Depression and Low Mood – An NHS self help guide
These are the thoughts of two people who are depressed:
“I feel so alone, I never see my friends now, I guess they have dropped me. They probably don’t like me – who would? There is no point in making any effort. It doesn’t pay off… I just hate myself.”
“I feel like crying all the time, I am so tired and can’t get interested in anything. In fact I don’t even do the things I used to enjoy. I can’t even do basic things that seem so easy to other people…”
You may have had similar thoughts yourself. Depression is a very common problem and many people feel low or down in the dumps at times. This is often due to life stresses such as bereavement, money or housing problems or difficulties in relationships. For some people the problem becomes much worse and gets in the way of normal life.
How can this guide help me?
It may seem that nothing can be done to help you feel better. But there are things that you can do to make a difference. There is also further help you can get if the depression does not seem to be getting any better.
This guide aims to help you cope with depression and begin to get better. The approach is called Cognitive Behaviour Therapy (CBT). CBT uses methods that have been tried and tested and found to be effective. It involves looking at the way you think about things and what you do.
You need a pen and paper as you work your way through the guide to help you begin to understand and begin to deal with depression practically. You should find it helpful to complete these exercises.
What is depression?
Depression is a common mental health problem. At least one in ten people will experience depression at some time. In its mildest form depression does not stop us from leading a normal life, but the most severe depression can be extremely distressing, with thoughts of death and suicide.
These are some of the signs or symptoms that you may experience if you are depressed:
Emotions or feelings – Please write down any that you are experiencing.
- Feeling sad, guilty, upset, numb or despairing
- Losing interest and/or enjoyment in things
- Crying a lot or unable to cry when a truly sad event occurs
- Feeling alone even if you are in company
- Feeling angry and irritable about the slightest thing
Physical or bodily signs
- Lack of energy
- Sleep problems, especially waking early
- Feeling worse at a particular time of day – usually mornings
- Changes in weight, appetite and eating
- Losing confidence in yourself
- Expecting the worst and having negative or gloomy thoughts
- Thinking that everything seems hopeless
- Thinking you hate yourself
- Poor memory or concentration
- Thoughts of suicide
- Not making decisions
- Can’t be bothered to do everyday tasks
- Putting things off
- Not doing things you used to enjoy
- Avoiding seeing people
If you are have many of these symptoms then you may be experiencing depression. Most people feel some of these symptoms from time to time. But if the feelings don’t go away after a few weeks, and are there most days for most of the time, then it may be that you are depressed.
When you’re depressed you may feel hopeless and alone in the world; you may blame yourself for all the faults you think you have and feel pretty worthless. In short, you feel negative about yourself, about the world and about the future. So you tend to lose interest in what’s going on around you, you don’t get any satisfaction out of the things you used to enjoy and you withdraw even further into yourself. Eventually it can become hard to make decisions or to carry out little tasks that you once did no problem at all. People who are depressed often say they don’t recognise themselves they feel so different. The good news is that there are many things that can help, and people do recover from depression.
What causes depression?
No single cause for depression has been found. Usually there is more than one reason and this differs from person to person. Life is sometimes difficult and we know that things such as low income, bereavement, loneliness, relationship problems and loss of work can make people more likely to become depressed, although this is not always the case. Some people may be more vulnerable to depression, due to a family history of depression, early experiences, personality factors or body chemistry. Sometimes there is no obvious reason at all.
Whatever the cause of a person’s depression, there is something that can help. But just as the causes can vary from person to person, so can the treatment. Some people may need medication, others may need to make some changes in their life. For others becoming more active may be the key, whereas others may really benefit from changing their thoughts. Sometimes it might be all of these. As you can see depression can be complex!
What does research tell us about depression?
Research has helped us to understand depression much better. Both in terms of what leads people to become depressed, and what keeps it going. We now realise that our body, thoughts and behaviours play an important role in depression. The way a person is physically and emotionally, and how they think and act when they are depressed can be very different to how they usually are.
Here are a few examples:
- The successful business person who thinks they are useless, stops enjoying work and withdraws from friends and colleagues.
- The caring father who thinks he is a rubbish dad so stops doing things with his children because of lack of confidence.
- The clever student who thinks they are stupid, tries to study harder, can’t sleep and has no energy.
