DAVID VEALE, FRCPsych, MD, BSc, MPhil, Dip CACP is a consultant

psychiatrist in Cognitive Behavior Therapy at the South London and

Maudsley NHS Foundation Trust and the Priory Hospital, North London.
He is an Honorary Senior Lecturer at the Institute of Psychiatry, King’s
College London. He is an accredited cognitive behavior therapist and
President of the British Association of Behavioural and Cognitive
Psychotherapies 2006–8. He has about 50 publications to his name,
accessible through his website www.veale.co.uk. He has been helping
people with depression and anxiety disorders for more than 15 years.
ROB WILLSON, BSc, MSc, Dip SBHS is a cognitive behavior therapist in
private practice. He also works as a tutor at Goldsmiths College, University
of London. He holds an honours degree in Psychology, an MSc in Rational
Emotive Behaviour Therapy, and a Postgraduate Diploma in Social and
Behavioural Health Studies. He has been involved in treating people with
depression and anxiety for the past 12 years.
David Veale and Rob Willson are authors of Overcoming Obsessive
Compulsive Disorder, also published by Robinson.
 Other titles in the Overcoming series:
3-part self-help courses
Overcoming Anxiety Self-Help Course
Overcoming Bulimia Nervosa and Binge-Eating Self-Help Course
Overcoming Low Self-Esteem Self-Help Course
Overcoming Panic and Agoraphobia Self-Help Course
Overcoming Social Anxiety and Shyness Self-Help Course
Single-volume books
Overcoming Anger and Irritability
Overcoming Anorexia Nervosa
Overcoming Anxiety
Bulimia Nervosa and Binge-Eating
Overcoming Childhood Trauma
Overcoming Chronic Fatigue
Overcoming Chronic Pain
Overcoming Compulsive Gambling
Overcoming Depression
Overcoming Insomnia and Sleep Problems
Overcoming Low Self-Esteem
Overcoming Mood Swings
Overcoming Obsessive Compulsive Disorder
Overcoming Panic
Overcoming Paranoid and Suspicious Thoughts
Overcoming Problem Drinking
Overcoming Relationship Problems
Overcoming Sexual Problems
Overcoming Social Anxiety and Shyness
Overcoming Traumatic Stress
Overcoming Weight Problems
Overcoming Your Child’s Fears and Worries
Overcoming Your Smoking Habit
 Copyright
Published by Robinson
ISBN: 978-1-47213-770-8
Copyright © 2007 David Veale and Rob Willson
The moral right of the author has been asserted.
‘Your Fitness Personality Profile’ (p.147) and ‘Fitness Personality Profile’
(p.148) copyright © 2005, James Gavin PhD and taken from Lifestyle
Fitness Coaching, Human Kinetics Europe Ltd, 2005.
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of the publisher. The publisher is not responsible
for websites (or their content) that are not owned by the publisher.
The publisher is not responsible for websites (or their content) that are not
owned by the publisher.
Robinson
Little, Brown Book Group
Carmelite House
50 Victoria Embankment
London EC4Y 0DZ
www.littlebrown.co.uk
www.hachette.co.uk
Contents
About the Author
Other titles in the Overcoming series:
Copyright
Note for practitioners
Foreword by Professor Paul Gilbert
1 What is Depression?
Are you depressed?
The effects of depression
Common emotions in depression
Types of depression
Types of anxiety problems
How common is depression?

2 What Causes Depression?

What makes a person vulnerable to depression?
What can trigger depression?
Understanding the psychological causes of depression
Identifying your triggers and vulnerability

3 A Psychological Understanding of Depression

Thinking styles
Putting aside ‘internal’ causes of depression
When your solutions are the problem
Avoid avoidance, escape from escaping

4 Effective Treatments for Depression

Recommended treatments for mild depression
Recommended treatments for moderate to severe depression
Treatments not recommended for depression

5 How to Start Helping Yourself

 Rating the severity of your depression
Defining your problem
Assessing the effect of thoughts and actions

6 Thinking About Thinking

Watching your thoughts pass by
Attention, attention
Rumination, self-attacking thoughts and worry

7 Activating Yourself
Understand your values
What are you avoiding?
Planning your activities and setting goals
The golden rules of behavioral activation
Monitoring and reviewing your activity schedule

8 Overcoming Obstacles to Activating Yourself

Identifying your traps

9 Understanding Self-harm and Suicide

Deliberate self-harm
Suicidal thoughts
What to do if you are feeling suicidal

10 Problem-solving
Define your problem
Brainstorm solutions
Evaluate your solutions
Try out a solution and review it

11 Being Physically Active

The importance of activity
Matching activities to your personality
How to keep yourself motivated

12 Getting a Good Night’s Sleep

 Sleeping problems
When sleep solutions are the problem
How to get a good night’s sleep
Medication for sleeping problems

13 Your Diet and Your Mood

The effect of a poor diet on your mood
Food Diary
Eating healthily
EPA

14 Sex and Drugs and Rock ’n’ Roll

Sex
Alcohol
Coffee and caffeine-containing drinks
Tobacco
Illegal substances
Stopping drink or drugs
Compulsive shopping
Gambling

15 A Herbal Treatment for Depression: St John’s Wort

Effectiveness of St John’s Wort
What dose should I take?
What side-effects can occur?
What if I am taking other medication?

16 A Guide to Medication for Depression

Can I combine medication with a psychological treatment?
SSRIs
What side-effects occur with SSRIs?
Other types of medication and physical treatments
Stopping taking antidepressant medication

Appendix 1 Am I Overweight?
Appendix 2 Resources
Appendix 3 Finding Professional Help
Appendix 4 Further Reading
Appendix 5 Blank Charts and Forms
Note for practitioners
If you are using this book with your client you should be aware that it is
based on Behavioral Activation (BA) which is part of the family of
Behavioral and Cognitive Psychotherapies and derived from the treatment
manual, Depression in Context: Strategies for Guided Action by Martell et
al (2001) (see Appendix 4.) There are differences between the standard
activity scheduling of cognitive behavior therapy (CBT) and that of BA.
BA is rooted in a contextual functional analysis of activities that are being
avoided, or that have the function of avoidance (e.g. ruminating). This
information then guides the choices in the activity scheduling. The aim is to
help people develop a pattern of approach behaviors rather than avoidance.
We have added elements of Acceptance and Commitment Therapy (ACT)
by also encouraging activities that are in keeping with one’s valued
directions in life. The distinctive feature of BA, ACT and newer approaches
in CBT is the process of thinking (e.g. rumination, worry, self-attacking)
rather than trying to change the content of a person’s thoughts. Thought
records and identifying schemas and assumptions are therefore not used
unless, for example, it is to identify and determine the helpfulness of one’s
assumptions about ruminating or self-attacking. This book can be used in
guided self-help for stepped care for mild to moderate depression, which in
the future we hope to evaluate.
David Veale and Rob Willson
Foreword
Depression is a very common problem in the world today – and the number
of reported cases is rising. It is estimated that 1 in 4 women and 1 in 7 men
will have an episode of depression at some point in their lives, with many
episodes beginning in early childhood and adolescence. Research has
shown that in some communities, particularly the impoverished, depression
can be even more widespread.
One of the difficulties with understanding depression is that it can vary
depending upon the individual. Some people experience high levels of
anxiety and a sense of dread; others experience elevated anger, frustration
and irritability. Some eat more while others eat less. Most people suffering
from depression have difficulty sleeping, but again, this can vary
enormously from case to case. Despite these variations there are
commonalities. For many, depression is seen as a state of exhaustion – you
can feel physically, mentally and socially exhausted. This exhaustion can
drain away positive feelings and interest in others and your environment.
The combination of feelings of dread and fatigue, plus a negative outlook
can make you want to hide away.
Over the centuries there have been many treatments for depression. More
recent treatments include medications and specific psychological
interventions. It is well known that depressed people’s negative thinking
and predictions about others and their environment make them more likely
to give up and thus spiral downwards into depression. Research was
conducted to explore whether helping people directly to change their
thinking, behavior and level of activities could be helpful. The answer was
it definitely could. For instance, regular exercise can really help to combat
depression. By gradually increasing your level of activity, focusing on small
but important steps, you can start to reduce the effects of depression.
David Veale and Rob Willson have written Manage Your Mood to share
with you some of the ways you can understand your thinking style and
reorganize your daily routines and activities to help overcome your
depression. By doing this you can start to take control of your life rather
than battling on as before, simply keeping going, or just putting on a brave
face.
Many of the ideas outlined in Manage Your Mood are derived from what
are called behavioral approaches to problems. This works on the basic idea
that in order for us to learn new tasks or overcome difficulties and anxieties
skilful action is required, for example, if we are anxious about learning to
drive, the best way to develop our skill and confidence is to get in a car and
practise with an instructor. Think of how many difficulties you have
overcome in life by actually going out and tackling your problem – even
when anxious!
When it comes to depression, skilful action means:
1. Recognizing what was happening in your life that triggered
depression. Sometimes it can be a life event such as the break-up of
a relationship, or a combination of difficulties that just seemed to
happen simultaneously. Some degree of depression may be a natural
way we deal with things when we feel over loaded.
2. Noting the way a life event elicited certain, understandable but
unhelpful, coping efforts and behaviors in you as you tried to adapt
to the context and stressor. This will show you how depression is
now piloting your life.
3. Recognizing how those behaviors (called ‘secondary problems’
such as avoidance and rumination) can themselves become sources
of depression. For example, when feeling low you might start to
avoid activities or people. Think back to the driving example. This
does not mean that simply increasing activities is always the
answer; much depends on how helpful you find the activities.
In Manage Your Mood, David Veale and Rob Willson outline which
behaviors can make your depression unintentionally worse and what actions
can be used to help. For example, hiding in bed and ruminating – while
sometimes an understandable reaction – can allow the depression to deepen
and ‘settle in’, making you feel much worse. In contrast, encouraging
yourself to get up and do one or two things during the day can help a little
and boost your confidence.
This book also contains strategies to help you develop plans to take on
your depression, while factoring in the fatigue inherent in depression.
Above all, David Veale and Rob Willson provide invaluable advice on how
to be kind to yourself in order to get better. Manage Your Mood is not
intended as an instant ‘cure’ for depression but instead provides a wealth of
strategies for working with depression to overcome it and achieve your life
goals. Written by two authors with many years of clinical experience and
research, Manage Your Mood is necessary reading for anyone struggling to
cope with depression.
 Professor Paul Gilbert,
Professor of Clinical Psychology at the University of Derby and Head of
Specialty, Adult Mental Health for the Derbyshire Mental Health Trust
1 What is Depression?
Depression is a distressing and painful emotional problem. If you have
depression you may be sad and tearful, lacking in energy, feeling guilty, and
not able to experience pleasure or emotion in the way you normally would.
You may be worrying excessively and feel anxious. This chapter describes
what depression is, and introduces some of the terms and ideas used
throughout this book. We explain how depression differs from other
disorders and from ‘normal’ ups and downs in mood. (Skip to Chapters 2
and 3 if you want to understand the causes of depression.)
CASE STUDY: Tim
Tim’s mother died just under a year ago, and he was recently made
redundant, following a company reorganization. He now suffers from
depression and has been signed off work by his family doctor. He feels very
low and pessimistic about the future much of the time. Tim typically feels at
his worst first thing in the morning, when he wakes up around 5am. He
usually goes to bed at around 11.30pm, having had three or four glasses of
wine to help him sleep. However, he often finds that his sleep is fitful. Even
though he wakes up early, Tim usually stays in bed thinking about his
problems and about why he can’t pull himself together until midday, when
he gets up to watch daytime television. Sometimes he spends some time on
his computer playing games or surfing the Internet. Although his appetite is
much smaller than normal, to break his boredom he goes to his local shop
once a day and stocks up on sweets and snacks. He washes these down with
several cups of tea or coffee throughout the day. Tim’s friends phone him
from time to time in the evenings, but he usually avoids their calls.
Throughout the day he has thoughts like ‘I’m a failure’ and is constantly
critical of himself. He broods on what he would have been doing at the
office. When he thinks about seeing his friends or going out to do things he
would usually enjoy he thinks ‘I don’t enjoy doing anything anyway, so
what’s the point’, and has no enthusiasm for seeing people or developing
any relationship. In fact, Tim feels so ashamed of his current state that he
prefers to keep himself hidden from his friends, unless he has a ‘good day’ –
which is rare –and then he makes a huge effort to seem like his usual self.
However, he finds this very tiring, and his friends then assume that he is
fine and that he’s simply not interested in seeing them any more. The longer
he is off work, the harder it is to get back into the employment market. He
finds it painful to think about his mother’s death and tries to avoid seeing
his father, who finds his son’s behavior odd.
CASE STUDY: Emma
Emma and her husband had been dating for about seven years before they
got married. She soon got pregnant, and changed her role from running her
own business, over which she had full control, to being a mother. She
started to feel isolated and no longer in control. Her relationship with her
husband started to deteriorate and they don’t communicate well. Emma
feels down and tired all the time. She lacks motivation and sleeps for about
12 hours a day, including a nap every afternoon. Her appetite is low and
she has lost about 14 pounds in weight. She is very critical of her
appearance and ability to function. She ruminates on her past and wishes
she had never met her husband and that she could turn back five years in
time. Emma views the future as bleak and has had suicidal ideas. She feels
irritable and tearful, hurt and angry and thinks a lot about the past. She
avoids a wide range of social and public situations, including going to the
gym, which she used to enjoy. Emma’s parents now come to the house every
day to look after her young son. She has shut down and lives each day as it
comes. She cannot enjoy her normal pleasures and her sleep is disturbed.
She drinks ten or more cups of coffee a day. Emma believes that if she were
given a gun or some barbiturates she could easily kill herself, but does not
have the courage to act and wants to stay alive for her son. Her parents
understand their daughter’s difficulty but are getting more annoyed with her
as they feel she could do more to take more responsibility for her life.
CASE STUDY: Jan
Jan is a 50-year-old married woman who lives with her husband. Her main
problem is a conflict she had with her daughter-in-law, which has led to the
loss of any relationship with her son and grandchildren. It was a silly
argument about childcare in which she was a bit critical of her daughter-in-
law. However, she feels she cannot apologize or try to resolve the
breakdown in their communication. She feels down and tired. Her
concentration is impaired. She has difficulty in getting to sleep and wakes
several times at night. Her appetite is poor. Sometimes she is more irritable
than usual and gets headaches easily. She feels tense and constantly
worries.
When Jan thinks about her son and grandchildren, she tries to think of
‘happy’ thoughts related to them. She tries to avoid thinking of the loss in
the relationship with her son and ruminates endlessly on trying to
understand why her son doesn’t sort things out. She tries to give reasons for
this (for example, he has a weak personality). Jan avoids having photos of
her son around the house as it makes her tearful. She blames herself for
being a failure and thinks ‘If only I hadn’t said anything.’ She throws
herself into housework and keeps herself busy so she does not have time to
think about her relationship with her son. The family tries to avoid
discussing the loss and sadness. Jan worries about what others might say if
they found out, or how she may never see her son and grandchildren again,
or the effect of her worrying on her health, or how she cannot solve the
problem with her daughter-in-law. She avoids conflict with everyone and
has learnt to be a peacemaker but cannot make it up with her daughter-in-
law. Everyone thinks she is coping but inside she is experiencing a lot of
pain.
Throughout this book we’ll be referring back to Tim, Emma and Jan to help
illustrate the process of regaining direction in your life, and improving your
mood using the research-proven techniques outlined in this book.
Are you depressed?
Everybody feels down from time to time, but the feeling usually passes
fairly quickly and doesn’t interfere too much with the way we live our lives.
When most people say ‘I’m depressed’ they mean that they are feeling low
or sad, or perhaps stressed, which are normal facets of human experience.
However, when health professionals talk of depression, they are using the
term in a different way. They are referring to a condition which is
qualitatively different from the normal ups and downs of everyday life. This
is the type of depression we will be discussing: it is more painful than a
normal low, lasts longer and interferes with life in all sorts of ways.
However, there is probably a link between normal sadness and depression,
with no clear dividing lines.
Checklist of symptoms
So how do you know if you are experiencing depression or are just going
through a period of feeling low? Depression can only be diagnosed by a
health professional, but to meet the criteria for a diagnosis you will have
been feeling persistently down or lost your ability to enjoy your normal
pleasures or interests for at least two weeks. In addition, you will probably
have at least two to four of the symptoms listed on page 4 persistently. Tick
off how many of these symptoms of depression you’ve experienced in the
past week. If you are diagnosed as having depression, when you set out to
overcome it, return to the checklist to help monitor how your symptoms are
progressing.
Significant weight loss
A decrease or increase in appetite
Difficulty sleeping, or sleeping excessively
Feelings of agitation or irritability
Tiredness or loss of energy
Ideas of worthlessness, or excessive or inappropriate guilt
Reduced ability to concentrate or pay attention
Reduced self-esteem and self-confidence
A bleak and pessimistic view of the future
Suicidal thoughts or attempts
The symptoms should be enough to distress you or handicap your life. The
lowered mood should vary little from day to day, and not usually change
according to your circumstances. However, it’s not unusual for people who
have depression to find that their mood is worse in the morning. There is a
lot of variation between one individual with depression and another,
especially among adolescents. In some cases, anxiety and agitation may be
more prominent than the depression, or masked by features such as
irritability, excessive use of alcohol, or a preoccupation with your health.
Severity of depression
Depression is often classified according to whether it is mild, moderate or
severe, depending on the degree of distress and handicap it is causing you.
So a health professional who assesses you will want to know whether the
way you feel affects your ability to work or study, or your enjoyment of
your social life and relationships, and even whether it is sufficiently
distressing to make you want to end your life. You can monitor the impact
of depression and anxiety on the quality of your life by completing the scale
in Chapter 5. If you do this before and after what you are doing to improve
your mood, you will see what effect those strategies have had.
 You will be diagnosed as having mild depression if you have at least two
of the symptoms in the list above and you can generally cope with your
everyday activities. Moderate depression is defined as having three (or
more often four) of the symptoms in the list and social, work or domestic
responsibilities as being a real struggle. Severe depression is characterized
by at least four other symptoms from the list. In this case, you are very
unlikely to be able to carry on with your normal activities or
responsibilities, except to a very limited extent. To be clear, though, even
mild depression is a very distressing experience to the person concerned.
About 50 per cent of the depression and anxiety in the community is mild.
The recommended treatment for mild depression is different from the
treatment for moderate or severe depression. For example, antidepressants
are not recommended for mild depression. There is, however, a whole menu
of effective treatments for depression to choose from, which we discuss in
Chapter 4. Antidepressants are effective only for people with moderate to
severe depression; they are discussed in Chapter 16.
The effects of depression
The best way of thinking about your depression is to divide the symptoms
into the way you think, the way you feel and the way you act. Not
everyone experiences the same symptoms – they partly depend on the
severity of your problem and your culture. Some people (especially young
people) may experience more irritability. Elderly people tend to experience
more physical symptoms, such as feeling tired or constipated or having
headaches.
Effect on thoughts
Negative thoughts
When you are depressed, you tend to think negatively about yourself, the
situation you are in, what you have done in the past, and your future. You
might believe that you are weak or a failure and that the future is hopeless.
The trouble is that when your mood is low, perhaps as a response to
difficulties in your life, then negative thoughts can seem very real and hard
to dismiss.
Throughout this book we’ll be emphasizing the importance of recognizing
that thoughts about yourself and the future are just that – thoughts, not
reality. Learning to accept these negative thoughts willingly as ‘just
thoughts’ and not buying into them as true has been proved by numerous
studies to be an important part of overcoming depression. You may well
have very understandable reasons for thinking negatively, such as painful
experiences in your early life, and it’s important to be kind and
compassionate toward yourself about this. However, no matter how
understandable it is that negative views of yourself, the world, or other
people may have arrived in your mind, we want to help you learn to
distance yourself from such views and be sceptical of their ‘truth’ so you
can more readily move forward in your life.
Self-criticism
When you feel depressed you might be self-critical and ‘label’ yourself as
useless, stupid or a failure. More severely depressed people tend to view
themselves as totally worthless, unlovable or even bad. You may frequently
focus on past mistakes which seem to confirm your negative view of
yourself. However, when you are depressed, thoughts become fused with
reality and accepted as facts. As a consequence, you develop a pattern of
thinking which is like holding a prejudice against yourself. You are then
more likely to avoid challenges or situations in which you believe others
will put you down. You will learn in this book to notice when you are
thinking about yourself in this prejudiced way by prefacing it with ‘I had a
thought that I was a failure,’ thus underlining that it’s just your thought or a
mental event and not reality.
Helplessness and hopelessness
When you are depressed you may think that you are helpless in solving
problems or feel trapped. You might believe the future to be hopeless and
even want to end your life as a way of escaping from your problems. In
depression, believing the future to be hopeless becomes fused with reality
and people with the condition think that things cannot get better or can only
get worse.
It is quite common for people who are experiencing depression to have
thoughts of suicide, without taking the further step of acting upon those
thoughts, like Emma in the example above. However, if you feel very
hopeless about the future and are planning ways to end your own life, seek
help as soon as possible. There’s every chance you could still use the
advice in this book to overcome your depression, but you may very well
need support and assistance from a health professional as well. See Chapter
9 on suicide and Appendix 2 for details of how to seek professional help.
 When ‘thinking solutions’ are part of the problem –
ruminations
People with depression often attempt ways to improve the way they feel
but unfortunately the techniques may leave them feeling worse. The
following examples are discussed in detail in Chapters 2 and 6.
Avoiding thinking about the situation you are in. This might bring
temporary relief, but results in problems being left unresolved or
building up.
Controlling your thoughts or suppressing them, which can mean
they enter your mind more frequently. You are probably trying to
‘put right’ or make sense of past events by ruminating on them,
perhaps mulling over them constantly. Unwittingly you are
probably trying to solve problems that cannot be solved or
analyse a question that cannot be answered. This usually consists
of lots of ‘why?’ questions. An example is that of Jan asking why
her son cannot help resolve the situation; others include asking
yourself ‘Why am I so depressed?’ or ‘Why did my partner leave
me?’ Another favourite is the ‘If only …’ fantasies, as in ‘If only
I had taken her advice’, ‘If only I looked better.’ Alternatively,
you may be constantly comparing yourself unfavourably with
others and making judgements and criticizing yourself.
Rumination invariably makes you feel worse as you never resolve
the existing questions and may even generate new questions that
cannot be answered. The process of worrying is a variation on the
same theme, in which you try to solve non-existent problems.
These usually take the form of ‘What if …?’ questions. Examples
include ‘What if my partner had an accident tonight?’ and ‘What
if I have cancer?’ Chapter 6 will help you to ‘think about
thinking’ in more detail and to cope better with your mind’s
invitation to try to solve non-existent or insoluble problems.
Loss of interest and pleasure
A common symptom of depression is a lack of interest in engaging in usual
activities such as work, family life, socializing, and hobbies. Even if you
are trying to ‘carry on as normal’ you might find that you get much less
pleasure from your activities than you usually would. Doctors and therapists
call this loss of pleasure anhedonia. It can be particularly distressing when
people find that they don’t have the usual feelings of love and warmth
toward partners or children. It’s vital to remember that these are normal
symptoms of depression and the good feelings will return as your mood
improves.
Changes in memory and concentration
Another very common and frustrating symptom in depression is difficulty
in concentrating. Again, this will improve as your mood lifts, so it’s very
important to be kind to yourself. It is also not unusual for a person’s
memory to be affected by depression, leading them to become more
forgetful. Combined with difficulties concentrating, this can sometimes
even lead sufferers to worry that they might have something wrong with
their brain, but this is an entirely normal symptom of depression and may
be related to being excessively self-focused and living in one’s head.
One of the more unhelpful ways that human memory is affected when
people are depressed is that they more readily remember negative
memories, and have difficulty recalling positive experiences. Naturally this
can lead you to think more negatively since you may draw conclusions
from a biased set of memories. This memory bias is also a real drawback at
a time in your life when you are faced with difficulties, since memories of
how you’ve solved problems in the past will be harder to recall. People with
depression have difficulty accessing their ‘positive memory bank’, which is
a very good reason to be highly sceptical of any negative conclusions you
draw about yourself and your future.
Images
Images refer to pictures that just pop into your mind. Pictures are said to be
worth a thousand words and they often reflect your mood. If you are very
anxious, you might have mental pictures of bad events happening to you in
the future. For example, a severely depressed person might experience
pictures of being in hell. Treating images as reality can create many
problems and it is important to recognize that you are just experiencing a
picture in your mind and not reality.
Attentional processes
When you are depressed, you usually become more self-focused on your
thoughts and feelings. This tends to magnify your awareness of how you
think and feel in your inner world and makes you more likely to assume
that your view of events is reality. This in turn interferes with your ability to
make simple decisions, pay attention or concentrate on your normal tasks or
what people around you are saying. You are likely to be less creative and
less able to listen effectively. In social situations, it means that your ability
to focus on what people are saying or how they are really acting towards
you is impaired. It may make you feel more paranoid. Your view of the
world now depends on your feelings and the chattering in your mind rather
than on reality. This also has an effect on other people, as you appear
uninterested in them. We will discuss some ways to help you refocus your
attention on the external world in Chapter 6.
Common emotions in depression
Changeable feelings
Feelings of depression or irritability often fluctuate. It’s common to feel
more down in the mornings and improve during the day. You may even feel
pretty okay in the evening, yet feel rotten again the next morning. However,
for some people it’s the other way round and they feel better in the morning.
Just remember that variation in how you feel is a common feature of
depression, although more severe depression tends to be worse in the
mornings.
Feeling anxious
Depression and anxiety frequently coexist. Anxiety is usually triggered by a
sense that you are under threat or in danger. The threat may be real or
imagined and may be from the past (for example, a memory), present or
future. When anxiety dominates the picture, there is a typical pattern of
thinking and acting. You may overestimate the degree of danger to yourself
or others. Your mind tends to think of all the possible disasters that could
occur. This is called catastrophizing. You may underestimate your ability
to cope and see yourself as being weak or helpless. Your mind will want to
know for certain or have a guarantee that nothing bad will happen in the
future. This leads to worrying about how to solve non-existent problems
and to control as much of your environment as is possible, or to plan ahead
to deal with all the possible problems that might arise. When anxiety is very
bad, you may be very agitated. This, along with worry, can make it even
more difficult to get to sleep.
Anxiety can produce a variety of physical sensations too, including
feeling hot and sweaty, having a racing heart, feeling faint, wobbly or
shaky, experiencing muscle tension (for example, headaches or chest
tightness), having cold, clammy hands, difficulty in swallowing, jumpiness,
and feeling sick, having stomach upsets or diarrhoea, to list a few. If such
sensations are misinterpreted as being immediately dangerous (for example,
‘my heart is racing too fast, I’ll have a heart attack’) then this can lead to a
very intense feeling of anxiety called a panic attack. Other symptoms such
as persistent headaches may make you fear a brain tumour, but as there is
no immediate threat you will simply become increasingly anxious.
Focusing on physical sensations
Some people (especially elderly people and those from certain cultures) do
not describe feeling depressed or anxious but focus more on physical
symptoms (for example, feeling tired all the time and being preoccupied
with aches and pains). This can develop into a picture of chronic fatigue as
they begin to do less and less and spend their time monitoring a particular
sensation or pain to see if it has improved or not. Friends and family may
want to see them less as they become so self-focused.
If you have this tendency to focus on your physical sensations, you may,
for example, want to hide from the light by closing the curtains and to cut
yourself off from all possible noise. Unfortunately, this has the effect in the
long term of making you more sensitive to light and sound as your body
compensates. You will learn in this book that focusing on your bodily
symptoms and trying to avoid light and noise invariably make you feel
worse. Instead we will try to help you refocus on what matters to you in life
and to pursue it despite unpleasant feelings and physical sensations.
Feeling guilty
Feeling guilty is common when you think you have done something bad or
broken a moral standard in some way (for example, having ‘sinned’ by
doing something wrong or failing to do something good). Your mind might
tell you that that you have let someone down, hurt someone’s feelings, or
caused offence in some way.
One of the things you might feel guilty about is having depression, and its
impact on other people in your life. For example, you might have a sense
that others are suffering as a consequence of your depression as you are
being less attentive, or irritable, or not fulfilling your usual commitments.
When you feel guilty you might have thoughts that you could have avoided
your sin or error, and that you absolutely should have done so. When you
feel guilty and are depressed, your mind may overestimate your personal
responsibility for a negative event and you could blame yourself
excessively. Your mind will not consider mitigating factors or other
people’s responsibility. Because you assume so much responsibility for
having done a ‘bad’ thing that you believe you absolutely should not have
done, you will be very likely to condemn yourself as a ‘bad person’. You
might also then tend to assume that other people will think of you in the
same way, and that you are likely to be punished in some way for your
‘badness’.
Guilt can be a very painful emotion and therefore you might be inclined to
try to escape from it by using distractions or alcohol. You might find that
you make unrealistic promises, to other people and to yourself, that you’ll
‘never do it again’, to relieve your guilty feelings. Guilt may lead you to try
to punish yourself or to deprive yourself of something but also –
paradoxically – to avoid responsibility for your actions and putting things
right if you can. You might frequently seek forgiveness from others or try to
escape from your feelings. Another common behavioral response to guilt is
to blame other people so as to ‘shift’ responsibility.
You will learn in this book to preface your view of yourself such as being
‘bad’ as ‘I had a thought that I was bad’ to underline that it is not reality, it’s
just a thought. Even if you have done something which contravenes your
own moral standards, it doesn’t mean you are a bad person through and
through, it just means you are human and fallible – the problem is your
‘solution’ of constantly punishing yourself. You can learn to focus on
improving your relationship with others and (possibly by making amends)
follow your valued directions in life.
Feeling hurt
People most often describe feeling hurt when their mind tells them that they
have been treated unfairly or unjustly, or that they have been let down by
someone important to them. This typically occurs when you have been
rejected or criticized. These events may have actually happened, or it may
be that your mind jumped to the conclusion that they happened. When you
feel hurt and low, your mind might be inclined to magnify the extent to
which you have been treated badly and the degree to which someone’s
actions ‘prove’ that they don’t care about you. You might also overlook
other explanations for a person’s behavior that would help you see it as less
personal. If, for example, after the break-up of a relationship, you tell
yourself ‘I’m unlovable. I’ll be alone for the rest of my life,’ you may be
hiding your hurt with anger: you demand in your mind that your ex-partner
should have treated you fairly and you just don’t deserve to be treated the
way you have been.
 One of the main ways you’re likely to behave when you feel hurt is to
sulk (yes, adults do it too!). This means that you may stop talking to the
person who you feel has acted in an uncaring way, and expect them
(presumably through telepathy!) to realize how upset you are and make
amends. You might also use an indirect form of punishment or way of
letting the other person know you feel upset without telling them directly.
Giving the person the cold shoulder, ignoring them, attacking them about an
unrelated matter are all examples of this. All these behaviors have an effect
on other people, as they are likely to be defensive or get angry too.
It can be helpful to consider alternative explanations for the behavior
which has upset you; it may not be directly related to you at all. There may
be some other cause entirely. Alternatively, you may treat ‘personalizing’
thoughts as symptoms of depression, rather than facts, and allow them to
pass through your mind – they are ‘just thoughts’ and you don’t have to sort
them out. When you are depressed and feeling hurt, your lack of
communication and withdrawal has a significant effect on others and this
book will emphasize the importance of communication and working to
improve your relationships with others.
Feeling ashamed
Shame is an intense, negative emotion when your mind thinks you are
‘flawed’ or ‘weak’ and should not have broken a personal standard. Many
people wrongly think that having depression is a personal weakness and
feel very ashamed of it.
If you are feeling ashamed of being depressed it’s likely that your mind is
overestimating how abnormal it is to suffer from depression and assuming
that only weak or defective people get it. In fact, depression affects one in
six people at some time in their life, and can affect all kinds of people from
all walks of life. There’s also a chance that you’ll be overestimating how
much others will disapprove of you if you reveal that you have been feeling
depressed, and how long they will think about and remember it. Most
people will know of someone who has suffered from depression, and of
course many other people will have had it too. It may take a person
suffering from depression many months or years to face up to their
depression and seek help. For many people this is because they feel
ashamed of the way they are feeling and behaving.
If you feel ashamed, you may withdraw from others, to prevent them
knowing you have a problem. The more you isolate yourself, the more it
tends to feed your thoughts or ruminations. You might also avoid eye
contact with people, and this could lead them to believe you are not
interested in them and so they might steer clear of you.
This can also mean that people with depression often don’t discuss their
problems with friends, family members, or even their partner. There are
several consequences of this. First, not discussing your feelings means not
getting the feedback that those thoughts about being weak are just thoughts,
not facts. Second, it can increase a sense of isolation, which can contribute
to a low mood. Third, it can lead to a lack of support that can be so helpful
when combating depression, and people who care for you might criticize
you for not seeking help or discussing your depression with them (not, it is
important to remember, for having depression).
Another behavior pattern you might fall into as a consequence of your
shame is criticizing others to save face. This can be a major problem when
people around you want to help you and lift your mood. If you feel ashamed
you might be overly critical of others in order to draw attention to their
weaknesses. The problem is that you’re doing this only because you feel
badly about your own problem, and it does nothing to improve the situation.
If you are not seeking help for your depression largely because your mind
considers you ‘weak’ for having it, you probably believe you have to hide
from other people and keep your head down. Shame is a common issue for
people with depression, though it shouldn’t be because it’s an extremely
common problem, affecting huge numbers of people from all walks of life.
You are not a failure, it’s just your mind producing the thought you are a
failure. People don’t choose to be depressed. The design fault lies in being
human – although animals too get depressed, and psychologists have
suggested that depression may once have been a helpful state to conserve
resources in times of hardship when we were more primitive! Nobody – not
even psychiatrists and therapists – can be sure they won’t become
depressed. We hope you will accept yourself for having an emotional
problem, and strive to overcome it by not avoiding the problem.
Feeling angry and irritable
Some people (especially younger men or adolescents of both sexes) may
experience being frequently irritable, angry, moody or aggressive rather
than low or sad. Anger is a complex emotion: it can be a way of avoiding
another emotion or thought, such as feeling hurt or fearful. Being short-
tempered is thus often a feature of depression and a key issue is being able
to experience the thoughts and feeling that have been obscured by the anger.
When you feel angry, your mind may label the other person in a global
manner (for example, ‘he is a total bastard’) and demand that they should
have acted differently. This usually has an effect on others, who may either
retaliate or bad-mouth you and keep well away from you. We hope that
after using this book you will be able to develop compassion for others and
recognize that even if someone does something bad they are not a total
bastard through and through, and that you will be able to communicate how
you would like that person to behave differently.
Effect on actions
The actions of a depressed person are those of avoidance, inactivity and
missing out on opportunities or pleasurable events. You may feel like an
animal hibernating. You may be:
withdrawn from social or public situations or putting off invitations
to go out
not answering the phone
distracting yourself and watching rubbish on television or on the
Internet
neglecting yourself and showering or bathing less often than
normally
harming yourself (for example, cutting or burning your skin) to
numb yourself
drinking excessively
taking an overdose of drugs as a way of emotionally numbing
yourself
not planning for the future
avoiding conflicts or dealing with problems
compulsively buying goods that you do not need.
The ultimate escape may appear to be to end your life and we discuss this in
Chapter 9. When you are very anxious, you also tend to avoid situations
that could make you more anxious or panicky – for example, because of a
fear of others rating you negatively. If you are very anxious that a panic
attack might prevent you from escaping from a situation in which you could
be physically harmed, you might end up avoiding public transport or
crowds altogether. If you do find yourself in a feared situation, you may use
safety-seeking behaviors. These are things you do to reduce the risk of a
threat. For example, very socially anxious people may keep their heads
down, maintain poor eye contact, say very little and monitor themselves
excessively to reduce the risk of being rated negatively and rejected.
Unfortunately, these behaviors tend to rebound: other people interpret such
withdrawn manners as a lack of interest in them so they make no effort to
be sociable. Invariably, socially anxious people end up feeling unpopular
and rejected.
In this book, we return repeatedly to the idea of escape, avoidance of
situations or people and inactivity as these are some of the most important
factors in maintaining depressed and anxious moods. The best way of
overcoming your symptoms is to act against the way you feel and to test out
what your mind is telling you.
Effect on your body
Having depression does not affect only the mind; it can have effects on the
body too. Some of the biological symptoms of depression may be
associated with a biochemical imbalance, such as increases in the stress
hormone, cortisol. They include the following.
Sleep disturbance: Different types of sleep disturbance occur in
depression and anxiety. Depression is often characterized by waking
early in the morning and not being able to get back to sleep. Other
people – especially those who are feeling anxious and worrying a lot
– may have difficulty in getting to sleep and may not nod off until
the early hours of the morning. Alternatively, you may be sleeping
too much and going to bed as often as you can to avoid feeling the
way you do. Chapter 12 looks at sleep problems and some solutions.
Eating problems: Core symptoms of depression are loss of appetite,
eating less or missing main meals, and weight loss. Alternatively,
some people eat chaotically, comfort-eat, gorge on junk food and
gain weight. This behavior is another form of numbing yourself
emotionally. When you are very anxious, you tend to lose your
appetite. We discuss overcoming nutritional chaos or self-neglect in
Chapter 13.
Loss of interest in sex: Diminished interest in sex and, for men,
difficulties in maintaining an erection, may be one of the earliest
symptoms of depression to occur and the last to go. Anxiety also
interferes with sexual performance. We discuss overcoming sexual
 problems in depression in Chapter 14 and problems with medication
and sexual activity in Chapter 16.
Low motivation: Not being motivated to do anything is a core
symptom of depression. It comes with frequently feeling tired during
the day, slowing down or lacking in energy. We will discuss how to
overcome these symptoms in Chapter 7.
Types of depression
Health professionals classify depression according to the pattern of
symptoms. Apart from the diagnosis of bipolar disorder (see below), these
classifications are not particularly helpful as there are more similarities than
differences between them. However, your doctor or therapist may use them
and so it is important to know what they mean. Some diagnoses such as
bipolar disorder may have implications for treatment, so we shall include
them for completeness. The various possible diagnoses include the
following.
Bipolar disorder
Bipolar disorder (or manic depression) consists of recurrent episodes of
both depression and mania, a state of extreme happiness, euphoria or
irritability. It is usually associated with being grandiose and losing your
normal inhibitions. You may feel you do not need any sleep and your
thoughts are racing. You may be very talkative and feel very creative. You
may take excessive risks or spend large amounts of money. Hypomania is a
milder version of mania which is more manageable. It is also possible to
have a mixed state of both mania and depression. Bipolar disorder is much
less common than unipolar depression and there is probably a strong
biological factor in its development. If you have bipolar disorder, this book
will be helpful for the times when you feel depressed. We recommend that
you also read Overcoming Mood Swings by Jan Scott.
Unipolar depression
Depression is often described in terms of whether it is a single episode or
recurrent. If your depression is recurrent, i.e. repeated without episodes of
mania, then it is termed unipolar.
Chronic depression and dysthymia
Dysthymia is a type of chronic depression that persists for at least two
years. Overcoming dysthymia is more difficult as your habits may have
become more deeply ingrained. This might mean having to persist more
steadily and for longer at achieving changes in thinking and behavior
patterns. One of the main problems with long-standing depression is that
people can find it hard to imagine feeling better as they might not remember
‘good’ times as easily. Another obstacle is a fear of making things worse,
for example the idea that it is safer to be pessimistic and play it safe than to
run the risk of being disappointed if your mood lifts and then worsens.
Beware of your depression trapping you with pessimism. If you have long-
standing depression, it is important to realize that you are not alone. Many
people in a similar situation have found that they have been able to improve
their mood more often and for longer by working on aspects of their
lifestyle, attitudes and behavior.
Psychotic depression
Psychotic means losing touch with reality. One example is auditory
hallucinations (voices you can hear when there is no one around – telling
you, for example, that you should die). Another example is delusions
(abnormal beliefs not held by others – for example, you are convinced that
you are the Devil or that you should be punished in hell). Fortunately,
psychotic depression is rare and is likely to have had a strong biological
influence. Needless to say, if you are experiencing any frightening
symptoms of the sort we have described then you must seek help
immediately. Despite being serious and perhaps scary, psychosis is very
treatable and you will recover.
Postnatal depression
Postnatal depression (PND) is an episode of depression that develops some
time in the aftermath of giving birth. It can occur in the context of an
unwanted pregnancy or a baby that is abnormal. More often, though, the
baby is much wanted, and the mother has been looking forward to the birth
and the labour went well.
The symptoms of PND tend to be the same as those for ‘ordinary’
depression – for example, feeling down, irritable and tearful, lacking in
appetite, losing your ability to enjoy life and worrying a lot. PND is very
common and may be partly related to hormonal changes following birth.
However, men can also suffer from it.
Many women are a bit tearful, lacking in confidence or enthusiasm, and
have difficulty sleeping by about the third or fourth day after having a baby.
This is extremely normal and is often referred to as the ‘baby blues’. It soon
passes after a week or so and does not count as postnatal depression. If,
however, these feelings persist over the next month or come on later, then
you may be suffering from PND. It is more likely to occur if you have had
PND with a previous baby, have a partner who is unsupportive or with
whom you do not have a stable relationship, and have other problems, such
as your partner losing their job or housing problems. A rare and severe form
of PND is when a mother loses touch with reality (‘puerperal psychosis’),
which occurs in about 1 in 500 births. It usually comes on within a few days
of the birth. This is similar to psychotic depression as described on the
previous page, but the mother may be deluded that her baby is evil, or may
feel suicidal, and in very rare cases she may take the baby’s life with her
own. Puerperal psychosis is usually a serious condition which may
necessitate intensive support or admission to a specialist mother and baby
unit.
Seasonal affective disorder
Seasonal affective disorder (SAD) is a type of depression that recurs
regularly in the winter months and continues until the spring. It is
dependent on the amount of length of daylight you receive, and so the
timing tends to vary according to how far away you are from the equator.
The symptoms tend to be different from classical depression and are more
akin to hibernating for the winter – for example, sleeping more, overeating
and lethargy. Treatment options could include the use of special lights
(phototherapy). This is discussed in more detail in Winter Blues by Norman
Rosenthal.
Types of anxiety problems
There are also a number of different anxiety disorders – which we do not
focus on in this book – but which frequently coexist with depression. In
fact, one of the most common diagnoses is that of mixed anxiety and
depression. We therefore describe the main anxiety disorders below, and
point you in the direction of reliable sources of information.
Generalized anxiety disorder
Generalized anxiety disorder (GAD) is characterized by persistent worry
that is difficult to control. However, people with GAD often describe
themselves as ‘being a worrier’ all their life and seek help only when their
condition has become severe and uncontrollable. For a diagnosis of GAD to
be made, the anxiety should occur most of the time. In most cases, the
content of the worries are most commonly about relationships or health. To
fulfil the diagnosis you will need to experience three of the following
symptoms most of the time:
restlessness or feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind going blank
irritability
muscle tension (for example, headaches)
sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
GAD can also cause a number of physical symptoms and interfere with
your ability to function normally. It is a very common problem, either on its
own or in combination with depression. For more information see
Overcoming Anxiety by Helen Kennerley.
Panic attacks and phobias
A panic attack is a sudden surge of intense anxiety. It makes you want to
escape from the situation you are in, and peaks within ten minutes. It
includes at least four of the following symptoms: palpitations or racing
heart; sweating; shaking; shortness of breath or feelings of suffocation;
feeling choked; experiencing chest pain or discomfort; feeling sick or
having stomach pains; dizziness or light-headedness; hot flushes; a feeling
of the world or you being unreal; and tingling sensations. If you experience
these sensations and misinterpret them to mean you are about to die, lose
control, ‘go crazy’, or have a heart attack, then you will feel more panicky,
and this will lead to a vicious circle. Panic attacks may come out of the
blue, without any warning or obvious reason. Others may occur in
particular contexts, for example when travelling on a train. If you then
avoid such situations, you can develop a phobia. Agoraphobia is a fear of
having a panic attack, leading you to avoid a wide range of situations which
are linked to panic from which you cannot escape easily. When it is bad,
you can become housebound or go out only with a family member. Further
information can be obtained by reading Overcoming Panic by Derrick
Silove and Vijaya Manicavasagar. Depression and panic attacks or
agoraphobia frequently coexist.
Social phobia
Social phobia consists of excessive anxiety in social or performance
situations (where you may be scrutinized or judged by others). People with
social phobia fear they will do or say something that will be humiliating or
embarrassing. They may fear that other people will see them blush, sweat,
tremble or otherwise look anxious. They try to avoid participating in
meetings, talking to strangers or people in authority, eating or drinking in
public, dating, or being the centre of attention. Social phobia is diagnosed
when the social anxiety significantly interferes with your life and stops you
doing things that you would otherwise like to do. When it persists and
becomes chronic, it is often linked to low self-esteem and depression.
Effective treatment of social phobia usually improves the depression,
although some people will require treatment of depression in its own right.
For more information read Overcoming Social Anxiety and Shyness by
Gillian Butler.
Obsessive compulsive disorder
Obsessive compulsive disorder (OCD) consists of recurrent intrusive
thoughts, images or urges which the person finds distressing. These
typically include thoughts about contamination; harm (for example, that a
gas explosion will occur); aggression or sexual thoughts; and a need for
order. It is associated with avoidance of thoughts and situations that might
trigger the obsession or compulsions. These are actions such as washing or
checking which have to be repeated over and over again until you feel
comfortable or certain that nothing bad will happen. Depression frequently
occurs alongside OCD. It is usually secondary to the OCD, and if you no
longer have OCD then your mood will tend to improve. However,
occasionally depression is the main problem and you have OCD only when
you are feeling depressed. For more details see our book Overcoming
Obsessive Compulsive Disorder.
Body dysmorphic disorder
Body dysmorphic disorder (BDD) consists of a preoccupation with an
aspect of your appearance or a minor defect that is either hardly noticeable
to others or not really abnormal. It leads to severe distress and handicap,
and is often associated with marked avoidance behavior, checking your
appearance in reflective surfaces and constantly comparing your features
with those of others. Some people affected by BDD may pick their skin or
seek cosmetic or dermatological procedures. As with OCD, depression is
usually secondary to the BDD; if you no longer have BDD then your mood
will tend to improve. Psychological treatments for BDD also involve
overcoming depression using the principles in this book. We are currently
working on a book on overcoming body image problems and BDD.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is an anxiety disorder that people can
develop after being affected by one or more traumatic events. They usually
experience a combination of symptoms such as unwanted thoughts and
memories of the trauma; flashbacks; nightmares; feelings of upset or
irritability when reminded of the trauma; avoiding talking or thinking about
the trauma or reminders of it; feeling emotionally numb or cut off from
other people; loss of interest in activities that used to be enjoyable;
difficulty sleeping; difficulty concentrating; being overly alert or vigilant;
and feeling jumpy. For more information see Overcoming Traumatic Stress
by Claudia Herbert and Ann Wetmore. Depression frequently coexists with
PTSD and may need treatment in its own right using the principles in this
book.
How common is depression?
Depression is one of the most common mental disorders, and at any
moment affects between 5 and 10 per cent of individuals seen by family
doctors. Two to three times as many people may have depressive symptoms
but do not meet the full criteria for depression. Twice as many women as
men are affected. Depressive disorders are the fourth most important cause
of disability worldwide and they are expected to become the second most
important cause by 2020. Depression occurs less commonly in children, but
by the age of about 16 it is as common as it is in the adult population. The
rates decrease slightly in elderly people but remain frequent. It can thus
affect people of all ages, cultures and backgrounds.
Depression is the third most common reason for GP consultations,
although many cases go unrecognized. This is because many people go
their doctor with physical complaints (for example, feeling tired, not being
able to sleep, headaches or back pain). They are not asked about, do not
divulge to the doctor or do not experience symptoms of depression which
are easy to recognize. Most people will feel better with treatment within
about six months, whereas for a few people who refuse help, the natural
history of depression can last more than two years. GAD is even more
common than depression. However, as we pointed out earlier, people are
less likely to seek help for this condition as many view themselves as ‘just a
worrier’. Left untreated, some forms of depression may persist for several
years, or recur regularly at times of stress. With help and some action on
your part, there’s every chance you can overcome your depression.
Famous people who have had depression
Given how common depression is, it is not surprising that there are many
dozens of famous people who have or have had depression. Actors,
scientists, poets, artists, authors, professors, politicians, religious leaders,
doctors, comedians, psychiatrists and therapists have all experienced
depression. No human on the planet is completely guaranteed to avoid
depression in the course of their life. However, following the principles in
this book will help improve your odds dramatically. Here are some famous
people who have suffered from depression:
Charles Dickens (author)
Winston Churchill (British prime minister)
John Cleese (comedian, actor, writer)
Stephen Fry (actor, writer)
Audrey Hepburn (actress)
Thelonious Monk (musician)
Vincent van Gogh (artist)
Isaac Newton (physicist)
Mark Twain (author)
Mary Shelley (author)
2 What Causes Depression?
This chapter summarizes what is known about the ‘causes’ of depression
and what makes someone vulnerable to experiencing it. Although it can be
important and useful to have some understanding of how you have come to
develop an emotional problem, we do not want to encourage you to look
endlessly for reasons or causes. Usually there are either obvious triggers to
an episode of depression (for example, the break-up of a relationship or loss
of a job) or vulnerability (for example, being abused as a child) or genetic
inheritance from a family history of mental disorder.
When considering possible causes for your symptoms of depression, it is
usually helpful to think of three groups of factors, those that:
have made you vulnerable to developing symptoms (for example,
childhood abuse, trauma, genetic inheritance, and unknown factors)
have triggered your symptoms (such as recent life events)
maintain your symptoms (the way you react, with particular patterns
of behavior and thinking).
We will discuss the third factor – that is, the patterns that maintain your
depression – in the following chapters. It is within your ability to change
them, and doing so is the cornerstone of self-help and cognitive behavior
therapy. In this chapter, we will examine the first two factors.
A psychological understanding of the development of your depression can
help you to take a more sympathetic, compassionate view of yourself, and
thus be more effective in your attempts to recover. However, we don’t want
you endlessly trying to ‘get to the bottom of it all’. Exploring possible root
causes ought to be a relatively brief process – when you fall down a hole,
you don’t need to know the exact route by which you arrived at the bottom
in order to climb out again.
As we outlined in Chapter 1, there are different types of depression. Partly
because of this, scientists, doctors and therapists do not fully understand
what causes it. What we can safely say is that depression results from a
person being vulnerable owing to a mixture of psychological and biological
factors and life experiences since birth, and that often there are long-term
difficulties that set it off. To complicate matters further, people with the
same severity of symptoms on a rating scale may have a different pattern of
symptoms and combination of causal factors. For example, a young woman
with good family support and a happy childhood, but a strong family
history of depression, may experience the same severity of depression on a
rating scale as someone who was emotionally and sexually abused as a
child and now has two small children to bring up on her own in appalling
housing.
At one extreme, depression can occasionally be caused by a medical
problem such as an underactive thyroid gland. At the other, factors such as
long-term parental neglect and a deep sense of being unloved that has lasted
from childhood may be important factors in a person’s depression.
Although we will discuss different contributions that are relevant to
depression, such as psychological and physical factors and life experiences,
they all interact with each other. Imagine that the cause of depression is like
a glass full of liquid. The components of the cocktail in the glass will be
different for each person and they will also mix and interact in different
ways. The point is that having depression is like having the glass full – it
will just vary from one person to another according to how much of the
glass is filled by different liquids.
A word of caution about ‘causes’
Trying to work out the exact ‘cause’ of your own depression can be
difficult. Spending too much time trying to work out ‘reasons’ may lead
you to avoid other feelings and prevent you from trying to solve the real
problem of not doing what you value in life. Some of the causes of your
depression may be in the ‘unknown’ category, buried in many years of
life experience and evolution. However, in most people, the factors that
have contributed to depression are fairly straightforward. People who
feel unlovable, rejected, alienated, bullied or pushed down are those who
are vulnerable. However, even if a partner is, for example, critical and
demanding, there will be other factors such as your temperament, genetic
predisposition, the way you respond to your partner and how you
subsequently cope which will determine whether you develop
depression. If you respond by avoiding your difficulties and don’t pursue
your own valued directions in life, then your life will be less rewarding
and further lower your mood.

