Coping with depression

August 2017

Pride in our care

A member of Cambridge University Health Partners

 Section 1: About depression

What is depression?
Depression is a very painful and difficult human experience. Depression is
actually quite common – it affects about one in ten people at some time in
their lives. For some people, it might happen only once and pass quite quickly
without any outside help. For others, depression may be more of a problem –
it may last longer or come back multiple times – in these cases, it may require
treatment. Sometimes depression can be so severe it requires admission to the
hospital. Because many people are ashamed of feeling depressed and try to
hide it, you may not have realised that it is quite so common – but it is.

Symptoms of depression
Depression has many different symptoms. It is very often characterised by
feeling sad, “blue”, and miserable it effects how you feel, act, and think.
Some of the most common symptoms of depression are listed below.

• Depressed mood. Feeling low, sad, miserable, hopeless, or irritable.

Sometimes people feel bleak, numb, and empty.
• Losing interest and enjoyment in previously enjoyed activities. Nothing
seems like fun anymore. Things that used to be enjoyable feel like a chore.
Motivation to do almost anything is very low.
• Self-criticism and guilt. Feeling that you are bad, useless, inadequate, and
worthless.
• Pessimism. Very negative interpretations of the things that are happening
around you. For example, thinking that nothing will work out right.
• Hopelessness. Feeling that everything is bleak and pointless, and that it
will always be like this. Some people feel as though there is “no point in
trying”.
• Loss of energy. Feeling tired all the time.
• Reduced activity. Sometimes it gets to the point that people do very little,
especially when compared to their life before depression.
• Withdrawal from social activities. You may stop returning phone calls and
begin avoiding occasions that involve socialising with other people.
• Difficulty concentrating. You may have noticed that it is harder to read a
book or watch a television program.
• Memory difficulties. For example, you may forget where you put
something, or forget your keys. There are other, more specific, memory
changes as well. For example, it becomes easier to remember bad things
that have happened to you and more difficult to remember good things.
• Changes in sleep patterns. Some people have a lot of difficulty sleeping,
while others feel as though they could sleep endlessly.

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• Changes in appetite and weight. Some people lose their appetite and may
notice that they lose weight. Others may “comfort eat”, which often
results in weight gain.
• Loss of interest in sex. Some people find that they lose interest in sex,
worry about their performance and experience difficulties with intimacy.
• Thoughts of death. These range from thoughts that it wouldn’t be so bad
to be killed accidentally to actively making plans for suicide. If you are
having frequent or serious thoughts about suicide, then you need to get
professional help as soon as possible. If you are not already seeing a
mental health professional whom you can tell about these thoughts, then
talk to your GP as soon as you can.

These are some of the most common symptoms of depression, although there
are others not listed that you may also experience. When people are
“clinically” depressed, they usually have at least five of these symptoms most
of the time for at least two weeks.These symptoms usually cause a great deal
of distress. Even if you do not have this exact pattern, you may still need some
help.

If you look at the above list, you may notice that these symptoms can be
roughly classified into four main groups.

Mood symptoms - these are often considered to be the main symptoms of

depression. In addition to experiencing low mood, people may feel irritable,
worthless, and hopeless. People may also lose any sense of interest or
enjoyment in their usual activities. Sometimes people may be unable to feel
love for the people closest to them.

Physical symptoms – changes in sleep patterns, appetite, weight and energy.

Cognitive (“thinking”) symptoms – difficulty concentrating, making decisions,

or working out problems. Memory difficulties. Changes in the content of
thinking also occur. For example, people who are depressed start to think very
negatively about themselves (“I’m worthless”), the world (“nobody cares for
me”), and the future (“I can’t do it – it’s hopeless”).

Behavioural symptoms – often, people start to withdraw from social activities

and many activities they previously enjoyed.

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 Myths about depression?
Myth 1: “Nothing bad has happened to me, there’s no reason why I should be
depressed. It must be my fault”.
Reality: Sometimes it is very hard for people to understand why they have
become depressed, and they end up thinking that the depression is in some
way their fault. But in almost every case, an outsider like a therapist can help
people to see their depression in a different way. They do not have to blame
themselves for feeling like that.

Myth 2: “I don’t know why people say this is depression. I’ve always felt like
this. It’s just me, and nothing can change it”.
Reality: This is common when people have been treated badly early on, and
have felt unhappy all of their lives. In this case, it is very difficult to see that
the way they feel can be classified as depressed, and therefore not just how
they are. It can be even more difficult to believe that it can change – but it
can.

Myth 3: “Depression is biological – like a switch going in your brain – and

there is nothing you can do about it. Only pills can make the difference”.
Reality: Depression is, in some sense, biological, more so for some people than
others. And medication does help many people. But even if it is biological, it is
clear that you may be able to speed the depression on its way by trying to
make changes in the way you think and behave.

Myth 4: “Other people can cope with their lives without getting depressed –
much worse things happen to them. I’m just weak and pathetic – I should be
able to cope”.
Reality: It can look as though everyone is getting on with life and coping
better than you. But this is partly because you tend to only focus on people
who cope and not notice those who don’t. It may also be because people go
to great lengths to hide it when they feel that they can’t cope, you might
never see other people when they are having trouble coping. It is important to
remember that the feeling that you cannot cope is a symptom of depression,
and is not a sign that you are weak and pathetic.

Myth 5: “I should just be able to pull my socks up and get on with things. I
shouldn’t need help from anyone else. Anyway, talking about yourself is just
selfish and self-indulgent, and doesn’t help”.
Reality: If it were this simple, no one would ever be depressed. In fact, vast
amounts of public money are poured into treatments of depression because it
is recognised that people cannot just snap out of it, and talking in a
constructive way that has been shown to help a lot of people.

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Myth 6: “Why should I take medication? It won’t help, it can’t change the
things that are making me depressed”.
Reality: It is true that medication will not change the things in your life that
are troublesome. But it can help to make you feel better and therefore to
cope with your problems in a different way.

What causes depression?