- The hard working woman who thinks that she has let everyone down because she has lost her job, then cuts herself off from friends and family and starts drinking as a way of coping.
Most people have low mood at times. It would be unusual if we never felt a bit low and unmotivated to face the day. However, when depression develops, this becomes more severe. There may be changes in body chemistry and energy levels, leading to lack of interest and enjoyment, which in turn leads to withdrawing from activities mentally and physically. Once someone isn’t doing the things they enjoy and value, their mood drops even more. And guess what? Yes, there is much more space in the mind for more and more gloomy thoughts to flood in!
No one cause for depression has been found, but it is likely that early experiences, difficult circumstances, individual differences, body chemistry, reduced activity and gloomy thoughts can all play an important role in depression. When someone is depressed there are usually changes in the way they feel, their body chemistry, what they think and how they behave.
What treatment is available for depression?
Most people are treated for depression by their family doctor. The doctor may suggest self help (like this), a talking therapy, antidepressant tablets or a mixture of all three. You may just see the doctor, or be referred to a specialist. This could be a psychological therapist, counsellor, psychiatrist or other mental health worker.
The talking therapies are usually Counselling or Cognitive Behaviour Therapy(CBT), although sometimes other therapies are offered. Therapy will help you understand your own difficulties and begin to work out ways of overcoming depression. This can usually be offered by phone or face to face. Quite often your therapist may suggest using a guide like this, but they can offer extra help and support if you have struggled to use it on your own.
Whatever type of therapy is used, it will usually take a little time before you begin to feel the benefits, but treatment of this kind has helped many people and can be very effective, so don’t give up too soon.
Antidepressants are sometimes prescribed by your family doctor or psychiatrist. They have been shown to be helpful for many people suffering from depression. Antidepressants work on the chemicals in the brain to make you feel less depressed. They are not addictive and once you begin to feel better, usually after quite a few months, you can plan, with your doctor, to stop taking them. This should not cause you any difficulty and your doctor will gradually adjust and reduce the dose.
When you begin a course of antidepressants it is important to remember that they do not work immediately. It will take 2-4 weeks before they take effect and you need to keep taking them regularly to feel the benefit. They can have some side effects at first but these are usually quite mild and will generally wear off as treatment continues. Your doctor or pharmacist will advise you about this. Although people often start to feel better within 2-4 weeks of taking antidepressants, it is important to keep taking them for as long as your doctor advises. This helps stop the depression coming back. If you are taking antidepressants it is important to consult your doctor before taking any other tablets, drugs or alcohol.
How can I help myself?
As mentioned, the way you think about things affects the way you feel, which affects the way you behave, and so it goes round and round. It is difficult to change the way you feel directly. Just telling yourself to cheer up and feel better doesn’t usually work! But you can change the things you do and the way you think, which will then in turn change the way you feel. This can be with or without the help of medication, depending on what your GP and you both feel is best.
Increasing helpful activity
First of all in this section we will look at some practical steps to help to overcome depressive feelings through increasing activity. Research evidence tells us that increased activity is very helpful in overcoming depression. In fact studies have shown that exercise is as effective as anti-depressants in some cases. Not only that, but withdrawing from the things and people we care about makes our mood much worse. Don’t expect to enjoy things as you used to straight away. This will come later, and gradually. Just do your best to do what you can.
It really helps even if you feel your depression relates to difficult life events.
- List things to do
- Mix with people
- Join in activities
- Take exercise
- Do things you enjoy and value
Making a daily plan
When people are depressed they often don’t feel like doing anything, find it hard to decide what to do each day and can end up doing very little. Hours can pass just staring into space, or having gloomy thoughts.
Begin to tackle this by making a list of things you might usually want to or need to do, even if you don’t want to do them right now. Then plan out an action list, start off with the easiest task at first and don’t aim too high. Try and have a mixture of activities, including some chores and some things you would usually enjoy. Work through your action list and tick off what you’ve done. At the end of each day you’ll be able to look back and see what you’ve achieved. Physical exercise and activity can really help to lift your mood. Try and build a little in each day. Classes are sometimes available to increase physical activity for people with low mood.
Your GP may be able to refer you to these, or to other activities that may help your mood. Mixing with friends, family, pets; anyone you feel close to, can also help. In particular try to plan simple things you value, such as walking in the countryside, being creative, listening to music.