What makes a person vulnerable to depression?

Depression seems to result from a person’s vulnerability to it and the
presence of a trigger. Vulnerability to depression could result from three
issues: personality or psychological traits; physical conditions that include
medical, biological and genetic causes; and life experiences. These factors
are not clear-cut, and there is a certain amount of overlap between them.
Psychological factors
Certain aspects of your personality may make you more vulnerable to
developing depression. For example, you may be a perfectionist and set
unrealistic goals for yourself, or excessively shy and reserved, or very
dramatic. Such traits, in combination with one or more triggers, can make
you more vulnerable to depression. As pointed out earlier, there is a certain
amount of intermixing of the factors: it is clear that some aspects of
temperament are partly genetically determined.
Physical conditions
Genetic factors
Depression can sometimes run in families, with as yet unknown genetic
factors. If a close relative has depression, you may be at increased risk of
suffering it at some time in your life. However, bear in mind that depression
occurs naturally in up to 10 per cent of the population so it is merely
elevating a normal risk. It is complicated because someone may have
experienced depression mainly because of difficult childhood experiences
and not because of a gene that increases their vulnerability.
However, genes usually require a life experience or a context to ‘switch
on’. In different or better circumstances the person concerned might not
develop depression at all. Life experiences might include adversity during
childhood or adolescence, such as emotional neglect, bullying or sexual
abuse.
Medical ‘causes’ of depression
Very few medical conditions aggravate or mimic depression. However, if
your history suggests a possible medical cause or if you are not getting
better with conventional treatments, it is important that such causes are
investigated despite their relative rarity.
Thyroid problems: Having an underactive thyroid
(hypothyroidism) might lead to weight gain, forgetfulness,
excessive tiredness, a hoarse voice, slow speech, constipation,
feeling cold, hair loss, dry rough skin, irregular periods and
infertility as well as symptoms of anxiety and depression. This
condition is easily detected by a blood test for thyroid function and
can be treated by a thyroid supplement. Hyperthyroidism (having
 an overactive thyroid) can mimic a state of anxiety, with excessive
agitation and weight loss.
Vitamin B6 deficiency: Vitamin B6 aids the production of
chemicals in the brain and is therefore important for normal
functioning. A deficiency of this vitamin can result in depression but
it is rarely found in anyone who eats normally. It is more common if
you neglect yourself and have a poor diet. The level of vitamin B6 in
your blood can be tested; if it is found to be too low, you can be
prescribed a supplement. In rare cases, depression can be a side-
effect of oral contraceptives which may be linked to B6 deficiency.
Folic acid deficiency: A deficiency of folic acid may result from a
poor diet, excessive alcohol consumption, malabsorption in the gut
or chronic diarrhoea. A deficiency can also occur during pregnancy
or with the use of oral contraceptives or anticonvulsants. Symptoms
of folate deficiency include depression, insomnia, loss of appetite,
forgetfulness, irritability, fatigue and anxiety. Folic acid deficiency
may be a contributing factor in some cases of depression and it is
worth getting yourself checked for it if you are not getting better. It
can be treated by a folic acid supplement.
Vitamin B12 deficiency: A deficiency of Vitamin B12 could result
in depression, but this is very rare and unusual with a normal diet.
Treating with vitamin B12 can rapidly relieve depression.
Excessive alcohol and drug use: Alcohol and recreational drugs
can be important factors in causing depression, and we discuss this
in more detail in Chapter 14.
Use of certain medications: A prescribed drug for a medical
condition (for example, an antimalarial drug) can, on rare occasions,
cause depression. If you have any doubt, check on the product
information leaflet that comes with the medication and always
discuss it with your doctor before stopping medication.
Biological causes of depression
Some doctors believe that depression has a biological cause such as a
‘defect’ in brain chemicals or an illness in the brain, like migraine. This sort
of explanation may reduce the stigma and blame attached to people who
have depression by ignorant people who think that they should just ‘pull
themselves together’. However, biological factors alone do not fully explain
the symptoms of depression, and the stigma is not necessarily reduced.
Furthermore, such explanations don’t place enough emphasis on the context
of the depression and the variety of possible ways of coping with particular
events.
Biological explanations for some types of depression are supported by
research using brain scans which show decreased activity in the frontal
lobes of the brain of people with depression compared to those of people
without the condition. However, the activity in the brain tends to return to
normal following therapy or medication. This suggests that the abnormal
brain activity is a consequence of depression rather than a cause. (For
example, a fast heart rate occurs in a panic attack but this is not the cause of
the attack, it’s a consequence of anxiety.) It also means that there is no
permanent brain damage in most people with depression. However, there
are some medical conditions, such as multiple sclerosis, which may make
you more prone to developing depression, over and above the difficulties
from a long-term disability, when biological factors are more relevant.
Chemical deficiency in the brain
Biological explanations focus on the role of chemicals such as serotonin
and noradrenaline (norepinephrine) in depression. These chemicals are part
of the nervous system and allow one nerve to communicate with another.
Serotonin plays a part in many aspects of normal human functioning,
including appetite, sexual desire and anxiety, so it is not unique to
depression. An imbalance of serotonin is not therefore necessarily a cause
of depression.
Medication that helps to enhance activity in nerves that use serotonin or
noradrenaline (norepinephrine) can help depression and anxiety, and we
shall look at such drugs in detail in Chapter 16. However, just because
drugs that help depression act on nerves that contain serotonin, it does not
mean that there is a deficiency of serotonin in depression or anxiety. This is
like saying that if aspirin improves headaches then headaches are caused by
a deficiency of aspirin. The changes in serotonin are likely to occur as a
consequence of your mind trying to switch off. Drugs that address the
imbalance in serotonin may help in depression (and anxiety disorders) by
enhancing the function of serotonin nerve cells in the brain. If your mood
improves or anxiety lessens, then it may help you to cope better and to face
up to and deal constructively with any difficulties you may have.
Furthermore, as there are different types of depression it is possible that
some types have a stronger biological basis than others.
 In summary, trying to unravel the biology of depression is complex, and
statements that depression is caused by an imbalance of serotonin or other
chemicals in the brain are simplistic nonsense. Unfortunately, many people
have been peddled this theory by pharmaceutical companies and cannot see
the wood for the trees.
Remember that any biological changes observed in the brain of a person
with depression can be reversed by using either a psychological or a
physical therapy. If a person overcomes their depression (by whatever
method), the brain will switch off the biological changes that may occur in
reaction to the depression and the system will return to normal. There is no
permanent structural damage in most people who recover from depression,
and the use of medication does not tell us anything about the cause of
depression.
What can trigger depression?
Depression usually occurs as a very understandable response to specific
events and in a particular context. Many of the triggers in depression are
long-term difficulties which may drain you over time. The most common
triggers for depression are:
loss (for example, the death of a loved one, the break-up of a
relationship, the loss of a job, ill-health, lost opportunities or a severe
financial downturn). For some people, loss is very difficult.
changes to your role in life (for example, moving job, children
leaving home, increased responsibility and stress at work). These are
particularly difficult when such changes occur without any choice.
conflicts in a relationship (for example, with your partner or a family
member). These are especially difficult when you may cope by
subjugating your own needs and feel resentful that you are not being
heard.
a sense that things are missing from your life (for example, a
relationship, children, or a job)
failing an important exam, not achieving adequately at work and
feeling ashamed about the consequences
chronic physical illness or pain
jetlag or anything that disrupts your sleep.
Sometimes depression seems to occur out of the blue, without any
identifiable trigger or social factors. In this case there are probably more
biological factors at work (especially in bipolar disorder). In this case you
may be excessively critical about being depressed and coping by avoiding
getting support from your friends and family.
Anxiety is usually triggered by a threat to your:
health
social standing
finances
relationships with loved ones.
People with anxiety tend to overestimate the degree of threat to themselves
or underestimate their ability to cope with such threats. The key issue in all
of these contexts is the meaning you attach to the event (or series of events)
and the way you deal with them. You may also feel threatened by the
experience of anxiety. You might misinterpret the sensations of anxiety
(heart racing, feeling short of breath, dizzy) as evidence that you are going
to have a heart attack, suffocate or collapse and die, and develop panic
attacks. When anxiety or panic attacks becomes a long-term problem it
becomes a major risk for developing depression.
Understanding the psychological causes of
depression
We tend to assume that being normal is ‘healthy’ and that abnormality
involves disease. This fits with most physical problems. Evolutionary
psychologists reject our understanding of depression as an illness for most
people and question whether being healthy is normal. Their analogy is that
happiness for a dog or cat is easy. So long as it is given shelter, warmth,
food and water, is in reasonable health and is given a bit of attention and
play, then it will be happy. If humans are denied any of these, it is not
difficult to understand why they are miserable. However, most of us have
our basic needs met – we have shelter, are warm, have food and water, are
physically healthy – and yet many of us are unhappy. Indeed, having all
sorts of material comforts, or even being an extremely attractive millionaire
with a loving partner, a high-status job and caring children, does not make
people immune from depression. This seems puzzling, although animals
that experience loss or defeat may also experience a type of depression.
Psychologists note that mental suffering is extremely common, so much
so that it is almost part of the human condition. This fits with the Eastern or
Buddhist philosophy that life is suffering. Such an approach views the
problem as not being inside (like bad genes or faulty thinking) but on the
outside. In other words, it’s normal to feel sad when bad things happen or
you have lost an important relationship.
This is not to say that there are no biological factors in depression
(especially in bipolar disorder and severe depression). There are several
types of depression and, even when there are strong biological influences,
the way you react to your depression still influences the severity of the
symptoms. For example, if you have a significant genetic component to
your depression you may be ashamed and depressed about being depressed
(a ‘double whammy’). The way you respond by being withdrawn, inactive
and ruminating on how awful you are for being depressed could determine
the severity of your symptoms and speed of your recovery.
Even if you are recommended medication for depression and decide to
take it, there is nothing to stop you improving your mood by using the
approaches described in this book. This will involve developing a more
compassionate and caring view of yourself, acting as if you truly believed
you had nothing to be ashamed of, and doing more of the activities you are
avoiding.
Another way of thinking about your mind is that it consists of a large
number of modules, each crafted to do certain jobs. For example, there is a
module for fear, another for memory, and so on. In some mental disorders,
there may be damage to a module. In conditions like dementia, for instance,
there may be damage to the module for memory. In other disorders, rather
than having a disease or damage to the brain, certain modules are trying too
hard or shutting down because there is an excessive load on the system.
Depression can be regarded as a failure in a system because it is overloaded
and has shut down. It is overloaded because of the way you try to escape
from unpleasant thoughts and feelings, or control your feelings by
ruminating about the past or worrying about all the bad things that could
occur. A normal process in the brain is trying to fix unpleasant thoughts and
feelings. It is coping the best way it can – waiting for bad feelings to go
away before you decide you can cope. This process can be seen in abnormal
brain scans and serotonin activity. In our opinion, these biological changes
do not cause the depression but are more of a reaction to it – the
consequence of the mind desperately trying to escape from and control the
way you feel. This is not to say that the biology is not important as it
becomes part of the process. For example, when you are stressed, your
cortisol level goes up and over time this will impact on your serotonin. As
your serotonin goes down, you may feel more tired and it affects your sleep
and the next day this will affect your way of coping. Your body and your
mind work together and one has an effect on another.
However, you can switch off these biological responses by acting against
the way you feel and in ways that will lead to better feelings. We shall
develop this psychological understanding of depression in the next chapter.
The assumption behind mental health problems is that we are a product of
our genes and what we have learnt since we are born. The way we think and
act is shaped by our experiences, though some people are more vulnerable
to depression through greater biological risk or particular personality traits.
Throughout this book we emphasize the importance of the context – lots of
‘bad’ events may occur, especially in childhood, from emotional and
physical abuse and neglect and lack of boundaries. If we experienced
unpleasant events when we were younger, we tend to avoid anything similar
and anything which remind us of them when we are older. If you were
criticized or not loved during childhood, it would not be surprising if you
grew up believing yourself to be inadequate or worthless. You would also
be adversely affected if you learnt from people in your family not to show
your emotions or to express them in dramatic ways, or if you were punished
inconsistently or not set any boundaries. Much of our development arises
outside of our awareness and we are exposed to literally millions of
moments of learning. It is scientifically impossible to unravel or organize
them into a causal order. This is why therapies that promise to ‘get to the
bottom of it all’ and discover the cause of your depression in childhood are
often unhelpful. Such therapies may sometimes make things worse and
encourage you to ruminate on the past.
If you have very low self-esteem and are very self-critical, you may
justify your actions as a way of protecting yourself or even deserving it and
making sure you are not hurt or not criticized by others. In this book, we
will be examining if this really prevents bad things from happening or
whether it makes it more difficult to achieve your valued directions in life.
Identifying your triggers and vulnerability
We have argued that the ‘cause’ of your depression is impossible to
determine scientifically because it is a complex mix of your genes and
millions of experiences since you were born. In this section, we will ask
you to try and identify any obvious triggers or areas of vulnerability to
developing depression.
 We can describe this in terms of a flower. In the drawing, the roots of your
flower represent the physical causes of vulnerability, such as your genes.
Your psychological make-up and life experiences (the other two factors that
lead to vulnerability) form the stem and leaves, and include your
temperament and ways of coping with bad events in the past. Bad things
that are happening now (that have triggered the depression) are shown by
clouds and lightning (as it’s never going to be all sunlight and warmth). If
Tim (see Chapter 1) were to draw a flower, his would look like this. Now
try this exercise for yourself on a blank flower with its stem and roots
(picture overleaf). Ignore the petals of your flower until page 66. You can
consider the risk factors under the following headings.
Biological factors (your roots)
Are there any possible genetic or biological risks – for example, do you
have a family history of mental disorder? Do you have a neurological
condition like multiple sclerosis or chronic pain that puts you at greater risk
of depression?
Psychological factors (your stem and leaves)
Are there aspects of your personality that make you vulnerable, such as low
self-esteem, perfectionism, an anxious temperament, extremely high
standards, or a significant degree of dependency on others? (These form
part of the stem and leaves of your flower.)
Social context
Did you had any bad experiences like bullying or neglect when you were
younger that might have made you more vulnerable and be less able now to
cope well with stress? (These also form part of the stem and leaves.)
Have there been social or personal problems like the break-up of a
relationship or a continuing conflict at work or with one of your children
that have triggered your depression? Have there been any major losses?
Have been there any major changes in your role in life? (These all form part
of the clouds and thunder in the diagram with your flower.)
By writing down the factors that might make you vulnerable to depression
and inserting labels on the roots, leaves and thunderstorms in your picture,
you are building an understanding view of the development and ‘history’
behind your depression. This will help you to be less critical of yourself for
having depression, and put your problems in context. There is a blank copy
in Appendix 5.
I can’t identify any factors in the cause of my depression
Don’t worry if you can’t identify some of the factors that make you
vulnerable to developing depression. It can sometimes be difficult to be
certain of the causes, especially if depression developed from a young age
or if there is no family history of a mental disorder. As yet, psychologists do
not fully understand all the causes of depression. Constantly searching for a
reason might seem like a good idea if you think that you need to find the
reason before you can fix the problem. This approach usually works with
physical problems: if you have a chest pain caused by a lack of oxygen to
your heart from a blockage in an artery, then a doctor can do the right
investigations to find the blockage and bypass the blocked artery with a
graft. However, this approach does not work if you have an emotional
problem, because the more you try to stop feeling depressed by searching
for an elusive ‘root cause’ the more you focus on how bad you are feeling.
You are likely to end up making yourself feel more hopeless as a result.
 Inevitably, you will read or be told different things by different therapists
or doctors. The more opinions you seek and the more books and websites
you read, the more your doubts will increase. We mentioned earlier that
some experts may emphasize the role of brain pathways and chemicals,
while others may empathize with your childhood experiences. Change
involves learning to tolerate uncertainty and accept that you will never
know the ‘exact’ combination of factors that might be relevant for you.
Some of the ‘causes’ are probably in the unknown category and, even if you
knew the exact order of events, you probably can’t do anything effective
about them. Just say no to any therapy that offers to find the route you took
into the hole. Insist on a proven psychological treatment for depression that
helps you get out of your hole!
During therapy, memories you had before the onset of depression can
sometimes be identified when you are doing things that you had previously
strenuously avoided. For example, when a therapist was helping a woman
to talk about past events that she had avoided and to do things that she
found uncomfortable, it triggered memories of abuse when she was much
younger which were clearly relevant to the development of her depression.
Ever since then she had felt ashamed about the abuse, but these feelings had
become generalized so that she not only avoided thinking about the trauma
but also sidestepped many activities which had become associated with it.
However, the relevance of the original trigger was identified only because
of the emphasis on overcoming her avoidance behavior and getting back to
a normal life. Once it was identified she could talk about the trauma, stop
believing her self-attacking thoughts and develop a more compassionate
attitude towards herself so that her mood improved.
3 A Psychological Understanding of
Depression
As pointed out in Chapter 2, this book concentrates on looking at factors
that keep your depression going – that is, those thinking and behavior
patterns that reinforce your depression and maintain it.
Understanding how your depression is being maintained is the first step to
overcoming it. In this chapter we will discuss a psychological
understanding of depression, and discuss what keeps your problem going.
Thinking styles
Aaron T. Beck, the founder of cognitive therapy, and Albert Ellis, the
founder of rational emotive behavior therapy, first described various styles
of thinking that occur in depression and other disorders. These kinds of
thoughts will run through anyone’s mind some of the time, but when you’re
depressed you’ll find they that tend to be more frequent and more extreme –
and seem truer. We are not saying that they are wrong – in many ways they
are extremely helpful in the right context. For example, the psychologist
Paul Gilbert describes how if you were a primitive man or woman living in
the savannah, you would need to think in black-and-white terms and to
consider the worst if there’s a chance of being attacked by a lion. In this
case, it’s better to be safe than sorry and to miss lunch – rather than be
lunch. This sort of thinking is a normal part of stress. Unfortunately, the
thinking styles that occur in depression are being triggered in the wrong
context. Here are some of the styles of thinking that characterize
depression.
Fortune telling: Negative and pessimistic predictions about the
future, for example, ‘I’ll never get over this’.
Mind reading: Jumping to conclusions about what others are
thinking of you, for example, ‘She thinks I’m boring’.
Catastrophizing: ‘Worst case’ thoughts and images that enter your
mind, for example, concluding that something terrible has happened
when a loved one is late coming home.
All-or-nothing-thinking: Sometimes called ‘black-or-white’
thinking, this refers to thinking in extreme terms like ‘I should do
something perfectly or not bother at all’.
Demands: Rigid rules you place on yourself and others: ‘must’,
‘should’, ‘have to’ and ‘ought’ are all words that often involve you
 making inflexible demands on yourself or others, which may not
help you to accept and adapt to reality.
Personalizing: Taking other people’s actions too personally, or
giving yourself too much responsibility for a negative event.
Mental filtering: Focusing on the negative events in your life or
your failings, and ignoring the positive elements or your positive
attributes.
Disqualifying the positive: Taking information that could be
interpreted as positive and discounting or distorting it, for example
‘That doesn’t count’, ‘They’re only saying something nice because
they pity me’.
Emotional reasoning: Thinking the way you feel indicates how
things are in reality, for example, ‘I feel I’m a hopeless case,
therefore it’s a fact’.
Fusion: Similar to emotional reasoning. To ‘buy into’ thoughts (with
their related memories and feeling) like they are facts i.e. ‘fusing’
thoughts with reality.
Labelling: Globally putting yourself, others, or the world down, for
example, ‘I’m a failure’, ‘I’m useless’, ‘I’m worthless’, ‘He’s so
stupid’, ‘She’s a horrible person’, ‘People are nasty’, ‘The world’s a
terrible place’.
Overgeneralizing: Drawing a general conclusion from a specific
event. ‘Always’ and ‘never’ statements are common, for example,
when your car refuses to start and you think ‘Nothing ever goes right
for me’.
Frustration intolerance: Telling yourself a difficult experience is
‘unbearable’, ‘intolerable’ or that you ‘can’t stand it’.
Awfulizing: Labelling a ‘bad’ event as ‘terrible’, ‘awful’, or ‘the end
of the world’.
These thoughts are one interpretation of reality, and are extreme and
unhelpful. They are really not worth engaging with and it is better to regard
them as ‘just thoughts’ without buying into their message and believing
them as facts. Thinking errors can be helpful to know since you can just
label your style of thinking when they occur (‘Oh yes, an excellent example
of emotional reasoning’).
 New developments: Cognitive behavior therapy and
variations
Much of this book is based upon the principles of behavioral activation
(BA). It is also in keeping with acceptance and commitment therapy
(ACT). These are newer developments within the family of cognitive
behavior therapies (CBT). Research shows that BA is just as effective as
traditional CBT for depression. There is some evidence that BA may be
more effective for individuals with severe depression. BA was originally
the ‘B’ in ‘CBT’, but it has now been developed as a therapy in its own
right.
Putting aside ‘internal’ causes of depression
Behavioral activation differs from most psychological and psychiatric
theories of depression in that it does not focus on an ‘internal’ cause for
depression, such as your thoughts, beliefs, internal conflicts or a chemical
problem in your brain. The assumption behind BA is that
the experience of depression is a consequence of avoiding or trying to
control unpleasant thoughts, feelings and problems and trying to find
reasons for the past or to solve unsolvable problems. The effect is that you
become inactive and withdrawn from avoiding people and your normal
activities. This in turn leads you to feel worse and you miss out on
experiences in life that normally bring satisfaction or pleasure.
Furthermore, the way you act has an effect on others and the environment
around you that may make your depression worse.
Depression is thus highly understandable given the context you find
yourself in (for example, a conflict in your relationship, the loss of your
job). For many people, the appeal of this shift of emphasis from ‘internal
defects’ (for example, lack of serotonin, faulty thinking) as an explanation
for depression is that it helps them to feel less blamed or stigmatized for
their problem. By focusing on the context and whether your reaction works
in helping you to achieve what you want in life, it is a highly practical
approach. Crucially, it’s also a highly scientific perspective in the sense that
the approach been scientifically proved to be effective and it rests on
testable theories.
Why seeking reasons can make things worse
Given the relative lack of certainty about what the psychological and
biological causes of depression are, it makes sense to focus on what makes
the condition worse or better. Believing what your mind is telling you, for
example, ‘Why am I feeling this way?’ or ‘I’m depressed because of the
way my husband treated me’, or ‘If only I’d found a way to make him
different’; or ‘Life is unfair, I don’t deserve to be treated this way’ may in
fact be part of what keeps you depressed.
Depression can be made even worse when you buy into your thoughts (for
example, comparing yourself to others and believing your mind telling you
that you are a loser or weak), leading you to try to control or escape from
them. Sometimes the methods you choose to avoid painful feelings (for
example, becoming less active, avoiding people, drinking alcohol) can also
serve to make depression worse. The approach we take in this book
emphasizes that the willing embrace of uncomfortable thoughts and
feelings, and acting in a way that is consistent with what’s important to you,
helps you achieve what you want in life.
Rumination and worry
Going over problems from the past asking yourself unanswerable questions
(this is called, as we mentioned earlier, ruminating) and worrying about
the future are important factors that keep depression going. As explained
above, a critical difference between the approach we’re outlining here and
traditional CBT is that, rather than questioning the content of your negative
thoughts (for example, ‘I’m a failure’) and scheduling activities, BD
focuses on developing a different relationship with your thoughts and doing
the activities you are avoiding and following your valued directions in life.
When your solutions are the problem
The American psychologist Steve Hayes has a useful way of describing
people trying to cope with bad events that are not their fault. Imagine
you’re blindfolded and placed in a field with a toolbag. You’re told that this
is what life is all about and that your job is to run around this field, with the
blindfold on. Now, what you don’t know is that there are some deep holes
in this field. So you start running around and are enjoying life. However,
sooner or later you fall into a deep hole. You can’t climb out and you can’t
find an escape route. So you feel inside your toolbag; maybe you can find
something you can use to get you out. The only tool is a shovel. So what do
you do? It’s natural and highly understandable to start digging. It seems so
obvious because you are stuck and can’t get out. You try digging but soon
you notice you’re not getting out of your hole, so you try digging faster and
faster; but you’re still in the hole. So you try big shovelfuls, you try
throwing the earth far away from you and so on, but you’re still in the hole.
Does this relate to your experience of trying to get out of your depression?
You might be seeking help from this book or going to a therapist in the hope
that you can find a bigger or better golden shovel to help you feel better.
Well, you can’t dig your way out. However, if you let go of the shovel, you
can feel around to see whether there is anything else to help you out – a
ladder, for example. Remember you are blindfolded and you won’t be able
to find the ladder or anything else until you drop the shovel. From the
perspective of this book your shovel is analogous to the attempts you are
making to control or escape from uncomfortable feelings, or trying to
answer unanswerable questions and avoiding the activities that make you
feel uncomfortable.
Looking at your actions compassionately
It is important to remember that, like falling down a hole in the example
above, becoming depressed is completely understandable. Bad events do
occur and to some people they occur more often than might seem fair. Yes,
life is unfair, but it’s not your fault you’ve fallen down the hole. You had
the ability to get out, but before you started to read this book you did not
know what to do and did what you did because it seemed natural. The way
you are trying to cope makes perfect sense given the situation in which you
find yourself. We are not saying that the situation is hopeless but, and this is
very important, your solutions of trying to avoid or control your thoughts,
feelings and situations are not working. All they do is make the situation
worse and you get more depressed and stressed. If you can give up your
current faulty solutions there is every hope for a long life which is
meaningful to you, without depression. Remember, working out how you
fell into your hole (or the route you took to get there) is not going to get you
out of it. Some therapies unwittingly provide you with a better shovel.
Trying to dig is a natural response if you don’t see an alternative – you are
doing the best you can with the tools you have! Remember that only when
you stop shovelling can you feel around for something to help you out. It is
a leap of faith but, if you don’t accept the uncertainty, it’s guaranteed to get
worse. The bottom line is that it’s generally unhelpful to focus on finding
reasons and working out how you ended up in a hole – you might justifiably
do this once you are well and are out of your hole and living the life you
want, as a way of trying to prevent a relapse and being more aware of
‘holes’.
Identifying your problematic solutions (spot your shovel!)
So what is your ‘digging’? This is what you are you doing to cope with
your depression or stress. It generally falls into two broad areas: escaping
from your thoughts, feelings and actions or excessive control of them. How
does this occur? As mentioned earlier, a fundamental process is ‘emotional
reasoning’ or ‘thought fusion’. Thus if you feel worthless or believe the
future to be hopeless, then that becomes your reality. Rating yourself as
worthless and the future as being hopeless is treated as a fact like the sky
being blue. Sometimes other people reinforce this tendency (for example,
friends or relatives who say ‘I’d be depressed too if I went through what
you did’; or ‘I’d want to figure things out in the same way’; ‘You need rest
to get over the way you feel whilst time will heal’).
While you focus on your negativity, the process of fusing your thoughts
and reality becomes missed as you totally buy into their content as facts.
These thoughts are just mental chatter rather than objective evidence that
everyone can agree with. We shall describe this in more detail in Chapter 6.
The aim is to ‘understand’ these thoughts, not so you can question whether
they are true or not, but to consider your relationship with your thoughts
and how you react to them.
Escaping from difficult thoughts
If you have fused your thoughts with reality and believe them to be true, it’s
not surprising that you want to escape from them or from the feelings of
depression. Thus, you may experience an emotional escape by feeling numb
or uninterested. In order to escape unpleasant thoughts and feelings, you
might start to:
avoid activities and people that you normally enjoy and become
more focused on yourself
withdraw from friends or family
use alcohol or drugs to numb your feelings
ruminate about the past and try to work out reasons for the way you
feel
avoid calling friends because you think you may be criticized or
rejected
try to distract yourself with ‘retail therapy’ or going out all the time
‘put your head in the sand’ and pretend that the problems around you
will go away if you ignore them.
spend a lot of time watching TV or DVDs
 ignore the doorbell or telephone.
Such behaviors become habitual so you may not even be aware of why you
are doing them. We will describe in Chapter 7 many ways of avoiding
things, all of which serve the particular function of trying to escape from
unpleasant thoughts and feelings. The problem is that the more depressed
you become, the harder it is to focus on the events that you are trying to
escape from in the first place. Escaping is insidious as it feeds on itself and
makes you more depressed and further and further away from the values
that are important in your life. You then miss out on normal positive
experiences and pleasures that occur in everyday life.
In many ways escape is a natural response to try to avoid bad feelings.
However, it also has consequences as you dig deeper into your hole and
make yourself more depressed and stressed.
Thought suppression
One way of not facing unpleasant intrusive thoughts or images is to try to
suppress them. This often occurs when people have experienced unpleasant
events such as the death of a loved one or a trauma. However, suppressing
intrusive thoughts also has an unintended consequence: it increases the
frequency of the thoughts and makes you feel worse. It is very normal to
have intrusive thoughts about distressing events as your mind is trying to
sort out what’s important to you. That’s why suppressing such thoughts
won’t work, since your brain will keep putting them back into your mind to
sort them out.
To understand how trying not to think of something makes it more
intrusive, not less, try the following exercise. Close your eyes and try really
hard not to think of a pink elephant for a minute – try and push any image
of a pink elephant out of your mind. Every time you think of a pink
elephant, try to get rid of it from your mind.
What did you notice? Most people find that when told not to think of a
pink elephant, all they can think of is a pink elephant. Understanding the
apparent upside-down way in which the human mind works is a key to
understanding and overcoming depression. Very many people with this
problem are caught in the trap of trying too hard to rid themselves of
thoughts and doubts, and in fact this brings about the very opposite of what
they want.
If you’re still not convinced that trying to get rid of thoughts, images or
doubts makes them worse, try a more ‘real life’ experiment. Spend one day
dealing with your thoughts in the usual way, and record their frequency and
the distress they cause you (step 1). Spend the next day trying twice as hard
to get rid of your thoughts and record their frequency, and your distress. Try
as hard as you can to suppress them (step 2). The following day go back to
your usual way of dealing with your negative thoughts (step 1), and then the
next day carry out step 2 again. Take a look at the results of your four-day
experiment. What do you make of them? Most people discover that their
thoughts become more frequent and more disturbing the harder they try to
get rid of them. So, if you don’t try hard to get rid of a thought or image you
will find that it bothers you less. After all, a thought is intrusive only if you
don’t let it in and recognize it for what it is. Embrace such thoughts and
fully accept them and carry them as part of you.
Learning theory
Learning theory can help to explain how your problems developed. It shows
that the way you think and act has been reinforced by the environment. If as
a child you had little affection from your parents and were bullied by your
peers, then you might have learnt that you are unlovable or worthless.
These beliefs then become linked with various other thoughts in your mind.
You might compare yourself with others. Knowing where you stand in life
means you will try to avoid any conflict with people ‘above’ you to reduce
the risk of being rejected or humiliated. You might avoid or escape from
people or situations where you think you could be criticized or rejected to
prevent yourself from becoming hurt or depressed. The downside is that
you become lonely and isolated in the real world and miss out on
developing any normal relationships.
Trying to avoid or escape from difficult situations is a very natural
response and often very helpful in the right situation. For example, it may
be sensible to keep your distance from bullies, but at other times you may
have to engage with them. It’s all about finding the appropriate response for
a given problem and not avoiding your thoughts and feelings about the bad
events.
Another example is if, when you are feeling down and ruminating on why
you feel the way you do, you escape by going to bed. Because you get away
from the pain for a few hours you start believing that ruminating ‘works’.
So the next time you feel bad, you have trained yourself to ruminate or
avoid activity and go to bed again. The problem is that this has
consequences in the long term and makes you feel more depressed. You
start to beat yourself up and tell yourself you are a failure; moreover, all the
time spent in bed means that you miss out on what is important to you in
life. It also prevents you from having any positive experiences, and
strengthens the belief that you are a failure or unlovable as you are unable
to test out your expectations. In Chapter 5, you’ll learn how to do a
functional analysis. This means having a good understanding of what is
maintaining a particular pattern of thinking and behavior (usually escape,
avoidance or control), and consequences, both short term (for example,
feeling ashamed and depressed) and unintended (for example, irritation felt
by others about your behavior and loneliness leading to further depression).
When problematic solutions seem to work
You may feel that digging your way out of a hole works because you are
doing something with the tools you have and reducing bad thoughts and
feelings. The activities are therefore learnt (like a habit) and can be difficult
to break. So it is likely that you will avoid or escape from unpleasant
situations in the future because such behavior has been ‘reinforced’,
perhaps because it has been successful. We are not saying that this is wrong
or bad; it just happens because human beings are like other animals and can
train themselves to behave in a particular way. However, if you continue to
cope by avoiding or escaping from unpleasant situations, the technique
becomes unworkable for a number of reasons.
Your solutions of avoidance and escape can make you feel worse and
more depressed as you come to realize that they are not going to
work and you begin to worry more about problems.
Avoidance often prevents you from finding out whether something is
true or not. For example, if you avoid discussing with a person why
he appeared to ignore you, you will never find out if it was because
he dislikes you or whether, for instance, he was not wearing his
contact lenses or worrying about a problem of his own.
Avoidance and escape has unintended consequences on your
environment and the people around you. Your friends and family
might stop trusting you and take on your responsibilities. This in turn
could have an effect on your level of depression, in a vicious circle.
You may miss out on meaningful events and opportunities that may
be enjoyable and keep you interested in life. Avoidance stops you
from doing what is important to you in your life – for example, you
want to be a person whom your friends and family can turn to and be
 relied on for support, or want to be a good parent. When you can’t
do these things you will inevitably feel more depressed. You might
spend more time focusing on yourself and beating yourself up and
find that you cannot act in a way that is important to you. Your
behavior then has an effect on your environment and others may be
critical or unsupportive and you become more depressed, in a
vicious circle.
Avoid avoidance, escape from escaping
Avoiding and escaping from bad feelings is like giving a bottle of vodka to
a man who is stranded in a desert and dying of thirst. It might stop his thirst
for short while but the alcohol will eventually dehydrate him further and
he’ll feel thirstier, or else he’ll get drunk and give up looking for water and
eventually die. The short-term solution becomes the problem.
Summary
In this book, you will learn the following.
1. You will recognize that symptoms of depression may be a message
that something is wrong in your life from which you are escaping.
This might be a problem in your relationship with your partner or a
major change in your life that you are having difficulty adapting to.
You will need to identify the problems you are avoiding and learn
to tackle them step by step in the way a plumber would fix a leak.
Look for guidance in Chapter 10 on problem-solving. However,
problem-solving should be used only for problems that currently
exist in your world or are very likely to occur (for example, you are
being made redundant; or you are abused by your partner; or you
are in conflict with your boss at work).
2. You will learn in Chapter 5 how to identify your ways of reacting to
events and try to understand their function. The first step is to
recognize how you are trying to control or escape from negative
thoughts and feelings, or even situations, activities, people, or
events that are associated with them (for example, going to the
cinema, a conflict with your boss, or going to a party). In other
words, anything that you might predict would be unpleasant. The
function is usually to escape or control the way you are thinking or
feeling. The aim here is to find activities that will allow you to
experience the feelings better. We we are not promising that you
 will be rid of unpleasant feelings or thoughts completely, because
this is part of being human. However, they are likely to subside in
intensity and frequency when you learn to see them for what they
are – just mental events, and not a reflection of reality. You will also
begin to have good feelings. Being alive means experiencing some
suffering and having both negative and positive thoughts and
feelings – feeling sad about bad events is normal and healthy. It’s a
natural reaction to loss, failing at something or adapting to change
in your life. As has been stressed before, depression occurs when
you try to escape, avoid or control negative thoughts and feelings,
and you become inactive and withdrawn so you miss out on the
positive experiences in life and your actions has an effect on other
people in the community. When you learn to embrace these
thoughts and feelings and see them as just mental events or neurons
firing in your brain, and stop avoiding activities and people, you
will be able to get back to your normal self and enjoy life again.
3. From Chapter 5 onwards, you will learn how to identify the
situations you are avoiding or escaping from, or pleasurable, or
satisfying activities that you have not tried before (or you have not
done for a long time) as part of increasing your activity levels. The
activities need to be varied and allow you to experience life. This is
what you miss out on when you are depressed. Of course, the theory
sounds easy and simple, but it may be difficult to implement. It may
take an act of faith and repeated practice to break a habit.
4. You will also learn how to identify your values and what is
important to you. Your activities therefore need to be consistent
with your values. If, for example, you believe in being a good
parent, you will set aside time to spend with your children. If you
believe in helping your community and making it a better place to
live in, or being a good saxophone player, then you will need to set
aside time to act on these beliefs.
5. In Chapter 7 you will learn how to structure your day so that you
incorporate your list of activities or problems to be solved and to
monitor the effect of what you are doing.
4 Effective Treatments for Depression
This chapter discusses which approaches are effective for overcoming
depression and which are not. We know this thanks to the enormous amount
of research into depression that has been published. All over the world,
experts in depression, including doctors, therapists and people who have
experienced depression, have got together to review the evidence and
produce treatment guidelines. Skip this chapter if you want to learn more
about applying these guidelines.
In the UK, the body responsible for producing such guidelines is the
National Institute of Health and Clinical Excellence (NICE), which is
highly regarded throughout the world. The guidelines can be downloaded
from their website (www.nice.org.uk). We have summarized its
recommendations for the treatment of depression below. This will help you
be more informed in any discussion with your doctor or therapist about any
treatment that they may recommend. There is a particular emphasis in all
guidelines on patient choice and on your experience with previous
treatment. However, what treatment you have partly depends on the
availability of therapists and local resources.
These guidelines are based on scientific evidence – that is, studies in
which depressed patients are randomly selected to receive one or more
different treatments. One group might be given a placebo or dummy
treatment so that researchers can see to what extent the attention of a doctor
or therapist and the passage of time affects the outcome. At the end of the
study the researchers then re-test participants to see which treatments are
more effective. The guidelines cannot cover every eventuality, and if you
are seeing a doctor or therapist, they will advise you as to what is best for
you given the resources available. It isn’t always obvious which treatment is
most effective for a particular person. Sometimes you may have to try two
or three different treatments before you find one which is effective for you.
The core message is that there is a lot of evidence that depression is
treatable and you can get back to a normal life.
Recommended treatments for mild depression
The following are all recommended approaches or treatments for mild to
moderate depression in adults or adolescents. Mild depression was defined
in Chapter 1.
‘Watchful waiting’
Mild depression can get better by itself with no treatment, and your doctor
or therapist may just keep an eye on you and provide some support for a
couple of weeks. This is called ‘watchful waiting’. If this applies to you,
you should get a follow-up appointment to review your progress. Such an
approach is very appropriate when the depression has been brief (for
example, it has lasted only a few weeks). Mild depression often gets better
by itself, especially if the symptoms are not too handicapping and there is
support from your friends or relatives. It is usually precipitated by a crisis
(for example, if your partner leaves you). If you have previously
experienced depression or if after a few weeks your symptoms persist, then
your doctor or therapist will want to recommend a more active treatment for
your depression.
Counselling
There are many different types of counselling that might be offered to you
for depression. Unfortunately, counselling is a minefield (even to health
professionals), and there is no easy way of predicting what type of
counselling you will receive. If you are referred to a counseller, your
therapist may not even tell you what approach they use. Certain types of
counselling (such as psychodynamic counselling) are in our opinion less
helpful for most people with depression as they don’t give sufficient hope.
We believe they can unwittingly encourage you to ruminate by endlessly
looking for reasons for why you are depressed. Counselling that is helpful
for depression is focused on supporting you so that you can move on in
your life and problem-solve rather than endlessly focus on past experiences.
It should allow you to feel understood and supported in solving problems
that you have been avoiding. For mild depression, the national guidelines
recommend six to eight sessions of counselling over a period of ten to
twelve weeks.
Problem-solving therapy
Problem-solving therapy is a psychological treatment that helps you to
identify the problems to be solved and the steps you might take to try to
solve them. It works well with solvable problems that you have been
avoiding. Most people don’t find it difficult to solve problems, but they may
have been avoiding solving them for a variety of reasons. Problem-solving
is generally used in CBT, although trying to ‘fix’ or control your internal
world (such as your thoughts and feelings) the way you might fix a problem
in the real world is not effective, and something different is needed. For
mild depression, six to eight sessions of problem-solving therapy over a
period of ten to twelve weeks is recommended in national guidelines.
Further details of problem-solving therapy can be found in Chapter 10.
Cognitive behavior therapy and its variants
Cognitive behavior therapy (CBT) is a way of treating depression and it can
be delivered in different formats such as individual or group therapy, and
guided self-help by using a book or computerized CBT. It was founded by
Aaron T. Beck, who revolutionized the psychological treatment of
depression in the early 1970s. Beck rejected psychoanalytical theories and
believed that depression was maintained by negative thinking and by being
inactive. Components of CBT include activity scheduling, identifying
negative thoughts and styles of thinking, and learning to distance one’s self
from negative thoughts and questioning their content so that alternatives
can be tested out. This method of treating depression has been found to be
as effective as antidepressant medication. Particular emphasis is laid on the
‘homework’ that you do to practise your skills between the sessions. A
number of books can assist in guided self-help with traditional CBT; they
include Overcoming Depression, Feeling Good: The New Mood Therapy
and Overcoming Depression and Low Mood (see Appendix 4: Further
Reading for details). A website that delivers CBT for preventing depression
can be found at http://moodgym.anu.edu.au/
As mentioned in Chapter 2, the approach used in this book, behavioral
activation (BA), is a development within the CBT family. It is a technical
name for an approach that is described in a treatment manual for therapists.
The ‘B’ in CBT has been developed and has become a treatment in its own
right. The approach has been subjected to several tests that demonstrate its
benefit. It is not generally included in national treatment guidelines because
the results are still very new and it usually takes a few years – and a number
of studies – for guidelines to be revised. In a large study published in 2006
that compared the effectiveness of BA, CBT and an antidepressant, all
treatments were equally effective for mild to moderate depression.
However, BA and the antidepressant were more effective than CBT for
treating severe depression in the short term. BA is generally easier to learn
than CBT and is certainly worth trying. This is the approach that is
highlighted in Chapters 5–9. These chapters can also act as guided self-help
when they are used with some input from a professional. If you find that the
approach doesn’t work for you, you can always return to classical CBT.
Exercise
Exercise can help improve mild depression. Taking up exercise is also part
of changing your behavior. An exercise program usually consists of up to
three sessions per week (lasting forty-five minutes) for at least ten weeks.
For moderate to severe depression, exercise can be used as part of a
program of activity in other areas. Exercise programs are discussed in more
detail in Chapter 11.
St John’s Wort
St John’s Wort is a herb that can be an effective alternative to ‘traditional’
antidepressant medication for mild depression. It can, however, interact
with other medications. Chapter 15 looks at the effects of this herb in detail.
We would not normally recommend St John’s Wort as the only intervention
for depression as it is important that you still tackle the problems or
activities you are avoiding and aim to develop a life that’s important to you.
It is not recommended for adolescents with depression because not enough
is known about its effectiveness or safety in young people.
Recommended treatments for moderate to severe
depression
Medication
Moderate and severe depression were defined in Chapter 1. Medication and
other physical treatments are usually recommended as an option in
moderate to severe depression. You might have noticed that antidepressant
medication was not recommended for mild depression. This is because
antidepressant medication is no more effective than a dummy pill for mild
depression. However, medication may nevertheless be recommended when
your symptoms are mild but you experience recurrent depression and your
doctor believes that your symptoms are likely to deteriorate (or if your
symptoms have lasted for a long time). Antidepressants are prescribed to
adolescents with depression only with great caution, and we discuss this in
more detail in Chapter 16.
Combining medication with other treatments
In general, we do not recommend using medication alone because there is
usually a higher rate of relapse when a person discontinues the medication
than when it is combined with an evidence-based psychological therapy.
However, given that there are different types of depression, a few people
may do fine on medication alone and get back to a normal life with just
that. The difficulty lies in identifying such individuals. Equally, there are
some people who want medication (especially tranquillizers) to avoid
having painful feelings. So think about the function of medication for you.
If you have already tried more than one course of medication and are
hoping that your doctor will come up with a drug that will get rid of your
bad feelings, you are not really helping yourself. Trying to escape from a
bad feeling is part of the problem and maintains your depressed mood. The
main goal of medication is to feel better (that is, to stop feeling depressed),
whereas the psychological approaches described in this book are generally
geared to helping you have better feelings and do the things you value in
life despite the way you feel. The two approaches may appear incompatible,
but we have no evidence that one interferes with the other. If anything,
some studies suggest that people with more severe depression may do better
on a combination of medication and an evidence-based psychological
treatment. It’s worth being aware, though, that the goals of these different
approaches seem to be slightly different and that more research is needed on
the long-term effects of combining medication and effective psychological
therapies in depression and how they interact. Unfortunately, mental
disorder is complex and there are no easy answers. Whatever approach you
take, make sure you monitor your progress with the rating scales in this
book so you can decide (with your therapist or doctor) what is helping and
whether to try something else.
Inequalities in funding for medication and psychological
treatments
When you recover from your depression, please think seriously about
campaigning on a political level for better access to evidence-based
psychological treatments so that there is a real choice for everyone, and
helping to raise funds for more research and psychological treatments
into depression. For example, we need to know how effective BA is from
just reading this book or whether there is a better result if you have a few
sessions’ support from a mental health worker. Is combining BA and
medication better than either treatment alone for severe depression in the
long term? Working out which treatment is most cost-effective in treating
depression can in itself be an expensive task. For example, medication
seems a cheaper option in the short term, but if there is a high rate of
relapse it can, in the long term, become a more expensive option as
 patients have to take the medication for many years. But proving this can
be difficult and expensive because you need to study lots of patients.
Pharmaceutical companies have plenty of money for research, whereas
scientists who want to investigate psychological treatments have great
difficulty in obtaining grants because the pot of money available is much
smaller. This is partly related to the stigma of mental disorder – scientists
studying cancer or heart diseases have a relatively easier time raising
funds for research.
CBT and other therapies
The psychological treatments recommended for moderate to severe
depression include CBT and interpersonal therapy (IPT). It can be hard to
find CBT in publicly funded medicine (like the NHS) in most parts of the
world. Interpersonal therapy is another brief therapy that helps individuals
concentrate on the link between symptoms and the losses and or conflicts in
their life, the changes in their role and what is missing in their life, with the
aim of focusing them on solving the problems they have been avoiding.
Although it is recommended as an option, there are very few trained
therapists delivering IPT compared to CBT. Couple therapy is another
option if you have a regular partner and there are problems in your
relationship (for example, your partner is excessively critical or jealous, and
this feeds your depression). In these circumstances, we would normally
recommend a cognitive behavioral approach within couple therapy with an
emphasis on teaching both partners to communicate, negotiate and
reciprocate with each other. This is outlined more in Michael Crowe’s
Overcoming Relationship Problems (see Appendix 4 for details).
For the psychological treatment of moderate to severe depression with
CBT, you might be offered up to sixteen or twenty sessions over a period of
six to nine months (although it could be longer or shorter depending on
your need). For the earlier stages of severe depression, treatment sessions
may be more frequent or you may be treated in hospital as an in-patient.
How long will it take me to recover?
This is very difficult to answer and depends on your circumstances. The
amount of time taken to recover from depression partly depends on the
context and the level of support. At one extreme, suppose you are a
young person who has broken up with your partner. You have had a
relatively happy childhood and have good support from your family or
 friends and no previous episodes of depression. In such a case, the
outlook is very good and you are likely to improve by using the methods
described in this book over the next month and be fully recovered within
a few months. At the other extreme, let’s suppose you have long-
standing difficulties in your personality and in relationships. You may
have been abused as a child and, if you do not have support from your
family and friends, then it is likely to take much longer.
For many people, mild depression will go away of its own accord.
However, no one can predict how long this will take – it could take a
year or more, and the techniques described in this book can greatly speed
up recovery. So using this book can be greatly beneficial to you.