There are a number of causes of depression, some to do with what happens
physically and some to do with what happens in your life. Very often when
people get depressed a combination of things comes into play. The main ones
are listed below.

Genetics. People may inherit genes that make them more likely to develop
depression. If a lot of people in your family have had difficulties with
depression, then this may be the case for you. However, keep in mind that a
high rate of depression in a family may also be because of the way people in
the family behave towards each other, and thus not due to the direct effect of
genes.

Brains and biology. When people are depressed, there are changes in the
brain, both in levels of special brain chemicals and in electrical activity. These
changes are more marked in people who suffer a lot of physical symptoms of
depression (e.g., difficulty sleeping, change in appetite, lethargy). When
people recover from depression, these changes disappear and brain activity
goes back to normal. It is not known whether brain changes cause depression
or are a side effect of depression.

Other aspects of physiology may also contribute to depression. For example,

disturbed sleep can lead to fatigue, irritability and poor problem solving. This
can set the stage for depression to develop. When people are depressed, they
often develop significant problems with sleep, which can help to keep the
depression going.

Early experience. For some people, life may have been difficult from very early
on. There may have been practical difficulties, or they may have been abused
or neglected. Their parents may have separated or died. Or they may have had
a tough time at school; perhaps they were bullied. In these cases, people are
more vulnerable to developing depression, particularly if their early
experiences taught them to think negatively.

Life events. For some people, things were going along reasonably well until
something awful happened – perhaps their marriage broke down, they lost
their job, or a loved one died. Such events can sometimes trigger depression,
particularly if they involve major losses.
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 Ongoing stress. For some people, there is not a single or major event that gets
depression started. Sometimes depression is caused by problems that seem to
go and on, with no solution in sight. These problems can be much more
ordinary things, such as ongoing problems with work, accommodation,
ongoing tension in relationships, or loneliness. The list is pretty long. These
stresses are more likely to cause depression if they make people feel trapped
or humiliated.

Why is it so hard to stop feeling depressed?

Once someone is depressed, he or she experiences many changes. Very often
the changes start to work in a vicious circle which helps to keep the depression
going and can be very hard to break out of. The first step is understanding the
changes and the way they fit together.

The following cycle illustrates the way in which these changes work together
to keep you depressed. We have filled it out with the example of what
happened to John, who lost his job.

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Life situation or ‘trigger’
As we saw above, certain kinds of life situations make it more likely that
people will develop depression. In this case John lost his job. But not everyone
who experiences these problems gets depressed – the link seems to be in the
way that people think about what happens.

Thoughts
Even if something bad happens, there are a number of different ways of
thinking about it. John could have thought “Well, that was really unfair and
it’s going to make life difficult for a while, but I can start looking for another
job straight away, and might even find something I like more”. In this case, he
might not have felt depressed. But in fact he thought “I’m such a failure, I’ll
never find work again”. People who feel depressed tend to see things in a
way which is harsh, self-critical, unfair, and unrealistic. We’ll talk about the
nature of depressing thoughts in much more detail in section 3 (page 16).
What is clear, however, is that because he did think like that, it was very
understandable that he should feel low and depressed.

Emotions
Once people start to think in a negative way, their feelings naturally follow.
Feelings like discouragement and sadness are common. If the depression
continues, more severe emotions such as despair, misery, and hopelessness may
take over. Sometimes, worry is also present (physical tension, worry). Other
people experience emotional where they don’t seem to feel anything at all.
Once the negative emotions start, they also make it more likely that people’s
thinking will become more negative as well, so there is a vicious circle where
thoughts and feelings both get worse.

Physical changes
Depression has many physical symptoms. Often people find that they have no
energy at all and get exhausted by everyday activities. They may have a lot of
trouble sleeping, or even sleep too much to try and escape from their
unhappiness. They may find it hard to eat, or may go the other way and eat
much too much, often very unhealthy ‘comfort’ foods. They may find that
their sex drive disappears completely, making relationships more difficult.
These physical changes make the emotions worse, and they also have a big
impact on people’s behaviour.

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 Behaviour
Depression usually has a significant impact on people’s behaviour. Some of the
major areas affected are:

1. Withdrawal from family and friends. Social invitations are refused, phone
calls are not returned, visiting with friends and family doesn’t happen so
much. Social isolation is a strong factor in low mood – it takes away the
comfort associated with a connection to others. Depressed people or people
suffering with low mood often think that others have no interest in their
company. Depression can also create problems with other people and put a
strain on relationships.

2. Reduced self-care. Depressed people may take less care in looking after
themselves; washing less or paying less attention to our appearance than
other people. Exercise often falls by the wayside. If we don’t look after
ourselves it can make us feel worse about ourselves. Not eating properly is also
an example of this.

3. Less involvement in rewarding activities. Hobbies, sports, reading, walking,

playing with children – all of these activities may decline. Depressed people
often feel too tired or motivated to engage in these activities. The less they
participate in them, the less they feel able to do so. They no longer receive the
personal satisfaction provided by these activities, which leads to negative
emotions, such as feeling low or thinking they are ‘useless’.

4. Problems with everyday tasks. Someone suffering with low mood tends to
find it difficult to do everyday things. For example, running errands, taking
out the rubbish, cleaning the house etc. Not being able to complete these jobs
can lead to negative thinking such as – ‘I am useless’ or ‘I have no control over
my life’.

So, depression touches all areas of your life: your emotions, thoughts,
behaviours, your body and life situation (including family relationships, social
support, major life events, ongoing stress, etc).

Because all of these areas are connected and influence each other, vicious
circles develop which mean that the problems take on a life of their own, and
keep themselves going. This can be very difficult to manage, but it also means
that when you are trying to get better, changing one area can lead to changes
in the others:

“If we change how we think or behave we can change how

we feel”

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Treatments for depression
The good news is we can do something to change this. For some people,
depression goes away on its own, without any treatment at all. However, for
many people, getting some help can be very useful. There are a wide variety
of treatments available for depression. Two of the most common are
medication and psychological therapy.

Medication. There is considerable evidence that medication does work well for
many people. Many people who take antidepressant medication
experience a lift in mood and a reduction in other symptoms (such as loss of
appetite or difficulty concentrating).

