associated with depressive symptoms among undergraduate students. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.ajp.2014.02.002

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Results of the present study showed that gender could significantly predict changes in depressive symptoms. This is in line with previous findings (Darling et al., 2007; Hankin, 2006; Nolen-Hoeksema, 2001). Familial and cultural factors (Ahmed, & Bhugra, 2006; Hammarstro¨m et al., 2009; Karasz, 2005) are considered as responsible for gender differences of psychopathology. Having some degrees of dependency, as well as showing feelings of any kind are parts of Iranian girls’ gender identity. Iranian families encourage girls to be more dependent and to show their feelings more easily than boys. These characteristics might make girls more vulnerable to depression when coping with daily high stressors than boys who are educated to be stronger in such hard situations. Within this environment, other family functioning such as parenting styles could have a stronger negative impact on girls rather than boys. These explanations are consistent with finding of research on family functioning (Chao & Aque, 2009; Davidov & Khoury-Kassabri, 2013; Ellison et al., 2011; Gunnoe et al., 2006; Niemi et al., 2010) and gender socialization (Cyranowski et al., 2000). Recent social changes in Iran have also put more pressure on women. Iranian women of new generations are expected to accept more responsibility for academic achievements, job satisfaction, and child protection while challenging to get social, legal, and economic sources as equal as Iranian men. These factors can also explain gender differences of vulnerability to psychopathology as put forward by sociocultural models (Ahmed, & Bhugra, 2006; Hammarstro¨m et al., 2009; Karasz, 2005). However, complex interplay between different sociocultural and other factors does not allow us to draw a firm conclusion. 4.1. Limitations and implications Results of the present study have several limitations. The crosssectional design of this study does not allow us to draw conclusions about the directions of causality among perfectionism, rumination, and attachment with symptoms of depression. Future longitudinal studies need to be conducted in order to clarify this important issue. These data were based upon a sample of Iranian undergraduate students and could not be easily generalized to other populations. Previous research (e.g., Arpin-Cribbie & Cribbie, 2007; Besharat & Shahidi, 2010) suggested that perfectionism may interact with other variables to produce positive or negative consequences. This imply that perfectionism may have different effects, depending on its interaction with other variables such as stress and daily hassles. Future studies need to be pursued to address this issue. Additionally, it is recommended for better understanding the risk factors associated with depressive symptoms, the relationship between these variables must be examined in other general populations as well as clinical samples. Nonetheless, results of the present study may have important implications. The results of the present study confirm previous research and theories concerning the relationship of perfectionism, rumination, and attachment with depression. The results of the present study improve our understanding of the determinants of depressive symptoms at a premorbid level. Perfectionism represents a personality characteristic which may be of potential interest for mental health professionals. Accordingly, the proper assessment of perfectionism, alongside of other cognitive, emotional and interpersonal variables in psychiatric patients may provide invaluable information for intervention and management programs. Clinicians should consider working with patients to reduce excessive perfectionistic tendencies. These efforts might involve attempts to identify and alter high standards and maladaptive irrational beliefs and replace them with more realistic and rational ones, which in turn should reduce the experience of psychological distress, negative emotions, and depressive symptoms. Knowledge on sociocultural factors for gender difference in

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depression holds important implications because theories on the development and maintenance of depression should be able to explain how these gender differences generate and continue, and in which way they can be resolved in an identified culture. Acknowledgement The authors would like to acknowledge the financial support of University of Tehran for this research under grant number 5106003/1/56.

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