Treatments that are not recommended for treating

depression
All the approaches described above have good evidence to recommend
them. Many others, from hypnotherapy to psychoanalysis, do not. Some of
these approaches are well-meaning and the practitioners may passionately
believe that they are providing effective treatments. Sometimes they are
harmless, but at other times the opposite is true. As recently as 2005, a
report from Russia described spanking with a cane as being an effective
treatment for depression! Dr Sergei Speransk was reported as saying ‘The
treatment works. I’m not sadistic, at least not in the classical sense, but I do
advocate caning.’ He went on, ‘At first they may not like it, but they come
back for more.’ He recommended thirty weekly sessions of sixty of the
best, and insisted it was more effective if done by a member of the opposite
sex. He claimed that caning works because it induces the body to produce it
own opiates called endorphins, leading to euphoria. Unfortunately,
vulnerable individuals are always subject to nonsense and pseudo-science.
Our advice is to use approaches that have research evidence and national
guidelines to support them. If you decide to see a therapist, it’s often a good
idea to get a recommendation if you can, from friends or a GP. Check with
the therapist about their level of expertise in treating depression, and make
sure you feel they understand you well enough. The therapist should be able
to give you a perspective on what they think is maintaining your depression
and an idea of what to try out to help improve your mood and functioning.
If this perspective and plan make sense to you, and fit your personal
experience, then give it a try. There is more on selecting a therapist in
Appendix 3.
5 How to Start Helping Yourself
This chapter is designed to help you measure and monitor your symptoms
of depression, define your problems, set some goals for recovery and focus
on the directions you’d like to take in life.
Rating the severity of your depression
Rating the severity of your symptoms at the start of your treatment and at
regular intervals will help you to monitor your progress and assess whether
what you are doing is effective or not. It’s a good idea to use these scales
even if you decide not to use any self-help or therapy or if you decide to
take medication, as it is still important to monitor your progress so you can
report back to the doctor and decide whether to try an alternative approach.
The scale described below, the Hospital Anxiety and Depression scale, is a
screening tool for depression and anxiety, and a way of monitoring your
progress, and is reproduced by permission of Dr Phillip Snaith.
To use the scale, answer each question and add up your score for anxiety
(in the left-hand column) and depression (in the right-hand column). You
can summarize the scores on a chart (see Summary of HAD and Quality of
Life Scores table in Appendix 5) so you can easily see the changes.
The Hospital Anxiety and Depression (HAD) scale
Please read each group of statements carefully, and then pick the one that
comes closest to how you have been feeling in the past week. Write that
number in the box. Don’t take too long over your replies: your immediate
reaction to each item will probably be more accurate than a long thought-
out response.
Anxiety Depression
1 I feel tense or ‘wound up’:

0 Not at all
1 Time to time, occasionally
2 A lot of the time
3 Most of the time

2 I still enjoy the things I used to enjoy:

0 Definitely as much
1 Not quite so much
 2 Only a little
3 Hardly at all

3 I get a sort of frightened feeling as if something awful is about to

happen:
0 Not at all
1 A little, but it doesn’t worry me
2 Yes, but not too badly
3 Very definitely and quite badly

4 I can laugh and see the funny side of things:

0 As much as I always could
1 Not quite so much now
2 Definitely not so much now
3 Not at all

5 Worrying thoughts go through my mind:

0 Only occasionally
1 From time to time but not too often
2 A lot of the time
3 A great deal of the time

6 I feel cheerful:
0 Most of the time
1 Sometimes
2 Not often
3 Not at all

7 I can sit at ease and feel relaxed:

0 Definitely
1 Usually
2 Not often
3 Not at all

8 I feel as if I have slowed down:

0 Not at all
1 Sometimes
 2 Very often
3 Nearly all the time

9 I get a sort of frightened feeling like butterflies in the stomach:

0 Not at all
1 Occasionally
2 Quite often
3 Very often

10 I have lost interest in my appearance:

0 I take just as much care as ever
1 I may not take quite as much care
2 I don’t take so much care as I should
3 Definitely

11 I feel restless, as if I have to be on the move:

0 Very much indeed
1 Not very much
2 Quite a lot
3 Very much indeed

12 I look forward with enjoyment to things:

0 As much as I ever did
1 Rather less than I used to
2 Definitely less than I used to
3 Hardly at all

13 I get sudden feelings of panic:

0 Not at all
1 Not very often
2 Quite often
3 Very often indeed

14 I can enjoy a good book, or radio or TV

program:
0 Often
1 Sometimes
 2 Not often
3 Very seldom

Anxiety Depression

TOTAL
If you score 9 or more on the depression sub-scale, you are probably
experiencing depression. If you score 9 or more on the anxiety sub-scale,
you are probably experiencing an anxiety disorder. Higher scores (15 or
more on the depression sub-scale) may mean that a self-help book is not
suitable for you, and you may need to seek additional professional help.
There is a duplicate of this scale in Appendix 5.
Rate the impact of your problem on your life
The next step is to rate the impact of your problems on your everyday life.
On the page opposite we have provided a Disability Ratings scale which
asks you to rate the severity of your handicap in your life. There is also a
duplicate of this scale in Appendix 5. Use the Summary of HAD and
Quality of Life Scores table to record your results.
Defining your problem
Any attempt to solve a problem is only ever as good as the definition of
what you think the problem is. This is especially important in overcoming
depression because having a more accurate understanding of what the
problem is forms a large part of recovery. For example, a faulty definition
of the problem (for example, ‘not knowing what made me depressed’) leads
to solutions that become the problem (for example, ‘trying harder to find
out what made me depressed’). Viewing other people (‘my husband’) or the
situation you are in (‘being alone’) as the problem is also unhelpful as it
does not describe your reaction. Problem definition has two distinct steps:
first, a description of how you are thinking and feeling and the context in
which you experience these feelings, and, next, the way you react to these
experiences. You can define your problem and rate the severity of it on a
simple scale between 0 and 10, where 0 is not a problem at all with no
distress and fully able to function, and 10 is extreme distress and a virtual
inability to function in any area of life. You can then monitor the severity of
your problem at regular intervals to determine whether you are making
progress. Tim, whose case history was set out in Chapter 1, defined his
problems as below.
Disability Ratings
Please rate how far your problems have held you back in various areas of
your life in the past week. Circle the number that best describes how badly
you were affected:
a Because of the problems, my ability to work or study or my role as a
homemaker is affected.
(Note: please rate this even if you are not currently working; you are rating
your ability to work or study):

b Because of the problems, my home management (e.g. cleaning, shopping,

cooking, looking after my home or children, paying bills, etc.) is affected:

c Because of the problems, my social life activities (with other people, e.g.
parties, pubs, outings, visits, dating, home entertainment, etc.) are affected:

d Because of the problems, my private leisure activities (done alone, e.g.

reading, gardening, hobbies, walking alone, etc.) are affected:

e Because of the problems, my general relationship with my partner (e.g.

affectionate feelings, number of arguments, enjoying activities together,
etc.) is affected:

f Because of the problems, my sexual relationship (enjoyment of sex,

frequency of sexual activity, etc.) is affected:

Problem list Severity rating

 0–10

1 Feeling life is pointless for the past year after the 8

death of my mother, leading me to drink too much
and avoid my friends.

2 Believing I am worthless after I was made 7

redundant after 25 years with the same company,
leading me to avoid friends or have any social life
or get a new job.
In Tim’s case, drinking too much was a form of emotional avoidance.
Avoiding friends was a way of avoiding feeling depressed and having to
discuss his redundancy or bereavement. Using the box opposite, try to
make a list of all the problems you want to work on and put them in
order of those that cause you the most handicap first to those that cause
you the least handicap. You may decide later that some of these problems
are related and you can combine them.

Problem list Severity rating

0–10
1. ____________________________________________
____________________________________________
____________________________________________
2. ____________________________________________
____________________________________________
____________________________________________
3. ____________________________________________
____________________________________________
____________________________________________
4. ____________________________________________
____________________________________________
____________________________________________

Assessing the effect of thoughts and actions –

functional analysis
What you do in your life has effects on you, other people and the world
around you. To see how this works, you can do a functional analysis. You
will need to do one regularly to work out whether what you are doing is
helping you to achieve what you want in the long term. Doing such an
analysis is usually straightforward, and Tim’s history will give us an
example.
We described in Chapter 3 how there are some activities that you do
repeatedly because the immediate consequences tend to be rewarding and
take away painful thoughts or feelings. So in the following table, ‘A’ stands
for Activating Event (or trigger, also sometimes called an ‘antecedent’).
This describes the context in which the behavior or event occurs. It can be
either a specific event (for example, being criticized by your boss or being
ignored by a friend) or a general context (for example, your home being
untidy). ‘B’ stands for Behavior. This is what you do or how you react (for
example, escaping from the situation or trying to control feelings), and
includes what you do in your head (for example, ruminating, worrying, or
stopping thinking). ‘C’ stands for Consequences, or what happens next.
There are often immediate consequences as there is some pay-off which
makes the behavior more likely to occur again in the future (such as not
having a bad feeling) and unintended (or usually long-term) consequences
which cause many of the handicaps. Remember that unintended
consequences affect not only yourself but also other people.
Tim’s Functional Analysis

Activating event (the context of an Sitting down on my bed to have

event occurring) a cigarette.

Behavior (remember to include Lie on bed.

ruminating) Ruminate.

Consequences (immediate) which Feel comfortable.

provide a payoff. What happens
 next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the
long term) which cause handicap.
What effect does it have on
yourself and others? What effect
does it have on the context?
Feel more tired. Put off dealing
with real problems. Ruminate
more and become more self-
focused and depressed. Others
in my family become more
critical.

Now try your own functional analysis on a problem behavior or one that
habitually occurs.
Functional Analysis

Activating event (situation or

context of event)

Behavior (what you do including

ruminating, worrying and self-
attacking)

Consequences (immediate) which

provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause handicap.
What effect does it have on
 yourself and others?

Identifying your own ‘vicious flower’

It’s important to identify the factors that maintain the problem and keep it
going in a series of vicious circles that aggravate your experience of
depression. One way of depicting this is to draw a ‘vicious flower’ diagram,
in which the circling thoughts and responses that keep the depression going
look like petals on a flower. Below and on the next two pages are vicious
flower diagrams for the case histories of Tim, Emma and Jan from Chapter
1, showing how they respond.
Tim has identified a number of ways his depression is being maintained
on his vicious flower. He puts his response in the clear box, and the effect in
the shaded box. For example, he realizes that avoiding seeing his friends
means not only does he feel more isolated, but in the long term this may put
strain on some of his relationships, making his life less rewarding. He also
notices that spending time in bed ruminating about his problem, especially
about being treated poorly at work, really lowers his mood.
Tim’s vicious flower
 When you draw your own vicious flower the aim is to make connections
between what you do (clear boxes) when you feel depressed and the effect
(shaded boxes) of those responses. For example, spending more time in bed
is a common response to feeling depressed and may feel more comfortable
in the short term, but it will lead to you feeling more tired; sleeping poorly;
missing out on activities that are normally satisfying or pleasurable; more
difficulties with your friends or family, who may be critical or give up on
you; and feeling more depressed.
Emma’s vicious flower
Jan’s vicious flower
You can now fill in a vicious flower for your own problems (page 69).
There is also a duplicate of the vicious flower in Appendix 5. Complete the
boxes for your ruminating, avoidance and excessive behaviors, which all
have an effect on your experience of depression. This in turn has an effect
on others in your environment and reinforces your experience of
depression. Once you have identified the maintaining factors in the vicious
circles, then you will be able to make a plan as described in the next two
chapters.
Try to consider the effect of your actions on your:
mood
living conditions
sense of wellbeing
body (for example, sleep, diet)
relationships.
‘Behavior’ in this context includes ‘mental behavior’ such as ruminating
(‘If only …’) or worrying (‘What if …’). Feel free to add more petals on
your own flower.
6 Thinking About Thinking
We discussed in Chapter 3 how depression occurs when you fuse your
thoughts and feelings with reality. This makes your reality very unpleasant,
and a natural way of coping is trying either to escape from, or to control
unpleasant thoughts and feelings, consequently missing out on rewarding
life experiences. This chapter is about developing a different relationship
with your thoughts and feelings, so you can treat them as just thoughts.
Your life will be more rewarding when you truly accept your thoughts and
emotions because trying to suppress, or ‘fix’, them only makes them worse
and makes your discomfort grow into pain. This chapter contains a number
of practical exercises to examine your relationship with your thoughts.
Label your thoughts
You may have forgotten how to observe the process of thinking as you
become bound up with the content. The first step is to thank your mind for
its contribution to your mental health. Try to distance yourself from its
endless chatter and commentary and rating of yourself. This is a difficult
skill which will take time and practice in a number of different exercises
that we are going to describe.
You can label your thoughts as examples of a particular thinking style –
‘Oh yes, a very good example of catastrophizing’ (for more on the kinds of
labels you can give to different kinds of thoughts see Chapter 3.)
Another strategy is to label the thought or feeling by saying it out aloud
and writing it down. For example:
‘I am having a thought that the future is hopeless.’
‘I am having a memory of my mother ignoring me when I felt upset as a
child.’
‘I’m having the feeling that something terrible is going to happen.’
‘I’m making a rating of myself that I am worthless.’
Now try to complete the following for your own habitual pattern of
thoughts and feelings:
I am having a thought that (describe)
________________________________________________________
________________________________________________________
I am having a thought that (describe)
________________________________________________________
________________________________________________________
I am having a feeling of (describe)
________________________________________________________
________________________________________________________
I am having memories about (describe)
________________________________________________________
________________________________________________________
I am making a rating about (describe)
________________________________________________________
________________________________________________________
Labelling your thoughts may feel awkward at first, but with practice it will
help you to accept your thoughts or feelings without buying into them.
Some people find it helpful to speak their thoughts out aloud in a funny
voice, like a cartoon character. This can again help to distance yourself
from your thoughts and defuse them from your ‘self’.
The aim of all these exercises is to acknowledge the existence of such
thoughts and label them for what they are. In contrast to traditional CBT,
we don’t want you to challenge their content or try to sort them out. As you
gain more practice you’ll discover that you can experience unpleasant
thoughts and feelings and still do what’s important for your life anyway.
Keeping a record of your thoughts
Try making a list of all your recurrent depressive thoughts and feelings,
label them for what they are and make a note whenever they occur. Such
thoughts are more likely to appear in difficult situations. It can be helpful to
monitor them just to see which ones turn up in particular situations and try
to bully you. We don’t want you to do this repeatedly; just see what happens
over a few days. You should start to develop different ways of looking at
your thoughts without comparing, rating or judging yourself through what
you think. Emma made a tick on her chart when these thoughts occured:
A Thought-Monitoring Chart which you can photocopy can be found on the
opposite page (see Appendix 5 for a spare blank chart). The purpose of
monitoring your thoughts is not to challenge their content, or to control or
make them happen less often – it’s just to acknowledge them and to thank
your mind for its contribution. If your thoughts are very frequent, you might
find it easier to use some sort of counter and transfer the total at the end of
each day to your chart. You can also note the situations in which the
thoughts tend to happen most often and you can see if there is a pattern that
would be useful to know so that you can predict what will turn up and make
sure you are better prepared.
Watching your thoughts pass by
You have gathered by now that what we want you to develop is a sense of
distance from your thoughts and feelings. This means not buying into them
but being aware of them as a passive observer. To show you what we mean,
try closing your eyes and bringing to mind, say, a bowl of fruit; then watch
it without influencing it in any way. It’s okay if your attention strays away
from the orange on the top or if the image changes (for example, the orange
falls off the top of the bowl). You should merely be aware of the changing
content of your attention without influencing the content in any way. This
may not be easy at first, but it’s worth persevering. The technique of
distancing your thoughts can also be used just to notice your intrusive
thoughts and not to engage with them by ruminating.
Another example is to imagine your thoughts as cars passing on a road.
When you are depressed, you might focus on particular ‘cars’ that tell you
that you are a failure and life is hopeless. You cope by either trying to stop
the cars or by pushing them to one side (if you’re not in danger of being run
over, that is). Alternatively, you may try to flag a car down, get into the
driving seat and try to park it (that is, analysing the idea and sorting it out
until you feel ‘right’). Of course, there is often no place to park the car and
as soon as you have parked one car another one comes along.
Distancing yourself from your thoughts means being on the pavement,
acknowledging the cars and the traffic, but just noticing them, and then
walking along the pavement and focusing your attention on other parts of
the environment (such as talking to the person beside you and noticing
other people passing you and the sights and smells of the flowers on the
verge). You can still play in the park and do what is important for you
despite the thoughts. In other words, such thoughts have no more meaning
than passing traffic – they are just thoughts and are part of the rich tapestry
of human existence. You can’t get rid of them, just as if you are in a city
where there is always some slight traffic noise in the background and you
learn to live with it. Notice these thoughts and feelings and acknowledge
their presence.
An exercise
This exercise will help you to distance yourself from your thoughts. First,
get into a relaxed position and just observe the flow of your thoughts, one
after another, without trying to figure out their meaning or their relationship
to one another. You are practising an attitude of acceptance of your
experience.
Imagine for the moment sitting next to a stream. As you gaze at the
stream, you notice a number of leaves on the surface of the water. Keep
looking at the leaves and watch them slowly drift downstream. When
thoughts come, put each one on a leaf, and notice each leaf as it comes
closer to you. Then watch it slowly moving away from you, eventually
drifting out of sight. Then go back to looking at the stream, waiting for the
next leaf to float by with a new thought. If one comes along, again, watch it
come closer to you and then let it drift out of sight. Allow yourself to have
thoughts and imagine them floating by like leaves down a stream. Notice
now that you are the stream. You hold all the water, all the fish and debris
and leaves. You need not interfere with anything in the stream – just let
everything flow. Then when you are ready, gradually widen your attention
to take in the sounds around. Slowly open your eyes and get back to life.
Attention, attention
An important component of overcoming fusion between your thoughts and
reality is to increase your attention on the outside world. In the right
situation, it can be productive for your attention to be focused inwards, for
example when you are trying to solve a particular problem or come up with
a new theory of relativity. (However, we have never yet met anyone who
has had a ‘Eureka’ moment when they are depressed.) Spending a lot of
time going over problems in your mind only helps to stimulate stress on
your mind and body. Refocusing your attention onto the outside world gives
your brain a rest and a chance to heal.
You can monitor how self-focused you are at any given moment on a scale
of between –3 and +3, where –3 represents being entirely self-focused on
your thoughts and feelings or the impression you have of yourself, and +3
means being entirely externally focused on a task (for example, listening to
someone) or the environment (for example, what you can see or hear). A
zero would indicate that your attention is divided equally between being
self-focused and externally focused. We recommend you monitor how self-
focused you are, especially when you are alone, and if you rate yourself
frequently as a –3 or –2 to do a functional analysis of your self-focusing
attention. The key question is whether focusing your attention inwards
helps you to achieve the goals and valued directions you want. Most people
find that being self-focused causes them to dwell more on the past, and feel
more depressed, which in turn makes them more negative and likely to do
less and become more self-focused. So, it’s a better option to be less on the
‘outside looking in’ at yourself and more on the ‘inside looking out’ at the
world.
Retraining your attention
Attention training was devised by the psychologist Adrian Wells from
Manchester University. It has been shown to be helpful in depression and
some anxiety disorders for reducing self-focused attention in the long term.
It is a form of mental training, like going to a psychological gym and
getting your attention muscles in shape. It’s best to practise these exercises
when you are alone and not distracted. In other words, this is not a
technique to distract yourself when you feel upset or are ruminating – it
needs to be practised when you are alert and not especially distressed. In the
long term the training can help you to break the cycle of being self-focused
so that you eventually become more naturally aware of the world around
you. It may appear difficult at first but it is worth persevering and doing it
in small steps.
The exercise consists of collecting together about nine sounds that can be
heard simultaneously. Examples of sounds could be: the hum of a computer,
the noise of a water filter in an aquarium, a tap dripping, a radio at a low
volume, a hi-fi, a vacuum cleaner in a nearby room and the noise of traffic.
Label each sound – for example, sound number one, the hum of the
computer. Try to make sure that one or two sounds do not drown out the
others. Sit down in a comfortable chair, relax and focus your gaze on a spot
on the wall. You should keep your eyes open throughout the procedure. You
may experience distracting thoughts, feelings or images that just pop into
your mind during the exercise. This doesn’t matter – the aim is to practise
focusing attention in a particular way. Also, don’t blank any thoughts out or
try to suppress them while you are doing the exercise.
The exercise consists of three phases. In the first phase, focus your
attention on each of the sounds in the sequence in a sustained manner. Pay
close attention to sound number one, as if no other sound matters. Ignore all
the other sounds around you. Now focus on sound number two. Focus only
on that sound, again as if no other sound matters. If your attention begins to
stray or is captured by any other sound, refocus all your attention on sound
number two. Give all your attention to that sound. Focus on that sound and
monitor it closely and filter out all the competing sounds, because they
don’t matter. Go through all the sounds in sequence until you have reached
sound number nine.
Then move on to stage two. You have now identified and focused on all
the sounds. In this stage we want you to shift attention rapidly from one
sound to another in a random order. For example, you could go from sound
number six to number four to three to nine to one, and so on. As before,
focus all your attention on one sound before switching your attention to a
different sound.
Then move on to stage three. Expand all your attention, make it as broad
and deep as possible and try to absorb all the sounds simultaneously.
Mentally count all the sounds you can hear at the same time.
The exercise needs to be practised twice a day for 10–15 minutes. If
possible try to introduce new sounds on each occasion so you don’t get used
to them. We appreciate that this is difficult. Like physical training, it needs
to be practised repeatedly or your attention muscles won’t get bigger. You
will not feel the full benefit until two or three months of repeated practice.
Task-concentration training
It is also helpful to reduce your self-focused attention in specific situations.
This can be done by an exercise called task-concentration training,
devised by the psychologist Sandra Bogels in the Netherlands. In any given
situation, especially when you are feeling more anxious or withdrawn, you
can estimate your percentage of attention on:
yourself (for example, monitoring how you appear to others or trying
to sort out your thoughts)
your tasks (for example, listening or talking to someone or writing)
your environment (such as the hum of traffic in the background).
The three must add up to 100 per cent, but the ratio is likely to vary in
different contexts. When you are very self-focused, about 80 per cent of
your attention might be on yourself, about 10 per cent on the task you are
involved in and 10 per cent on your environment. Someone without
depression might normally focus about 10 per cent on themselves, 80 per
cent on the task and 10 per cent on the environment. This is an important
observation because it means you can train yourself to be more focused on
tasks and the environment and less on yourself. Every time you notice that
your mind is excessively self-focused, then immediately refocus your
attention onto the task or the environment. If you are on your own and have
no specific task to do, you will need to refocus on the environment and
make yourself more aware of:
the various objects, colours, people, patterns and shapes that you can
see around you
the sounds that you can hear
what you can smell
what you can taste (for example, in the case of food or drink)
 the physical sensations you can feel from the environment (for
example, whether it is hot or cold, whether there is a breeze, the
ground beneath your feet).
Every time you notice your mind’s endless chatter and focus on how you
feel, refocus your attention back to the task or the environment.
This training was originally developed to be done in a graded manner for
specific situations – for example, if you experience marked anxiety in social
situations. You can then practise the exercise for easier situations (for
example, listening to a friend telling you about their holiday) and the most
difficult situations (for example, being at a party with strangers).
Rumination, self-attacking thoughts and worry
Rumination, self-attacking thoughts and worry have many similarities as
they are all repetitive patterns of thinking that are linked to self-focused
attention.
The first pattern of thinking that you may be engaging in that will worsen
your mood is ‘ruminating’. Rumination is a wonderful word derived from
the description of the way cows or sheep naturally bring up food from their
stomach and chew the cud over and over again. It describes perfectly the
way a person thinks for long periods of time, brooding, and going over
something in their mind time and time again. Sometimes this kind of
thinking can be productive and creative in trying to solve an actual problem.
However, it is not productive when someone is ruminating as it involves
thinking too much about past events or questions that have no answers, and
trying to find reasons for the situation you find yourself in. People ruminate
because they are attempting to solve problems by trying to figure things out.
You may find you’re endlessly comparing yourself to others with self-
critical and self-attacking thoughts, for example ‘You are so stupid
compared to him’, ‘You just love wallowing in your misery don’t you?,’
‘I’ll give you something to really worry about’, ‘You need a good boot up
the backside’. Such thoughts tend to make you fall into submission and you
can end up feeling very small and pathetic.
Ruminating or self-attacking could lead to a number of unintended
consequences, such as:
feeling more depressed
thinking more about bad events from the past
believing thoughts when you criticize or put yourself down
being more pessimistic about the future
 being less able to generate effective solutions to problems and less
confident in the ones you do generate
becoming more withdrawn and doing less of what is important to
you
becoming more likely to be ignored by others.
When most people ruminate, it makes them feel worse and they are more
likely to avoid life. Incidentally, any counselling or psychotherapy that
encourages you to search endlessly for reasons for why you are depressed
has a lot to answer for as it can encourage you to ruminate.
By contrast, worry is thinking about all the possible things that could go
wrong in the future (also called catastrophizing – see page 37) which will
make you more anxious. Many people with ‘depression’ therefore
experience a mixture of rumination and worries depending on their mood.
When you are more depressed ruminations tend to focus on the past, with
‘Why?’ types of question, for example: ‘Why didn’t I save my
relationship?’, or ‘Why am I feeling this way?’ There are variations on this
theme, including fantasy thinking, which starts with ‘If only’, for example:
‘If only I could feel better’; ‘If only I could turn the clock back’. By
contrast, worries tend to start with ‘What if’ type of questions, for example,
‘What if my partner is bombed on the train today?’
Understand your ruminations, self-attacking thoughts and
worries
Now you can understand how difficult ruminations are to stop and how
powerful they are because they are pulled by emotions. However, they can
also be very harmful and we are now going to show you ways in which you
can begin to lift yourself out of the power of rumination.
The first step in understanding ruminations, self-attacking thoughts and
worries is to do a functional analysis on the process. Work out the
unintended consequences of your ruminating on a Functional Analysis form
(see page 82).
What effect does ruminating (including comparing, worrying or self-
attacking) have on the way you feel?
What effect does ruminating have on the time you can devote to
what is important in your life?
What effect does ruminating have on your environment or the people
around you?
Do you avoid anything in life as a result of ruminating?
 Do you do anything in excess as a consequence (for example, drink
more)?
How helpful is it to answer your questions or buy into your thoughts
in helping you to reach your goals?
Alternative directions for ruminating
The goal is to stop engaging in the content of your rumination or worries
and not respond to the incessant demands. Eventually you will be able to
stand back and observe your thoughts, not buy into them, and act in a
valued direction in your life.
Spot when, where and how often you ruminate
The first step is to monitor yourself to see in what contexts (times of day,
places and situations) you ruminate and how often you do it. You can do
this with a tally counter or a simple tick chart for whenever you ruminate
(use the same chart that you used for monitoring thoughts). Being more
aware of when you are ruminating allows you to change your behavior.
Functional Analysis