List some exercise or activities that you could do. This can be as simple as a brisk walk; or doing a crossword with a member of your family
Use your list to complete an action plan for each day of the week.
Achievements, pleasure and gratitude diary
When people are depressed they often forget what they’ve achieved and what they enjoy. Most people have more things going for them than they are usually aware of. On your daily action plan write down all events of the day, put a P next to those which have given you pleasure and an A next to those activities where you felt you achieved something and did well. You can even rate this from 1 to 10 so you can see which things please you most and can notice any changes with time. Try not to be too modest; people who are depressed tend not to take credit for their achievements. Don’t dismiss what you achieve by comparing with what you were able to do when you were not depressed. Think only of your progress. Small steps are all steps in the right direction. Try and build some pleasant events into your day and treat yourself. Each evening, spend a few minutes writing down two or three things you are grateful for from the day. Some people find it helpful to have a nice notebook especially for this. This is called a gratitude diary and studies have shown improvements in mood from this simple act.
Reducing unhelpful activity
Sometimes when people are depressed they start doing things to try and feel better that are really quite unhelpful. For example: drinking alcohol, staying in bed, binge eating, zoning out in front of the TV. By noting everything you do in your daily plan, you can start to see patterns of what helps and what guide makes you feel worse. So it might be a case of increasing some behaviours and reducing others.
It is important to get a good night’s sleep. A further guide in this series describes how to go about this. If you think you may have sleep apnoea, a condition where your breathing is affected while you sleep, please consult with your GP. This is known to prevent improvement from depression.
Solving difficult problems
Sometimes we feel overwhelmed by the very complicated and difficult things we have to do. One thing which helps with this sort of problem is to write down each of the steps which you have to take in order to complete the job – then tackle one step at a time.
Problem solving can seem more difficult when you feel depressed. If you have a particularly difficult problem, try and look back to times when you may have successfully solved similar problems and use the same approach. Or ask a friend what they would do in a similar situation. Be clear. Write down all your possible options – even what you think are silly solutions can be written down and considered. Choose the best approach.
Try this way of problem-solving yourself. What is the problem? It may help to write this down.
Then try the following:
List all sorts of solutions. Remember how you may have solved similar problems in the past. What would your friends advise? Or how would you advise a friend with a similar problem.
Choose the best of these solutions and then think of the steps you need to take to tackle the problem.
Depression can be a signal that something is wrong in your life. If you feel that your relationship is part of the problem then talk to your partner or consider couples therapy. Couples therapy is often available through local mental health services.
Understanding depressive thinking
As we have said depression not only affects our behaviour but also our thoughts. Sometimes negative thoughts can stop you from doing the things that you would normally do. You might say to yourself ‘what’s the point’ ‘I can’t face it’ and this will have a real effect on your activity levels. As a result, you may then get self-critical thoughts about being lazy, or irresponsible, which make you feel even worse, and so able to do less and less. In other words, you get caught up in a vicious cycle which can be something like this:
You feel low in mood which leads to gloomy thoughts such as “I’m no good” There’s no point” “I’m lazy”, so you do less which can make you feel physically unwell, cause low mood and then the cycle begins again.
Has a similar cycle happened to you? Try and draw it out
What do gloomy, depressive thoughts look like?
Suppose you are walking down the street and you see a friend who appears to ignore you completely. Normally this wouldn’t bother you too much. You might wonder why your friend didn’t speak and feel a little disappointed maybe. Next time you see them you might mention the incident to your friend, and they might tell you that they were preoccupied at the time and didn’t even see you. If you’re depressed, you probably believe your friend has rejected you. ”They don’t like me. What have I done to upset them?” may pass through your mind. You may not even ask about the incident, and then the mistake goes uncorrected. The next time you spot your friend, perhaps you ignore them and walk straight by. If you’re feeling depressed you’re more likely to make mistakes like this over and over again.
When you are feeling low the gloomy thoughts may be so familiar and happen so often to you that you just accept them as fact.
Gloomy thoughts are often about yourself, and are usually self-critical; for example:
“I’m no good”
“People don’t like me”
“I’m a bad mixer”
“I look ugly”
Do you have any gloomy thoughts about yourself? – jot them down.