Sometimes medication is helpful because it reduces the depressive symptoms

enough that people are able to sort out the problems in their lives that are
contributing to the depression – it gives them a sort of “chemical leg-up”. But
medication is rarely a complete treatment for mood problems – although it
helps, it is often important for people to make changes in their lives. It has
also been shown that for a number of people, the most effective treatment is
a combination of medication and psychological treatment.

Here is some information about medication:

• Anti-depressant medication is prescribed by a doctor or a psychiatrist.

• There are many kinds of anti-depressant medications available;
unfortunately, it is impossible to be sure which one will work the best, so
sometimes people have to try a few to find one that produces the best
effect.
• Usually, medication takes two to four weeks to kick in.
• Certain people take medication over the long term. Others take
medication for a while to give them energy and a lift in mood that enables
them to make some positive changes in their lives. Eventually, these people
gradually reduce and stop taking the medication with the help of their
doctor.
• It can be tempting to stop taking medication when you start to feel better.
Common result: a rapid return of the problem. It is generally best to stay
on the medication until your mood is steady for a while. Talk to your
doctor if you want to stop taking medication, and he or she will help you
along.
• There are some side effects to antidepressant medication, such as dry
mouth, drowsiness and weight changes, but these often become less after
the medication is taken for a longer period of time.

Many people suffering with depression can be treated without medication. By

increasing activity, living a healthier life, dealing openly with problems, and
challenging negative thinking, the depression will lift.
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 Psychological treatment
There are many different psychological treatments available for depression.
This booklet is based on cognitive-behavioural therapy (CBT), a
well-researched and common form of psychological treatment. This kind of
therapy focuses on the behaviour and thinking of people that are depressed,
because these factors often play a very important role in starting depression
and keeping it going.

Section 2: Getting going again

Steps to tackle your depression

When people are depressed, they often stop doing many things that used to
be a part of daily life – sometimes, they even stop doing things that they
previously enjoyed. This can make you feel even worse, even though it may
feel like the only thing you can do. In other words, it is like a vicious circle:

Depression leads to doing less, but the doing less

can make depression worse. What may seem like
a good coping strategy at the time actually tends
to either keep the depression going, or even
Depression Doing less
make it worse. So don’t wait until you feel like
doing more. The more you wait, the less likely
you are to get better. Instead, gradually get
yourself moving even though you don’t feel like
it. Sometimes, the less you feel like doing
something, the more important it is to do it.

Step 1: See what you are actually doing

Because you are depressed it may be hard for you to think that you are
managing to do anything. So it may be a good idea to have a look at what
you are actually doing.

One way to find out is to record what you are doing – like a personal diary. Try
this for a few days using the Activities monitoring sheet on page 12 (you will
also find a blank version at the back of this guide). Each time you write down
an activity, give it two ratings out of ten - one for Enjoyment (E) and the other
for Achievement (A). ‘0’/10 for enjoyment would mean that you did not enjoy
the activity at all, and ‘10’/10 for enjoyment would mean that the activity had
been extremely enjoyable. ‘0’/10 for achievement would mean that you did
not feel like you achieved anything at all after that activity, while ‘10’/10
would mean that you had an extremely strong sense of achievement.
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• Try to do the ratings at the time of the activity– that way it’s much easier
to remember how it was for you.
• Remember that things seem more difficult when you are depressed –
therefore, an activity that once was easy now seems to be quite a
challenge. If you manage to accomplish such an activity, you should give
yourself credit.

Activities monitoring sheet overleaf

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 Activities monitoring sheet

Morning Afternoon Evening

Monday Stayed in bed

A 2 /10
E 4 /10
Made cup of tea
Went back to bed
A 7 /10
E 7 /10

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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Your Activities Monitoring Sheet can give you information on what you are
actually doing and enjoying. You may find that you are more active and
capable than you thought, or that you are doing more things that you enjoy
than you thought. Or you might find that you are doing very little and not
enjoying yourself at all. In either case, this is a good place to start setting some
goals. It is time to start trying to do a little bit more, and planning activities
for specific times during the day.

Sometimes starting to get active again can seem quite scary – like you don’t
know where to start. The first question to ask yourself is what activities can be
increased? What does your activity monitoring sheet suggest these could be?
You may remember from the previous section in this guide that when people
feel depressed, activity in the following four areas tends to get less:

Step 2: Make a list for yourself

Involvement with family and friends

Examples: Inviting people to do things. Keeping in contact with friends.
Returning phone calls. Going to a social group or class.

Your examples............................................................................................................

....................................................................................................................................

Self care
Examples: Getting dressed each day. Following your usual self care routine
(eg washing face, brushing teeth, shaving or putting make up on).
Exercising regularly. Eating properly.

Your examples............................................................................................................

....................................................................................................................................

Personally rewarding activities

Examples: Reading, walking, playing a computer game, watching TV, playing
cards/games, gardening, listening to music, looking at a social network site,
doing a crossword

Your examples............................................................................................................

....................................................................................................................................

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 Small duties
Examples: Opening bills, paying bills, housework, food shopping, running
errands, tidying up a bit

Your examples............................................................................................................

....................................................................................................................................

Step 3: Pick your goals

Now pick two of the activities that you listed that are the most practical for
you to start changing right now. Your first two choices should be from
different areas.

Write them down.

1..................................................................................................................................

2..................................................................................................................................

Step 4: Make your goals SMART

For each of the activities you have chosen, set a doable goal for the coming
week. Remember – when you are depressed it is often very difficult to get
moving. As a result, you will need to set smaller goals than you usually would.

To succeed, your goals should be SMART:

Specific: Your goal should be very clear, so you will know when you have done
it.

Manageable: Start off with smaller goals – a good place to start is choosing a
task that you can handle no matter how bad you are feeling.

Active: Make a plan for what you will do, not how you will think or feel while
you are doing it.

Realistic: Your goals should be easy enough to do even if you feel terrible.

Time: It will help to carry the goal out if you decide when and how you are
going to do it, as well as how many times or for how long.