Activating event (situation or

context of event or ruminating)

Behavior (including ruminating,

worrying and self-attacking)

Consequences (immediate) which

provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause handicap.
What effect does it have on
yourself and others? What effect
 does it have on your thoughts and
feelings?

Valued directions What directions

could you take that would be in
keeping with your values and give
you better feelings?

Effect of valued direction What

effect does taking the valued
direction have on yourself, others
and the community in the long
term?

Interrupt your rumination and refocus

As soon as you have noted yourself ruminating or worrying, refocus your
attention outwardly on the real world and choose to do something that is in
your valued directions or on your activity schedule (see next chapter) that
takes you closer to long-term improvement in your mood. Then monitor
what effect taking the valued direction has.
Considerations about problem-solving
Problem-solving is appropriate only if the problem is current and exists in
the real world. For example, if your car has broken down and you have to
get to a job interview, you could ruminate on ‘Why does this always happen
to me?’ (and make yourself more frustrated and depressed) or ‘What if I
don’t get the job?’ (and make yourself more anxious). You can problem-
solve only if you can turn rumination or worry into a ‘How?’ question, for
example, ‘How am I going to get to the centre of town on time? I could ring
for a taxi, but that will be a bit expensive. I could get a train, but I might
now miss the one that would get me there in time. Getting this job is
important to me, so I’ll take a taxi.’ The most important point is to solve
only existing problems or ones that you do can something about (or if you
can practise for an event, and this is usually fairly limited). For example, if
you have an interview coming up, then ask a friend to do a role play and
practise being interviewed.
Be sceptical about ‘searching for reasons’
As has been emphasized earlier, a common preoccupation in depression is
to try to find reasons for why you are depressed. The problem is that this
type of enquiry takes your mental focus straight back into your mind
(usually looking over the past) again, whereas your aim should be to focus
on the ‘here-and-now’ outside world. If your ruminations help you to
achieve what you want (and this is very unlikely), then you can stop at this
chapter! However, if they make you feel worse or cause you to become
inactive or to do something else unhelpful, then read on. If you are not sure
whether your ruminations are helpful, keep a record of their frequency over
the next few days and fill in the Functional Analysis form. If you are still
not sure, try to alternate a period (for example a day) of ruminating extra
hard with equal periods of not ruminating at all and note the effect on your
mood and what you avoid.
Assumptions about ruminating and worrying
Sometimes people ruminate because of an intrusive thought. For example,
if someone you love has died then your mind keeps coming back to it.
However, in this case, the ruminating may be interfering with your ability to
experience the painful feelings that come with the loss. In this case, it’s
important to do a functional analysis and understand the unintended
consequences of your ruminating or response to your intrusive thoughts.
If you are struggling with trying to stop ruminating, it may be helpful to
understand your motivations about ruminating (or your ‘thoughts about
your thoughts’). What do you think the motivation is for your ruminating
and worrying? Examples of the motivation that people with depression give
are:
‘I can prepare myself for the worst.’
‘I can figure out where I went wrong and I won’t make the same mistake
again.’
‘If I don’t, it will let people who have hurt me off the hook.’
‘It means I don’t have to think about the bad things that are happening
now.’
People may hold positive motivations about worrying (for example, ‘I must
worry in order to think through all the possible things that could go wrong’)
as well as recognizing the negative consequences (‘If I worry then I will go
crazy and I won’t be able to think straight’). Not surprisingly, this brings on
a further state of anxiety and depression. Emotions will pull you into
rumination and self-focused attention and you have to break free. Learning
to distance yourself and break free from your emotions is tough and
requires a lot of practice.
What is your motivation for ruminating and worrying?
For example, ‘I can find out what made me depressed, so I can do
something about it’
1. ______________________________________________________
__
______________________________________________________
__
2. ______________________________________________________
__
______________________________________________________
__
3. ______________________________________________________
__
______________________________________________________
__
4. ______________________________________________________
__
______________________________________________________
__
What are your negative assumptions about ruminating and worrying?
For example, ‘Too much worrying will make me go mad and make me feel
more stressed’
1. ______________________________________________________
__
______________________________________________________
__
2. ______________________________________________________
__
______________________________________________________
__
3. ______________________________________________________
__
______________________________________________________
__
 4. ______________________________________________________
__
______________________________________________________
__
The types of question to ask yourself are:
Does this assumption or rule about ruminating help me in my goals?
Can this rule be made more flexible?
Does my assumption help me to follow the directions in life that I
want?
Is the cost of ruminating too expensive?
While I hold this assumption, do I become more depressed and do I
act in ways that are unhelpful?
For how long am I going to carry on with my solution?
Now decide whether holding on to such assumptions about your ruminating
is really helpful and whether you could try an alternative.
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Assumptions about self-attacking thoughts
People who are critical of themselves (feeling, for example, that they are
ugly, stupid, weak, or pathetic) might also have reasons for allowing
themselves to be bullied by their mind. It is often helpful to ask yourself:
what is my greatest fear if I give up criticizing and bullying myself?
Criticism can also act as a warning (‘If I don’t tell you how fat you are and
you don’t lose weight, then nobody will love you’). Sometimes self-
criticism can be triggered from a memory or be linked to one’s identity.
Examples of assumptions behind self-criticism in depression are:
‘If I don’t put myself down, then I’ll be arrogant.’
‘If I don’t get in first with criticism, someone else will.’
‘I attack myself so I can improve myself.’
‘I attack myself so I get the punishment I deserve.’
‘If I don’t criticize myself, I’ll get lazy.’
This sort of reasoning is probably an important factor in maintaining long-
standing depression and low self-esteem. You might like to consider the
costs and benefits of keeping up such a strategy.
Benefits of self-attacking thoughts
What do you think is your motivation or assumptions for self-attacking?
1. ______________________________________________________
__
______________________________________________________
__
2. ______________________________________________________
__
______________________________________________________
__
3. ______________________________________________________
__
______________________________________________________
__
4. ______________________________________________________
__
______________________________________________________
__
Costs of self-attacking thoughts
Does self-attacking make your mood worse? Does it help you achieve the
goals you have set yourself? Does it help you stick to your valued directions
in life? Is self-attacking something you would teach a friend or relative in a
similar position?
1. ______________________________________________________
__
______________________________________________________
__
2. ______________________________________________________
__
______________________________________________________
__
3. ______________________________________________________
__
______________________________________________________
__
 4. ______________________________________________________
__
______________________________________________________
__
Having identified what you believe to be the costs and benefits of self-
attacking, it’s a good idea to talk these ideas through with a friend or health
professional. Does it help, or is there an alternative to your strategy? You
might want to consider whether a different, more compassionate approach
could help you to achieve the goals you want in life. Compassion is putting
yourself in another person’s shoes and being able to understand their
emotional experience and to be moved by it. It means being non-judgmental
and sensitive to the distress and needs of your mind. Thus it is very
understandable for your mind to want to try and protect you and, for
example, prevent you from being arrogant or being rejected. However, there
are alternative ways of achieving the same goal. It may be helpful to talk to
someone about an alternative that does not lead you to feel more depressed
and to miss out on life.
7 Activating Yourself
This chapter concentrates on one of the keys to overcoming depression –
activating yourself. As we’ve shown earlier in the book, things you do to
escape, avoid, or control uncomfortable experiences in your mind may well
help to keep your depression going. By focusing on the effect of what you
do, you will understand how you can choose activities which bring lasting
improvement in your mood and make your life more satisfying.
The kinds of behavior to focus on
Some activities produce an immediate pay-off because they prevent bad
feelings. Examples are situations you avoid (seeing friends), things you put
off (opening mail) or activities you do excessively (watching television).
Activities such as ruminating are another form of avoidance. In the long
term, though, all these activities have unintended and unwelcome
consequences. You may feel worse than ever and the chance of
experiencing any pleasure or satisfaction becomes less and less. Activation
stops this spiral because activating yourself means acting against the way
you feel. You can make your life more rewarding by first identifying the
things you regularly avoid and then planning gradually to tackle them, as
described below.
Reservations about activation
It’s no surprise that many people are doubtful about the possibility that they
can become more activated. People who try it, though, usually discover that
it leads in the long term to a greater sense of control and satisfaction.
Normally, when you are tired you need rest. When you are depressed,
however, the opposite is true: you need to become more active. Not doing
much makes you feel lethargic and exhausted, and there is nothing to give
you a sense of achievement, which would in turn motivate you. In other
words, the more you do, the more you feel like doing. Activating yourself
also improves your ability to think and to get many of your problems into
perspective.
Understand your values
Before you set out on an activity program, you need to understand your
values or what you want your life to stand for. This is because when you
experience depression, your behavior is usually inconsistent with many of
your valued directions in life. This is very understandable, as you may be
trying to avoid painful thoughts and feelings.
 If you are going to do all this hard work to overcome your depression, it
needs to be done for something that is important to you, not for ‘activity’s
sake’, nor even just so you no longer feel depressed. It is therefore
important to know what your valued directions are so you can work towards
them.
To help you monitor whether in fact you are acting according to your
values, we have adapted the Valued Living Questionnaire from Steve Hayes
and Kelly Wilson, who have developed acceptance and commitment
therapy (ACT). There are various prompts for different types of values, or
‘areas’, for you to write down a brief statement (see pages 94–5). You don’t
have to fill in a values statement for every area; just leave it blank if you
think it is inappropriate. After writing down your statement for each area,
you may want to clarify them with a friend or therapist. Be careful not to
write down values you think you should have because they will be approved
by others. Write down only what you know to be true to yourself. It is
probably a valued direction if you have acted on it consistently before you
experienced depression. If you have been depressed for many years you
may struggle with this exercise, but please persevere because it is very
important.
Note that values are not goals – they are more like a compass, pointing in
a direction and must be lived out by committed action. Goals are part of the
process of committing yourself to action. Thus, getting married is a goal
but, with values, you never reach a destination as there is always something
more you can do to be a good partner or whatever direction you have
chosen. If your valued direction in life is to be a good parent, then the first
goal now might be to spend a few hours just hanging out with your son or
daughter or playing with them. Goals might be to get them through school
or college, as part of the valued direction of being a good parent. This does
not mean you will not fail at times – it means that, if and when you fail, you
can learn from it, take responsibility and restart the commitment to the
action. It might take some time to discover all of your values so, alongside
the questionnaire, here are some ideas to help you:
Imagine what aspects of life you would be engaging in if you were
not feeling depressed at this moment. We understand that you may
feel upset at the things you seem to have lost, but the exercise is
helpful to define where you want to chart your course towards.
 Brainstorm all the activities/interests you can think of and consider
which might be close to your valued directions.
Remind yourself of what you used to value or aspire to when you
were younger. Have any simply been ‘squashed’ by your mood?
Consider whether a fear of what other people will think or a fear of
failing might be holding you back from pursuing your valued
directions.
Consider a role model or hero, and the values they hold.
Have a chat with a trusted friend (or therapist) who knows you well
and see what they would guess your values to be.
Be prepared to experiment and ‘try on for size’ living consistently
with a given valued direction to see how it ‘fits’.
Emma, who we first met in Chapter 1, wrote down her values in the form
on pages 92–3. Read through her answers and then try to define your own
valued directions in life. Use the space below to make notes. There is a
spare blank copy of the form in Appendix 5.
Emma’s Valued Directions Form
Area Valued direction

1 Intimacy (What is important to you I want to be a good

in how you act in an intimate
relationship? What sort of partner do
you want to be? If you are not
involved in a relationship at present,
how would you like to act in a
relationship?)
partner and spend more
time with my husband,
eating together and going
out to see things together.

2 Family relationships (What is I’d like to be a good

important to you in how you want to
act as a brother/sister; son/daughter;
father/mother or in-law? If you are not
in contact with some of your family,
would you like to be and how would
you act in such a relationship?)
daughter and less
dependent on my parents
for support and to help
them more in the future.
I’d like to spend more time
with my brother, getting to
know him better.
3 Social relationships (What is
important to you in the way you act in
the friendships you have? How would
you like your friends to remember
you? If you have no friends, would
you like to have some and what role
would you like in a friendship?)
4 Work (What is important to you at
your work? What sort of employee do
you want to be? How important to
you is what you achieve in your
career? What sort of business do you
want to run?)
5 Education and training (What is
important to you in your education or
training? What sort of student do you
want to be? If you are not in
education, would you like to be?)
6 Recreation (What is important to
you in what you do to follow any
interests, sports or hobbies? If you are
not following any interests, what
would you ideally like to be
following?)
7 Spirituality (If you are spiritual,
what is important to you in the way
you want to follow a spiritual path? If
you are not, would you like to be and
what do you ideally want?)
8 Voluntary work (What would you
like to do for the larger community?
For example, voluntary or charity
work or political activity.)
I’d like to be a good
friend, more open and
available to my friends.
I’d like to go back to work
and be a more
approachable and friendly
boss and help to make it a
more successful company.
To improve my prospects of
securing a better job in the
future I’d like to take more
management and IT
training.
I’d like to take up playing
tennis and swimming
again. I might like to learn
to play a musical
instrument.
I’d like to learn more
about Buddhism.
I’d like to do more to help
others in a charity for
depression and raise
money for research.
9 Health/physical well-being (What I’d like to look after my
is important to you in how you act for body.
your physical health?)

10 Mental health (What is important I’d like to be better at

to you generally in how you act in managing my stress at the
your mental health?) end of the working day.

11 Any other valued directions that

are not listed above?

Valued Directions Form

Area Valued direction

1 Intimacy _________________________________________
(What is _________________________________________
important to you _________________________________________
in how you act _________________________________________
in an intimate
relationship?
What sort of
partner do you
want to be? If
you are not
involved in a
relationship at
present, how
would you like
to act in a
relationship?)

2 Family _________________________________________
relationships _________________________________________
(What is _________________________________________
important to you _________________________________________
in how you want
to act as a
brother/sister;
son/daughter;
father/mother or
in-law? If you
are not in
contact with
some of them,
would you like
to be and how
would you act in
such a
relationship?)

3 Social _________________________________________
relationships _________________________________________
(What is _________________________________________
important to you _________________________________________
in the way you
act in the
friendships you
have? How
would you like
your friends to
remember you?
If you have no
friends, would
you like to have
some and what
role would you
like in a
friendship?)

4 Work (What _________________________________________

is important to _________________________________________
you at your _________________________________________
work? What sort _________________________________________
of employee do
you want to be?
How important
to you is what
you achieve in
your career?
What sort of
business do you
want to run?)

5 Education _________________________________________
and training _________________________________________
(What is _________________________________________
important to you _________________________________________
in your
education or
training? What
sort of student
do you want to
be? If you are
not in education,
would you like
to be?)

6 Recreation _________________________________________
(What is _________________________________________
important to you _________________________________________
in what you do _________________________________________
to follow any
interests, sports
or hobbies? If
you are not
following any
interests, what
would you
ideally like to be
following?)
7 Spirituality _________________________________________
(If you are _________________________________________
spiritual, what is _________________________________________
important to you
in the way you
want to follow a
spiritual path? If
you are not,
would you like
to be and what
do you ideally
want?)

8 Voluntary _________________________________________
work (What _________________________________________
would you like _________________________________________
to do for the
larger
community? For
example,
voluntary or
charity work or
political
activity.)

9 _________________________________________
Health/physical _________________________________________
well-being _________________________________________
(What is
important to you
in how you act
for your
physical
health?)

10 Mental _________________________________________
health (What is _________________________________________
 important to you _________________________________________
generally in
how you act in
your mental
health?)

11 Any other _________________________________________

valued _________________________________________
directions that _________________________________________
are not listed
above?

What are you avoiding?

The next step is to consider what you are avoiding. Below is a list of
activities most commonly avoided or done excessively by people who are
depressed. These items are drawn from a questionnaire reproduced with
permission from Nicole Ottenbreit and Keith Dobson, who are
psychologists in Canada. Tick the statements which apply to you. When
you tick an item, think of a concrete example and do a functional analysis
on the action (use the form on page 82). Think of a specific situation in
which it was relevant and work out the immediate effect and the unintended
effect on yourself, others and the environment around you. Don’t confine
yourself to this list. There may well be other situations or activities you are
avoiding (use the spare copy in Appendix 5). Later in this chapter you will
use this information to plan your activities.
Cognitive and Behavioral Avoidance Checklist
I avoid social activities
I make excuses not to attend social events
I ignore the phone and texts or emails from friends
I limit myself to events where the people are familiar
I tell myself that I prefer to be alone
I leave social gatherings early
I keep to myself or stick to someone I know at a social gathering
I avoid socializing with people of the sex to which I am attracted
I have reduced or stopped my leisure activities (for example,
visiting pub, cinema, theatre, club, restaurant, gallery, football
match)
I have reduced or stopped solo hobbies (for example, fishing,
playing a musical instrument, DIY, reading, painting, gardening,
running)
I do not take as much care of myself as I used to (for example,
washing, hair care, regular clean clothes and sheets)
I have reduced or stopped paying attention to my role as a
parent/partner/son or daughter
I have reduced time spent cooking and live on junk food
I have given up tidying or cleaning my home
I have stopped opening or replying to letters, and paying bills
Instead of acting as a good student or employee, I accept what I
think are my limits at school or at work
I am not following up what I want to achieve at college or work
I am sticking with the things I know rather than developing new
interests (whether at college or work or in my spare time) where I
may fail
I quit activities early where I feel that they are too challenging
even though others do not agree with me
I try not to think about problems in any of my relationships but just
let things go on as they are
I do not think about what I really want in life
I avoid communicating with my partner/parents/children
I am not getting serious about college or work
I am trying to find a reason for the way I feel
I am constantly thinking about why I acted in the past in the way I
 did
I am trying to answer ‘What if?’ questions in my mind
I am turning down opportunities to further my education or career
I am fantasizing ‘If only’ situations (for example, if only I had not
acted in the way I did, or if only such and such had not happened)
I avoid making important decisions about my future
I distract myself when I think about work or education, or my role
as parent or partner

The following are relevant only when you do them excessively to stop
yourself thinking or to numb yourself emotionally or to avoid doing
something else
I comfort eat or binge-eat
I watch excessive amounts of TV
I listen to a vast amount of music
I spend a large part of my day on the computer/Internet
I binge-drink alcohol
I stay in bed in the morning or have frequent naps in the day
I exercise excessively
I use illegal substances

Raising your awareness

The next step is to find out exactly what you do in your everyday life and
how long each thing takes. If you assume you already know, you may be
surprised to find how much of what you do is automatic and done without
conscious intent. Through looking closely at what you are actually doing
day to day, you may also become aware of habits that are contributing to
your depression. Tim thought that he was doing very little, so it was
interesting for him to find that his activity level was higher than he had
predicted (see page 99). He also saw some variation in mood. However,
what he did notice was that it did not relate to his valued directions in life
and there was very little in the way of pleasurable activities.
Using an activity schedule
An activity schedule is a timetable of your activities during a particular time
period – an afternoon, a day, a week, or even several weeks – which is
useful for recording what you do, understanding the effects of it, and
planning and structuring for the future.

Tim’s Daily Activities Record Sheet

Day/date:

Time Activity Time Activity

7am Sleeping 4pm Frank called but I avoided his

call

8am Sleeping 5pm Did some washing up

9am Awake in bed 6pm Went out to the shop

10am Awake/Dozing in bed 7pm Cleared away a few papers

11am Watched TV 8pm Made myself some dinner

12pm Went out to shops 9pm Watching TV

1pm Watched TV 10pm Watching TV drinking wine

2pm Played on the 11pm Watching TV drinking wine

computer

3pm Computer 12am Bed

Using your activity schedule you may:
record your current level of activity and use it as a reference point as
you build up your activation
 look at your current activities and do a functional analysis to find out
the effect each activity is having on your mood in the long term. This
will improve your understanding of how what you do influences how
you feel.
record what you are doing and then review the extent to which you
are ‘stuck’ in a narrowed range of activities. Are you avoiding some
activities and overdoing others?
understand the extent to which your behavior reflects what is
important to your life. To what extent does you activity schedule fit
with your valued directions in life?
Recording your time
Use the Daily Activities Record Sheet opposite to keep a detailed record of
what you do and how long it takes over the next few days and then link
each activity to how you were feeling at the time. Rate the severity of your
depression on a simple scale between 0 and 10, where 0 is not depressed at
all, and 10 is extremely depressed. The chart does not have to be ‘perfect’
but it will help you if you can manage some details. Copies of the Daily
Activities Record Sheet can be photocopied and can be found in Appendix
5.
Analysing the results
Now bring together the results of all your analysis and activity schedules.
Review the avoidance checklist: This provides an overview of the
activities that you are avoiding or not taking seriously, or are doing
excessively. Now consider alternatives to what you are avoiding or
activities such as ruminating and watching excessive amounts of TV.
Review your activity schedule over the past few days: Can you
now identify situations, activities, thoughts or feelings which you are
avoiding or trying to escape from or to control that keep you feeling
depressed? If you are not sure, do functional analyses (that is, work
out the immediate and unintended consequences) on some of the
activities to find out whether they are helpful or not. How does your
recorded activity level compare to your perception? Are you more
productive than you realized, or doing more/less of a particular
activity than you had thought?
Review your valued directions form: What activities that are
important to you have you set aside that you want to introduce or do
more of?
 What pleasurable activities are you missing out on?: These could
either be activities that you used to enjoy or that soothe you.
Soothing might include having a long bath; having a massage;
walking in a wood or along the beach; taking in pleasant smells;
drawing or painting; listening to your favourite music; listening to a
recording of the sound of water falling, birds at sunrise, or sounds in
a jungle; going to a spa for the day; or doing random acts of kindness
to others.

Daily Activities Record Sheet

Day/date:

Time Activity Time Activity

7am 4pm

8am 5pm

9am 6pm

10am 7pm

11am 8pm

12pm 9pm

1pm 10pm

2pm 11pm

3pm 12am

Planning your activities and setting goals

You should now have a good idea of your own patterns of avoidance,
escape and control and what you are missing out on in life. Try making a
detailed list of goals that will incorporate activities which
 relate to the problems that you identified in Chapter 5
you have cut down on or avoided since you became depressed.
Remember ‘activities’ include making decisions or planning (for
example, thinking about the steps you need to take to improve your
education or career)
you would like to start or do more of because they are important to
you
are alternatives to activities that you wish to limit or stop (for
example, excessive drinking, sleeping, comfort eating, exercise or
illegal drugs).
It’s a good idea to start with short-term goals, which are easier to tackle,
and set yourself a realistic timetable by which you intend to move on to the
next set of goals. Try to identify one or two goals from the activities you
have avoided and which are in your valued directions and introduce them
on a daily basis. Here are Tim’s goals which relate to the problems
identified earlier.
Tim’s goals
Short term
1. To stop drinking altogether
2. To answer the phone and new emails
3. To telephone my friends Frank and John and suggest we go out
for a coffee
4. To prepare a shopping list and go to the market
5. To cook myself meals
6. To tidy my home
7. To visit my father at least once a week
Medium term
1. To resume my social life by meeting up with Emma
2. To resume my saxophone practice four times a week
3. To return to studying
4. To clear out my mother’s belongings and sort out her will
5. To visit my mother’s grave
6. To regularly go for a walk in the local woods
Long term
1. To be a good partner for someone
2. To get a new job
 3. To keep up routines and systems to help me stay on top of
household chores
Try to make your goals as specific and realistic as possible so you can put
them in your activity schedule. Some people with depression have forgotten
what is normal and may set themselves goals which are unrealistic. A rule
of thumb is to try to revert to how you used to behave before you developed
depression but in a gradual manner. Your list should help you to follow
your valued directions in life as you leave behind your habits of avoidance
and excessive control. There is a spare Goals form in Appendix 5.
You will need to repeat this for goals in the short, medium and long term.
You can then monitor your progress towards your goals on a scale of
between 0 and 10, where 0 is no progress at all towards the goal and 10
means that the goal has been achieved consistently and sustained constantly
in your activity schedule. Remember to make your goals relate to your
valued directions in life and to what you have been avoiding.
Some activities in your medium term may need to be broken down into
smaller steps and require more forward planning – for example, a visit to a
concert in a few weeks might involve booking a babysitter, getting tickets
and agreeing where and when to meet up with a friend. Long-term goals
(for example, getting a new job) may require a number of detailed steps
(such as preparing your CV, talking to a career counsellor or someone in a
personnel department and reading advertisements). All these elements need
to be part of your goals and plan.
The next step is to put these goals and activities into your Planned
Timetable (see Appendix 5 for a spare copy). Start with the short-term goals
and act as if you have a series of appointments that you have to keep so that
you do not let yourself down. You might also need to bring order to the
chaos of your eating and sleeping habits (after reading Chapters 12 and 13)
by timetabling roughly when you plan to get up, buy food, cook and eat.
All this may seem overwhelming at first, but it’s important to introduce
new activities, that you have previously avoided or are in your valued
directions, gradually.
On page 106 there is an example from Tim’s Planned Timetable for the
day.
Goals
Progress rating (0–10)
Short term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________
Medium term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________
Long term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________

Tim’s Planned Timetable

Day/date:

Time Planned Actual What was Did it contribute

activity activity the effect of towards my goals
what I did and valued
on my directions in life?
emotions or Rate it from 0–10
the context where 0 is not at all
in which I and 10 is extremely
live?

7am
8am Get up by Got up at Felt pleased 6
8.30 9.15 as earlier
than usual

9am Have Had Felt OK 6

breakfast breakfast a
little later
than
planned

10am Go for Did go and Feels odd to

short walk get paper be outside
to get but more
paper awake

11am Spend 20 Surfed the Ok at the 2

minutes Internet time,
on the looking for afterwards
Internet new games depressed
looking to play and
for jobs other
rubbish

12pm Games on As above As above 6

the Ate lunch
computer at 12.30

1 pm Have a Watched Low 2

sandwich, TV
a bag of
crisps and
an apple
for lunch

2pm Watch TV Watched Low 2

for an TV
hour
3pm 3.30: As Slightly 7
Have cup scheduled better
of tea and
a banana

4pm Spend half Spent 15 More in 5

an hour Minutes touch with
reading reading the world
the paper for
newspaper as long as I
could
concentrate

5pm One hour Took myself Tired but 7

on the out for more relaxed
computer walk early
and
managed
over an
hour

6pm Go for a Made pasta OK 7

walk
around the
block for
20
minutes

7pm Make Watched OK

myself TV
some
dinner

8pm Rang Sam, Bit more 8

spoke for alive
about 10
minutes
 9pm Ring Sam Watched 0
or Carlo TV Had
bath

10pm Have a Watched Restless 0

hot bath DVD Had
2 glasses of
wine

11pm Go to bed,
read for
20
minutes
and then
go to sleep

12– Went to bed Tired

7am

The golden rules of behavioral activation

If your BA is to work, you will need to follow these guiding principles.
1 Build up gradually from where you are now; don’t ruminate on what
you ‘should’ be doing.
When you approach changes in your activity level, it’s a major mistake to
focus on all the things you think you should be doing. These might include
household chores, work tasks, social events, academic work, family
responsibilities, hobbies and so on – a daunting enough list for anyone and
probably overwhelming for someone with depression. Instead, choose your
activities carefully and aim for small changes to begin with, building up the
level of activity gradually towards your goals.
2 Relate your plan to your analysis
Don’t fill your day with activity just for the sake of doing stuff. Make sure
your activities relate to what you are avoiding and that you are acting in
your valued directions in life. After completing a difficult task, reward
yourself with tasks that are soothing and pleasurable.
3 Keep going in the right direction
If you want to climb Everest, you have to stop at various camps. Each time
you set out, your goal is to reach your next camp, not the top of the
mountain. On your route, you will carry a compass, which points you in
your particular direction (north, for example). You never actually reach a
destination with this compass; it just keeps pointing the way forward. Once
you have climbed all the way up Everest, you will use your compass for the
next journey (climbing down!). Thus if your valued direction in life is to be
a good parent, for example, then ‘base camp’ might be to spend a few hours
just hanging out with your son or daughter and playing with him or her. The
‘top of Everest’ might represent getting them through school or college.
Your support probably won’t finish there, though, and you can incorporate
further actions in your plan which will contribute to your desire to continue
as a good parent.
4 Incorporate a range of activities
In this book we cover a number of areas of activity relating to depression,
including sleep patterns, diet, and exercise. It might, for example, be
beneficial to set a time to get up each day to help regulate your sleep. You
might also need to schedule in rest periods that do not involve going to bed
and sleeping, to help you gradually build up stamina. Planning what, when,
and where to eat might help you to rebuild a healthier eating pattern. You
need to consider a full spectrum of activities in your activity schedule to
help yourself become physically and psychologically healthier, and get your
life on course in the directions you prefer.
Each day, try to set aside some time to plan your activities for the next day
or week. Use a different sheet for each day and keep a record as you go
along of what you actually do. As you go on, you’ll be able to decide
whether something worked or not and modify it accordingly.
Carrying out your plan
1 Focus on the moment
As you undertake each activity, focus on the moment and the process of
what you are doing. If your mind wants to chatter away negatively, just
notice it and thank your mind but don’t buy into the thoughts. For example,
if you are cleaning and tidying your home, it’s better to focus your attention
on moving the vacuum cleaner around and the dirt being vacuumed, rather
than listening to yourself saying: ‘The place is such a mess’ or ‘If people
could see how I’ve let things go, they’d be so shocked’. Experience the
world as it is now rather than how you believe it should be.
2 Don’t let your thoughts get in the way
Your mind will tell you that there’s no point in trying anything because: (a)
you won’t enjoy it; (b) you’ll mess it up and make a fool of yourself; (c)
nothing you can do will make any difference; or (d) you’ll end up feeling
worse. You can learn to expect this from your mind and quietly ignore your
mental chatter. Feeling like you’ve no ‘get-up and go’, coupled with a sense
of ‘what’s the point’, is a central experience when you are suffering from
depression. Buying into your thoughts for being ‘lazy’, ‘good for nothing’,
and ‘useless’ only serves to compound the problem by lowering your mood
and leading to inactivity. You may want to reread Chapter 6 on ‘Thinking
about Thinking’ to understand how you may be fusing your thoughts with
reality.
3 Be compassionate and understanding
Activity can be difficult when you are feeling depressed and you’ll find that
you still have ‘bad’ (less active) days during your journey to reclaiming
your life. Try to act like an encouraging friend or trainer rather than a
negative and unhelpful critic.