These thoughts are sometimes about other things such as the world around you or the future.
“All people are unkind”
“The world is a horrible place”
“Nothing will work out well”
Do you have any gloomy thoughts about other things? – jot them down:
What more should I know about these gloomy negative thoughts?
We have given some examples of the negative thoughts people have when they are depressed. It is important to remember that most people have some of these sorts of thoughts even when not depressed. This is normal. The difference is that we would generally dismiss them from our mind. When you are depressed, however, these thoughts are around all the time and are hard to dismiss. Let’s look at negative thoughts in more detail so you might begin to recognise them. You may notice some of the following unhelpful thinking styles if you are feeling depressed:
This means we think things are much worse than they really are by jumping to the worst conclusion. For example you make a small mistake at work and fear that you may be dismissed because of it, or you may spend a long time worrying that you have upset and lost a friend by something you have said only to find later they didn’t even remember the comment.
Do you ever castastrophise?Think back over the last two weeks and make a list:
This is when we generalise from one small thing. For example, if someone isn’t friendly to you, you may think “No one likes me, I’m a waste of space” or if one of your daily tasks hasn’t been finished you may think “I’ve achieved nothing, today has been pointless”.
In other words from one thing that has happened to you, you draw a negative conclusion which is much bigger and covers all sorts of things.
Do you ever over-generalise? Think back over the last two weeks and list some examples:
Ignoring the positive
People who are depressed tend to focus their thinking on negative or bad events and ignore positive or good events. For example, you might have had a game of pool and missed the shot once, but played well in general. After the game you just think about that one missed shot and not the rest of the game played well. Or you may have many good friends who you have known for years but you concentrate and worry about one that has fallen out with you rather than remembering all the other good friendships.
Do you sometimes ignore the positive? Jot down some examples from the last two weeks:
Taking things personally and being self-critical
Often if our mood is low we blame ourselves for anything that goes wrong, even if things have nothing to do with us in reality. For example, you go into a local shop and the assistant who knows you is ‘off-hand’, your automatic thought is “she doesn’t like me… have I done something wrong?”, but the most likely reason is that she’s tired or upset or has had a ‘bad day’. In this example you have taken the blame personally. You may also be self-critical and put yourself down with thoughts such as “I am an idiot” “I never get things right”.
“Are you sometimes self critical?” jot down some examples from the last two weeks.
Mind reading or fortune telling
We sometimes believe we know what others are thinking and if our mood is low we may expect that they are thinking badly of us. For example if a friend is quiet you may think “that is because she thinks I am boring”. Or we may predict the future by imagining a negative outcome before it even happens. So you may think “I know it’s not going to be good enough so I’m not going to even bother trying.”
Do you find that you ‘mind read’ or ‘fortune tell’? Jot down some examples from the last two weeks.
Did any of these look familiar? If so, don’t worry. Once you have begun to recognise them in yourself, there is plenty you can do to stop depressed thoughts affecting your mood. The following simple techniques might help:
The ABC of changing thoughts and feelings
Most people who are depressed think their lives are so awful that of course they feel sad. In fact our feelings come from what we think about rather than just facts.
Try to think about a recent event which had upset and depressed you. You should be able to sort out three parts of it:
A. The event.
B. Your thoughts about it.
C. Your feelings about it.
Most people are normally only aware of A and C. Let’s look at an example:
Suppose someone at work criticises you for a piece of work you have done.
A. The event – criticism of your work.
B. Your thoughts – what might you be thinking? You may need to concentrate to discover this. “He thinks I’m no good and he’s right, I’m hopeless”
C. Your feelings – hurt, embarrassed.
How depressing! No wonder you feel bad! The important point about trying to become aware of these three stages A, B and C is that you can change what you think about an event and therefore you can change how you feel about it.
A useful technique to try is called balancing. When you have a negative, critical thought, balance it out by making a more accurate and positive statement to yourself. For example:
The thought: “I’m no good at my job”, could be balanced with: “my boss said how much he appreciated the piece of work I did yesterday”.
Try and balance the negative thought with a positive thought
The double column technique
Another thing you could do is to write down your negative automatic thoughts in one column, and a more balanced positive thought in another. For example:
- Negative automatic thought: John hasn’t called, he doesn’t like me
- Balancing thought: He is very busy and thinks I am doing better than I was last week, so he doesn’t need to worry about me.