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An example of setting a SMART goal in a complicated situation is shown
below:

Leslie hadn’t looked at her bills for a month or even opened her post.
Knowing that getting her finances in order was important but feeling like it
was too much to do in one go, she decided to do it in a few steps.

Firstly, she decided to spend five minutes each day just opening the envelopes
that she had piled up (but not looking at the letters). Once she had opened
everything she decided to spend five minutes each day looking at the letters
and putting them in order of importance. Once she had done this she decided
to make a plan for dealing with them. She decided that Monday evening
would be a good time to start this.

Activity How often? What day?

Some people find it helpful to treat your goals like appointments with
yourself. If you wouldn’t break an appointment with someone else (like your
doctor), then don’t break a goal with yourself. If you must cancel one of these
appointments with yourself, reschedule immediately and don’t miss it a second
time.

What if you do extra? That’s great – but you still need to keep the next
appointment! Remember to keep it doable.

Step 5: Carry out your goals

Now it is time to carry out your goals. Write your goals into your Activities
Record and Goal Sheet (you will find a blank copy at the back of this guide).
You can continue to monitor your activities alongside your goals and rate your
enjoyment and achievement. At first, you may not notice a sense of
achievement from completing your goals, but remind yourself that you are
doing something positive to help your depression so make sure you check it
off your list you made in step 2 – you have done something you wouldn’t have
done last week, and it probably wasn’t easy.

Congratulate and reward yourself. Remember, when people are depressed,

they tend to focus on the things they haven’t done, and ignore or downplay
the things they have managed to do. Deliberately remind yourself that you did
it – it counts, especially during depression.

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 Some people find it helpful to treat your goals like appointments with
yourself. If you wouldn’t break an appointment with someone else (like your
doctor), then don’t break a goal with yourself. If you must cancel one of these
appointments with yourself, reschedule immediately and don’t miss it a second
time.

What if you do extra? That’s great – but you still need to keep the next ap-
pointment! Remember to keep it doable.

Step 6: Review your progress

After a week of doing these goals, review the situation.

• Are there any differences between your initial Activities Monitoring Sheet
and your Activities Record Sheet that includes your goals?
• Are you doing more?
• Are you feeling better at times?
• Do you want to keep doing these goals at the same level until they feel
more comfortable?
• Do you want to increase the goals slightly?

If you had some difficulty achieving your goal, what got in the way? Look back
at the criteria for a SMART goal.

• Was your goal too ambitious?

• Was it too vague? Then is probably time to rework your goal.
• If you set your goal too high or aren’t specific enough, it will be harder to
achieve.
• Do something more manageable, and make it as specific as possible.
• As your energy comes back, you will be able to do more. The most impor-
tant thing is to start moving, no matter how slowly.

When you feel ready, add another SMART goal. Pick one from another area.
For example, if you had one goal from “involvement with family” and
“friends”, and another from “self-care”, this time choose one from “personally
rewarding activities” or “small duties”. Add your goal into your activity diary.

After another week of doing these goals, review the situation again.

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 Tip: Are you a morning person or an afternoon person? When is your
energy level the highest? You may want to plan your activities
accordingly.

Tip: If your activity plan is very busy – don’t forget to schedule in some
time for rest. We all need some time to unwind!

Tip: Usually, having no more than three goals at one time is the most
manageable.

Summary

• Monitor your activity to see what you are actually doing, rate your
Achievement and Enjoyment.
• Use your Activity Monitoring Sheet to see what activities you normally do
that have decreased or stopped all together and make a list.
• Pick 2 activities from your list (from different areas).
• Make these activities into SMART goals.
• Carry out your goals – write them into your Activities Record Sheet, rate
your Achievement and Enjoyment. When you have completed your goals
check them off your list and remember to praise yourself!
• Review your progress after and when you are ready, add another goal
from your list.

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 Section 3: Negative thinking and depression
Each person is affected differently by outside events, depending on how they
think about these events. For example, imagine that Mary is walking down the
street and sees a friend – but the friend walks by her without acknowledging
her. Mary thinks to herself – “Oh dear, she must be angry at me. Or perhaps
she doesn’t like me and she’s trying to avoid talking to me. I’ve lost another
friend. I will always be alone”. Mary feels awful – she notices her sadness and
loneliness growing. Now, imagine that Sarah encounters the same situation.
Sarah thinks to herself – “wow – she is really distracted! I bet she is still
thinking about that date she had last week”. Sarah feels a bit amused, and
goes about her day.

Note that in this example, the event that Mary and Sarah experienced was the
same. But because they had different ideas about it, what they felt in the
situation was completely different. This shows our basic understanding of the
links between thinking and feeling in depression.

When people feel depressed they have

particular ways of thinking about the
world that can trigger or worsen the
Negative thoughts Depressed mood
experience of depression – so depression
can cause us to think very negatively. This
thinking is very often:

• Unfair. For example, negative events are given much more significance
than positive ones.
• Unrealistic. Things seem much worse than they actually are and take on a
bigger meaning to us.

This unfair and unrealistic thinking affects the way we make sense of events
and situations. For example:

Thinking in a very critical fashion, judging ourselves in a harsh and unfair

manner. The bad things we have done are very obvious, and we have a hard
time remembering anything good about ourselves.
“I am so useless, I’m just a complete failure”

Often seeing life in an unrealistically pessimistic way, emphasising it’s negative

or threatening aspects and ignoring more positive or promising aspects.
“My situation is terrible and there is nothing I can do about it”

Seeing a future that is bleak and disappointing and expect the worst to
happen.
“This will never get better – it will probably only get worse”
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When people are depressed, they tend to have thoughts that are generally
unfair and unrealistic. They are unhelpful because they aren’t accurate
thoughts about the self, the current situation, and the future. They are also
automatic; they seem to appear out of nowhere, and are not the result of
reasoning or decision making. Sometimes they are so automatic they are
difficult to spot. Unfortunately, these thoughts can also seem very believable –
and so there seems to be very little reason to doubt them.