Planned Timetable

Day/date:

Time Planned Actual What was the Did it contribute

activity activity effect of what I towards my goals and
did on my valued directions in life?
emotions or Rate it from 0–10 where
the context in 0 is not at all and 10 is
which I live? extremely

7am

8am

9am

10am
 11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm

9pm

10pm

11pm

12–
7am
Acknowledge the pain in your life. Life can be full of suffering, but it is
how we respond that is important.
4 Plan, plan and plan again!
Keep on planning on a daily, weekly and monthly basis – even if you don’t
stick entirely to your plan, you can get yourself back on track rather than
giving up because you experience thoughts like: ‘I’ve blown it so I might as
well go back to bed!’ Label this as a thought that you can quietly thank your
mind for and then ignore.
Monitoring the effect of your scheduled activities
As you go through the week, note on your activity schedule exactly what
you did (including times when you didn’t follow your plan).
1. Rate what emotions were associated with each activity, marking the
intensity from 0 to 10 where 0 is not at all distressing and 10 is
extreme distress.
2. Recognize how much the action contributes towards your goals and
your valued directions in life. Evaluate the effect on yourself, on
those around you and on the environment. Rate the action on a scale
between 0 and 10, where 0 is it did not contribute at all and 10 is it
contributed in full.
This will help you to:
see an increased range in your behaviors
appreciate changes in your mood
assess areas that you are still avoiding or activities you are still over-
using to block out problematic or painful thoughts.
Reviewing your activity schedule
Once you’ve completed activity scheduling for a few days (it doesn’t have
to be a week), look over your completed activity schedule to see how you
can continue to build your activation. For example, if you didn’t manage
many of your planned activities you might need to plan fewer of them for
the next few days and then build up. If you’ve spotted ongoing avoidance
activities, do the extended ABC functional analysis (see opposite) to be
clear of their effect and target them for change by working out an
alternative direction that would be in keeping with your values.
Functional Analysis

Activating event (situation or

context of event)

Behavior (including ruminating,

worrying and self-attacking)
Consequences (immediate) which
provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause handicap.
What effect does it have on
yourself and others? What effect
does it have on your thoughts and
feelings?

Valued directions What directions

could you take that would be in
keeping with your values and give
you better feelings?

Effect of valued direction What

effect does taking the valued
direction have on yourself, others
and the community in the long
term?
8 Overcoming Obstacles to Activating
Yourself
Knowing how to approach and work through a problem like depression is
only part of the battle. Reading this book in itself will have little effect on
your life, but repeatedly and consistently applying the principles in it should
help to move you in your valued directions and help you have better
feelings. You may know in your mind what you need to do but nevertheless
have problems putting that knowledge into action. These obstacles may
arise from feeling scared or from your mind’s reluctance to experience
unpleasant thoughts and feelings. This is understandable, and people who
identify these obstacles and decide to act despite them can be very effective
in changing their lives around. So when you get to the end of this chapter,
please take some time to consider your mind’s reservations and ‘blocks’
(without ruminating on them!) Then do a functional analysis of the way
your mind prevents you from acting in your valued directions. We discuss
below the most common traps to activating yourself.
The comfort trap
If you’re a big fan of hiding under your duvet or sitting in front of your TV
there’s a chance that you are caught in the ‘comfort trap’ of trying to avoid
uncomfortable feelings. The comfort trap can be a big obstacle in
overcoming depression as it tends to reduce your activity and interfere with
you achieving your goals, which in turn will reduce the chances of your
mood improving. The most common types of comfort trap are:
avoiding situations which are difficult or uncomfortable, such as
exercise, chores or seeing people
procrastination – putting off the uncomfortable process of doing the
things you are avoiding.
Unfortunately, this means being left in the very uncomfortable position of
living with depression in the long term. The solution is always to act
according to your plan – not according to how you feel. People get caught
in the comfort trap when their mind says any of the following things to
them:
‘I’ll do it when I feel motivated’: It is common in our culture for
people to say they’ll wait until they feel ‘motivated’. Unfortunately,
this doesn’t work with depression, and the longer you wait, the
greater the chance that you will become even less motivated. This
also has consequences for the people around you as their irritation
mounts and they begin to give up on you. There is a simple way to
break through this block: whatever it is that you have been avoiding,
start doing it in an unmotivated way. For example, if you have a
difficult letter to write or an essay to hand in, write down anything to
do with the topic to get yourself started – you can always delete it
later. This is because changes in your behavior (‘just doing it’) lead
to differences in the way you think and feel which in turn increase
your motivation and change the way people see you.
‘I’ll do it when I feel like it’ or ‘I need to feel better first, then I’ll
do it’: This is also putting the cart before the horse. Act first, then
your depression will improve. Just do it, despite the fact that you
don’t feel like it.
‘I need to build up my courage and confidence before I can do
it’: This is yet another example of putting the cart before the horse.
If you can get yourself to take that first step, however unconfident
you are, you will find that your confidence and courage start to
build.
‘Activating myself is too much like hard work, I’ll wait for my
medication to kick in’: Although medication can help many people,
it may or may not ‘work’ and will not necessarily ‘cure’ you totally.
Without changing the way you act and developing a different
relationship with your thoughts, you really aren’t giving your
medication much of a chance. If you’ve been taking an
antidepressant at a standard dose for six weeks or more without
seeing significant improvement, then you are more likely to need a
psychological treatment program such as the one we have described.
If you have to try a series of different medications, then your chances
of recovery with medication alone become less and less.
Furthermore, if you are already taking medication you can probably
improve your results if you combine it with activation. The
discomfort of taking action is hard but, if you do nothing about your
depression, your life will get harder.
‘I need to find an easier solution’: Activating yourself is hard
work, but not half as hard as living with depression. There is no
easier solution: if there were, we would have told you about it.
 ‘I can’t possibly set aside enough time to work on my depression;
it’ll interfere with my life too much’: If you don’t set aside enough
time to work on your depression, your depression will interfere with
your life too much.
‘If change doesn’t come naturally or easily then it’s not genuine,
and I’m just play-acting a part’: If you continue to adopt this
attitude your depression will persist. Change does not come naturally
or easily. Acting against the way you feel is a temporary state while
you overcome your depression.
The guarantee trap
The guarantee trap stems from attitudes like:
I must be certain that the approach will work before I put in so much
effort
I have to be certain that I won’t make myself worse by trying out the
principles
I must be sure that I can get this right, I couldn’t bear failing.
Of course, there are no guarantees that following the principles we’ve
outlined in this book will work for you, but there is an excellent chance that
they will. On the other hand, taking no action to challenge your depression
is fairly sure to prolong it. A fear that making changes will worsen things is
common, especially among people with longer-term problems. Try to treat
activation as an experiment: observe the effect on your mood as well as on
your life and on your environment. Remember, you can always go back to
your old patterns of thinking and behavior if you decide that they were
better in the long term.
Pride
Pride is said to come before a fall, but it can also be an obstacle to
overcoming depression, and can cause people to resist approaching their
depression differently because they are afraid to lose face. Pride in this
sense is usually linked to shame, and is usually a ‘compensatory strategy’
aimed at avoiding having the feelings of shame you might experience if you
accept that the way you’ve been trying to cope with your depression has
been less than ideal. There is no shame in this. Debate still rages between
doctors and therapists as to the best way to help people overcome
depression. The defensive trap of unhelpful pride stems from attitudes like
these:
 ‘If I start activating myself, my family and friends whom I’ve
asked for help to do the activities I have avoided will think I’m a
fool’: They are more likely to think your behavior is foolish if you
don’t attempt to activate yourself (especially when you’ve learnt
from this book what you can do).
‘I should resist attempts to change otherwise it feels like they’ve
won’: If you don’t change yourself, the depression has won and is in
control.
‘I didn’t do anything to deserve being treated in the way I did’:
Let’s suppose you were mistreated by someone close to you. It’s a
fact, and you have reacted by becoming depressed. There are other
ways of reacting, for example being disappointed and deciding this
was someone you really wanted in your life – then moving on. You
may not have realized that it was possible to respond in this manner.
After reading this book, you have a choice and can act against the
way you have reacted.
‘The principles of activating myself are too simple and since I’m
basically an intelligent person, I should be able to work out how
to get rid of my depression without any advice’: The principles of
activating yourself may be simple, but the implementation is hard.
This is another rule your mind has adopted to avoid unpleasant
thoughts and feelings.
‘It’s ridiculous to suggest I can do more to help myself – if I
could do that I would have done so years ago’: It’s rare for
someone with depression to just stop avoiding what they do. First,
you need knowledge about how to activate yourself, then you can
gradually implement a program of change.
The ‘if only’ trap
Like the comfort trap, the ‘if only’ trap stems from the idea that certain
conditions must exist before you can activate yourself. An example that
often arises is when someone with depression remarks to another person ‘If
only I was depressed about what you’re depressed about – I’d have no
problem overcoming that.’ But thoughts have personal meanings and
associations for each individual, so if you don’t share the meaning, you
couldn’t have the distress.
The ‘yes but’ trap
‘Yes but’ is a similar trap to ‘if only’. You may have lots of reasons why
you can’t do something (for example, ‘I would like to go out but I feel
down’). This is the same as thinking ‘I’ll do it when I feel better’ or more
motivated, or whatever. By saying ‘but’ in the first part of the sentence you
avoid following your valued direction. Ask yourself what would happen if
you replaced the word ‘but’ with ‘and’. ‘I would like to go out and I will
feel down’. You can do it and carry the unpleasant thoughts and feelings
with you. How many opportunities will open up if you do this?
The ‘to be the on the safe side’ trap
Take a long look at what are your biggest problems in your life. The
chances are that your depression is at the top of your list. However, one of
the attitudes that can keep your depression alive is the idea that it’s better to
‘be on the safe side’, or ‘err on the side of caution’. This may be one of the
styles of thinking that made you vulnerable to depression and anxiety in the
first place. This style of thinking is not doing you much good if you apply it
to activating yourself, as it will probably guide you towards falling short of
enough risk-taking to overcome the problem. If you want to err on the side
of caution, err against your depression. If you know you have a tendency to
be over-cautious steer towards more tolerance of uncertainty and risk.
The perfectionism trap
Some people believe that there is a perfect solution to everything; that
doing something perfectly is possible and necessary, or that even minor
mistakes have serious consequences. This leads to beliefs such as ‘failing
partly is as bad as failing completely’. This may then lead to changes in
behavior that are counterproductive. An example is spending hours
correcting a document so you can feel it is just so’ rather than ‘good
enough’ and losing sight of the actual goal to be achieved. Control and
perfectionism are common features of depression in individuals with a
desire for control and order. The main style of thinking in perfectionism is
black and white rather than shades of grey. The problem might be your
mind telling you that you absolutely must reach the highest standard all the
time or you are an utter failure. A healthy goal would be striving to
complete something to a high standard while accepting that you may
sometimes fail. Waiting until you have a perfect understanding of the
treatment principles can lead to long delays in getting started.
Perfectionism can result in thoughts like the following:
 ‘Since there’s a chance that I might carry out the principles of
activating myself wrongly I must think about them and talk them
over with someone qualified until I’m absolutely certain I won’t
make a mistake’: The problem is that attempting to activate yourself
‘perfectly’ is an exercise for making yourself more depressed and is
therefore doomed to failure. Instead, aim for a ‘good enough’
understanding and do what you think is probably the best thing.
The ‘I’ve tried it all before’ trap
Some people with depression reading this book will have made previous
attempts to overcome their depression with BA or CBT without managing
to overcome it fully. A psychologist once pointed out that when BA or CBT
fails it’s much more likely to be the way it was applied that was the problem
rather than the individual being ‘untreatable’. We often meet people who
have tried to activate themselves, but discussion reveals that their
activations were too short, or that they didn’t truly stop avoiding, or that
they did more ruminating.
There is no good reason to assume that because you haven’t managed to
overcome your depression in the past you couldn’t do it successfully now.
On the contrary, there is a good chance that you have useful experience to
bring to the process, and in fact this may give you an advantage over
someone who has never tried activation before, so long as you approach it
with an open mind and a strong commitment to tolerate your thoughts and
feelings and not to respond to them.
The trap of ‘having a good reason to be depressed’
This final obstacle to breaking free from your depression is an interesting
one. It’s the idea that you are depressed because you have ‘good reason’.
You may assume that, given the degree of loss, hardship, failure, or let-
down you have experienced, anyone would be depressed – it’s inevitable.
For example, Camilla’s husband had run off with a younger woman and left
her with two children to bring up. She felt that her circumstances gave her a
very good reason to be depressed and led her to ruminate on how unfair life
was. She had become very inactive and withdrawn.
If you think you have a good reason, try listing your ‘good reasons’ for
being depressed, and rate how ‘good’ a reason each is on a scale between 0
and 100, where 0 is not a very good reason and 100 is the best reason ever.
1. ____________________________________________________
2. ____________________________________________________
 3. ____________________________________________________
4. ____________________________________________________
The interesting thing about having a ‘good reason’ to be depressed is the
implication that there are ‘bad reasons’ to be depressed. Now try listing
some ‘bad reasons’. Your list might include the war in Iraq, the poverty and
torture in Zimbabwe, England losing in the World Cup, or the weather
being dreadful. Again, rate each one on a scale between 0 and 100, where 0
is not a very bad reason and 100 is the worst reason ever.
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
4. ____________________________________________________
We hope you see that there are no really good or bad reasons for being
depressed – being depressed is being depressed. Be compassionate and
understanding to yourself about being depressed. Certainly accept feeling
sad about negative events – this is a normal human reaction. However,
don’t stop trying to adapt to circumstances, maximizing your support and
getting on with your life in your valued directions.
Identifying your traps
Have you identified any particular traps among the reasons your mind is
giving you for not activating yourself or sticking to your plan?
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
What are the immediate consequences of buying into these traps?
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
What are the unintended consequences of buying into these traps?
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
What will you now do?
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
9 Understanding Self-harm and Suicide
Thinking about suicide is extremely common when you are depressed, but
fortunately most people who have suicidal thoughts do not go on to end
their lives. Tragically, some people become convinced that their situation is
hopeless and attempt to end their lives. It’s also not unusual for people with
depression to harm themselves physically, but without intending to die, in
reaction to painful feelings or difficult situations. In this chapter we discuss
both deliberate self-harm and suicide, with an emphasis on living with your
destructive thoughts, feelings and urges, and identifying when to take action
or seek help. Deliberate self-harm and suicide are usually completely
different – but the two may also cross over. Acts of self-harm can
sometimes go wrong and you could end your life even if you did not intend
to, or end up permanently disabled.
Deliberate self-harm
Deliberate self-harm (that is repeated and does not end in death) is twice as
common in women as men and is aggravated by alcohol. It is more
common in young people, and about 10 per cent of 16-year-olds have self-
harmed, usually by cutting themselves. Girls are far more likely to do this
than boys. The most common methods involve taking an overdose of
medication or cutting or scratching. Self-harm can also include picking a
scab or interfering with the healing of a wound, burning, punching oneself,
inserting objects in bodily openings or bruising oneself. For many people
it’s the final solution to the problem of how to control their minds.
Self-harming may fulfil different needs for different people at different
times. It is often an impulsive act at a time of a crisis or feeling bad. The
immediate thoughts associated with the self-harm are often complex but
might include:
it reduced my level of tension and distress
it stopped me from experiencing painful thoughts and feelings
it distracted me from a situation that was unbearable
it allowed me to punish myself
it helped me to communicate my distress
it allowed me to feel more in touch with reality
it expressed my needs, frustration, anger and hatred
it is an act of cleansing
it makes me less attractive and less likely to get attention.
Self-harm can sometimes be risky. We hope that this book will show that
there are alternatives to self-harm so that you can tolerate unpleasant
thoughts and feelings, and recognize that they do not go on forever. Most
acts of self-harm, such as cutting, are a low risk and usually serve a
particular function such as reducing distress. You may not experience any
physical pain and may become quite detached from yourself. Conversely,
some people may experience physical pain and welcome it as a way of
validating their emotional pain and making them feel alive. Self-harm thus
nearly always serves a function in the short term which has a pay-off so that
it becomes a habit. For some people, self-harm becomes a way of averting
suicide and thus highly reinforcing, because they do not want to die. By
following the activating program and developing a different relationship
with your thoughts, you can learn to tolerate unpleasant thoughts and
feelings.
People who self-harm often have complex problems, or a history of
emotional, physical or sexual abuse, and may have an additional diagnosis
of a personality disorder. If you suspect that this may be the case for you,
we would advise you to seek professional help, as overcoming self-harm
needs to form part of an overall package of care. A useful website for
advice and resources is the National Self-Harm Network
(www.nshn.co.uk/). Try to understand the context in which the self-harm
and unpleasant feelings occur (as part of your functional analysis). A
pattern may emerge which you can then discuss with your health
professional. You can try an alternative to self-harm or a safer form of it
that can help reduce emotion. Some people have found the following
activities helpful:
squeezing a ball
listening to loud music
using a ‘punch bag’ (for example, a cushion or pillow)
squeezing ice or rubbing it on the part of your body you want to
injure
taking a cold or very hot shower
using body paint (for example, a red felt-tip or lipstick) to mark your
body, instead of cutting
using art and pottery or sculpture to express your feelings
taking the medication as prescribed by your doctor.
You can also try to delay your urge to harm by, for example, cleaning,
washing clothes or tidying; doing a sport or exercise; gardening;
telephoning a friend or a helpline; listening to music; going to the cinema;
visiting a friend; or joining a self-help group for self-harmers.
You could also use something to comfort yourself, such as:
talking about your feelings to a friend or relative at the time you are
distressed
writing poetry or feelings in a diary
holding a safe object
listening to soothing music
singing a favourite song
spraying room fragrance or burning incense
stroking your pet
buying fresh flowers
having a relaxing bath
having a massage or using a relaxation technique
hugging someone.
The goal is to tolerate your painful thoughts and feelings and to act in your
valued directions with your thoughts and feelings. Always try to plan your
safety and be willing to move away from self-harm. At least stay within
safe limits and minimize the harm to yourself. Hand over your razor blades,
tablets or money to a friend or relative you trust, or lock them in a
cupboard. We have emphasized throughout this book the importance of
doing a functional analysis to understand the context and the consequences
immediately after the self-harm and other behaviors as well as the
unintended consequences in the long term to yourself and others. Now try
your own functional analysis on any self-harming behavior that you have
used habitually.
Functional Analysis

Activating event (situation or

context of self-harm)

Behavior (including ruminating,

 worrying and self-attacking)

Consequences (immediate) which

provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause distress
and handicap to yourself and
others?

Valued direction What can you do

as an alternative to self-harming
which is towards your valued
directions? What can you do to
delay yourself until the urge has
subsided?

Effect of valued direction

Friends’ or relatives’ concerns about self-harm

If you self-harm, it might be worth asking your family and friends to read
this section of the book, or summarize it for them. Many people who self-
harm (for example, cut themselves) have no immediate reason to stop – it is
usually the friends, relatives or health professionals who are more
concerned by self-harm. However, the person who self-harms still needs to
be given responsibility for change and resisting their urges.
Relatives should be aware that self-harm is not about attention
seeking – there are many easier ways of seeking attention.
A person who self-harms is not being masochistic or manipulative or
‘acting out’. It is usually a very private activity – you may be aware
of only a small amount of the self-harming or you may become
 aware of it only by seeing the evidence, such as scars on a person’s
arms. It’s worth remembering that someone who self-harms often
chooses a part of the body where the scars can’t easily be seen. Only
more dangerous acts of self-harm resulting in significant injury will
end up in the hospital emergency department. However, the extent of
an injury does not reflect the degree of distress or suicidal intent.
Thus if an episode of cutting was deeper or more extensive than
usual, it doesn’t necessarily mean that the self-harmer is at greater
risk of suicide. Equally, a person may cut very superficially and yet
be a high suicide risk – it’s the function and the intention of the
cutting that is important.
Even if people have been harming themselves for years it does not
mean that they can’t change their behavior – never assume anyone is
‘a hopeless case’.
Warning signs that someone is injuring themselves include
unexplained frequent injury, including cuts and burns, or the wearing
of long trousers and sleeves in warm weather.
Suicidal thoughts
In reacting to suicidal thoughts there are two crucial points to grasp. On the
one hand, if you are feeling depressed it’s not in any way abnormal to feel
hopeless and have thoughts about killing yourself. Understanding this will
help you to allow suicidal and hopeless thoughts to pass through your mind
without you feeling you have to act on them or further criticize yourself for
having them. On the other hand, if you are beginning to ‘buy’ your negative
thoughts about your life and your future to the extent that you begin to
make plans to kill yourself (see below for more on identifying when you
might be at higher risk), then you need to take action to keep yourself safe.
Suicide might seem attractive because you think escaping from your mind
and the unpleasant thoughts and feelings will be a relief. When you are
feeling very bad, these thoughts of relief and escape can be very powerful.
Ending your life is a very drastic way to manage negative thoughts and
feelings. Bad feelings will end eventually and there are things you can to do
to make yourself think and feel better sooner.
Hopelessness and helplessness
As we point out throughout this book, depression has the effect of making
you think more negatively, and if you believe your negative thoughts to be
true, rather than treating them as just thoughts, they will make you more
depressed. In relation to suicide, thoughts that suggest you are a hopeless
case, the future is going to be nothing but black and painful, and that you
are powerless to do anything to improve your mood or your situation are
particularly relevant. It’s easy to imagine that if you mistakenly interpret
these thoughts as facts, then ending your life might seem like a logical
decision. In fact, suicide would be a permanent (and devastating) solution to
a temporary problem. Try to distance yourself from this thought.
How your memory could make things worse
One of the reasons you may become more negative about the future
when you feel depressed is because your memory becomes biased. It’s a
design fault in the human brain that you find it much easier to access
negative memories than positive ones when your mood is low. Thus at a
time when you might be experiencing a difficulty and you really could
do with memories of how you’ve coped with problems before, you have
difficulty accessing them. This is one of the main reasons that your life
and your ability to cope can seem much worse than they really are when
you’re feeling very down. This of course is yet another reason to take
your negative conclusions with a pinch of salt, and to focus on
improving your mood before deciding that your situation is hopeless.
A further impact on your memory when you feel depressed is that of
increasing over-generalization. This means that it gets harder for you to
recall specific positive memories which hold all the detail required to
give you information on how to manage a current problem. When you
use the problem-solving techniques in Chapter 10, give yourself a little
more time to recall solutions to problems that you’ve found helpful in the
past, and try to brainstorm solutions at a time when your mood is at its
best (in the evening rather than the morning if your mood tends to be
worse in the morning, for example).
Identifying risk factors
The act of suicide is an extreme solution when you are desperate to escape
from unpleasant thoughts and feelings. People tend to use whatever method
is most available to them to attempt suicide. Suicide rates are therefore
higher among, for example doctors or vets, as they have access to lethal
drugs, or farmers because they have access to shotguns. Statistically, three-
quarters of deaths by suicide are men, especially, elderly and young men,
and suicide is more common when a person:
suffers from depression, alcoholism, drug abuse or schizophrenia
has a previous history of attempted suicide or has a serious
psychiatric family history
has a long-term physical illness, especially with a lot of pain
is a widow, widower, divorced, or socially isolated
is unemployed
has a lower intelligence or educational achievement
is an immigrant
had a low birth weight or poor growth as a child
has had a recent loss (for example, death) or conflict with a partner
is unsupported and has conflicts with their family
has a history of sexual abuse.
These are all recognized risk factors for suicide. The way the different
factors interact is complex, and we don’t know how they may make
someone more likely to commit suicide. Some factors cannot be altered (for
example, if you are an elderly man and have a history of suicide in the
family) but others can definitely be influenced, such as overcoming your
depression or social isolation. We shall therefore concentrate on what you
can do to help yourself and make your life more rewarding and fulfilling.
What to do if you are feeling suicidal
Feeling suicidal is the most serious symptom in depression. If you are
feeling suicidal, please seek the advice of an emergency doctor or a
therapist and be honest with them about how you feel, immediately. This is
absolutely vital if you:
are thinking a lot about the method by which you may commit
suicide and have access to the means
have a specific plan to use when you are alone and unlikely to be
disturbed (for example, when your partner or family are out for the
day)
are acting dangerously (for example, driving very fast in the hope
you may have an accident)
are writing letters to be found after your death
are preparing for your death (for example, putting your papers in
order, paying off bills or writing your will), or
 are feeling very hopeless about the future and are preoccupied by
death or dying.
You may need to be admitted to hospital. Of course, people rarely want to
go into hospital but this is a measure taken for your own safety and is for a
limited time. You can overcome suicidal thoughts and a brief stay in
hospital can keep you safe until your suicidal urges pass. If at this stage you
feel you just can’t talk to a doctor then please either phone one of the
helplines listed in Appendix 2, or talk to a relative or close friend. You will
need to convey to them calmly that you are feeling unsafe and describe how
you are thinking. If you have made plans to end your life in any of the ways
listed above, please share these plans with another person. There is nothing
to be ashamed of. Feeling suicidal is an extremely common symptom of
depression – it would be most unusual if you experienced depression and
did not have at least occasional thoughts of suicide. However, if ideas of
suicide become persistent and louder in your mind, you should see a health
professional. You will need to feel safe and supported and receive help for
your depression as well other problems in your life. If you feel you are not
getting adequate support, then find a different professional. There are lots of
approaches that work (see Chapter 4 to help to you make changes in your
life and to have good feelings). If you are a friend or relative and suspect
someone you care for or care about is feeling suicidal, take them seriously.
Be willing to listen and voice your concerns and assure them that there are
alternatives.
Minimizing the risk of harming yourself
The main message from this book is that you can overcome depression and
that there are many other alternatives to suicide. We understand that you are
suffering. You may be going through a crisis but the bad feelings will pass.
Suicide is usually motivated by a desire to escape permanently from
unpleasant thoughts of being inadequate, worthless, unloved or
blameworthy. Feelings such as depression, guilt, hurt or loneliness and
feeling trapped can also lead to suicidal thinking. Steve Hayes notes that
one of the interesting facts about suicide is how a person has trained
themself to believe that once they are dead then they will no longer be
experiencing the suffering from which they wish to escape. No one knows
what it is like to be dead and this is a rule that you may have learned (‘If I
am dead, then I will no longer suffer’). Unfortunately, this will bias your
thinking and cause you to ignore the other consequences of suicide. You
may overlook the possibility that suicide attempts can go wrong and you
may end up severely disabled. You probably ignore the consequences for
your loved ones. You might be telling yourself that your son or daughter,
parents, partner, siblings or friends will soon forget you or be better off
without you, or that they love you only because they have to. However, if
you check these destructive thoughts against reality by sharing your plans to
end your life with loved ones, you are likely to get strong reactions. If you
end your life, you won’t be able to be a good father or mother to your
children, or a good son or daughter to your parents, or a good friend to
others. The most important thing to remember is that, however bad your
situation seems, there are alternatives to suicide. Discuss these with a
friend, a telephone helpline or a professional. All problems can be solved at
least in part.
Overleaf is a checklist of actions that you can take to minimize the risk of
harming yourself:
Abstain from alcohol and other illegal substances when you are
feeling suicidal.
Ensure that all means of committing suicide are removed from your
living space – for example, destroy stockpiles of drugs or give them
to someone else for safekeeping, or restrict access to firearms.
Maintain contact with your therapist and/or doctor and tell them how
you feel.
Tell your family or a friend about how you feel and the risk of
suicide.
Reduce time spent in isolation or phone a support line. This might
include ringing an organization such as the Samaritans.
Write a diary or blog of how you feel. However, be sure that you do
not endlessly review the past: write about you feel now and your
hopes and dreams for the future.
Make a contract with your therapist or doctor and close family not to
harm yourself.
Keep up good sleep hygiene (see Chapter 12).
Act in ways that are consistent with what is important to you (your
values) despite your depressed feelings. Start doing activities that
used to be rewarding even if you find it hard to enjoy yourself now
(see Chapter 7). Eventually your feelings of suicide will subside. Try
to follow important directions in your life. If you do act on suicidal
 thoughts, you won’t be having the chance to achieve what is
important to you in life and you may miss out on many wonderful
events in the future.
If you want to end your life, try to write a list of ‘Reasons for Living Life’
which is in keeping with your values. You may struggle with this task but
please persevere. If you are having difficulty, seek the help of a friend,
relative or professional.
Tim listed his reasons for staying alive as:
being able to watch the sunset again
being able to spend time with my friends
knowing that my depression can pass
seeing my son/daughter maybe have their own children
avoiding distress to my wife.
While you are alive you have the chance to pursue your valued directions in
life.
Now try to list your reasons for living, relating back to the valued
directions in life you identified in Chapter 5.
Reasons for living
1. ____________________________________________________
____
____________________________________________________
____
2. ____________________________________________________
____
____________________________________________________
____
3. ____________________________________________________
____
____________________________________________________
____
4. ____________________________________________________
____
____________________________________________________
____
5. ____________________________________________________
____
____________________________________________________
____
10 Problem-solving
Problem-solving is an essentially simple approach to helping you manage
daily tasks, engage more fully with the world and pursue your valued
directions in life. It is very understandable to feel frustrated and ground-
down if your car won’t start or your child often tells lies, but the question is,
do you get caught into the frustration and hopelessness which pulls you into
avoiding or trying to control the way you think and act? There is good
evidence that the technique of problem-solving is helpful in overcoming
hopelessness and depression. Hence, if you are having counselling we
would suggest that you have counselling that focuses on problem-solving in
the here and now rather than trying to find out reasons for the past.
Problem-solving probably works because it helps you confront the issues
that you are avoiding and leads to activity when you try the solutions.
However, it does not work if you try to solve non-existent problems or
events that have occurred in the past – if you apply problem-solving to the
wrong problem, it could make you feel worse. It also does not work by
trying to ‘fix’ or control the way you feel in your mind. This is dealt with in
Chapter 6. Here are the steps in problem-solving in the real world.
Define your problem
At the top of a sheet of paper write down the main problems you are
struggling with. Alternatively, try to talk this through with a friend or
counsellor. When you have a number of problems, try to choose the ones
that have the biggest impact on your life. The kinds of problems for which
you might use this technique could include:
having a poor relationship
being socially isolated
having too few interests or hobbies
being unemployed or being unhappy in your current employment
not getting training or furthering your education
not having enough money and mounting debts
being in trouble with the law or needing to use the law to resolve a
conflict
having poor housing or living far away from friends, relatives or
work
health problems
not getting enough exercise.
Examples of real problems to be solved might be ‘My partner doesn’t seem
to pay me any attention’; ‘People in my firm are being made redundant and
I’m not being paid very well’; ‘My son is being bullied at school’; ‘My
neighbours are drug dealers and make too much noise at night.’
When not to use problem-solving
It’s not a good idea to use problem-solving for non-existent problems
that could remotely occur in the future. These can usually be identified
by the ‘What if such and such happens?’ type of questions which
underpin worry. If you try to respond with problem-solving for non-
existent problems, you will create more ‘What if’ questions and you’ll
go round in circles. The exception to this is practising something to
prepare yourself for an event in the future that is likely to occur or where
it’s helpful to be prepared for something, for example:
preparing yourself for a job interview by asking someone to do a
mock interview with you.
doing a fire drill so you know what to do if a fire occurs
writing your will in case you die under a bus tomorrow.
Also, problem-solving is not suitable for problems from the past that
cannot be solved. Examples of this are trying to find reasons for bad
times in the past or why you feel bad now (such as ‘Why didn’t my
mother love me?’; ‘If only I’d done more work before the exam’; ‘Why
do I feel so awful?’; ‘I don’t deserve to feel the way I do’). It’s best not
to use problem-solving for these problems – read Chapter 6 on
ruminations.
Brainstorm solutions
Write down on a piece of paper all of the possible solutions you can think of
to the problems you defined earlier. Ask someone else to help or bounce off
ideas if you need to. The following list may help you generate solutions:
How have you dealt with similar problems in the past?
How have other people coped with similar problems?
How would you imagine tackling the problem if you weren’t feeling
depressed?
How would you imagine someone else approaching the problem?
Can the solution be broken down into smaller steps and how can
each step then be solved?
 What resources (professionals, voluntary services, others) can you
access for help with the problem?
Evaluate your solutions
Look over your ‘brainstorm’ and select some of your possible solutions,
and list the pros and cons of each. Photocopy the Cost–Benefit Analysis
Form on the next page and write out the pros and cons for each option. Use
the space provided below to make notes. There is a spare form in Appendix
5.
Cost–Benefit Analysis Form
Option: _________________________________________________
Costs – for you and other Benefits – for you and other
people. Consider short- and people. Consider short- and long-
long-term costs. term benefits.

For self in the short term For self in the short term

For self in the long term For self in the long term

For others in the short term For others in the short term

For others in the long term For others in the long term

Try out a solution

On the basis of your rating of the pros and cons, choose a solution to try
out. Try to choose solutions that have the most long-term benefits. Make
sure you are specific about how, where, when and with whom you will try
out your solution. When you are fearful or avoiding trying something out, it
may be helpful to make some specific predictions about what you think
might happen so you can then see if it’s true or not.
Review the situation
Once you’ve tried out a solution, review how far it has helped to resolve
your problem. Does the problem still occur? Do you need to take further
steps, or could you move on to tackling another problem?
Jan’s problem-solving
As we learned in Chapter 1, Jan has had a dispute with her daughter-in-law,
who she fell out with after trying to give her advice on childcare. The fact
that she was no longer able to see her grandchildren made life significantly
less rewarding for Jan, and she felt very depressed about this loss. Instead
of spending time ruminating about if only she had handled things
differently, if only her daughter-in-law could see her good intentions, and
why didn’t her son do more to resolve the situation, she decided to turn her
attention to seeing what she could do in the here and now.
To begin with Jan defined her problem as:
I can’t see my grandchildren because my daughter-in-law doesn’t want
to see me.
She went on to brainstorm the following solutions:
decide never to see them again and just focus on other relationships
kidnap my grandchildren
ring her and try and talk some sense into her
go round to their home and insist she talks to me
send her a letter explaining how I feel
invite her to meet me for a coffee somewhere neutral
speak to my son and ask him to speak to her.
Notice she brainstormed all solutions she could think of, from the simple to
the ridiculous.
Jan narrowed these possibilities down to two as they were the least likely
for her daughter-in-law to react badly to and the most likely to resolve the
problem:
send a letter
meet on neutral territory.
In the end, she decided to send a joint letter to her son and daughter-in-law,
and give them options of different meeting places or the telephone should
they wish to communicate further.
She found that writing the letter at least gave her the sense that she was
taking control and acting in the direction of her value of being a caring
grandmother to her grandchildren. She noticed that this helped her to stop
ruminating and improved her mood.
At this stage Jan doesn’t know whether her solutions will be helpful in
achieving what she wants. However, she will soon find out – if it doesn’t
work, then she can go back to brainstorming to think of another solution.
We recognize that some problems are insurmountable – perhaps you have
tried many different solutions and consulted professionals and friends to
help. You might need to take a different approach as you have to accept and
mourn the loss or changes in your role before moving on and acting in your
valued directions. Use the blank Cost–Benefit Analysis Form on the
opposite page to reassess the pros and cons of the options available to you.
Cost–Benefit Analysis Form
Option: __________________________________________________
Costs – for you and other Benefits – for you and other
people. Consider short- and people. Consider short- and long-
long-term costs. term benefits.

