The main objective of the present study was to examine the relationship of cognitive emotion regulation with anxiety and depression symptoms in women with infertility. In the present study, the prevalence of anxiety and depression symptoms were 41.7% and 29.6%, respectively, which are consistent with previous studies in Iran [3, 4]. We investigated the relationships of demographic and infertility variables with anxiety and depression. Among demographic and infertility variables, only the history of spontaneous abortion was significantly related to anxiety scores, as women with a history of spontaneous abortion had high anxiety symptoms. Our findings showed that depression was more common in women with short marital duration as well as women with low educational level and women with female factor and unknown cause of infertility [3, 17].
Generally, our findings show that the adaptive strategies were reported to have been used more often than the maladaptive strategies. Among the adaptive strategies, acceptance was the least frequently implemented, and among the maladaptive strategies, other-blame was the least frequently implemented. These findings are consistent with previous studies [10, 18,19,20,21].
According to the bivariate correlation analysis, all CERQ subscales, except for acceptance, correlated significantly with both anxiety and depression. Positive refocusing, refocus on planning, positive reappraisal, and putting into perspective correlated negatively with both anxiety and depression symptoms. Self-blame, rumination, catastrophizing, and other-blame correlated positively with anxiety and/or depression symptoms. When looking at the strengths of the correlations, the maladaptive strategies were more strongly related to depression than anxiety.
Among cognitive emotion regulation strategies, only refocus on planning strategy was independently negatively correlated with depression in multivariate analyses after controlling for demographic and infertility variables. In multivariate analysis, more engagement of rumination as well as less engagement of acceptance and positive refocusing independently contributed to anxiety. This finding corresponds to findings reported in previous studies performed in various populations [12,13,14,15, 18, 19, 21, 22].
One implication of the current study is that it may not be appropriate to consider the Acceptance subscale as an adaptive strategy, as recommended by Garnefski et al. [10]. Although we found partial support for the adaptive role of acceptance in that it was positively related to some other adaptive strategies (i.e., refocus on planning, positive reappraisal, and putting into perspective), acceptance was also positively correlated with some maladaptive strategies (i.e., self-blame, rumination, and catastrophizing strategies). In addition, among 9 subscales of CERQ, only acceptance subscale was not correlated with anxiety and depression symptoms according to the univariate analysis. One possible explanation is that the acceptance items (e.g., “I think that I have to accept that this has happened,” “I think that I have to accept the situation,” etc.) may reflect a degree of hopelessness. Therefore, acceptance strategy may be adaptive only in certain conditions. Due to the abovementioned findings, we suggest interpreting this subscale with caution. Whether acceptance strategy is adaptive or maladaptive depends on the circumstance and the type of mood under study. This finding is in line with a study performed by Martin and Dahlen [23].
For future research, we recommend comparing cognitive emotion regulation strategies by gender, cause of infertility. In addition, it would be useful to set up randomized controlled trials in which anxiety and depression symptoms in patients with infertility are compared before and after cognitive behavioral therapy.
The present study has several limitations that need to be noted. First, it was a single-center study utilizing only infertile women. Second, the sample size was relatively small. So, the generalizability of the findings may be limited by the characteristics of our study sample. Third, all variables were measured via self-report instruments. This may have caused bias. Forth, because of the cross-sectional nature of the study, it is not possible to infer causality between study variables.