You will find some common forms of unhelpful thinking on the next page. Do
recognise any of them in yourself?

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 Filtering. Only looking at the bad, never the good. You may single out a negative
detail and dwell on it, ignoring any good things you have done. You may see only your
weaknesses and mistakes, and disregard your strengths and accomplishments.

Overgeneralisation. One negative event is the beginning of a never-ending pattern. If

you fail the first time, you will fail every time. If you have difficulty with one friend,
nobody likes you.

All or nothing thinking. You see things as black and white with nothing in between.
You are either fat or thin, smart or stupid, depressed or happy, and so on. There is no
in-between. Gradual progress is never enough – only a complete change will do.
“Who cares if I only did half of it? It’s still not finished!”

Catastrophising. A small disappointment is a disaster. For example, after making an

mistaken comment at a meeting, you think you made a complete fool of yourself and it
was a complete disaster, everyone at work thinks you are stupid and you may lose your
job. As a result, you react to the imagined catastrophe (everyone at work thinks you are
stupid, you may lose your job), rather than to the little event (the mistaken comment).

Labelling. You talk to yourself in a harsh way, calling yourself names like “stupid”,
“idiot”, “failure”, or whatever is the worst insult for you. You feel like these labels sum
you up.

Mindreading. You know what others are thinking of you, and it’s always bad. As a
result, you react to what you imagine they are thinking without bothering to ask.

Fortune Telling. You know what the future will bring, and it’s usually negative.
Nothing will work out, so why bother trying? Result: You bring about the future you
fear.

Disqualifying the positive. Anything positive about you or anything positive that
happens is discounted. For example, “I did manage to get some things done, but
anyone could have done that”, or “I enjoyed going out, but I felt depressed again
afterwards”.

Personalisation. If something bad happens, it must have been your fault. Other more
likely causes are ignored.

Perfectionism. It’s only good enough if it’s perfect. And because it’s never perfect, you
are never satisfied and can never take pride in anything.

Shoulds. You know how you should be and how the world should be – but you are
not, and neither is the world. “I should not upset people”. “I ought to have achieved
more than this.” Result: You are constantly disappointed and angry with yourself and
everyone around you.

20
Where do these thoughts come from?

For some people, patterns of negative thinking begin in childhood. Some

people grew up in families where only negative and critical comments were
made. In other families, children were discouraged from saying positive things
about themselves and may have been rewarded for being self-critical. For
other people, the cause of the negative thinking may be more immediate. For
example, a major life event (e.g., loss of a job, death of a loved one, divorce,
financial setback), social isolation (e.g., after moving), relationship conflict, or
stress (e.g., related to employment, physical health, family), may trigger
negative thinking. In all of these cases, negative thinking puts people at risk of
feeling depressed. In some people, the depression may actually cause the
negative thinking.

Whether negative thinking starts before depression or is caused by depression,

it can have a very big influence on your experience of the world. Negative
thinking increases the negative impact of difficult life situations and can make
people more sensitive to emotional pain. Negative thinking can make
depression worse and make it last longer.

Step 1: Recognising your negative thoughts

Negative thinking is so quick and automatic we don’t even realise we are

doing it. It is important to learn to become aware of negative thinking as it
occurs. A good strategy to help to identify negative thinking is to fill out a
thought diary (like the one on page 21) over the course of a week. Every time
your mood sinks a little further, ask yourself: What was going through my
mind just then? Write it down!! Then make a note of the emotions you were
feeling. Keep recording your thoughts – maybe you will notice the same kind
of thought happening over and over again – you might want to put a mark
beside thoughts that keep repeating themselves. This will help you identify
the most common kinds of negative thinking that you do as seen on the
previous page.

When you start to become aware of unhelpful thinking, you may feel tempted
to attack yourself. “How could I think such stupid thoughts??” Remember,
depression causes you to criticise yourself, and recognising unhelpful thinking
gives you one more way to beat yourself up. Instead, remind yourself that
unhelpful patterns of thinking may have been learned during a difficult
childhood, or may even be the product of depression itself. You are not stupid
for having unhelpful thoughts – they are normal during depression. There is a
blank thought diary form at the back of this guide that you can copy and use
to record your thoughts.

21
 Date Situation Negative thought Emotion
What was going Rate how strongly
through my mind? you feel that
Record thought and try emotion (1-100)
to classify the
distortion

1 Oct Friend cancels lunch She doesn’t like me Sad – 100%

plans (mind-reading) Lonely – 90%
No one likes me Hopeless – 90%
(overgeneralisation)
Everywhere I go I’m
rejected – the world is
a cold place
(catastrophising)

23
 Tip: Sometimes it is difficult to identify automatic thoughts. Here are
some questions you can ask yourself to help you figure out what your
automatic thoughts are:

• What was going through my mind right before I started to feel this
way?
• What does this say about me?
• What does this mean about my life? About my future?
• What I am afraid might happen?
• What is the worst thing that could happen if this is true?
• What does this mean about what the other person thinks or feels
about me?
• What does this mean about other people in general?

Step 2: Learning to challenge these negative thoughts and replace them with
more fair and realistic thoughts:

Challenging negative thinking requires deliberate re-thinking of the situation

that got you upset. You can use a form similar to the one used for Step 1
(have a look at the next page) and you can find a blank version at the back of
this guide.

First, note the date and make a note of the situation.

Next, write down the negative thoughts that seem to be related to how you
feel (you can categorise the type of distortion if you want.).

Then record your emotion/mood and rate its strength.

The next step is the most important: Think about the situation and try to come
up with a different explanation or a different idea about it. Sometimes this is
as simple as reminding yourself you don’t have enough information to know
for certain what is happening! This process is similar to having an argument
with yourself – fight back against your negative thinking by giving yourself a
chance to think fairly and realistically about what has happened. Ask yourself
‘what would my friend say in this situation, if it happened to them?’ Finally,
check your mood after coming up with some different, more rational, ways of
thinking. The table on the next page show’s this process in action (you will
find a blank version at the back of this guide).