For self in the short term For self in the short term

For self in the long term For self in the long term

For others in the short term For others in the short term
For others in the long term For others in the long term
11 Being Physically Active
CASE STUDY: Kevin
Kevin suffered from depression after he lost his wife. She left him after
years of arguments and his jealousy and took the children to stay with her
parents many miles away. He had become slovenly and spent his time
lolling around on the sofa zapping the TV channels. He lost his job. He used
to enjoy playing football once a week but had given it up as he did not feel
motivated. He ignored the phone, fearing it would be a friend with whom he
used to go to the gym. He thought of himself as a failure and felt too
ashamed to return to any exercise. He planned to exercise again only when
he felt better.
CASE STUDY: Jean
Jean, a single mother, lives with her nine-year-old daughter. She became
increasingly depressed following a conflict at work, where she felt she had
been treated unfairly by her new manager. Her loyalty and hard work for
the company appeared to her to have been completely ignored. She began to
neglect herself at home. She did only the bare minimum for herself and her
daughter. She was signed off sick from work and spent most of the day at
home nibbling and grazing on food. She did not normally do formal
exercise but, before she became unwell, she was a ‘doer’ and always on the
go.
The importance of activity for depression
Inactivity is a hallmark of depression. Research shows that exercise is
effective for overcoming mild depression and is recommended in clinical
guidelines for treating depression. Of course, exercise can be difficult
enough to start and maintain even when you are not depressed, but you will
see benefits to your mood even if you don’t become fit. This chapter will
focus on what you can do to make it easier to start exercising. We’ll discuss
why exercise may be helpful in defeating depression, and work through
some examples of people using exercise as an effective antidepressant.
The benefits of activity
Exercise:
is effective as a treatment for mild depression
helps to keep you physically fit and more energetic
helps reduce stress
relieves muscle tension
 improves your social contact if you join a sport/activities club –
many will take a wide range of ages
can be good fun
is physically helpful in reducing the risk of heart disease and some
cancers.
Being more active
Many of us as think of exercise as a chore because it triggers associations
with school and physical education, sweaty gyms and pain. We’ve headed
this chapter ‘Being Physically Active’ because any form of activity is better
than none. Exercise doesn’t just mean going for a run or to a session in the
gym – it’s any form of activity that requires some effort and can be
repeated. It probably helps because it opens you to new experiences and
helps you to stop ruminating and focus on life. Apart from all the usual
sports, activity includes:
getting up from your sofa to change the television channel rather
than using a remote control
walking to buy a newspaper or groceries
walking or cycling rather than using the car or public transport (or in
addition to public transport) to get to work or school or when visiting
a friend
walking up the stairs rather than using a lift
gardening.
The mechanism of how exercise ‘works’ is not known, but we have seen in
previous chapters that the experience of depression frequently leads to a
person being withdrawn, inactive and ruminating about events. These
‘solutions’ then become the problems. Exercise can help to counterbalance
the natural consequences of depression and prevent a downward spiral. Our
view is that physical activity is an important part of activating yourself,
especially if you used to enjoy it. If you’ve not previously done much
exercise, this chapter may help you to identify a new activity which may
provide pleasure and satisfaction. Even if you really feel that exercise has
never been for you, you should still read this chapter as it’s about matching
activity to your personality. A new activity might include learning a musical
instrument, doing yoga, dancing, walking or gardening. All these may
involve some activity as well as stimulation for your mind.
Matching activities to your personality
Consider returning to an activity that you used to enjoy or taking up a new
one. Have you ever tried fencing? Yoga? Power-walking? Physical activity
isn’t boring, but how you participate in it can be. Jim Gavin, author of
Lifestyle Fitness Coaching, recommends matching your personality with a
particular activity or sport because some people may give up on a new
activity because it simply does not suit them.
In his test, you need to work out your personality profile, which will help
match you with a particular sport. A good match is more likely to lead you
to enjoy the activity and to stick with it. There are seven scales on which
you rate yourself (see the chart on page 147). Each item in the scale is
briefly described below.
1. Sociability is the degree to which you prefer social interaction over
solitary pursuits. Team sports or activities like golf and squash are
very sociable, while swimming, cardiac conditioning and yoga are
usually not social activities.
2. Spontaneity is the extent to which you live in an intuitively guided,
open manner and welcome spur-of-the-moment happenings. The
opposite is a desire for high levels of control and predictability in
life and avoidance of situations that are highly changeable. Sports
that involve a lot of spontaneity are team sports, squash and
downhill skiing. Sports at the opposite end of the spectrum and
wholly predictable are tai-chi, cardiac conditioning and swimming.
3. Self-motivation is the degree to which you exhibit high levels of
determination and willpower, as opposed to requiring external
supports and reinforcements to adhere to challenging activities or
goals. Sports that involve self-motivation are running, cycling,
cardiac conditioning and weight training. Sports that involve more
external motivation are team sports, racquet sports and dancing.
4. Aggressiveness is the extent to which you behave or interact in
strong, forceful, highly assertive ways that may border on
aggression, rather than behaving in a gentle, non-aggressive, or
perhaps even passive, manner. Examples of aggressive sports are
racquet sports, team sports, weight training and martial arts. Non-
aggressive sports include tai-chi, walking, yoga, skating and
dancing.
5. Competitiveness is the extent to which you enjoy competing, in
contrast to a tendency to avoid competition coupled with a
 preference for solitary or collaborative pursuits. The most
competitive sports are team sports, racquet sports, group training
and golf. The most non-competitive activities are yoga, tai-chi,
walking and dancing.
6. Mental focus is the extent of your ability to concentrate or focus
and your preference for activities in which the mind is totally
absorbed. At the other end of the scale is someone who is easily
distracted or who prefers high levels of stimulation and multiple,
simultaneous engagements. Sports that require focus are racquet
sports, team sports, martial arts and downhill skiing. Activities that
do not require such focus are walking, running and cardiac
conditioning.
7. Risk-seeking is the extent to which you prefer to engage in risky
behaviors or pursue adventure. Are you a thrill-seeker? The
opposite personality type is cautious, risk-avoiding and highly
concerned with safety and security. Risk-taking is associated with
downhill skiing, team sports and martial arts.
When you have completed your profile, you can then see which activities
you are best suited to by looking at the chart on page 148.
Kevin learnt from his functional analysis that doing less made him feel
worse. It made him feel more depressed and strengthened his belief about
being a failure. It also made him less able to be a good father. He learnt
that he had put the cart before the horse by planning to exercise again
when he felt better. Kevin learnt that exercising was a means towards
getting better and that he had to exercise despite feeling unmotivated. He
resolved to explain to his friend that he hadn’t been coping with the
break-up of his marriage and that he would really appreciate his help in
getting him to commit to a timetable of activity. Kevin tended to be
someone who was strong on activities that were sociable, spontaneous
and largely depended on external motivation. He was also competitive
and aggressive. Team sports suited him well but he wanted to try
something different from football. He didn’t always enjoy going to the
gym before he was depressed, but felt that making it a social occasion
with his friend was adequate compensation. He found from his profile
that a racquet sport would suit him and he made it his goal to take up
squash. He found out the name of a local club on the Internet and went
along to an introductory evening. He met some other beginners and
joined a squash ladder. He realized that if he was to become a good
 squash player, he needed to get himself fitter at the gym and added a
couple of sessions per week to his timetable.
Jean did her functional analysis and recognized that neglecting herself
and her daughter increased her depression. Her self-esteem was getting
worse as she was gaining weight from her grazing. She started to
timetable the activities that she was avoiding but she was not
enthusiastic about exercising. She was normally a ‘doer’ but did not like
being competitive, being aggressive or taking risks. She couldn’t see the
point of it. However, she liked some social contact and was internally
motivated. She preferred more controlled movements. She resolved to
join yoga and tai-chi classes on two different days and to walk her
daughter to school rather than use public transport. On their walk every
day they cut across one of the parks and she began to focus her attention
more on her daughter and the nature around them. Overall she increased
the amount of activity and this contributed to the improvement in her
mood and acting in one of her valued directions in life of being a good
mother. She also lost some weight on the low glycaemic load diet
described in Chapter 13.
Tackling your attitudes about activity
You may notice yourself thinking in black-and-white terms and being self-
critical when you fail either to reach a target you have set yourself or to do
the activity at all. For example, if you fail to get to an aerobics class you
had planned to attend, you might start ruminating along these lines: ‘Why
do I always fail?’, or ‘If only I was born differently’, or ‘I am so useless, I
can’t even get to a class on time.’ In Chapter 6, you learnt to acknowledge
your thought patterns and change ‘Why’, ‘If only’ and self-critical thoughts
into ‘How’ and ‘What changes can I make’ questions which focus on
solving your problems in the here and now. So non-answerable questions
become answerable ones, such as ‘How can I be active in the time I have
available?’ or ‘What changes can I make in my life to make it happen next
time?’ Then you can start to think creatively about timetabling a brisk walk,
for instance, or ringing around to find out about other aerobics classes that
fit better with your timetable.
How to keep yourself motivated
Once you start an activity, there are a few tips to bear in mind to help you
stick with your schedule.
1 Set yourself realistic goals
Goals might include increasing the frequency or duration of your activity. If
you can afford it, engage a personal fitness trainer who can help you
determine appropriate or realistic goals in the same sport and the time
period to reach them in. Alternatively check out other sports to find out
what is realistic as you may be a perfectionist or have unrealistic goals. For
some activities it can help if you keep a log of the activity done or your
achievements (for example, the number of miles you ran or the grades you
have passed). However, many activities are just there to be enjoyed in their
own right – you don’t have to achieve anything; you just have to act without
rating or comparing yourself to others; and it doesn’t matter if you don’t do
it particularly well. You are likely to have more difficulty sticking to your
plan when you feel tired or stressed, so be ready for that and continue
despite the way you feel. Remind yourself that you will probably feel more
energized after you have exercised and had a shower.
2 Stimulate your brain
Some people like to listen to music or watch TV while they exercise though
this is not possible or necessary with all activities. Be aware of any
sensations that could indicate an injury or overtraining. As you become
more experienced, you can concentrate on the movement of your body to
help you increase your enjoyment of the activity. Consider getting tuition in
your chosen activity: a good teacher can usually find ways of stimulating
you and making it more interesting.
3 Get a partner or group
Find a friend, trainer or group to help motivate you and commit you to a
regular activity. Some sports such as golf include a social component. In
other sports, you can either be active with your partner, or simply tell each
other about your progress. If your sport is not a team one, choose places and
times to exercise where there will be other people who are actively involved
in exercise.
4 Plan to stay active
Don’t decide at the last moment that you can exercise – make a plan
beforehand as part of your timetable. It’s easiest to stick to a routine and to
do it regularly – for example, Kevin made an appointment with himself
every Monday and Thursday evening to go to the gym and kept this as a
priority. Always plan ahead – leave a set of clean clothes at the office today
so that you can cycle to work tomorrow. Arrange a babysitter so that you
can take that fencing class next week. Act according to the plan you have
made, not according to how you feel.
5 Don’t listen to your mind
As discussed in previous chapters, our minds are constantly chattering away
about all sorts of nonsense – like ‘skipping exercise today won’t matter
much’. Just thank your mind for its contribution to your well-being and act
in the direction you have set yourself. Your mind will constantly seek the
least uncomfortable option in the short term, but trying to control and
escape the way you feel always becomes the problem. Remember ‘trying’
to do an activity is not an option – it is either one thing or another – either
you ‘try’ to act (which means not doing anything) or you act despite your
mind telling you that missing one meeting won’t matter. If you are flexible
about the plan you make but then stick to it rigorously, you won’t need to
feel like a dropout.
Plan your activity
What physical activities will you add to your activity schedule?
1. ______________________________________________________
__
2. ______________________________________________________
__
3. ______________________________________________________
__
4. ______________________________________________________
__
What obstacles do you have to overcome to make sure you can do the
activity regularly (for example, arranging child care or leaving work on
time) and what steps will you take to solve them?
1. ______________________________________________________
__
2. ______________________________________________________
__
3. ______________________________________________________
__
4. ______________________________________________________
__
12 Getting a Good Night’s Sleep
CASE STUDY: Laura
Laura had difficulty sleeping after she and her husband separated, which
triggered her low mood. Her main difficulties were getting to sleep and
waking early in the morning at around 5am. She became very worried that
not sleeping would mean she would become tearful and unable to cope at
work the next day. In response to this she would try and imagine what she
could do to avoid being tearful in front of friends. She would also have
thoughts like ‘I’m so upset I can’t sleep, my depression will only get worse
if I don’t sleep.’ She would try and will herself back to sleep because of
these fears, and started to dread going to bed. At the weekends she would
try and ‘catch up’ by lying in bed late and taking an afternoon nap. In order
to try and get to sleep she began to increase the amount of wine she drank
in the evenings.
Normal sleep
Some people worry they have a sleep problem when in fact their pattern of
sleep is perfectly normal. Most of us will wake at least once in the night,
although we won’t always remember it, so if you do wake don’t
automatically assume you’ve got a problem. The amount of sleep the
average adult needs is between seven and eight hours. However, there is a
lot of variation in the amount people sleep – anything from four to nine
hours or more. Children need a lot of sleep. Adolescents need a bit less and
the need for sleep then plateaus during adulthood. As you become older,
you need less sleep, but it also becomes more broken.
Sleeping problems
The most common emotional problems that affect sleep include depression,
anxiety and drinking too much. Sleep disturbance is a common symptom of
depression: typically, depressed people wake early in the morning and
during the night. So if this is true of you, bear in mind that it does not mean
that you are losing your mind, and that there is a very good chance your
sleep difficulties will improve as your mood lifts. Worry and anxiety can
also have a nasty habit of focusing on pretty much anything that’s bothering
us, and this includes sleep problems. Anxiety especially tends to get in the
way of someone trying to fall asleep.
Common kinds of sleep problems
Difficulty sleeping or insomnia is very common – about a third of adults
report trouble sleeping although it’s much more common in people with
depression. There are four main problems:
getting to sleep
waking during the night or early in the morning
excessive sleep
nightmares.
When sleep solutions are the problem
As with the other difficulties we’ve discussed in this book, when you
consider what you are doing regarding sleep try asking yourself if your
current solutions are in fact causing the problem. As ever, try to spot if
anything you’re doing has the quality of ‘digging your way out of a hole’.
Attitudes about yourself and your sleep that will cause
problems
You may lie awake worrying that you’ll be too tired to cope the next day if
you don’t sleep, and trying desperately to make yourself go to sleep. Other
common worries about sleep include ‘I’m making myself physically ill’,
‘I’m making my depression worse’ or ‘I’m going crazy.’ There’s no doubt
that not sleeping well is very unpleasant, but worrying about your sleep
makes it even harder to sleep.
An important point to focus on if you have a sleep problem is the way you
think about sleep. The thoughts and attitudes you have directly affect the
way you will feel about sleeping or your difficulties in sleeping, and the
way you behave in relation to sleep. Here are some common examples of
unhelpful rules about sleep:
I must have at least eight hours’ sleep or I can’t function.
I can’t stand feeling tired.
I’m so useless I can’t even sleep properly.
Unless I sleep well I’ll never recover.
I must think of ways to get a good night’s sleep.
If I can’t sleep well I must rest in other ways.
Sleep’s a physical problem – there’s nothing I can do about it.
The crucial thing to remember is that sleep is often sort of ‘upside down’;
the more pressure you put on yourself and the more significance you give
poor sleep, the harder it is to sleep well. If the content of your ruminations
is not being able to sleep, remember the trick is to regard your thoughts
about sleep as just thoughts, not fused with reality as facts. It is just your
mind chattering away like a radio in the background. You don’t have to tune
in to the radio and listen to it.
The problem of focusing on sleep and tiredness
There’s good research evidence showing that the degree to which you focus
on discomfort affects how much discomfort you feel. This research has
been conducted with people who experience physical pain, but it’s also true
of sleep. If, for example, you get very little sleep because you have a
newborn baby, you may find that how tired you feel is made worse when
people ask how you are sleeping and then exclaim ‘You must feel really
exhausted!’ This makes you temporarily focus on how tired you feel. The
trick then is to focus your attention on the world around you or on the task
at hand, rather than on how tired you feel.
As we’ve shown in other chapters in this book, rumination and worry –
spending too much time going over problems in your mind – add to
depression and anxiety. It’s tempting to spend a lot of time during the day
either dreading bedtime, or trying to work out how to sleep better. The
problem is that this will worsen your mood and increase the pressure on
your sleep.
Behaviors that will add to your sleep problems
On the next page are some examples of solutions that will add to or even be
the cause of your sleep problems.

Behavior The unintended consequences

Napping during the day This will disrupt your natural
sleep pattern further and make it
harder to sleep at night

Reducing your activity or ‘rest’ This is a form of escape and can

during the day worsen your mood and increase
your focus on yourself

Watching the clock and working This will fuel preoccupation and
out how many hours you sleep anxiety about sleep

Cancelling appointments or social This will reduce activity and

engagements if you haven’t slept reinforcement from meeting
 well new people or seeing old friends
(thereby increasing depression),
and fuel your worry that not
sleeping well is adversely
affecting your life

‘Lying in’ or having an early night This will reduce your activity,
if you haven’t slept well fuelling depression and
disrupting your normal sleep
pattern

Trying to block out or sort out Will fuel worry and keep you
problems when lying in bed awake

Looking at the clock to see when Will fuel your worry and
you get to sleep preoccupation with sleep which
is likely to keep you awake

Putting off tasks or solving Will lead to further

problems until you’ve slept better procrastination, adding to
depression and anxiety and thus
contributing to your sleep
problem

Your body clock

Generally our quality of sleep is better if we sleep at night, since our body
clock tends to be set by triggers like the sun rising and mealtimes. Even
people who are used to sleeping during the day, such as night workers, tend
to perform less well at tasks than when they’ve been sleeping at night. This
is one of the reasons it’s going to be helpful for you to retrain your body
and brain back into a healthy sleep routine so you can function better.
How to get a good night’s sleep
There are a number of things you can do to drastically improve the chances
of getting a good night’s sleep – and without using medication. These
principles are sometimes called ‘sleep hygiene’ because the idea is that you
are trying to ‘clean up’ your sleep pattern so that you can set the best
conditions for a good night’s sleep.
Get a routine
If your body could give you one piece of advice on how to get a good
night’s sleep, routine would be it. Part of the problem for many people who
have depression is that they use sleep as an escape, and that, coupled with
the desire to catch up on lost sleep, can lead to sleeping during the day. This
then puts their sleep cycle out of routine and means it’s less likely that
they’ll sleep well at night. Reintroducing a relatively strict routine is a
fundamental of getting a good night’s sleep. So here is the best advice for
setting a healthy sleep routine.
Get up at the same time each morning, between 7am and 9am. The
most you should sleep in at weekends is an extra hour. Do not try to
catch up on lost sleep during the week.
Structure your day and avoid working late at night
Have a ‘pre-bed’ routine such as a hot bath or a drink that is low in
caffeine.
Do not stimulate yourself with checking emails, doing work or
surfing the Internet before you go to bed. You should not have
stimulation in the form of television, DVDs, games consoles or
Internet access in your bedroom.
Avoid sleeping or cat-napping during the day.
Avoid eating too late and eating foods that may be difficult to digest.
What if I already have a routine and I still can’t sleep well?
If you do have a regular routine, you may be going to bed too early. Go to
bed only when you are feeling sleepy. Try to catch the time that you are
becoming sleepy as your trigger to go to bed. If you get up at a regular time
(between 7am and 9am), then this should be between about 10pm and
midnight. If you do not go to bed when you feel sleepy, then it will take
longer for you to get to sleep when you do go to bed.
Setting the scene for sleep
Make your bedroom restful. Try to remove as much stimulation from your
bedroom as you can.
Is your bedroom tidy and uncluttered? Take your TV set out of the
room. Remember, you are trying to set the best conditions for restful
sleep, and an untidy or cluttered room will increase the level of
tension you feel.
Is your bedroom too noisy? Noise from neighbouring houses can
sometimes be a problem. Consider simple solutions such as ear
 plugs. Talk to your neighbours if their music or TV is too loud. Do
you have a partner who snores? Do they need to lose weight (as this
usually improves snoring)? Do they snore heavily in a crescendo –
that is, snore louder and louder until there is an ominous silence for a
few moments (meaning that they have stopped breathing)? They will
then suddenly wake, sometimes with a shudder, before falling asleep
again almost instantly. The cycle is repeated throughout the night but
your partner is unlikely to remember this when they keep
awakening. If this is the case, they should go and see their doctor to
exclude a condition called ‘obstructive sleep apnoea’.
Is your bedroom too warm or too cold? Make sure your room is
warm but not too stuffy, and open a window or use a fan. If it is too
cold, get another blanket or a heavier duvet.
Is your bed uncomfortable? Do you need to get a new mattress or
board under your old one?
Is your partner restless? Consider a bigger bed or sleep in separate
beds.
Is there too much light or streetlights? Consider using an eye mask.
Get curtains with a blackout lining or secure dark material like a
blind on the window.
Do you feel secure? If you feel under threat after a burglary, then
you may want to review your window locks and alarms.
What to do if you wake up in the night
Avoid lying in bed awake watching the clock or wanting to talk to your
partner. In your anxiety to get to sleep, you may lie in bed awake, willing
yourself to go to sleep. Of course, the mental effort of trying to get to sleep,
and then worrying about feeling tired the next day, is more than enough to
keep you awake. This can build up into an association in your mind
between being in bed and being awake, the last thing you need if you want
to sleep well. To break this pattern and association, get up, go and do
something boring (like reading a difficult textbook or doing a difficult
jigsaw) until you feel sleepy, and then go back to bed. Make sure you do
this in a warm environment. Many people find this a tough principle to stick
to as they are so desperate to sleep. The main question to ask is ‘Is lying in
bed trying to get back to sleep working?’ If you’re not sure, then try getting
up to break out of lying in bed awake. If you’re desperately trying to make
yourself go to sleep, it becomes self-defeating because you can’t make
yourself go to sleep, it just happens! If this is the case, sometimes it helps to
try to keep awake! Don’t watch yourself like a spectator – just lie back and
try to concentrate on a spot on the wall or ceiling. Another problem occurs
if you start to stimulate yourself when you wake in the night by watching
TV or playing a computer game or get into instant messaging on the
Internet – all these activities will stop you getting back to sleep and a
normal routine.
The benefits of exercise on sleep
Exercise and activity can be a great way of releasing the tensions of a
difficult day (see Chapter 11). Research has shown that aerobic exercise
like running, swimming or cycling during the day will make your sleep
deeper and longer at night. However, avoid exercising within roughly three
hours before your bedtime as it could leave you too wide awake.
Dealing with worry
To tackle worries about not sleeping, refer to Chapter 6 and apply these
approaches:
Try to allow your thoughts and images to pass through your mind
without responding to them. Trying to make yourself go to sleep can
easily keep you awake as it means you are actively trying to do
something (get to sleep).
If your worries are related to things you have to get done, then try
making a list and allocating the tasks to a specific time on your
activity schedule in the following days and weeks.
Practise a relaxation technique and focus your attention on a point of
light in your room.
Get up rather than lying awake worrying and go back to bed when
you feel ready to drop off.
Other steps you can take
Avoid caffeine in the evenings
Coffee, cola drinks and energy drinks all contain caffeine, which is a
stimulant particularly good at keeping people awake. Some people do not
break down caffeine quickly and as result it is in the system for much
longer and thus causes them to stay awake. Many people who have
difficulty sleeping begin to rely on caffeine to help them cope, others just
don’t realize how much they are taking, or that it may stay active in the
body for several hours. Caffeine can itself contribute to anxiety and
irritability, but in terms of sleep you want to make sure you don’t drink any
in the evenings. In general, switch to caffeine-free drinks after late
afternoon and calculate your total caffeine intake (see Chapter 14).
Avoid alcohol in the evening
Alcohol is a sedative and can help you get to sleep. However, if you use
alcohol in this way, you may then experience a rebound (like withdrawal
symptoms) or want to go the toilet in the early hours of the morning. Of
course, many people sleep when they have been drinking a lot but if you are
depressed or anxious then avoid alcohol in the evenings because it will
wake you during the night (see Chapter 14).
Avoid smoking or using illegal substances
Nicotine and other substances can contribute to difficulties sleeping as they
are stimulants. If you’re going to smoke or take other substances, don’t do
so in the evenings.
Be patient and persistent
Stick consistently to the principles outlined for a couple of weeks and you
will improve your chances of getting a good night’s sleep. The big mistake
that many people make when they are having trouble sleeping is trying too
hard to force themselves to sleep or desperately trying to ‘catch up’.
Remember, relaxation and routine are the foundations for good sleep.
Taking steps to restart your sleep pattern
Some people stay up during the night (for example, watching TV or playing
computer games) and then feel sleepy and go to bed only during the early
hours of the morning. They may then sleep until lunchtime. If this happens
to you, try moving the time you go to sleep forward by an hour or two a day
until you get to the desired time. For example, if you currently go to sleep at
5am, force yourself to stay awake until 7am, 9am the next day and so on
until you go all the way around the clock to, say, 11pm at night, when you
can start your normal routine. This method has the disadvantage that if
you’re working you’ll have to time off work for about two weeks because
you will be sleeping during the day until you reach the desired time. The
advantage of this method is that most people find that moving your
biological clock forwards is much easier than moving it backwards. Others
may take a more bold approach and not go to bed for the night and stay up
until 11pm, but this isn’t recommended.
Tackling excessive sleepiness
Excessive sleepiness, tiredness and loss of energy are very common in
depression. Sleeping too much is another form of avoidance of people or
activities. The only way to solve this is to stick to your sleep routine and
activity schedule. Ensure you get up by 8am. If you are on medication, you
may want to review it with your doctor to see whether it is contributing to
excessive tiredness. Some antidepressants are sedatives and others may be
better at improving alertness (see Chapter 16). There are occasionally
medical causes of excessive sleepiness. Do you suffer from obstructive
sleep apnoea (see page 158)? This is a treatable condition; if it’s left
untreated, the tiredness may interfere with your performance in driving or
operating machinery, and cause depression.
Overcoming nightmares
Nightmares can undoubtedly disrupt your sleep. They are frightening
dreams in which you awaken from your sleep frightened and anxious. It
may then take a long time for you to get back to sleep. Nightmares are often
a symptom of an emotional problem such as depression or anxiety but
commonly occur in people with post-traumatic stress disorder. They can
sometimes be caused by medication (for example, cimetidine, clonidine,
steroids, digoxin and propranolol). If you are in doubt, ask your doctor.
Whatever the cause, recurring nightmares can be overcome, like a phobia,
by a willingness to embrace them as just a bad dream and not having any
other meaning. A dream becomes a nightmare only if you are frightened by
it. The following steps can help you learn to accept and embrace your
dreams.
1. When you next have the nightmare, describe it out aloud over and
over again until it becomes less frightening. You can do this by
talking aloud to yourself or to a sympathetic partner. In the morning
you can write the nightmare down and repeat writing it down until
it is no longer frightening. When you first write it down or describe
it out aloud you will be anxious, but each time you repeat it you
will become less anxious. In this way you are learning to confront
your worst fears so they will not arouse such anxiety when the
nightmare next wakes you. After all, it is just a mental event. If and
when the nightmare does return, repeat the instructions. Each
successive time the nightmare returns, it should be less frightening.
If this method doesn’t work then go on to Step 2.
2. Recite the nightmare as in Step 1 before you go to sleep, but this
time change the end of the nightmare to a triumphant or neutral
ending. Again, write the dream out several times and rehearse it
 before you go to sleep so that you know your new dream off by
heart. For example, one woman who had been burgled had a
recurrent nightmare of a burglar coming in through a bedroom
window. However, she changed the ending of her dream to one in
which she used a judo throw and easily threw the burglar out of the
window. She learnt the dream off by heart by rehearsing it over and
over again before she went to sleep. When she did go to sleep, she
had her new dream but she was no longer frightened by it and could
get back to sleep easily. If you are still having problems with
nightmares after a stressful event talk to your doctor; they may want
to refer you to a specialist because you may be suffering from post-
traumatic stress disorder.
Dawn simulators
Do you hate getting up in the dark in the winter? Does your alarm clock
scream at you with some horrible electronic noise while you grope for the
snooze button?
An alternative is a dawn simulator, and there is some research to back up
claims that this can improve sleep. Dawn simulation is a technique using a
light that comes on very slowly in the early morning, to imitate a natural
sunrise. It uses a special bulb, but the level of light is the same as a normal
light bulb. As a result, our body responds by speeding up the process of
‘waking-up’ so that we have more or less woken up even before our eyes
open. Some dawn simulators include a sunset go-to-sleep facility which is
like a pleasant hypnotic feeling that allows you to fall asleep more easily
and seems to help in improving sleep problems and the quality of sleep. The
light can be set to fade slowly to darkness, making it ideal for shift-workers
and young children. Many people with seasonal affective disorder (SAD)
use both a dawn simulator and a lightbox in the morning to arouse them.
Medication for sleeping problems
Hypnotic drugs or ‘sedatives’ are medicines prescribed by a doctor that help
you get to sleep. Hypnotic drug-induced sleep may be better than no sleep
but it is not natural sleep and tends not to make you feel refreshed.
Common hypnotic drugs are listed below with their trade names in
brackets:
zopiclone (Zimovane)
zolpidem (Stilnoct or Ambien)
 promethazine (Phenergan)
nitrazepam (Mogadon or Somnite)
temazepam (Restoril).
Of these, zolpidem lasts only a few hours and can cause you to wake in the
early morning. By contrast, promethazine acts all night but may take a little
while to get you to sleep. Unfortunately, all hypnotic drugs can be addictive
when they are used for more than a few weeks. When you stop taking them
you may find it more difficult to get to sleep for a few days as there is
rebound insomnia. They are therefore recommended for use only in the
short term while you recover from depression or anxiety, or once in a while.
You can reduce the risk of having future problems by not taking them every
night (preferably not more than three nights in a row) and only when you
really need them.
Remember that disturbed sleep is a symptom of depression. In general
your sleep will improve naturally as your mood improves. If you are being
prescribed an antidepressant, your doctor might choose one that is more
sedative (see Chapter 16). (Examples of sedative antidepressants include
mirtazapine, mianserin, trazodone, trimipramine, dosulepin and
amitriptyline.) If the antidepressant is too much of a sedative, it can be
taken in a low dose (sufficient to help you go to sleep) and be combined
with a standard antidepressant to help improve your mood.
There are also natural herbs which are supposed to help with sleep
problems and which can be bought over the counter, but it is difficult to
evaluate claims of their efficacy. They include valerian root and camomile.
If you’re still having difficulties sleeping, go to your doctor. They may wish
to refer you to a specialist for a detailed assessment, as there are some rare
sleeping problems which require expert management.
Laura resolved to resist sleeping in at the weekend, instead getting up at
the same time each day of the week. She also decided to reduce her
alcohol consumption to only one glass of wine at the most, and to ensure
she had nights off from drinking. If she found she wasn’t able to drop off
after about 20 minutes, she got up and read a book in another room until
she felt sleepy and ready to drop off. The principle Laura found most
difficult was getting up in the morning by 7am if she woke in the night
and could not get back to sleep. She would get up by 7.30am at
weekends. Initially she thought it seemed silly to get up if you needed to
go back to sleep but, when she recalled that the effect of lying in bed and
 taking time off was in fact just leading her to become more frustrated,
she gave it a try.
Alongside not buying in to her ruminations and increasing her physical
activity, Laura found that her sleep improved after a couple of weeks of
sticking to her sleep program. She found that managing a poor night’s
sleep more effectively meant that she had a greater sense of control over
her depression, and she became more confident that she could cope.

An exercise
If sleep disturbance is a problem, write down your functional analysis of the
problem and what you are doing that has unintended consequences for
interfering in your sleep.
Functional Analysis of Sleep Behavior

Activating event (situation or

context of event)

Behavior (what you do including

ruminating, worrying and self-
attacking)

Consequences (immediate) which

provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause handicap.
What effect does it have on
yourself and others? What effect
 does it have on your thoughts and
feelings?

Valued direction What directions

could you take that would be in
keeping with your values and give
you better feelings?

Effect of valued direction What

effect does taking the valued
direction have on yourself, others
and the community in the long
term?

You might need some more information first to identify the problem. Use
your activity schedule to identify what time you go to bed, what you do at
night if you do wake, what time you get up, whether you go back to bed and
whether you nap in the day. In this way you can calculate the total number
of hours sleep during a 24-hour period. If sleep is a problem, reread this
chapter and try to identify what you are doing that you thought might help
you to sleep but has the unintended consequences of making it worse in the
long term.
Summary
1. Try to identify the current sleeping problem and possible solutions
and then put it into your formulation. Discuss it with a close family
member or therapist.
2. Decide what you are going to do to break your pattern that you have
developed and the effect on your sleep.
3. Decide on what you are going to do, monitor the effect on your
sleep and review your progress regularly.
13 Your Diet and Your Mood
CASE STUDY: Marc
Marc suffered from depression. He had a conflict at work and at first stayed
at home trying to do odd jobs. He had no luck in getting the problem
resolved so he began to lose heart. He had a poor appetite and no longer
enjoyed his food. It became an effort to eat, and he lost weight. Over the
following months he began to look pale and have a haunted look. He
started to neglect himself, his eating became more chaotic and he missed
main meals. Over time, he started to comfort-eat and graze on junk food.
He ate large amounts of saturated fats (takeaways, French fries and pizzas)
and sugars (cakes, sweets and fizzy drinks). He drank quite a lot of alcohol
(up to a bottle of wine a night) to help him get to sleep. He became inactive
and smoked more. Over the next year, he gained over 14lbs in weight, which
made him feel more ashamed about his appearance and led him to become
more withdrawn and to do less. He got up late and felt constantly sluggish
and tired and spent more time in front of the TV.
The effect of a poor diet on your mood
A poor or chaotic diet can make your mood worse. We are not saying that a
bad diet is the cause of your depression or that if you eat healthily it will
stop you getting depressed in the first place. There are many people in the
world who follow a poor diet and are not depressed. Equally, some people
with depression have a healthy diet. However, people with depression may
be more sensitive to a poor and chaotic diet and it is likely to be another
factor in keeping you depressed. Giving your brain and body regular and
healthy food is an important step you can take to give yourself the best
conditions for recovering from mood swings. Here are some of the ways
your diet and mood can be linked:
Comfort-eating food containing sugars and saturated fats feeds a
vicious cycle and in the long term leads to weight gain, a reduced
sense of well-being and possibly further loss of self-esteem.
A blood sugar level that goes up and down as a result of unhealthy or
irregular eating can at first make you feel good in the short term but
then leave you feeling lethargic and more prone to being anxious and
irritable.
If you neglect yourself, your diet may be deficient in some vitamins
(for example, B6 and folic acid), minerals (such as zinc) and
 essential fatty acids (EPA, see later in this chapter for details). The
deficiency of EPA in particular has been linked to depression.
Not eating regularly and healthily can be a way of acting as if there’s
‘no point’ or ‘I’m not worth it,’ which reinforces your feelings of
depression.
Restricting food to numb your feelings can be a temporary way to
‘feel better’ and avoid tackling problems or daily activities. This
means that you ultimately feel worse as problems don’t get solved
and your environment doesn’t improve.
One of the key messages in this book is to understand the function and
consequences of your actions. You can apply this principle to the content
and pattern of your eating too. There are two main ways of eating in
depression – one is restricting your food and the other is comfort-eating,
which provides an instant rise in blood sugar but then leads to a ‘crash’.
Loss of appetite and weight
If you have a poor appetite, are restricting your food or are losing weight, it
probably means you are missing meals or cutting down the amount you eat.
You may be smoking more, which might suppress your appetite. Your
stomach may feel as if it is in a knot from anxiety and you may feel
constantly tired. You can use functional analysis on a pattern of eating. The
example on the page opposite comes from Jan.
This is another form of emotional avoidance, like being down a hole and
trying to dig your way out of it. As with other types of avoidance, the
solution becomes the problem. You feel even more sluggish, and end up
feeling worse and less motivated. Because you are eating less, you may be
getting constipated, making you feel still more sluggish and causing the
cycle to continue.
To make progress, you have to drop the spade, stop trying to dig your way
out of the hole and decide on a new direction.
If you have been neglecting yourself and have lost weight, it is
important that you eat regularly or the lack of nourishment will
aggravate your depression. Try to start eating small amounts of
healthy food regularly even if you don’t feel like eating or have lost
your appetite. Remember to act according to your plan – not by how
you feel. You can’t expect to recover without any nutrients for your
brain. This is similar to the problem of inactivity and the assumption
that you will do something only when you feel right. It is putting the
 cart before the horse – you have to eat even if you don’t feel like it,
in order to get your appetite back.
If you are underweight, monitor your weight weekly. Use the eating
diary (see below) to plan each meal and snack on a daily basis and
then write down what food you actually eat and at what times.
Review this regularly to check that you are achieving what you plan.
You may need the assistance of someone who will help to nourish
you. However, unless you are very malnourished, you can
incorporate the process of planning meals and purchasing food as
well as eating into the activity schedule. If you have a partner,
discuss which meals you will prepare and cook for them.
If constipation is a problem, ensure a diet full of roughage. More
vegetables, bran and prunes or a bulking agent such as Fybogel or
psyllium husks will help. Drink plenty of water. Laxatives that
stimulate the bowel should be used only occasionally.
If you have been neglecting yourself for some time, you may need a
supplement (vitamins B6, B12 or folate) or EPA.
It is not just how much you eat but what and how you eat that is
important. This theme is developed in the section called ‘Eating
healthily’.

Activating event (situation or Feeling depressed about my son

context of event) who has a gambling problem.

Behavior (what you do including Restricting my food by skipping

ruminating, worrying and self- meals, eating less and losing
attacking) weight. Ruminating – if only my
son did not gamble.

Consequences (immediate) which Feeling emotionally numb and

provide a payoff thinking less, so I become like a
zombie.
 Unintended consequences (in the
long term) which cause your
handicap
Make myself more depressed
because my diet is probably
deficient in vital nutrients. Since
I don’t have enough energy I am
now too tired to do anything and
so become more withdrawn and
ruminate more in a vicious
circle.

Comfort-eating junk food

If you are comfort-eating, use the functional analysis to understand the
context and the effect of your comfort eating and therefore what is
maintaining the problem. On the page opposite is an example.
This is another form of avoidance of an emotion (feeling lonely) in which
the solution becomes the problem. Avoiding the thoughts and feelings mean
you carry on avoiding trying to solve the problem. Food or alcohol is being
used to boost your sugar levels so that you feel better in the short term.
Eating a packet of crisps and a muffin washed down with a fizzy drink lead
to a rapid increase in your blood glucose levels. The meal ‘works’ in the
sense that it briefly reduces your feelings of being tired and down. This
happens because when your blood sugar is high your body responds by
releasing a large amount of the hormone insulin. This results in the transfer
of as much glucose as possible into fat stores. As soon the glucose is
removed from the bloodstream, you get a sugar low (hypoglycaemia), and
after an hour or two you start to crave for more sugar and snacks. The
insulin is released again and the whole cycle continues. A more exaggerated
form of this cycle occurs in bulimia and binge-eating, leading to regular
cravings for carbohydrates. In the long term this pattern of eating will make
you more prone to diabetes (which is caused by insulin deficiency), weight
gain and heart disease.
Food Diary
To get a clear picture of your eating pattern it can be helpful to keep a
record of your eating for each day over the next week. See the Food Diary
on page 172.

Activating event (situation or Feeling tired and depressed

context of event) about being alone in the world
 and without someone to share
my life with.

Behavior (what you do including Regularly have a Big Mac or

ruminating, worrying and self- pizza, French fries, a large fizzy
attacking) drink, milk shake or chocolate
muffin, and snack on crisps and
chocolate.

Consequences (immediate) which Feel briefly better, and

provide a payoff comfortable for a couple of
hours.

Unintended consequences (in the Gained a lot of weight and feel

long term) which cause your worse about myself. It makes me
handicap look less attractive and less
likely to get the partner of my
choice. Feel more sluggish and
depressed.

There are duplicates of the Food Diary provided in Appendix 5.

Food Diary
Day ___________ Date __________________________
Time Context Food/drink and
(for example, thoughts, emotion, amount consumed
activity or situation)
Do you notice any pattern of either avoidance or chaos in your eating? Now
try your own functional analysis on a pattern of eating that that is habitually
occurring.

Activating event (situation or

context of event)

Behavior (what you do including

ruminating, worrying and self-
attacking)

Consequences (immediate) which

provide a payoff

Unintended consequences (in the

long term) which cause your
handicap

Are you overweight?