It may be helpful to keep a diary of events, feelings and thoughts. Use the approaches described to gain more balanced thoughts and look out for unhelpful thinking styles. Use the following headings Event, Feeling or emotion, Thoughts in your mind, Other more balanced thoughts.
- Event – a neighbour ignored me
- Feeling or emotion – low and depressed
- Thoughts in your mind– she doesn’t like me, no one does
- Other more balanced thoughts – she’s probably got something on her mind. I am jumping to a conclusion that she doesn’t like me.
Try and remember details
Research tells us that people who are depressed don’t remember details of events but tend to think in general statements, such as “I’ve never been any good at anything”. Try and train yourself to remember specific details so that good times and experiences are easy to recall. A daily diary can help you to do this. Make lists of actual achievements and good aspects of yourself such as “I’m always on time”, “I helped my friend on Tuesday” or “My partner complimented me on my work last week”. Listing past achievements and pleasurable activities in detail can also be helpful, as can the gratitude diary described earlier.
Challenge long term beliefs
Sometimes people have long held views about themselves that are very self-critical. For example, “I’m not a very clever person” or “I’m not a very lovable person”. These beliefs are often a product of our past experience and may hold no truth in present reality. Try to challenge this self-criticism, stop knocking yourself down and look for evidence that disproves the beliefs. What would you say to a good friend if they held that belief about themselves? Again writing things down can be really helpful. Improving your self-esteem is very important to recovering from depression.
Dealing with rumination
When people are depressed they may ruminate. That means they go over an upsetting thought again and again without finding a solution. This can become an unhelpful habit. One way of dealing with this is to try and notice what’s going on when this sort of thinking starts, and try to do something different. So for example, if the rumination is bad when sitting watching TV, then try to do something else, such as: getting active, practicing relaxation, reading or doing a puzzle. If you can interrupt the habit, then you may be able to reduce the time given to these unhelpful ruminations.
Mindfulness and acceptance
Sometimes no matter how hard we try, our thoughts will not be changed. If you find yourself getting in to endless arguments with your thoughts, this can then become part of the problem. You may start to feel useless for not being able to challenge your thoughts well enough and before you know it there are a whole host of more negative, self-critical thoughts in your mind. This can be the case particularly if you have had a few bouts of depression.
Research has shown that a form of meditation called mindfulness can be really helpful. Mindfulness is about paying attention to the present moment, in a non- judging way. Because depressed thinking is almost always about the past or the future, focusing on what is happening in the here and now is incredibly helpful.
A good place to start is with some mindful breathing.
The goal of mindful breathing is calm, non-judging awareness, allowing thoughts and feelings to come and go without getting caught up in them. Follow these instructions:
- Sit comfortably, with your eyes closed or lowered and your back straight.
- Bring your attention to your breathing. Don’t try and change it. Just notice what it feels like.
- Notice where you feel the breath. In your nose and your throat and your chest. Notice your chest and stomach rising with the in-breath, and falling with the out-breath. Just as though you were observing a wave, coming in and going out.
- Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. Just notice those thoughts, then bring your attention back to your breathing.
- You may notice sounds, physical feelings, and emotions, but again, just bring your attention back to your breathing.
- Don’t follow your thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. Just accept them. It’s okay for the thoughts to be there. They are just thoughts. You can notice them, and let them drift on by; bring your attention back to your breathing.
- Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note this without judgement, and then gently bring your attention back to your breathing. Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. The more you can practice this exercise the more it will help you not to get caught up in your negative thoughts.
There are many books and websites about mindfulness for depression, some of which are listed in the written version of this guide.
We hope you will use the exercises suggested in this guide. They should help you to begin to overcome your depression and get back in control of your thoughts, your depression and your life.
If you feel that you are making little progress then as mentioned other help may be available to aid you in overcoming your problem, and your family doctor is usually the best person to talk to.
If you feel so depressed that thoughts of harming yourself or taking your own life have been in your mind then visit your doctor as soon as possible and talk about how you are feeling.
A list of useful contacts, books and references are available in the written version of this guide.
Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists. This guide has been developed from an earlier manual by Sheila Sharkey and Kevin Gibson.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.