24
25
Date Situation Negative thought Emotion Fair and realistic Emotion
What was going through my Rate how strongly hought (1-100)
mind? Record thought and try you feel that W
to classify the distortion emotion (1-100)

1 Oct Friend cancels lunch plans She doesn’t like me (mind-reading) Sad – 100% I don’t know why Sad –
No one likes me Lonely – 90% she cancelled: 40%
(overgeneralisation) Hopeless – 90% maybe something Lonely –
Everywhere I go I’m urgent came up. 20%
rejected – the world is a cold place It’s only lunch. Hopeful –
(catastrophising) Some people do 40%
seem to like me, so I
must be likable.
This lunch doesn’t
mean much about
the world as a
whole.
I’ve been accepted
before.
Here are some questions that might help you come up with more fair and
realistic thoughts:

Testing the reality of negative automatic thoughts

1 What evidence do I have for this thought? Would most people say that it
supports your negative thought? If not, what conclusion could you draw
instead?
2 Is there any alternate way of looking at this?
3 Is there an alternate explanation?
4 What is a less extreme way of looking at this situation? (Negative thinking
tends to be extreme: I’ll always be alone, I’ll never succeed at anything.
Does this situation mean that you will always be alone, or never succeed at
anything?)
5 How would somebody else think about this situation? How would
someone else react? Maybe I need to ask around and find out.
6 What would I tell somebody else if they were worried about this? (We are
often much more realistic about other people than ourselves.)
7 Am I setting myself an unrealistic or unobtainable standard? What would
be more reasonable?
8 Am I forgetting relevant facts?
9 Am I over-focusing on irrelevant facts?
10 Am I thinking in all-or-nothing terms?
11 Am I over-estimating my responsibility in this situation?
12 Am I over-estimating how much control I have in this situation?
13 What if this happens? What would be so bad about that?
14 How will things be in X months/years time?
15 Am I over-estimating how likely this event is?
16 Am I under-estimating how well I can deal with this problem/situation?

Remember:

It is not enough to come up with a rational, fair, and realistic thought just
once. Negative thinking gets repeated over and over – it is a habit that is hard
to break.

More balanced thinking will help you feel better, but it will take practice.
Unlike negative thinking, it is not automatic, at least not at first. It usually
takes practice before getting the hang of more realistic thinking and we can
start seeing a more balanced and realistic picture of ourselves and our
experiences.

26
 Step 3: Preparing for “trigger” situations

There will be some situations in your life that are quite likely to trigger
unhelpful thoughts. If you can be prepared for these it will be easier to deal
with them at the time. Look back over your charts from Step 1 and 2: What are
some of your most common trigger situations? Write them down.

“Trigger situations”:

1..................................................................................................................................

2..................................................................................................................................

3..................................................................................................................................

4..................................................................................................................................

5..................................................................................................................................

Now – go over your fair and realistic thinking for these situations. When you
find yourself in these situations, don’t wait for your automatic thoughts to
kick in. Deliberately start rehearsing your fair and realistic thinking. You will
have to tell yourself how to look at the situation – almost as though you were
giving advice to a friend. If the unhelpful thinking starts – respond! Fight
back! You may feel as though you are having an argument with yourself, but
that is okay – every time you talk back to your unhelpful thinking, it gets
weaker and your fair and realistic thinking gets stronger.

Summary

• Keep a thought diary of your negative thoughts and write down how they
make you feel. Try to recognise what kind of negative thinking you are ex-
periencing, mind reading? Catastrophising?
• Start challenging your negative thinking with more fair and realistic
thoughts.
• Prepare for trigger situations.
• Remember that challenging your negative thinking is not easy at first so it
is important to keep trying to make the negative thinking weaker and the
realistic thinking stronger.

27
Section 4: Problem-solving
When people get depressed, they find it more difficult to solve problems.
Sometimes this means an inability to deal with the problems that started the
depression in the first place, but often it spreads to difficulty dealing with
many of the common problems that occur in daily life.

Why does this happen? There are several reasons:

• Solving problems requires energy – and as depression worsens, energy

levels sink.
• Depression causes problems with concentration, memory, and
decision-making – and these are all valuable skills to have when solving a
problem!
• Everyday problems take a back seat to a bigger problem: The depression.
Often people become very concerned about their mood problem, and put
aside other issues in their lives.
• Loss of confidence. Remember the effects of negative thinking? If you
think you can’t do it, it’s not worth it, it won’t work anyway – it is less
likely that you will feel confident enough to try.

When you consider these factors, it is no great surprise that problems aren’t
getting solved and are piling up. What can be done? A good place to start is
to remind yourself that your problem-solving ability is not as good as it usually
is – so go easy on yourself! This is a normal symptom of depression, and can
get better.

One way to make problem solving more doable is to follow a specific process.
If you’re having difficulty trying to solve problems, try the following steps.

Step 1: Identify problems you are facing

Before you solve a problem, you have to figure out what it is. What are the
problems you are facing at the moment? Make a list. Some of your problems
may be larger then others. Write them all down, even if they seem trivial or
embarrassing. Don’t spend time thinking about them – just list them on the
next page and move on.

Problem list

1..................................................................................................................................

2..................................................................................................................................

3..................................................................................................................................
28
 Step 2: Choose a problem

Chose a problem that you really want to solve, and one that seems
manageable (remember to think SMART from page 15).

....................................................................................................................................

....................................................................................................................................

Step 3: Think about solutions

What are the things that you could do that might help this situation? Write
down as many things as you can think of – don’t worry if they will solve the
problem completely or if the idea seems unlikely to work. Write it down
anyway!

....................................................................................................................................

....................................................................................................................................

Step 4: Choosing a solution

Now think about the advantages and disadvantages to the solutions you have
listed. You can use the chart on the next page to help you choose a solution.

Solution Advantages Disadvantages

29
Now pick the best solution to your problem and write it down.

....................................................................................................................................

....................................................................................................................................

Step 5: Making it happen

The solution may need to be broken down into smaller steps. For example, if
your problem was being out of work, the solution may be “Look for a new
job”. It’s hard to know where to start! Think about all of the steps that will be
needed to carry out this action. Be very specific! SMART thinking applies here
too.