Everyone is built differently, but there are some guidelines for what a
healthy weight is for your height. A problem for some people with
depression is being overweight as a result of eating unhealthily or comfort-
eating and being inactive. Some antidepressants may contribute to weight
gain. Alternatively, your weight may be normal, but you may feel bad about
your appearance and be more self-conscious. You can make an objective
assessment of whether you are over- or underweight by reading Appendix
1. Whether you are overweight or not, you may already be following a diet
that restricts the amount you eat. However, the problem with many diets is
that they often make you feel hungrier and make your health worse. The
key is in not just the amount of food but the types of food you eat and
combining healthy eating with an exercise program.
Eating healthily
This section discusses ways of eating which are both healthy for your mind
and, coincidentally, for your body, and how you can adopt them. The
section is relevant to you whether you are restricting your food, are
comfort-eating or neither.
Eating healthily is something you can do to help improve your mood.
How you eat is important in reducing comfort-eating or if you are planning
to eat more healthily. Here are some simple rules that can powerfully
influence your behavior.
Make eating an experience that you savour. Sit down to eat in the
same room with others if you have a family or flatmates. This means
that eating food will be associated with sitting down at a particular
table. Try not to eat food in the other living rooms or your bedroom.
Similarly, store food only in the kitchen and not in other areas.
Keep eating as a sole activity and do not read the paper or watch TV
at the same time as eating. This will help you to give your food your
full attention and to be really aware of how much you eat and when
you become satisfied (which you may have ignored in the past).
You don’t have to eat everything that is on your plate (contrary to
what your mother told you!). You can practise leaving at least one
piece of food on the plate and eating only what you need.
Make purchasing, cooking and eating food part of your activity
schedule (see Chapter 7) so that you eat regularly and plan it
beforehand. If you can afford it, occasionally go out to eat in a nice
restaurant or invite someone around for dinner. You have probably
 missed out on pleasurable events like these by being depressed, as
you have become more withdrawn from the world.
Carbohydrates
There are three main types of food: carbohydrates, fat and protein.
Examples of foods rich in carbohydrates are bread, pasta, potatoes, cakes,
biscuits and pulses. Carbohydrates are converted by the body (metabolized)
in the liver into glucose. The converted glucose is used immediately as fuel
for the body (for example, for you to walk, talk or think), or, if it is excess
to requirements, stored as fat, often around your waist and hips, so it may
be used rapidly when you need it. Virtually all carbohydrates are
metabolized to glucose, which may then be either used as fuel or converted
into fat. Different carbohydrates vary in the speed at which they are
metabolized. This difference is measured by the glycaemic index. Foods
which are rapidly converted into glucose and which increase your insulin
level have a high glycaemic index (GI). This is only half the picture and a
more accurate measure of the rate of metabolism is the Glycaemic Load
(GL), which takes into account the average portion size for a meal. Foods
with a low GL score 10 or less, those with a medium GL score 10–20 and
those with a high GL score 20 or more. Examples of low GL foods include
soya and linseed bread, wholemeal pitta, rye bread, all beans and pulses,
muesli, porridge oats, bran cereal, barley, couscous, cornmeal tortillas and
taco shells, rice bran, oat bran, milk, cheese, dairy foods, unsweetened
juices (a small glass), most fruits, meat and most vegetables (although
potatoes, yam and parsnips have a moderate GL rating).
Healthy eating means avoiding eating carbohydrates that have a high GL
and sticking to low and medium GL foods. If you want to lose weight, you
may follow a diet that emphasizes foods which have a low GL and
minimizes foods containing trans-fatty acids and saturated fats (see below).
A low GL diet is not a passing fad: it has been regarded as healthy eating,
and has been recommended for diabetics, for many years. It is achievable
and sustainable and can lead to weight loss in the long term when combined
with an exercise program. There are a number of popular diet books that
include recipes from foods with a low GL or GI. If you are not overweight,
eating foods that are mainly low or moderate GL is a healthy option in the
long term. It will reduce your cravings for sugar and the urges to comfort-
eat when you are down or irritable.
Fats
The second major contributor to our diet is fats. We need some fat in our
diet to keep us healthy. If you are dieting or neglecting yourself, cutting out
fat can make your mood worse. Alternatively, if you are comfort-eating and
grazing you may be eating the ‘wrong’ sort of fats which may make you
feel better for an hour but then make you feel worse, and ultimately make
you overweight. A healthy diet and fuel for your brain needs the right sort
of fats.
Foods contain four main types of fats or fatty acids: monounsaturated,
polyunsaturated, saturated and hydrogenated (also known as ‘trans-fats’).
Hydrogenated fats have had hydrogen bubbled through them in a process
called hydrogenation to improve their flavour and shelf life. The resulting
product is a more solid fat, called hydrogenated fat or hydrogenated
vegetable oil, which is an ingredient in many processed foods including
manufactured cakes, biscuits, margarines, pastry, pies and fried foods.
These are guaranteed to pile on the pounds around your waist. In general,
foods with a high proportion of monounsaturated and polyunsaturated fats
are healthier than saturated fats, which are in turn healthier than
hydrogenated or trans fats (see Table 13.1). Meat has a greater proportion of
saturated fats than polyunsaturated fats. Fish has the opposite ratio. Healthy
fats tend to be vegetable oils such as olive, corn, sunflower, rapeseed and
flaxseed oil. Coconut and palm oils are vegetable oils that contain a high
level of saturated fats. They are frequently found in snack foods, biscuits
and pastries.
Table 13.1: Examples of different classes of fats
Healthy fats Unhealthy fats

Monounsaturated Saturated fats

fats

Olives and olive oil Butter

Sunflower oil Full-fat dairy products

Nuts Red meat

Avocados Coconut oil

 Palm oil

Polyunsaturated Hydrogenated fats or

fats trans-fats

Fish (especially Hydrogenated vegetable

mackerel, herring, oils
tuna, salmon)

Flax seeds and Cakes or biscuits

flaxseed oil containing hard
margarine

Rapeseed oil

Walnuts
The table provides some guidance as to which fats to eat. In general,
minimize your intake of foods that contain highly saturated fats. We are not
suggesting you should avoid saturated fats altogether, but eat them in
moderation and either remove any obvious fat or skin from meat or buy
lean cuts of beef, mince, chicken breast, ham or veal. Avoid frying in
saturated fats and choose low-fat dairy products. However, it is best to
avoid foods containing hydrogenated fats or trans-fats.
Eicosapentaenoic acid (EPA)
Of particular relevance to depression and mental health is the role of a
certain type of polyunsaturated fat. When at least 20 carbon atoms make up
a fatty acid chain, it is called a highly unsaturated fatty acid (HUFA). Two-
thirds of the brain is made up of HUFAs. They are the basic components of
the lining of all nerve cells, through which one nerve cell communicates
with another. There are two main types of HUFAs – omega-3 and omega-6.
Scientists are only just beginning to realize the importance of omega-3 to
the human diet. Like the nerves in the rest of the body, brain cells need
regular replacement of HUFAs. These fatty acids are also called ‘essential’
fatty acids as the body cannot make them; we have to get them from our
diet.
Omega-3 fatty acids come from algae, plankton and some grasses. Fish
that feed on algae and plankton therefore accumulate omega-3 fatty acids in
their body. Omega-6 mainly comes from grains and occurs in vegetable oils
and animal fat, especially in the meat of animals fed with grains. A typical
Western diet has an imbalance in the ratio of omega-3 to omega-6 fatty acid
of 1 to 10 or 20. The consumption of omega-3 fatty acids seems to have
decreased especially since the Second World War and the subsequent rise in
the use of processed foods.
Omega-3 fatty acids can be taken as a nutritional supplement, as
eicosapentaenoic acid (EPA). They appear to have some benefit in some
controlled trials of depression. Research on EPA is at a very early stage and
it is probably most beneficial to people with more severe forms of
depression who experience sleep disturbances or loss of appetite or are
neglecting themselves.
Professor David Horrobin and his colleagues in Scotland conducted
research several years ago comparing the amount of fatty acids in a group
who were depressed against a group who were not depressed who were
matched for age, alcohol and dietary habits. They found that the depressed
group had lower EPAs and that the lower the intake of dietary fatty acids,
the worse the depression. Interestingly, it has also been noticed that
postnatal depression is more common in countries such as the UK, the
USA, France and Germany than Japan, Singapore and Malaysia. This is
perhaps because the consumption of fish and the concentration of omega-3
acid in the breast milk are much higher in the Pacific basin countries.
The first controlled trials by researchers in Scotland compared omega-3
fish oil supplements with a placebo (which was olive oil) in 70 people with
manic depression who had persistent symptoms of depression despite
treatment with antidepressant medication. Those patients who received
omega-3 fatty acids had fewer symptoms than those who received olive oil
after four weeks and had a lower rate of relapse. The second controlled trial
was conducted a few years ago in Israel on 20 patients with depression who
had not responded to conventional antidepressant drugs and whose
medication was not altered during the study. The results were similar to
those in Scotland: patients receiving EPA supplements did better than those
receiving a placebo after only three weeks. Since then there have been four
other controlled trials, most of which have demonstrated positive benefits.
The results are therefore promising. However, the research is still in the
early phase and we don’t fully understand in what circumstances omega-3
fatty acids might be helpful. For example, are they helpful only for people
with a poor diet and low EPA levels? Do they benefit only those people
with depression who have higher than normal levels of the stress hormone
cortisol? Are they helpful for people with milder depression? At this stage
scientists do not know, but there is no evidence of harm and some
promising research. If you do use EPA, beware of using supplements as a
form of avoidance (‘I’ll wait until I feel better’) or in isolation, or you may
be waiting for a very long time – it is still important to deal with the
problems you are avoiding and to do in life what is important to you.
Side-effects of EPA
Supplements derived from fish oils may leave a fishy aftertaste, but EPA
has very few side-effects. The different taste can be prevented by taking the
supplements at the beginning of a meal or taking a version derived from
vegetables. Occasionally, people experience loose stools or mild diarrhoea.
If this happens to you, reduce the dose for a short time. On rare occasions,
EPA can cause bruising or problems with blood clotting. People taking an
anticoagulant such as warfarin or daily aspirin should let their doctor know
that they are taking an EPA supplement as this may limit the use or alter the
dose of the anticoagulant. In summary, the ratio of benefit seems to
outweigh the risks as there are virtually no side-effects. The only
disadvantage is the financial cost as it is not a ‘drug’ and it cannot be
prescribed. However, more research needs to be done if EPA is to be more
widely adopted and to find out which people with depression it can help.
EPA dosage
Research suggests that in order to obtain an antidepressant effect, you need
to take at least 1 gram a day of omega-3 fatty acids. Some people may
require higher doses. The easiest way to take EPA is purchase a supplement
like VegEPA, which is derived from flaxseed (www.VegEPA.com). Most
people will need only two capsules of this twice a day. Other supplements
you can take for EPA are derived from fish oils, for example the brand
MaxEPA.
If you don’t want to take a supplement, the option is to eat a lot of fish on
a daily basis and risk environmental toxins. The highest omega-3-
containing fish are mackerel (100gm contains 2.5gm of omega-3), herring
(100mg has 1.7gm), tuna (100gm has 1.5gm) and salmon (100mg has
1.4gm). Note that farm-raised fish may have lower levels of omega-3 than
fish from the wild. Vegetarian sources of food that have a high
concentration of omega-3 fatty acids are flaxseeds (100gm contains 2.8gm),
flaxseed oil (1 tablespoon contains 7.5gm), rapeseed oil (1 tablespoon
contains 1.3gm) and walnuts (100gm contains 2.3gm). Vegetables that
contain a higher proportion of omega-3s include spinach (40gm contains
2.3gm) and watercress (40gm contains 5gm). Organic farming also appears
important in the concentration of omega-3 fatty acids – for example, the
eggs of free-range organic chickens contain 20 times more omega-3 than
those of the grain-fed hens. A study which tracked 14,541 women from
their eighth week of pregnancy to eight months after giving birth found that
those who had eaten no seafood – rich in omega-3 – experienced nearly
twice the rate of depression as those who ate 10oz (300g) of fish daily.
Even if omega-3 supplements do not directly improve your brain, they
should help your heart and other organs. For example, one study
demonstrated that cardiac patients who followed a Mediterranean diet rich
in omega-3 fatty acids had a 76 per cent lower chance of dying in the two
years after a heart attack than those following a diet recommended by the
American Heart Association. Omega-3 fatty acids may also be relevant for
reducing the likelihood of inflammatory disease, cancer and arthritis.
Snacks
As well as good meals at regular intervals, you need healthy snacks – ones
that keep up your energy levels throughout the day without creating further
cravings. Choose snacks that have a low GL (for example, almonds, brazil
nuts, hazelnuts, cashew nuts, macadamia nuts, pecans, walnuts and dried
fruit), but keep them to a minimum (that is, no more than a handful a day).
Also consider raw vegetables such as baby carrots. Chocolate is in the high
GL section but if you want to eat it, you can still have a small quantity (say,
three squares) of cocoa-rich chocolate (70–85 per cent) which has less sugar
and lowers the GL score.
Marc was encouraged to plan his eating and to eat foods with a low GL.
He also avoided foods with hydrogenated fats and minimized foods with
saturated fats. This allowed him to lose weight gradually over the
following six months while at the same time his mood improved. He
returned to his previous weight and then in the long term ate foods from
both low and moderate GL groups. He no longer experienced the mood
swings associated with his comfort-eating. He found it difficult to give up
coffee and so he set himself a target of a maximum of two coffees a day.
He achieved this by gradually replacing his coffee with a decaffeinated
variety. He also decided to restrict his alcohol consumption to one drink
a day in the evening and his wife agreed to the same restriction. He
drank more water regularly during the day and took EPA supplements.
Marc’s typical daily eating plan
8am breakfast: A small bowl of high-bran cereal, blueberries and
skimmed milk. One slice of rye bread with scrambled eggs. Cup of
coffee. Glass of water.
11am snack: Apple. Glass of water
1pm lunch: Home-made vegetable soup. Small piece of cheese. Slice of
wholemeal bread or crispbread. Piece of fruit. Glass of water, cup of
coffee.
Or garden salad with tin of sardines, or low-fat cottage cheese, or lean
ham or hummus. Wholemeal bread or oatcakes. Piece of fruit.
4pm snack: Cup of tea and small handful of dried fruit (for example,
raisins, apricots, prunes) and small handful of almonds, brazils, walnuts,
or hazelnuts or oatcake with peanut butter.
7pm supper: One glass of wine. Grilled chicken or fish (for example,
trout, plaice, mackerel or haddock). Two vegetables (at least one green).
Wild rice. Fresh fruit and natural yoghurt (no sugar). Three pieces of
dark chocolate with 75 per cent cocoa.
Glass of water, cup of decaffeinated coffee.

Hints on eating well

Be guided by a plan for your eating rather how you feel at the
moment
Eat regularly: have breakfast, lunch and dinner plus snacks
Don’t skip meals
Minimize use of alcohol
Try to eat healthily with low GL foods instead of high-sugar and
high-fat food. Include plenty of fruit, vegetables, and lean protein.
Once you have a clear picture of what you are eating and drinking, try to
plan your eating (meals, snacks and drinks) in advance so you have the
right ingredients in store or what you need to take to work with you.
Incorporate your shopping and preparing or cooking your food into your
activity schedule as well as a planned timescale for when and where you
will eat or drink (see Chapter 7). Be sure to stick to the plan rather than
eat according to how you feel.
14 Sex and Drugs and Rock ’n’ Roll
Alcohol and illegal drugs are not necessarily a problem (apart from the
obvious potential legal problems with illegal drugs). However, you will
need to do a functional analysis on your alcohol or drug use or other
lifestyle choices to determine whether the activity has any unintended
consequences. The consequences will determine if the activity is
maintaining your depression. At the end of the chapter, we discuss
compulsive shopping, gambling and other activities that people sometimes
take to excess in an attempt to avoid or escape from bad feelings.
Sex
When you’re depressed, sex is usually the last thing on your mind.
However, not everybody with depression loses their interest in sex and
some maintain a normal sexual life. Some people with depression find that
it is one of the few things in life that gives them any comfort. Occasionally,
people may use sex and pornography on the Internet as a way of avoiding
thinking about their problems; this is discussed at the end of this section.
Loss of interest in sex
Very often loss of interest in sex is the first symptom to appear in
depression (and the last to go). This can cause conflict in a relationship
which in turn may make depression worse, so some relationships may not
survive. Support and communication is therefore very important when you
are depressed, even if you can’t share the fun (for advice, read Overcoming
Relationship Problems (see Appendix 4 for details). Not communicating
with your partner or letting sex become an area of conflict is often the cause
of such problems. The book discusses various ways to improve
communication and reduce conflict.
Another issue is that some antidepressants (especially SSRIs, see Chapter
16) can delay orgasm or prevent it from happening at all. Sometimes they
can reduce your libido (your desire to have sex). Chapter 16 discusses these
issues in detail. There are also a number of medications, such as
antipsychotic drugs prescribed to reduce anxiety, that may reduce sexual
interests. Some blood-pressure pills (ACE inhibitors, betablockers, diuretics
or calcium channel blockers) can sometimes cause men to have erectile
difficulties. Illegal substances can also reduce libido – for example,
cannabis can reduce your motivation. Always check with your doctor
before wanting to stop a medication you think might be linked to reduced
sexual interest.
CASE STUDY: Carol
Carol had never had a high sex drive but she enjoyed her physical
relationship with her partner. When she developed depression, she
completely lost her sexual interest. There had been some conflict with her
partner as she wanted him to take a more active role in running the house
and helping with childcare. However, their incompatible levels of interest in
sex now led to an increase in their conflict and intensified her feelings of
being used and worthless. They set aside time to negotiate solutions to the
domestic and childcare problems and to talk about their relationship. They
agreed to stop arguing over the past and to focus on how they each wanted
each other to change their behavior. They agreed to restrict sexual activity
to once a week so that there was no conflict over sex during the rest of the
week. Also, Carol had help for her depression and started to stick to the
activities which were important to her despite the way she felt. Her mood
gradually improved over the following two months and her sexual interest
returned within about four months.
Wanting more sex
Although loss of interest in sex is a common symptom of depression, some
people use sex, pornography, masturbation or prostitution to give
themselves temporary relief from their emotions or to distract them from
their problems. As pornography has become so readily available through
the Internet, and can be accessed without leaving home, the number of
people becoming ‘hooked’ on porn has increased. As with most of the
behaviors we discuss in this book, the concern here is the function of the
behavior. Remember that, just like watching TV, your ‘use’ or reason for
the sexual behavior will determine its effect. In short, when it’s about
escaping or avoiding something (for example, emotionally numbing
yourself or not thinking about your problems), it’s likely to add to your
problems. When it’s reinforcing and positively aids you in pursuing your
values (for example, within a relationship) it’s likely to help. However,
some people find it’s better to be ‘abstinent’ from pornography as it’s very
difficult to stop viewing it once you have started.
CASE STUDY: Alex
Alex would spend hours each evening searching on the Internet for
pornography as a way of trying to lift his mood and get sleepy for bed. The
effect of this was that it took away time he needed to spend on finishing
coursework and doing household chores, which meant he felt stressed and
irritated with himself the next day. He tackled this by scheduling in 20
minutes per evening for chores, and deciding to do his coursework for an
hour. He stuck to the timetable despite his worries that his work would not
be good enough. He then allowed himself occasional and limited access to
pornography, which felt much more in line with his values about his
sexuality. His mood and sleep improved within ten weeks.
Alcohol
Alcohol is a drug. It is a depressant because it slows down your ability to
think and make judgments. It is also a way of numbing yourself emotionally
so you can avoid thinking and feeling negatively. Using alcohol in this way
provides another example of your solutions becoming your problem, as
excessive drinking can cause depression in a vicious cycle.
Whether you drink beer, wine or spirits makes no difference. It’s the
amount of alcohol in your drink that matters, not the type. So, the first step
in deciding whether alcohol is a problem would be to calculate the number
of units of alcohol you have per week as well as the number of binges. Most
people underestimate the amount they are drinking, so the best way of
calculating the total amount is to write down the amount you drink as you
go along in a diary and total up the number of units for an average week.
Use the blank Drink or Drugs Diary in Appendix 5 and table 14.1 below to
calculate the number of units of alcohol you drink in a typical week.
Table 14.1: Number of units of alcohol per drink
For example, one large can of extra-strong lager is equivalent to 5.5 units of
alcohol. A bottle of wine is about 9 units. Safe drinking is defined for a man
as a total of 21 units per week or less. This does not mean you can binge-
drink your weekly limit on one day of the week, because you should not
drink more than 3 or 4 units per day. Safe limits for women are no more
than 2–3 units per day or 14 units per week. Drinking alcohol within safe
limits is usually okay when you are depressed, unless you are on a
medication that advises against it. The limits above are conservative but a
reasonable guide to follow. As emphasized throughout this book, it’s not so
much what you are doing that is important, but the consequences, both short
term and long term. Consider whether you are using alcohol as a form of
emotional avoidance (for example, to help forget problems or put things
off).
A popular way of helping you decide whether you have a drink problem is
the CAGE questionnaire for your current drinking.
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you Ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover?
If you answer ‘yes’ to two or more of these questions (or have more than 21
units a week for men and 14 a week for women), you need to reduce your
drinking. As pointed out earlier, consuming excessive amounts of alcohol or
binge-drinking is another form of avoidance – it makes you emotionally
numb and reduces unpleasant thoughts and feelings in the short term.
However, they cause depression, tiredness and sleep problems. Alcohol also
has a high GI and creates a sugar high which makes you feel good in the
short term. This is followed by a sugar low and a craving for more alcohol.
Thus excessive amounts of alcohol lead to weight gain – alcohol is best
avoided if you want to lose weight and have a stable mood.
Other alarm bells signs for a drinking problem are if you
have often been unable to remember what happened the night before
because of your drinking
often feel embarrassed about what you did because of your drinking
are often late for college or work or are taking days off because of
hangovers
have frequent arguments with your partner about your drinking
do not fully participate in family life because of your drinking
have convictions for drink-driving
often get into fights when you drink
find yourself having sex with someone you don’t particularly like
find that drinking is a way of coping with feeling stressed or bad
cannot control the amount you drink at any one time.
If you become addicted to alcohol, you may need to drink more to
experience the same highs as you did before – this is called increasing
tolerance. You might also experience withdrawal symptoms. In the
morning after drinking you might have cravings, or be restless, nervous,
sweaty, shaky, or nauseous. In this case, you should seek medical help to
stop drinking safely as stopping suddenly could trigger an epileptic fit or
another complication. Over time, excessive amounts of alcohol can cause
permanent memory loss and brain damage. Other medical complications of
excessive drinking include indigestion and stomach ulcers, weight gain,
high blood pressure, liver disease, various cancers and nerve damage.
Pregnant women who drink alcohol risk having babies with birth defects: it
is best not to drink at all as safe limits in any given pregnancy are not
known.
Most people will find that their general mood has improved within a few
weeks of stopping alcohol. You will probably also feel physically better and
may find that you get on better with your family. It is therefore best to stop
drinking first and then use the strategies in this book if your mood has not
improved within four weeks of stopping.
If you are not addicted to alcohol and believe you can reduce your
drinking to within the safe limits, set yourself a target to reduce the amount
you drink. However, if this does not work, consider a goal of abstinence as
it may be easier than trying to control your drinking. What is important is to
recognize that you have a choice. Consider not just the amount you are
drinking but also the damage being caused by alcohol to your physical and
emotional health and whether it is creating other problems to you or your
family. Choose the goal you have decided and that you believe you can
stick to.
Keep a record of the amount you are drinking so you can monitor it and
the situations in which you are more likely to drink or the contexts in which
they occur (for example, when you feel bad). This will make it easier for
you to avoid situations where you are more likely to drink excessively (for
example, going to the pub after work). As an alternative to drinking, plan
other activities in your schedule to do with a friend or relative. A partner
can also help you to stick to your goal and support you in your progress.
When you are in high-risk situations, say, at a leaving do for a colleague in
a pub:
sip your drink slowly – don’t gulp it down
drink a non-alcoholic drink in between your alcoholic drinks
don’t drink on an empty stomach: eat something first
choose drinks with ordinary-strength alcohol.
Remember that changing a habit is always a challenge and takes time and
that healthy drinking means it does not interfere with your health, work or
relationships, or with the safety of yourself or others. At the end of this
chapter there are a series of steps for you to follow to reduce your drinking
to a safe limit or to stop altogether.
Lastly, be cautious about mixing alcohol with other drugs (prescribed or
illegal), especially tranquillizers or hypnotics. One drug may boost the
effect of another and you may feel drunk or become unconscious with even
a small amount of alcohol. Check with your doctor or the product
information leaflet that came with the drug concerned whether you can
safely drink. Taking stimulants such as caffeine, cocaine, or amphetamines
after drinking a lot of alcohol can make you feel more alert, but this is an
illusion. In reality, although you feel more awake you will be liable to make
bad decisions or drive dangerously.
CASE STUDY: Neil
Neil would often come home late after he had been to the pub, where he had
gone to try to take his mind off his problems. He would drink several pints
of lager, and snack on crisps and peanuts. Although he did succeed in
temporarily switching off his worries and low mood, the effect on him was
that he ultimately felt bored and unsatisfied. His hangover left him feeling
more depressed and made it harder for him to get out of bed in the morning.
The calories from the beer and snacks made him overweight and reduced
his sense of well-being. Neil ultimately tackled his problem by learning not
to buy into his worry thoughts and pursuing his values of seeing his friends
and spending time with his partner by keeping alcohol consumption limited
to the weekends and to a safe limit that he agreed with himself beforehand.
Coffee and caffeine-containing drinks
Coffee contains caffeine, which is a brain stimulant. Other caffeine-
containing drinks are listed in Table 14.2 on the following page. Caffeine
can give you a sense of being more alert. However, if you drink too much
coffee, fizzy sports drinks, or cola you may be making yourself more
anxious. As well as caffeine, fizzy drinks contain large amounts of sugar
(on average 7 teaspoons per can) which can also give a sugar ‘high’
followed by withdrawal symptoms when the sugar has been removed from
your bloodstream by the release of insulin.
Some people are especially sensitive to caffeine and find that it triggers a
feeling of panic. If you are addicted to coffee or are drinking more than
eight cups a day, stopping suddenly could cause withdrawal symptoms such
as headaches and feelings of anxiety. Coffee also stimulates insulin
production and may lead to comfort-eating.
To be safe, drink no more than four cups of coffee (or the equivalent) a
day. If you are drinking excessive amounts of coffee, gradually replace the
coffee with a decaffeinated variety or reduce your daily intake slowly.
Consider switching to water (still or carbonated), tea, herbal tea, or
skimmed milk, all of which have a low GI and very little or no caffeine.
Diet soft drinks are fine if they have no caffeine or sugar. If you have read
the chapter on diet and are trying to choose drinks with a low or moderate
GL, unsweetened fruit juices (such as apple, cranberry, grapefruit, or
orange) are okay if you limit your daily consumption to 200ml or less. As
mentioned earlier, alcohol, fruit drinks, tonic water and fizzy drinks (for
example, cola) are also high in sugar (or a high GL) and will give you a
short-term high which can lead to further craving.
Table 14.2: Caffeine content of popular drinks
Soft drinks
330ml can Caffeine content
(milligrams)

Red Bull 80
Diet Coke 45
Dr Pepper 41
Sunkist Orange 39
Pepsi Cola 37
Diet Pepsi 36
Coca Cola Classic 34
Cherry Coke 34
Lemon Coke 34
Vanilla Coke 34
Snapple Flavoured Teas 31
(regular or diet)
Snapple Sweet Tea 12
Sprite 0
7-Up 0
Other beverages

8oz beverage Caffeine content

(milligrams)

Coffee, drip (filter) 115–175

Coffee, brewed/cafetière 80–135
Coffee, espresso (2oz) 100
Coffee, instant 65–100
Tea, iced 47
Tea, black 45
Tea, green 20
Tea, white 15
Hot cocoa 14
Chocolate milk 4
Coffee, decaf, brewed 3–4
Snapple Sweet Tea 12
Coffee, decaf, instant 2–3
Tobacco
Tobacco smoke is made up of many different chemicals: the chief ones are
nicotine, tar and carbon monoxide. Nicotine is the main drug of addiction.
Tar contains hundreds of chemicals that cause damage to tissues around the
body. Carbon monoxide is the gas obtained when tobacco is burned and
reduces the amount of oxygen you can carry in your blood, so smoking is a
bit like breathing your car exhaust.
Smoking causes premature death from lung cancer, heart disease and
stroke. It increases the risk of cancer of the colon, throat, pancreas, bladder
and cervix. It causes most cases of bronchitis and emphysema. On average,
people who smoke die about 13 to 14 years earlier than non-smokers. The
good news is that, if you quit, the health benefits are almost immediate.
Within a day, your blood pressure and pulse start to return to normal.
Within a year your risk of heart attack reduces by half, and over a longer
period your risk of stroke or lung cancer reduce to that of someone who has
never smoked.
Rather worryingly, many people with depression either start to smoke
more or restart smoking when they had previously stopped, which raises the
issue of whether smoking could also be a factor in causing depression. If
you smoke, you probably feel that smoking causes a temporary reduction in
stress. Indeed, past theories on this subject included the theory that smoking
was a form of self-medication as the chemicals in a cigarette might include
a mild antidepressant. However, it also seems that nicotine might cause
symptoms of depression in people who are not depressed.
The evidence for the link with depression comes from a study done a few
years ago on 8,000 teenagers who were not depressed and whose smoking
habits varied. The researchers compared them with another group of 7,000
teenagers who were not smokers, but who had some depressive symptoms.
They then followed up these two groups a year later. For teenagers in the
first group who were originally not depressed, cigarette smoking was found
to be the strongest predictor of developing depression. In the second group,
when all possible contributing factors to smoking were considered,
depression did not prove to be a strong predictor of heavy smoking. This
suggests that smoking may be related to the development of depression.
Another survey of 3,000 individuals in USA confirmed that the likelihood
of having depression was more common among smokers than non-smokers
(6.6 vs 2.9 per cent) and that smokers who reported a history of depression
were less likely to succeed in smoking-cessation programs than smokers
without depression (14 vs 28 per cent).
It’s probably more difficult to stop smoking when you are feeling
depressed, so you may decide to wait until their mood has recovered.
However, consider this: if you stop smoking, you will probably not only
feel much better but also find that your self-esteem has improved. Make
giving up smoking a goal. There is no safe smoking, and cutting down is
not a good idea because many people just change the way they smoke – by
taking more puffs or a longer puff to get the same effect.
As with any addiction, withdrawal symptoms are normal. Stopping
smoking may make you feel more nervous, depressed, irritable, or hungry
for a few days or weeks. Some people experience headaches, or have
difficulty concentrating or sleeping. It may make you feel like your
depression is getting worse. But, although it may take longer for you to
overcome your urge for a cigarette, it will get easier. People often worry
about gaining weight although this occurs only in about a third of people
and then by only two or three pounds or so. If you are concerned about
weight gain, you can prepare for this by reading the chapter on healthy
eating, cutting down on fatty or sugary snacks, and exercising more. You
will more than compensate by the way your skin looks and the way you feel
about yourself.
 You can help yourself to stop smoking by using the method at the end of
this chapter. Discuss it with your doctor, as they may be able to help or refer
you to a smoking cessation clinic. There are many different ways to help
you stop smoking, such as nicotine patches or medication like bupropion
(which is also used as an antidepressant, see Chapter 16). No single method
works for everyone and you may need to try a variety of approaches before
you succeed. In fact, only one in five people succeed on the first attempt,
but do keep trying.
Illegal substances
There are a number of illegal substances which some people use to
emotionally numb or distract themselves when they are depressed.
However, as with legal substances, your solution can be the problem and
cause you to be more depressed in the long term.
Cannabis
CASE STUDY: Vik
Vik smoked cannabis most evenings in the belief that it helped him to get to
sleep. He had occasionally used it recreationally when he was much
younger. However, the strength of cannabis is now much higher than when
he used it in the 1960s. He began to use it earlier in the evening to help him
relax. It helped him to stop thinking. His mood deteriorated and he felt less
motivated to do anything.
Cannabis is usually regarded as being low risk; indeed, many governments
have downgraded the penalties for possession although it is still illegal in
most countries. In the UK, the maximum sentence for possession is two
years in prison and an unlimited fine. The maximum penalty for supplying
cannabis is fourteen years in prison and an unlimited fine.
People who are depressed often use cannabis as a way of numbing
themselves emotionally and avoiding thinking about problems. Recent
evidence has shown that cannabis can not only trigger psychosis in some
people but can cause lack of motivation, anxiety, paranoia, or memory
difficulties.
Unfortunately, there are no safe limits to the number of joints you can
smoke when you are depressed. We would advise you to avoid smoking
cannabis altogether if you are experiencing depression or if there is a
history of mental disorder in your family as it will probably make your
symptoms worse (even if it feels like it helps in the short term). Although
the odd joint may not harm you, it is important to conduct a cost–benefit
analysis on your cannabis use. This will enable you to review the
consequences of cannabis on the way you think and feel and the effect on
others, in both the short and long term. Consider whether you are using
cannabis as a form of emotional avoidance (for example, to help forget
problems or put things off). If this is the case, your solution can become the
problem as it makes you more boring and isolated, and it also means that
problems do not get not solved and become worse. If you are using
cannabis to block yourself emotionally, you need to set yourself the goal of
stopping using cannabis. Long-term cannabis users are sometimes referred
to as ‘sleeping beauties’, because they seem to be stuck in a form of
avoidance that does not allow them to move on in life. In summary, if you
are using cannabis to avoid thinking and feeling, it’s time to tune in to the
real world and experience it as it is.
Remember that cannabis has become more potent in the past ten years.
Some versions now contain about 20 per cent of THC (the hallucinogenic
ingredient), compared with 5 per cent in older strains. There is a lot of
evidence that heavy or frequent use of cannabis can cause mental health
problems. This is particularly true of teenagers, who seem to be especially
vulnerable to long-term damage. Heavy users of cannabis might experience
a craving for more cannabis. It can also cause impotence and a low sperm
count, and possibly other physical problems.
Alarm bells for cannabis use include:
using more joints than you plan, or in increasing amounts
wanting to use it most days and giving in or being unable to resist
the urge
spending a lot of time getting supplies and smoking
spending less time on your valued directions in life or giving them
up altogether
experiencing withdrawal symptoms when you stop (for example,
feeling sweaty, shaky, constipated, or restless, or having frequent
hiccups, loss of appetite, and insomnia)
being late for college or work or taking days off because of using
cannabis
having arguments with your partner about using cannabis
not fully participating in family life because of using cannabis
using cannabis as a way of coping with unpleasant feelings.
When you stop taking cannabis, the withdrawal symptoms will subside over
the following week. Use the method described at the end of this chapter to
stop using cannabis. Many people can get away with occasional use of
cannabis if they do not have a mental health problem. However, a cannabis
user will be at greater risk of developing a mental health problem than a
non-user. If you experience depression, cannabis is very likely to be another
solution that has become the problem and a factor in keeping depression
(and other mental health problems) going.
Cocaine and amphetamines
Cocaine and amphetamines are stimulants that speed up your nervous
system and numb whatever tissue they touch, such as the inside of your
nose. In the short term, they make you feel more alert, energetic, sociable
and over-confident. If you are sensitive or use a large dose or repeat the
doses over a short period, these drugs lead to anxiety and withdrawal,
paranoia, or hallucinations (seeing or hearing things or feeling strange
bodily sensations). When you come down from your high, you may
experience withdrawal symptoms of fatigue, depression, panic, or being
unable to sleep; in addition you may have diarrhoea, vomiting, the shakes,
difficulty sleeping, loss of appetite and sweating. With everyday use,
restlessness, nausea, hyperactivity, feeling ‘wired’, paranoia, insomnia and
weight loss are all signs of a serious problem. If you regularly use cocaine
or speed, your priority is to treat the addiction as it’s impossible to
overcome depression without stopping cocaine or amphetamines. Cocaine
is not without its physical dangers: it can cause damage to the heart tissue
and heart failure, convulsions, a stroke or sudden death even when you are
healthy – especially if you inject or smoke it. Beware of warning signs such
as blacking out (whether you are clubbing or not) as it is dangerous if you
have an unknown abnormal heart rhythm.
There are no safe limits for stimulants such as cocaine or amphetamine –
make it your goal to stop, and seek help for any of the withdrawal
symptoms.
Ecstasy
Ecstasy is another type of stimulant. The chemical name is 3,4-
methylenedioxymethamphetamine or MDMA for short. In contrast to
cocaine and amphetamine, it acts on the serotonergic system (the system
related to mood regulation) and has mild hallucinogenic qualities.
 If you take ecstasy, your pupils become dilated, your jaw tightens, you
feel sweaty, experience a dry mouth and lose your appetite. You might feel
a ‘rush’ followed by feelings of energy and relief from stress and anger.
Some people feel more aware of their surroundings and experience an
increase in their sensual experiences. Ecstasy can sometimes cause a ‘bad
trip’, anxiety or panic, paranoia or a sense of being distorted in some way.
Feelings may last for days or even weeks. This is more likely if you are
taking a high dose or are already feeling depressed or anxious. Ecstasy is
not without its risks: there are some deaths from its use each year,
especially if the drug has been cut with other substances. Again, a key issue
for someone with depression is that repeated ecstasy use can cause
difficulties in your memory and make you more depressed. Therefore, as
with cannabis, there are no safe limits for ecstasy use when you are feeling
depressed. Make it your goal to stop or seek professional help.
Stopping drink or drugs
You can use the following program when you want to stop drinking or using
a substance such as tobacco, cannabis, cocaine, ecstasy or an injected drug.
1. Keep a record of the number of units of alcohol you drink or the
number of cigarettes or joints you smoke or the amount of a drug
you use in a week on the following diary (see Appendix 5 for
duplicates). This will help you to monitor your progress, and if you
are a heavy user it can help to make you more aware of the amount
you are drinking or using. This is because you may be
underestimating how much you are using. The diary on the
following page can help you to identify the situations or feelings
that trigger your drink or drug use. Total up the amount you have
taken at the end of the week and repeat this for future weeks.
2. Conduct a cost–benefit analysis (a blank form is available in
Appendix 5) and review it with a friend who is objective and is not
using or drinking excessive amounts of alcohol or other substances.
Understand the effect of alcohol or drug use on your mood and the
consequences on yourself and others. Consider both the immediate
or short-term consequences and the long-term consequences.
3. It may be possible to stick to a safe limit for drinking, but it’s
advisable to set a goal to stop using cigarettes, cannabis, cocaine,
amphetamines and most other illegal substances as they maintain
symptoms of depression. Set a target either to stop or to reduce the
 amount you plan to use the following week (for example, once a
week when I go out).
People may aim to have a safe limit for alcohol or a drug but it
often does not work: taking the substance tends to reduce your
inhibitions and makes it less likely for you to be able to resist the
substance. It’s perfectly okay to have as your goal abstinence from
alcohol either permanently or until you have recovered from the
depression. Whatever goal you choose, write down in your activity
schedule when you are going to start and when you will review
your progress. Keep your diary and set a time for you to review
your progress. Check whether what you are doing is working and
within a particular time frame.
4. Make a list of alternative activities that you can do instead of using
drugs, smoking or drinking. If you resist the temptation to take the
substance, the craving will not go on for ever and will usually fade
within half an hour. Ensure your day contains a planned activity and
if you have an urge to drink or smoke try to talk to friends or family
or do some other activity that is important to you. Stick to the sleep
routine and activity schedules that you have planned on a daily
basis by following the instructions elsewhere in this book.
5. Try to identify situations which place you at higher risk (for
example, feeling low or more stressed, having difficulty falling
asleep, or being in a place where you can buy alcohol or a drug).
When you know your trigger, you can alter your behavior to reduce
your risk of using. For example, you might avoid walking past your
dealer and take a different route. Or you might decide to get rid of
cannabis you have at home and smoke only once a week or only if
you are away from home.
6. Continue to keep a record of the amount you drink or smoke that
you are unable to resist. Use this information when you review your
progress. If you can’t stick to your limits, you should probably have
a goal of not using the substance at all. Enlist the support of family
and friends to review your progress and be honest with them. Talk
to a friend if you don’t achieve your target for the day.
7. It will be difficult to stop if many of your friends are either into
drugs in a big way or drink excessive amounts of alcohol.
Overcoming an addiction means developing new relationships.
 There will undoubtedly be peer pressure not to stop smoking
cannabis or using alcohol. It’s important not just to say no but to
look the person in the eye and say it as if you mean it (that is, with a
clear, firm voice). Don’t feel you have to give excuses and try to
change the subject. If they persist, be clear about asking them to
stop as it is upsetting for you and unhelpful for overcoming
depression.
8. If you can’t manage to stop on your own, seek help through support
groups such as Alcoholics Anonymous or Narcotics Anonymous.
When alcohol or substances are the main problem, you will
probably need professional help. Once you have overcome your
addiction, you and your doctor will be able to check on your level
of depression and whether this is still a problem.

Vik made this list concerning his cannabis dependence. Try to review
your list with a friend or counsellor who can help you focus on both the
advantages and the disadvantages (especially the unintended
 consequences in the long term) to yourself as well as the effect on others.
A counsellor can also help you decide whether what you think are
advantages really are advantages or whether you have missed writing
down some of the unintended disadvantages.
• Advantages of using cannabis
It numbs me emotionally
I think it helps me socialize and get to sleep
• Advantages of stopping cannabis
I’ll have more energy
I’ll have more friends
I’ll feel healthier
I’ll get more interest in other things
• Disadvantages of using cannabis
It costs $50 per week
Friends are restricted
I am not motivated to do anything
My family is fed up with me
I am missing out on life
• Disadvantages of stopping cannabis
I’ll feel anxious in the short term
My sleep will be disrupted in the short term
If you decide to stop or limit your use, write down the most important
reasons why you want to stop. Read it at regular intervals and decide on
your personal reason why you want to stop.