So, if one of the solutions to your current problem is to look for a new job, a
good first step might be “go to the newsagents and buy a newspaper this
afternoon”. A second step might be “tonight, look at the job advertisements
and see what is available”. A third step might be “decide which ones I will
apply for by the end of the week”, and a fourth step might be “ spend one
hour updating my CV on Tuesday”. And so on.

Write down your action plan and most importantly, carry it out!

....................................................................................................................................

....................................................................................................................................

Keep working on your problem in a step-by-step manner. Remind yourself

about any progress you have made and congratulate yourself if you are able
to solve the problem.

Perhaps it is time to tackle a new problem – have a look back at your problem
list. What should you try to work on next? Follow the steps of problem solving
we have worked on, and record your results.

30
 Summary

• Identify problems you are facing and write them down.

• Choose a problem you want to solve from your list, one that you feel is
doable (SMART) and write it down.
• Think about all the possible solutions to the problem and write them
down, no matter how unlikely the solution seems.
• Choose a solution, list the advantages and disadvantages to help you
decide.
• Make it happen – carry out your chosen solution. You may need to break it
down into smaller steps (SMART thinking applies here too). Remember to
congratulate yourself when you solve a problem and once solved, you can
begin working on a new problem.

Tip: Watch out for negative thoughts!

Remember, when you are depressed, you are likely to have negative
thoughts popping into your mind. When you think about solving this
problem, are you having any negative thoughts? If so, write them down.
Then evaluate them – use the skills you worked on in the last section.
How is this thinking holding you back? Try to weigh up the problem and
your ability to solve it in a fair and realistic way!

Section 5: Recognising the positive

One of the very unfair things about depression is that your brain deals with
positive information and negative information very differently. Good things
that happen are very often ignored, and all the focus is placed on the negative
things that happen. If someone says something that you think is critical of you,
you may remember it for days – but if someone says something nice, you may
tell yourself they don’t really mean it. So – what you notice are the negative
things, and what you ignore and forget are the positive things here are some
techniques to try to challenge this unhelpful thinking style.

Step 1: Keeping track of good things that happen

Start keeping track of the good things that happen in your life by writing
them down. This will allow you to develop a more fair, realistic, and positive
view of yourself and your situation. This will be very hard. At first, you may
think that the things you write down are silly or trivial or don’t mean
anything. But it is important to write them down anyway! Over time, you may
begin to realise that there are more positive occasions than you once noticed –
and many that you previously ignored.
31
Some things it would be helpful to record include:

• Times when you manage to get something done.

• Times when something you do goes according to plan.
• Times when something you do goes better than expected.
• Times when you do something that is worthwhile.
• Times when somebody compliments you.

Step 2: Reward yourself

Tackling depression is hard work. You deserve to reward yourself for things
you do manage, or for any positive changes you notice in yourself – like
changes in your thinking, behaviour, or mood. Rewards you can give yourself
may be limited by money and time, but there are some things you can do.
What about letting yourself go for a nice walk when the sun is shining? Or
have a nice bath? Or spend half an hour reading a book? Think about what
you enjoy – then do it!

Sometimes a good reward is allowing yourself half and hour to do something

for yourself, something that you really enjoy. Keep a record of any successes
and positive changes you make (including efforts to change) and the rewards
you give yourself. Watch out for thoughts like “I don’t deserve a reward – this
should be normal behaviour”. Remember, things are more difficult when you
are depressed, and any effort to change your thoughts or behaviour is hard
work.

Step 3: Creating a more positive view of yourself

When people are depressed, it is very unusual for them to be able to name
very many good qualities about themselves. Most people can only come up
with very negative things. In fact, even when not depressed, many of us have
grown up in a culture that frowns on people who “blow their own trumpet”
and encourages people to be modest about their achievements. Because of
this, recognising your positive points can be doubly hard.

Look at the list overleaf and give yourself a rating for each. Zero means you
have none of that quality; one means you have a little, and two means you
have quite a bit.

32
 Kind Clever Honest Unselfish
Efficient Quiet Entertaining Artistic
Assertive Intelligent Responsible Good listener
Considerate Gentle Funny Generous
Flexible Well-read Genuine Imaginative
Determined Forthright Creative Hard-working
Helpful forceful Mechanical Giving Loyal
Compassionate Attractive Thoughtful Good
Not easily put off Sympathetic Conscientious housekeeper
Practical Tidy Loving Good manager
Forgiving Cuddly Warm Punctual
Organised Caring Good cook

Now go through the list, and pick out all the qualities you rated with a 2 or a 1
and write them out below.

....................................................................................................................................

....................................................................................................................................

....................................................................................................................................

....................................................................................................................................

If you think of any other positive personal qualities that aren’t on the list, add
them on and give yourself a rating.

You may have made a number of ratings of 2 and 1, or perhaps only a few. But
even if you only have one or two, then that is a start. These are good qualities
about yourself that you can use to start building up a better, more positive
picture of yourself.

How do your friends and family see you? How would they rate you on that
list? Would they have more positive things to say about you? Sometimes it can
be quite helpful to think about what a good friend would say. If you feel
brave enough, show the list to a friend or family member and ask them to rate
you. Compare that list of ratings to your own.

Now try writing your good qualities out on a card. Look at it as often as you
can. Instead of listening to the voice in your head that says you are useless, a
failure, or whatever insult it prefers, try to think over your positive qualities. If
you can make yourself rehearse your good qualities as often as you rehearse
the bad ones, then you might come to believe there are some positive things
about you.

33
Step 4: Reflection

Try keeping your diary of good or nice things that happen to you and times
where your positive qualities occur in a notebook that is handy to carry
around with you. It is best to write down these times as soon as possible after
they happen so you don’t forget or discount them later. Just one or two
positive recordings a day is a great start. Take some time to reflect upon your
diary weekly to allow positive qualities to sink in and affect how you feel
about yourself.

Summary
•
• Write down good things that happen to you no matter how small or trivial
they seem, remember that you will need to watch out for negative
thoughts during depression.
• Take some time to reward yourself when you have done something
positive.
• Take some time recognise your positive qualities and build upon this,
writing down when you have recognised other qualities and when these
qualities have been demonstrated.
• Take time on a weekly basis to reflect upon your findings, this will help
create a more positive view of yourself and your situation.

This guide was designed to provide information about depression, and to

introduce you to strategies that have been shown to be effective in
tackling depression. These strategies focus mainly on changing the way
you think and the way you act. They are not easy – in fact, it takes a lot
of practise to master the skills discussed in this guide. It is important to
keep practising these strategies in order to make them easier and more
automatic. It is also important to remind yourself of what you have
learned once you are feeling better – because these skills are also
important for preventing depression from recurring.

34
 Section 6: Extra tips and advice
Physical activity
Exercise can reduce symptoms of depression for many people. Sometimes the
improvement in mood happens quickly, and for others it takes a few weeks of
regular exercise (three to four times a week, for about 20 minutes at a time).
Exercise can improve your energy level, improve physical well being, burn off
stress and provide a sense of achievement.

Here are some tips for starting an exercise program:

• Talk to your doctor. Ask about any limitations on your activity.

• Pick activities that you really enjoy. Some people prefer vigorous exercise,
like running or fast walking. Other people enjoy exercises, like weight
training or yoga. It doesn’t matter what you pick – all exercise has been
shown to have a positive effect on mood. Sometimes people are most
successful at sticking with an exercise routine if they pick several activities
and rotate.
• Frequency is more important that duration. Regular short periods of
exercise are better than infrequent or irregular long periods.
• Remember – nothing changes overnight. Use your goal-setting skills when
you are developing an exercise program – start small and build up over
time.

Sleep
Depression can affect your sleep. If you’re having trouble:

• Set a standard bedtime and rising time. Your body operates on a sleep-
wake cycle that works best when it is on a regular schedule. You will find it
easier to fall asleep if you keep regular bed and rising times.
• Don’t go to bed too early. It may seem like a good idea, but if you never
fall asleep until midnight, then don’t go to bed at 11 pm. If you want to
start falling asleep earlier, do it gradually. Start by going to bed about 30
minutes before you usually fall asleep. You can gradually increase then (for
example, 30 minutes a week).
• Save your bedroom for sleep. If you can, avoid associating your bedroom
with activities unrelated to sleep – like arguing, watching TV, doing work,
exercising, talking on the phone and so on. Sex, though, is fine.
• Create a good sleeping environment. Not too hot, not too cold. Nice and
dark. Is noise a problem? Consider earplugs or devices that emit white
noise (e.g., fans).
• Avoid napping during the day. Unless you can keep it to 20 minutes, a nap
may make it harder for you to fall asleep at bedtime.
• Prepare for sleep. Avoid strenuous activity, exercise, heavy meals and
bright lights for at least an hour before going to bed.
35
• Practice deep breathing or other relaxation strategies when attempting to
fall asleep.
• Focusing on your worries or on how much you need to sleep will only keep
you awake! Try to focus on something else, something more pleasant. If
you can’t stop worrying, sometimes getting up and making a list of your
worries can help –remind yourself that you can address the problems on
the list tomorrow.
• Are you a clock checker? It might help to turn your alarm clock around so
that you can’t see the time.
• Remind yourself that everyone has a terrible night’s sleep sometimes –
don’t get too stressed about it. People can very usually operate just fine
the next day, even without a good night’s sleep.
• You probably slept more than you think! Research shows that people –
especially those with difficulty sleeping - tend to underestimate how much
sleep they actually get.

Self-help resources
Mind Over Mood (1995) by Dennis Greenberger & Christine Padesky.
Guildford Press.

Overcoming Depression (2000) by Paul Gilbert. Constable & Robinson Ltd,

London.

Overcoming Low Self-Esteem (1999) by Melanie Fennell.

Constable & Robinson Ltd, London.

www.livinglifetothefull.com
(Dr Chris Williams) - an online life skills course.

36
 34

Activities Monitoring Sheet

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

Evening

Coping with Depression Primary Care Psychological Treatment Service, Cambridge

 35

Activities Record and Goal Sheet

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Morning

Afternoon

Evening

Coping with Depression Primary Care Psychological Treatment Service, Cambridge

 36

DATE SITUATION NEGATIVE THOUGHT EMOTION

What was going through my mind just then? Rate how strongly you feel that
Record thought, and if you like, try to classify the kind of emotion (1-100 scale)
distortion

Coping with Depression Primary Care Psychological Treatment Service, Cambridge

Further help
Psychological Wellbeing Service
If you are registered with a GP in Peterborough, Cambridgeshire, Wansford or
Oundle, you can access the Psychological Wellbeing Service via self-referral or
through your GP. Call 0300 300 0055. Lines are open from 9am to 5pm,
Monday to Friday, excluding Bank Holidays. it offers a range of support to help
you make changes in your life to improve your wellbeing and to help you cope
with stress, anxiety and depression. This includes self-help reading materials,
guided self-help (both over the telephone and face-to-face), one-to-one
therapies.

First Response Service

If you or a loved one is in mental health crisis, you can call our 24-hour First
Response Service on 111 (option 2). This service is for anyone, of any age,
living in Cambridgeshire and Peterborough. Specially-trained mental health
staff will speak to you and discuss with you your mental health care needs

Mind
www.mind.org.uk/Depression

Urgent Care Cambridgeshire

Dial 111

NHS Choices
www.nhs.uk/conditions/depression/Pages/Introduction.aspx

Leaflet updated August 2017

Leaflet review date: August 2018

Patient Advice and Liaison Service (PALS)

If you have any concerns about any of CPFT's services, or would like more information
please contact: Patient Advice and Liaison Service (PALS) on freephone 0800 376 0775
or e-mail [email protected]

Out-of-hours’ service for CPFT service users

Contact Lifeline on 0808 808 2121

7pm-11pm
365 days a year

en Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.

q 01223 219400
c 01480 398501

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