Compulsive shopping
Compulsive shopping can be another way of emotionally numbing yourself
or avoiding problems. It frequently hides feelings of depression. This type
of shopping can become out of control and people who do it (usually
women) run up significant debts and buy large quantities of things that they
do not need.
CASE STUDY: Katie
Katie did not like herself. She frequently rated herself as being not good
enough and weak, and kept comparing herself to other women. She bought
vast amounts of clothes, make-up, CDs and gifts for others. While shopping
she could distract herself and escape from her thoughts and feeling of being
bad. She could forget about the problems of her mounting debt (caused by
her compulsive shopping) and be in a trance-like state.
If you are a compulsive shopper it is important to do an analysis of the
function of the behavior and understand what you are trying to avoid or
escape from. You may then need to follow a similar program to that
outlined above for overcoming an addiction. As with other addictions, once
you have stopped compulsive shopping, you and your doctor will be able to
check on your level of depression and whether this is still a problem.
Gambling
Compulsive gambling, which is more common in men than women, is
another form of addiction that frequently hides depression. Gambling
occurs in many shapes and sizes, from playing the National Lottery, and
betting on horses or dogs, to going to casinos or following stock-market
movements. If you gamble, and especially if the amount of gambling has
increased while you experience depression, do an analysis of its function. In
what contexts does the gambling occur? What effect does the gambling
have on your mood and for how long? Does it mean you avoid feeling bad
while you gamble? What are the unintended consequences of the gambling?
What effect does it have on your family and friends?
If gambling is a major problem, you may find it helpful to read
Overcoming Compulsive Gambling (for details see Appendix 4). You will
earn how to stop gambling and get back your life by acting in a direction
that is important to you. Help can also be obtained though Gamblers
Anonymous. As with other addictions, once you have overcome it, you and
your doctor will be able to check on your level of depression and whether
this is still a problem.
Rock ’n’ roll
Just about anything from listening to music, working, exercising, watching
TV, playing computer games, using the Internet, or eating can be done to
excess and used to numb yourself emotionally or to avoid thinking about
problems.
CASE STUDY: Gillian
Gillian was depressed after an unhappy history of sexual abuse and neglect.
She would spend several hours driving in her car at night listening to loud
music as way of switching off and numbing herself. During the day she
would block her thoughts and feelings by watching the morning shows and
all the soaps on TV, and then go to sleep in the afternoon.
CASE STUDY: Mike
Mike felt tired and irritable. He was a workaholic who spent virtually all
his time in the office, money-trading. Although it was well rewarded, the
personal cost to him was enormous and his behavior became problematic.
His symptoms of depression, low mood and inability to enjoy anything in
life became apparent only when his employers ordered him to rest.
By now, you will have learnt the importance of analysing Gillian and
Mike’s actions and the context in which they act in the way they do. The
consequences for both of them are that their behavior is reinforcing because
it stops them having unpleasant thoughts and feelings. The way for Gillian
to have better feelings is to gradually give up her current behaviors and
follow a plan that involves her valued directions in life. For Mike, his
analysis revealed that work prevented him from thinking about the death of
friend from Aids.
15 A Herbal Treatment for Depression: St
John’s Wort
St John’s Wort (hypericum perforatum) is a perennial herb from which
extracts are derived for the treatment of depression. It can be an effective
alternative to traditional antidepressant medication for mild depression.
However, it should not be used as the only treatment for depression: you
could use it to complement the approach described in this book. Some
people like to take St John’s Wort because it is ‘natural’, unlike most
antidepressants, which are synthetic drugs. In most countries it is sold as a
herbal remedy.
Is St John’s Wort an effective treatment for depression?
Most independent scientific studies have concluded that St John’s Wort is
more effective than a dummy pill (placebo) in treating depression.
However, the benefit is perhaps weaker than originally thought as more
recent studies have been more rigorously controlled. Generally, St John’s
Wort is as effective as other antidepressants, although most clinical
guidelines recommend it only for mild depression.
As mentioned above, you should not use St John’s Wort as the only
intervention for depression or anxiety as it is important that you still tackle
the problems or activities you are escaping from or avoiding and to have a
life that’s important to you. The main goal of medication (whether it is
natural or synthetic) is to make you feel better (that is, to stop feeling
depressed), whereas the psychological approach described in this book is
geared to having better feelings and to do the things in life which are
important to you despite the way you feel. The two approaches may appear
incompatible but there is no evidence that one interferes with the other.
However, it’s worth being aware that the goals are slightly different and that
more research is needed on the long-term effects of drugs and how they
interact with psychological therapies.
Apart from a few people discussed below, anyone with mild to moderate
depression can take St John’s Wort either alone or with a psychological
therapy.
What are the limitations of St John’s Wort?
Because St John’s Wort is a herbal remedy and not always as standardized
as a medication would be, you must check yourself that you are getting a
therapeutic dose (see below). It is not recommended for persistent or severe
depression or bipolar disorder.
What dose should I take?
Although the optimum dose for depression is not known, the usual
recommended dose is 900mg a day (either as one tablet or three 300mg
tablets a day) standardized to contain 0.3 per cent hypericin (if the
concentration is 0.15 per cent, you’d need to double the dose). Some people
take it spread out during the day and others take 900mg in the morning or
before bed. If this ineffective, you can increase the dosage up to 1,800mg a
day; if the treatment still does not work you should stop taking it. Always
use the rating scales in Chapter 5 to monitor your progress so if it does not
appear to work you can decide to try something different.
How long should I take it for?
If St John’s Wort is going to work, you will notice an improvement in your
mood within about four to six weeks. If it is helpful, you should probably
take it for up to a year after recovery as this is the time when you are most
at risk of relapse.
How do I obtain St John’s Wort?
St John’s Wort is not a drug that can be prescribed by your family doctor or
psychiatrist (except in Germany). You can buy it at your local health-food
shop or herbalist and at pharmacies. The product is not regulated and there
are many different brands and qualities on the market, so try to obtain the
best you can: look at the label on each preparation and avoid those that do
not contain information on the dose, the extraction fluid (for example,
methanol 80 per cent or ethanol 60 per cent). Neither extraction fluid is
better or worse than the other – they are just different. The ratio of raw
material to extract should be between 3 to 1 and 6 to 1.
What side-effects can occur with St John’s Wort?
St John’s Wort seems to have few side-effects (and usually fewer than
standard antidepressants).
Some people experience a dry mouth, diarrhoea, headache, or
increased sweating.
A minority become more sensitive to sunlight. In this case, you will
need to keep properly covered up or use a high-factor sunscreen. You
are also advised to avoid intense sunlight or lightboxes and wear
sunglasses to reduce the risk of a cataract.
 If you experience nausea or heartburn, it may be best to take St
John’s Wort after food.
St John’s Wort can cause a skin rash, though this is rare. If it happens
to you, try a different brand as the sensitivity may be related to
additives.
A small number of people experience increased tiredness and some
people find that this is related to when they take the drug; if you find
this is the case, you could try taking the dose at night.
If you experience insomnia after taking St John’s Wort, try taking it
in the mornings.
What if I am taking other medication?
If you decide to take St John’s Wort, remember it is a drug and you should
tell your pharmacist or doctor if you are taking another medication. (Other
prescribed drugs may also be derived from natural products, like digoxin.)
The safety of St John’s Wort has not been tested as much as that of other
antidepressants. It is known to interfere in the metabolism of a number of
other drugs. Usually, the interaction reduces the effectiveness of the
medication; sometimes, however, St John’s Wort may increase the effects of
a medication. Some of the most common interactions between St John’s
Wort and prescribed drugs are shown below. If you are taking St John’s
Wort and are prescribed any of the drugs listed, you must let your doctor
know.
Antidepressants: St John’s Wort may interact with antidepressants
and can lead to the worsening of some side-effects, including
headache, dizziness, nausea, agitation, anxiety and lethargy. A
combination of St John’s Wort and other antidepressants is therefore
not recommended.
Anticonvulsants: Some drugs used to treat epilepsy (chemical
names carbamazepine, phenobarbitone, phenytoin) may interact with
St John’s Wort, making them less effective.
Digoxin: St John’s Wort should not normally be taken by anyone on
digoxin because it may decrease levels of the digoxin and reduce its
effectiveness.
Immunosuppressive medications: St John’s Wort should not be
taken by those on immunosuppressant medications such as
ciclosporin because it may reduce its effectiveness. In some cases the
decreased levels of an immunosuppressant in people with a heart or
kidney transplant has even led to rejection of the transplanted organ.
Indinavir and other protease inhibitors: St John’s Wort may
interact with protease inhibitor drugs used to treat HIV or AIDS
(chemical names indinavir, nelfinavir, ritonavir, saquinavir,
efavirenz, nevirapine), which can result in decreased effectiveness of
the medication. St John’s Wort should not be used with any type of
antiretroviral medication used to treat HIV or AIDS. Please discuss
this with your doctor, who may suggest you have your HIV viral
load checked.
Loperamide: St John’s Wort may interact with the antidiarrhoeal
medication loperamide, leading to delirium (a state of extreme
confusion).
Oral contraceptives: There are reports of breakthrough bleeding in
women on birth control pills taking St John’s Wort. Theoretically,
this could mean the pill being less effective and an increased risk of
pregnancy. However, not a lot is known about this. To be on the safe
side, if you are taking St John’s Wort, you should use either an
alternative or an additional form of contraception.
Theophylline: St John’s Wort can reduce levels of theophylline
medication in the blood, leading to an asthma attack. Theophylline is
used to open the airways in those suffering from asthma,
emphysema, or chronic bronchitis.
Triptans: Triptan drugs are used to treat migraine (chemical names
sumatriptan, naratriptan, rizatriptan, zolmitriptan). St John’s Wort
may make these medications less effective.
Warfarin: St John’s Wort interferes with the anticoagulant
medication warfarin by reducing blood levels as well as the
effectiveness. Therefore you may need to make adjustments to the
dose of this medication.
16 A Guide to Medication for Depression
This chapter aims to help you make an informed choice about whether you
wish to take medication if you are offered it by your doctor, by discussing
the potential benefits and disadvantages. If you have been recommended
medication and decide to take it, it is also important that you take it in the
correct dose and frequency. The possible side-effects and what you can do
to minimize them are also discussed. In addition, the chapter provides
advice on how to come off an antidepressant. Being well informed is vital
as some people who are prescribed medication will not use the prescription,
and others may take their medication inappropriately (for example, at a
lower dose than recommended or not daily) or not at all. If, after reading
this chapter, you still have doubts and questions, discuss them with your
doctor, rather than just ignoring a prescription or stopping your medication.
There are several ways of overcoming depression. Chapter 4 describes a
number of treatments for depression, all of which have a substantial amount
of evidence to recommend them. However, because antidepressants are no
more effective than a dummy pill for mild depression and may have side-
effects, an evidence-based psychological treatment (such as cognitive
behavior therapy or behavioral activation) is recommended in national
guidelines for mild depression. Antidepressant medication might be
suggested if you:
have a form of depression which has persisted despite an effective
psychological treatment
have mild depression, but have a history of moderate to severe
depression, in which case the aim of the medication is to try to nip
the depression in the bud
currently have moderate to severe depression and are frequently
tearful and inactive with symptoms such as poor appetite and
disturbed sleep, in which case the medication will be used to
improve these symptoms.
Informed patient choice is very important, but you may find it difficult to be
offered an effective psychological treatment because of long waiting lists or
other restrictions in public medicine and insurance cover. As a result, you
may be offered medication before you receive a psychological treatment.
More research is needed on how best to optimize combined treatments in
depression. The evidence so far is that psychological treatment and
medication are equally effective for most people with moderate to severe
depression. In our view, it is therefore very important that people should
have a real choice – but, as pointed out in Chapter 4, there is a problem as a
psychological treatment may be more costly to provide than drug therapy in
the short term. However, in the long term, psychological treatments are
usually more cost-effective, as the cost of the drug continues for several
months and there is a higher risk of relapse with medication alone if it is
stopped compared with an effective psychological therapy.
Can I combine medication with a psychological treatment?
Some people may do better on a combination of evidence-based
psychological treatment and antidepressant medication than on treatment
alone. This is usually recommended when you fail to respond adequately to
a psychological therapy or if your depression is more severe. The problem
is that no one can predict with any certainty who will respond best to what
treatment.
Isn’t taking medication a sign of weakness?
Taking antidepressant medication is not a sign of weakness or failure. You
probably wouldn’t think that taking medication was a weakness if you had
heart disease or cancer. Your relatives and friends are more likely to think
of your behavior as weak if you don’t take medication and find it difficult to
understand why you don’t do everything you can to get better. If some of
them do criticize you, they probably don’t understand what you are
experiencing and good riddance to them. Mental disorder is no different
from any other medical problem in this respect and taking medication is a
pragmatic approach.
How quickly does medication work?
Even if antidepressant medication is of benefit, it will not work right away.
Most people notice some improvement in their symptoms after three or four
weeks, and maximum benefit should occur within twelve weeks. It is
important to continue to take your medication at the highest dose you can
tolerate for this period before judging how effective it has been.
How long will I need to take medication for?
Never stop taking medication without discussing it with your doctor first,
and always make sure that you have another prescription ready before you
run out of drugs. If you do not take an antidepressant regularly, or stop it
suddenly (for example, you forget to take it on holiday), you are at risk of
experiencing withdrawal symptoms. This is discussed in detail at the end of
the chapter.
Once you have recovered from depression and stop taking medication,
you may find you relapse into depression if you have had no other therapy.
The risk of relapse will partly depend on the natural pattern of your
depression without treatment. For example, for a first episode of depression
the chance of recurrence is less if you continue to take an antidepressant for
six to nine months after you have recovered. If you have a second episode
of depression, then your chances of becoming depressed again are lower if
you keep taking an antidepressant for a couple of years after you have got
better. If you are someone whose depression keeps recurring, then the risk
of relapse is much higher and you may be advised to remain on the
medication for at least five years. A few people may need to be on
medication for many years to reduce the risk of relapse.
For many people, the risk of relapse is minimized by combining the
medication with an evidence-based psychological treatment. If you are
planning to stop medication, ensure you do it after discussion with your
doctor and within an agreed time frame. Be aware that your depressive
symptoms may start to return within a few weeks or months, so don’t plan
to stop before predictable major stresses and life events.
Which medication will I be prescribed?
This is something your doctor will discuss with you. In general, all
antidepressants are equally effective for depression overall, but people
respond differently to different drugs, so you may respond better to one
than another. If you or someone in your family did well or poorly with a
medication in the past, this may influence the choice. If you have medical
problems (for example, problem with sleeping) or are taking another
medication, these factors may influence your doctor’s choice so that side-
effects and possible drug interactions are minimized. Make sure you tell
your doctor if you:
are pregnant or plan to get pregnant or are breastfeeding
have any other medical conditions
are taking any other medication or herbal drugs such as St John’s
Wort.
SSRIs
The first choice of medication in clinical guidelines for most people with
depression is a class of antidepressants called selective serotonergic
reuptake inhibitors (or SSRIs for short; see Table 16.1). ‘Serotonergic’
means that the drugs act on serotonin nerve endings in the brain. ‘Selective’
refers to the fact that they act on serotonin nerve endings rather than others
such as noradrenaline or histamine nerve endings. ‘Reuptake inhibitor’
refers to the way the drug acts: it helps to increase the concentration of
serotonin in the nerve cells. This in turn helps to increase the messages
passing along certain pathways in the brain and to reduce anxiety. As
mentioned in Chapter 2, which describes the causes of depression, a part of
your nervous system may have an excessive load on it as your mind tries to
improve your mood. SSRIs enhance this normal activity of the brain and
improve its ability to dampen anxiety and lift your spirits. SSRIs are also
used for panic attacks, obsessive compulsive disorder and eating disorders,
so they are not used specifically for depression. A family doctor may
prescribe the drug or may refer you to a psychiatrist who can discuss your
issues in more detail.
Which SSRI might be prescribed?
All SSRIs are equally effective in treating depression. However, your
doctor will help you choose the most appropriate one for you given your
circumstances and history. For example, citalopram or escitalopram is
usually a good choice if you are on other drugs at the same time. Fluoxetine
takes longer to be metabolized by the body, so if you forget a dose one day,
you can get away with it because the drug does not vanish from the blood
when you stop taking it. It is also now the cheapest of the SSRIs and the
easiest to come off. However, some people find fluoxetine slightly more
likely to increase anxiety when they first start taking the drug. Some SSRIs
such as paroxetine and venlafaxine may be more difficult to withdraw from
(see ‘Stopping taking antidepressant medication’ on page 220).
Can I drink alcohol with an antidepressant?
In general, you can drink alcohol as long as you do so in moderation and do
not binge-drink. However, people’s reactions to alcohol do vary when
taking medication and some people can become more aggressive or sedated.
See how you respond to one drink initially.
Fluvoxamine and sertraline may not mix very well with alcohol, so be
aware that this mix may impair your judgement; also, when you are on one
of these, you should not drive or operate machinery. Excessive alcohol can
also be a factor in depression and will interfere in your recovery. Compared
with the older antidepressants, SSRIs are generally safe. An overdose will
not usually harm you.
What dose of an SSRI should I be prescribed?
The normal starting dose and suitable target doses of different SSRIs are
listed in Table 16.1. When progress is slow, there is some evidence that you
may need to increase the dose. If you experience significant side-effects,
you can always reduce to a lower dose after discussion with your doctor.
You can then build the dose up slowly. Tablets should be swallowed with
some water while sitting or standing. This is to make sure that they do not
stick in your throat. If you miss a dose, take it as soon as you remember it.
However, if it is almost time for the next dose, skip the missed dose and
continue your regular dose. Do not take a double dose to make up for a
missed one.
Table 16.1: SSRI antidepressants
Common trade Usual starting Liquid
Chemical name
names dose Preparation

Citalopram Cipramil, Celexa 20mg Yes (20mg=5ml)

Escitalopram Cipralex, Lexapro 10mg Yes (5mg=5ml)
Fluoxetine Prozac 20mg Yes (20mg=5ml)
Fluvoxamine Faverin, Luvox 50mg No
Paroxetine Seroxat, Paxil 20mg Yes (10mg=5ml)
Sertraline Lustral, Zoloft 50mg Yes (100mg=5ml)
Trazodone* Molipaxin, 100–150mg Yes
Desyrel
* Not strictly an SSRI
Can vegans have SSRIs?
Citalopram elixir, fluoxetine elixir, clomipramine elixir, sertraline tablets
and paroxetine tablets or liquid do not contain any animal products.
What about reports of SSRIs causing suicide?
There is some evidence that a few antidepressants can cause a slight
increase in suicidal ideas (not acts) in young people with depression. For
young adults, the increased risk of suicidal ideas is extremely small. So
long as you monitor such feelings, talk about them openly with your doctor
and relatives, and are seen regularly, this is something that can be managed.
The thoughts of suicide will then decrease as your depression lifts.
Antidepressant medication for children and adolescents
Antidepressant medication for children with depression is not so well
studied, and an evidence-based psychological treatment is recommended
as the first line of treatment. This includes individual CBT or short-term
family therapy for at least three months. This is because scientists don’t
yet know the longterm effects of antidepressants on the immature brain
of a child and also because antidepressants are often ineffective in young
people or may be associated with a slight increase in suicidal ideas (see
above). Equally this needs to be judged against the risk of a young
person with severe depression who is not using medication or not
responding to a psychological treatment (or refuses it). If they are
continuing to experience severe depressive symptoms, this may have a
major adverse impact on both development and education. In such cases,
an antidepressant is recommended. Only fluoxetine has been shown in
controlled trials to have a favourable balance of risks and benefits for the
treatment of depression in people under eighteen. The dose should
usually start at a half the adult dose (10mg) and may be increased
gradually. Therefore, a psychiatrist should supervise the use of an
antidepressant for a child or adolescent and monitor their mental state
closely (for example, weekly for the first four weeks). An SSRI should
be offered in combination with an evidence-based psychological
treatment. If treatment with fluoxetine is unsuccessful or is not tolerated
because of side-effects, consideration should be given to the use of
another antidepressant. In this case, sertraline or citalopram are the
recommended second-line treatments. Guidelines recommend that
venlafaxine (Efexor) and paroxetine (Seroxat, Paxil) and tricyclic
antidepressants should not be used for the treatment of depression in
children and young people. The side-effects listed below occur in
children as they do in adults. In addition, children may become over-
excited, irritable or ‘silly’; if this is severe it may be a reason to stop the
medication.
What side-effects occur with SSRIs?
Some people experience side-effects with SSRIs, and those who do
normally find them to be minor irritations which usually decrease after a
few weeks. The main side-effects are described in this section. Most people
find that they are not usually a problem in the long term. They will not alter
your personality or turn you into a zombie and will cease when you stop
taking the drug. The worst side-effects usually occur in the first few days or
weeks after you start taking the drug. This is the time when you are most
likely to stop taking the drug because you have not experienced any
improvement in symptoms of your depression. (This is because it takes four
to six weeks for the full benefits of the medication to become clear.) There
is one side-effect that does not tend to improve over time: sexual
difficulties. However, side-effects that persist, including those of a sexual
nature, will decrease when you stop taking the medication.
You are more likely to experience side-effects if you are on a large dose or
if your dose has been rapidly increased. If you are unable to tolerate the
medication, you can try reducing the dose and then increasing it to the
previous level more slowly. For example, if you find that you are feeling
nauseous after a few days of taking fluoxetine or paroxetine 20mg, you can
reduce the dose to 10mg for a week or two and then increase it to 20mg
again when your body has become more accustomed to the drug. With a
liquid preparation, you can increase the dose very slowly. Another
alternative is to switch to a different SSRI altogether.
The possible side-effects of SSRIs and how to deal with them are given
below. The list looks rather daunting, but remember that the symptoms
occur in a minority of people. They stop if you discontinue the drug under
guidance from your doctor. Alternatively, your doctor may discuss with you
how to manage them better. Monitoring of your mood and possible side-
effects is the key to all treatments – keep track of how you feel with a
standard measure of depression such as the one in Chapter 5 and use it like
a temperature chart on a weekly basis. If your mood is not improving, and
especially if you are becoming more suicidal, discuss the issue and whether
you need to change tack with your therapist or psychiatrist.
Nausea
Nausea (feeling sick) is the most common but transitory side-effect of an
SSRI and affects about 25 per cent of patients taking an SSRI compared
with about 10 per cent of those on a placebo. Citalopram and fluvoxamine
are slightly more likely than the other SSRIs to cause nausea. The feeling
can be minimized by taking the drug after food. Alternatively, halve the
dose for a couple of weeks and then increase it slowly back to the normal
dose. If the nausea still persists, an antinausea drug (for example,
metoclopramide) may help.
Diarrhoea or constipation
SSRIs can cause diarrhoea in up to 15 per cent of patients compared with
about 5 per cent who take a placebo. Diarrhoea can be minimized by
drinking plenty of apple juice (which contains pectin) or the use of a drug, a
Kaolin preparation or bismuth subsalicylate. Constipation occurs in 5 per
cent of patients taking an SSRI. Diarrhoea or constipation may be improved
by taking bulking agents such as Fybogel or psyllium seed husk and eating
plenty of bran and roughage. For both diarrhoea and constipation, you
should drink at least 2 litres of water a day.
Headache
Up to 20 per cent of patients taking an SSRI find they develop headaches.
Headache is a common symptom of tension and occurs in about 15 per cent
of patients taking a placebo. Symptoms of headache can usually be helped
by simple painkillers such as paracetamol and should decrease after a few
weeks of taking an SSRI.
Excessive sweating
Excessive sweating occurs in about 10 per cent of patients taking an SSRI
compared with 5 per cent of those taking a placebo. There is no easy
solution to this problem although it should decrease over time.
Dry mouth
Dry mouth affects about 10 per cent of patients taking an SSRI compared
with 5 per cent of those taking a placebo. Sucking on sugarless gum or
sugar-free boiled sweets may stimulate production of saliva, or you could
try a spray that can be bought over the counter that provides artificial saliva.
Again, the symptoms usually decrease over time.
Tremor
Shakiness or tremor occurs in about 10 per cent of patients taking an SSRI
and 3 per cent of those on a placebo. A beta blocker (for example,
propranolol) may be prescribed to help reduce the tremor if it is severe.
Sedation or insomnia
Between 10 and 20 per cent of patients on SSRIs feel sedated and between
5 and 15 per cent cannot sleep. With some SSRIs, the problem can
sometimes be resolved by changing the time of day you take your
medication (take it at night, for example, if it makes you drowsy),
temporarily reducing the dose, or taking a different SSRI altogether.
Fluoxetine may be activating and should normally be taken in the mornings.
Sertraline is less likely to cause sedation. Fluvoxamine and trazodone are
more likely to cause sedation and are best prescribed at night. If sedation is
a problem, do not drive or use machinery.
Sexual problems
Sexual side-effects of SSRIs can take the form of delayed ejaculation in
men and an inability to reach an orgasm in women. They can also
occasionally cause both men and women to lose libido, although this is
complicated to assess in the presence of depression. (However, there is one
case report of an SSRI causing orgasms with yawning!)
Some serotonergic antidepressants do not cause delayed ejaculation.
Trazodone is one example, which very rarely in men can cause priapism, a
persistent and painful erection which should be treated as an emergency at a
casualty department. Nefazadone was similar to trazodone and did not
cause delayed ejaculation or erectile problems but unfortunately it was
withdrawn by the manufacturers for commercial reasons and is now only
available on a named-patient basis. Other antidepressants to consider if
sexual dysfunction is a problem are reboxetine or lofepramine, as they act
on the noradrenergic nervous system.
In the case of SSRIs generally, if you are on a relatively high dose the
problem of sexual side-effects can sometimes be solved by lowering the
dose. Another possible solution is ginkgo biloba. This is a herbal extract
that is sometimes used to enhance memory, particularly in elderly people. It
can be purchased in health-food shops. Ginkgo biloba has been used to treat
sexual problems caused by antidepressant drugs in a study of 14 patients.
They had a variety of difficulties including erectile problems, delayed
ejaculation, loss of libido and an inability to reach orgasm. The patients
took a daily dose of 240mg for six weeks. The only side-effect was gastric
irritation (reported by two patients). Overall, the group reported
improvements. Two out of the 14 patients reported no improvements and
two reported that sexual functioning was completely restored. This study
needs to be done as a controlled trial, but in the meantime gingko biloba
may be worth trying as a natural supplement. It would be polite to inform
your doctor that you are taking it.
 There are also reports concerning the use of sildenafil (Viagra) or tadalafil
(Cialis) for men and women taking SSRIs. Sildenafil has been reported as
successful in reversing the sexual side-effects of SSRIs. Again, this needs to
be researched carefully. If you want to take sildenafil, try a dose of 50mg
one hour before sexual activity, having first discussed it with your doctor. If
this does not improve things or gives only a partial response, you could try
increasing it to 100mg. Some patients with heart conditions will not be able
to take it. Tadalafil has the possible advantage of a longer lasting effect. The
possible side-effects of these drugs include headache, flushing and
dizziness. Do not buy such drugs from the Internet as you have no
guarantee of quality and it could just be a dummy pill.
Loss of appetite
Symptoms of loss of appetite and weight loss occur in between 5 and 10 per
cent of patients taking SSRIs (especially fluoxetine). Reducing the dose can
halt this effect though the symptoms usually fade away over time anyway.
Some SSRIs can sometimes cause slight weight gain in the long term and
you may need to adjust your diet and exercise program. Depression and
inactivity will also contribute to weight gain.
Nervousness or agitation
Some people feel more anxious or ‘wired’ or more impulsive when starting
an SSRI. This may be more common with fluoxetine, which may then cause
agitation or insomnia if taken too late in the day. Sertraline may be less
likely to cause anxiety.
It is always difficult to tell whether anxiety is associated with the depression
or whether it is caused by the drug. If it is caused by the drug, the problem
may be solved by (a) trying a lower dose or (b) switching to a different
SSRI or (c) adding a different drug that may reduce anxiety. The feeling of
increased anxiety is usually temporary and will subside over time. Feelings
of increased agitation in some SSRIs may rarely be associated with an
increase in violence or suicidal ideas. This is more likely to occur in a
young person. If this happens, seek urgent medical advice. The feelings will
subside on gradual withdrawal of the medication and you may need a
different therapy or type of antidepressant.
Rashes
Rashes are rare but, if you do get one, you will probably need to speak to
your doctor and stop taking your medication. This is more likely to occur
with fluoxetine.
Mania
Antidepressants can sometimes induce mania, especially in someone prone
to bipolar disorder. You may be overactive, disinhibited, full of energy,
irritable and able to go without any sleep. This condition can involve
dangerous or risky behaviors. You should seek medical attention quickly.
You may be advised to discontinue the medication.
Whenever side-effects are a problem, always discuss them with your
doctor. The doctor is likely to advise you to:
reduce the dose
try a different SSRI
add another medication to counteract side-effects such as insomnia
or sexual problems
perhaps wait and see, as many of the side-effects tend to improve
over time.
All SSRIs are equally effective overall, but one person may get a better
response from one than another, or your doctor may wish to try you on
another or a different class of antidepressant according to how well your
mood improves or how troublesome your side-effects are.
Other medication
NaSSA
NaSSA stands for noradrenergic and selective serotonergic antidepressant.
This class of antidepressants is different from SSRIs as they act both on
serotonin and on alpha-2 adrenergic receptors. Mianserin or mirtazapine
(Zispin in the UK, Remeron in the USA) may be used alone or as additional
treatment to an SSRI. The usual starting dose is 15mg, increasing after a
week to 30mg either in tablets or a liquid. The tablets melt or disintegrate
on your tongue and can be swallowed with saliva. No water is needed.
There is some evidence that mirtazapine starts to act more quickly than an
SSRI. The main side-effects are similar to those experienced with SSRIs,
especially sedation. This effect can be turned to advantage by taking the
medication at night. Increased appetite and slight weight gain is more
common, so these medications can be used to good effect in someone who
has lost their appetite. It does not cause sexual problems or nausea.
Mianserin or mirtazapine is therefore a useful alternative to SSRIs when
sleep disturbance, nausea or weight loss is a problem. However, it is less
useful in those who are sensitive about weight gain.
SSNRIs
SSNRI is an acronym for selective serotonergic and noradrenergic reuptake
inhibitor. It is a new class of antidepressants, of which there are currently
two, venlafaxine (Efexor) and duloxetine (Cymbalta). They are called
SSNRIs because they act on both serotonin and noradrenaline nerve
endings in the brain. Treatment guidelines generally recommend them as a
second line of treatment if an SSRI has failed. In some people high doses of
venlafaxine may lead to a slight increase in blood pressure. Both drugs are
prone to cause withdrawal symptoms and they should be reduced carefully.
The daily dose of venlafaxine is can vary between 75 and 375mg depending
on the severity of the symptoms and the response. The daily dose of
duloxetine is 60mg. Possible side-effects of SSNRIs are similar to those of
SSRIs. In general such drugs should be prescribed by specialists.
SNRIs
An SNRI is a selective noradrenergic reuptake inhibitor. It selectively acts
on noradrenaline nerve endings in the brain. ‘Reuptake inhibitor’ refers to
the way the drug acts: it helps to increase the concentration of noradrenaline
in the nerve cells. Reboxetine (Edronax in the UK, Vestra in the USA) is an
example of an SNRI. Lofepramine (Gamanil in the UK, Lomont in the
USA) is a potent SNRI. Possible side-effects are generally different from
those caused by SSRIs and include blurred vision, a faster-than-normal
heartbeat, difficulty in passing urine, dry mouth, drowsiness or insomnia,
disturbances of the gut such as diarrhoea, constipation, nausea, vomiting or
abdominal pain, a drop in blood pressure and light-headedness when
standing (hypotension), sweating, balance problems involving the inner ear
(vertigo) and pins and needles (paraesthesia). SNRIs are generally less
likely than SSRIs to interfere with sexual functioning. Some of these side-
effects are discussed under the section on tricyclics.
NDRIs
An NDRI is a noradrenaline and dopamine reuptake inhibitor. The only
drug in this category is bupropion (Zyban in the UK, Wellbutrin in the
USA). It is licensed in the UK as an anti-smoking drug but is promoted in
the USA as an antidepressant. It is less likely to cause weight gain or sexual
problems. Possible side-effects include dizziness, difficulty in getting to
sleep, nausea and vomiting, dry mouth, constipation, lack of appetite,
difficulties concentrating and fever. NDRIs should be avoided for people
with epilepsy as seizures can be a rare side-effect. Sometimes bupropion is
used in combination with other antidepressants for severe depression.
Tricyclics
Tricyclics are an older class of antidepressants: they were first developed
for the treatment of depression in the 1960s. Some experts believe they are
slightly more effective for severe depression but they lost favour to the
SSRIs because they have more side-effects and were more likely to be fatal
in an overdose. The name ‘tricyclic’ is used to describe the structure of the
chemical which was first synthesized. The most common tricyclics are
listed in Table 16.2. They are just as effective as the newer drugs and there
is some evidence that they may be more effective in severe depression.
However, they tend to have more side-effects.
A tricyclic is normally started with a low dosage (for example, 75mg at
night) and gradually increased to a maximum that you can tolerate. The
minimum dose required for an antidepressant effect is usually 125mg.
Higher doses are sometimes used – up to 300mg a day – although the usual
dose is up to 225mg. Higher doses tend to increase the frequency of side-
effects. Most of the side-effects are related to the dose and tend to reduce
over time but some may persist. They will cease if the drug is discontinued.
Dosulepin, clomipramine and amitriptyline are more often prescribed at
night so that the sedative side-effects have worn off by the morning. Some
people metabolize a tricyclic very quickly and so even when they are taking
a high dose they may have a relatively low level of the drug in the
bloodstream. If necessary, the level of a tricyclic and its metabolite can be
checked by a blood test to determine if it is safe to increase the dose to a
higher level. Alternatively, you may be given a genetic test to see if you are
someone who metabolizes such drugs faster than others.
Table 16.2: Tricyclic antidepressants
Common trade Usual dose range for
Chemical name
names depression

Amitriptyline Tryptizol, Elavil 125–225mg

Clomipramine Anafranil 125–225mg
Desipramine Pertofrane, 125–225mg
Norpramin
Dosulepin Prothiaden, Dothapax, 125–225mg
Prepadine
Doxepin Sinequan 125–225mg
Imipramine Tofranil 125–225mg
Nortriptyline Aventyl, Pamelor 125–225mg
Trimipramine Surmontil 125–225mg
Common side-effects of tricyclics
Dry mouth: At least two-thirds of patients taking a tricyclic
experience a dry mouth. You get a dry mouth when you produce less
saliva than normal. Sucking on sugarless gum may stimulate
production of saliva or you could try a spray that can be bought over
the counter that provides artificial saliva. Good mouth hygiene is
important, as is a regular visit to your dentist.
Dizziness: Dizziness on standing is a common side-effect for about
25 per cent of patients taking a tricyclic. You can minimize dizziness
by rising slowly or sitting on the side of the bed and squeezing the
muscles in your calf as you stand up.
Tremor: About 15 per cent of patients taking a tricyclic develop
shakiness or a tremor in their arms. There are no simple remedies for
tremor although another drug (a beta blocker, such as propranolol)
may reduce a tremor if it is severe.
Weight gain: Weight gain can be a problem with a tricyclic and you
should therefore be especially careful to eat healthily.
Constipation: You have a one in four chance of becoming
constipated if you take a tricyclic. A diet full of roughage from
vegetables or bran and prunes or a bulking agent such as Fybogel or
psyllium husks will help. Always remember to drink plenty of water.
Laxatives that stimulate the bowel should only be used occasionally.
Drowsiness or fatigue: Clomipramine, amitryptiline and dosulepin
can cause drowsiness which can be minimized by taking the dosage
at night. Some people may still experience a hangover in the
morning: if that happens with you, spread the dose over the day.
Blurred vision, headache: A tricyclic can also cause blurring of
vision or a headache. There is no good solution to this apart from
switching to a different antidepressant.
 Sexual problems: A tricyclic can be a reason for delayed ejaculation
or, less commonly, impotence in men. It can also cause women
difficulties in reaching orgasm. For suggested solutions see under
side-effects of SSRIs.
Increased sweating: People taking a tricyclic may complain that
they sweat more or that their hot flushes have increased. There is no
easy solution to this but it should improve over time.
Epileptic fit: There is a small risk (for about 0.5 per cent of
individuals taking a tricyclic) of having an epileptic fit. In this case,
the drug will need to be discontinued or the dose significantly
reduced. The majority of fits, however, occur in patients taking
above 250mg of a tricyclic.
Urinary problems: Occasionally, a tricyclic can cause urinary
retention or hesitancy in elderly people, in which case the drug will
need to be discontinued.
Heart problems: Anyone with pre-existing heart disease who is
treated with a tricyclic should have an ECG (electrocardiogram)
before beginning treatment and at regular intervals during treatment
as it could cause them to develop an irregular heartbeat.
MAOIs
Monoamine oxidase inhibitors are a very old class of antidepressant that are
rarely used nowadays except for depression that other drugs can’t reach or
when there are non-typical symptoms. They include isocarboxazid
(Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). Their main
disadvantage is the strict restriction of certain foods and drugs which could
cause high blood pressure. Side-effects are generally the same as for
tricyclics. There is a newer class of MAOIs (called reversible MAOIs) such
as moclobemide which do not have the problems of food and drug
interaction.
Stopping taking antidepressant medication
If you are already taking antidepressant medication, then don’t stop or
change the dose on your own. The reason is that you may experience
withdrawal symptoms from the antidepressant and it’s best to reduce such
medication slowly. Whether you experience withdrawal symptoms or not is
unpredictable – many people do not have any or only minor ones; a small
minority have marked or severe symptoms that require careful reduction of
their medication. Note that some doctors may refer to withdrawal symptoms
as ‘discontinuation’, which is partly a euphemism to avoid the association
with an addiction or dependence. However, it is now generally recognized
that, for a few people, it is a type of addiction as the stopping of the drug
causes withdrawal symptoms and craving. The body finds it difficult to
adapt if a drug is removed suddenly and it is therefore sensible to taper the
dose gradually over several weeks. Withdrawal symptoms can be
minimized or prevented if you are prepared for them and manage the
situation. Always discuss your wishes with your doctor and plan things
together. Do not be afraid to ask for a second opinion if you think it is
necessary.
Possible physical withdrawal symptoms can include:
flu-like symptoms (aches, fever, sweats, chills, muscle cramps)
gastroenteritis-like symptoms (nausea, vomiting, diarrhoea,
abdominal pain or cramps)
dizziness, spinning, feeling hungover, feeling unsteady
headache, tremor
sensory abnormalities (numbness, sensations that feel like electric
shocks, abnormal visual sensations or smells, tinnitus).
The second group of symptoms that can occur are predominantly
psychological:
depression (crying, deteriorating mood, fatigue, poor concentration,
loss of appetite, suicidal thoughts/attempts)
anxiety-like symptoms (anxious, nervous, panicky)
irritability (agitation, impulsivity, aggression)
confusion, memory problems
mood swings (elation, mania)
hallucinations (auditory, visual)
feelings of dissociation (detachment, unreality, nightmares).
In most people these withdrawal effects are mild. For a small number of
people – and no one can predict who they might be – the effects can be
severe if the medication is stopped suddenly. Being knowledgeable about
potential withdrawal symptoms allows you to be forewarned and to manage
any symptoms that emerge by reducing the dose more slowly. The speed at
which the discontinuation of a drug causes withdrawal symptoms is related
to how fast the drug is metabolized and gets out of your system. Fluoxetine
is the least likely of all SSRIs to cause withdrawal symptoms. This is
because it breaks down very slowly and is in your body for up to five weeks
after your last dose. If it does cause withdrawal symptoms, they tend to
come on within two or three weeks of stopping it. The worst drugs linked to
withdrawal symptoms are venlafaxine (Efexor) and paroxetine (Seroxat,
Paxil), which can cause symptoms on the same day you miss a dose.
Sertraline (Lustral, Zoloft) commonly causes withdrawal symptoms within
two to three days.
Are my symptoms those of withdrawal or a relapse?
Another problem is deciding whether symptoms that emerge on stopping
medication are those of withdrawal or whether they are a relapse of
depression. The following differences may help you and your doctor to tell.
Do your symptoms come on suddenly over days or within a week after
stopping?
Withdrawal symptoms come on relatively suddenly within days to weeks of
lowering or stopping an antidepressant. Symptoms of relapse of depression
usually occur within one or more months of stopping.
Are your symptoms physical?
Physical symptoms such as feeling dizzy or light-headed, having flu-like
aches, sweating, nausea, numbness, electric shocks and headaches are
usually part of a withdrawal state. Although some of these physical
symptoms can occasionally occur in relapse of depression, they would have
been part of the original symptoms you had, and you might recognize them
as such.
How quickly do your symptoms improve when you stop medication?
Withdrawal symptoms peak within seven to ten days or so and are usually
gone within three weeks; by contrast, symptoms of a relapse of depression
will persist and may get worse.
How quickly do your symptoms improve if you restart the medication?
Withdrawal symptoms improve immediately when you restart the drug.
Symptoms of relapse may continue or get worse and take several weeks to
improve when you recommence an antidepressant.
How do my doctor and I reduce the drug slowly enough?
The first step is to decide when to reduce the dose. This normally depends
on whether you have been well for long enough and whether you are still
vulnerable to relapse. Have you had an effective psychological therapy that
can now protect you? The optimum rate of reduction of an antidepressant to
a standard dose is related to the type of drug. In general each reduction
should take place over a month.
The rate at which you reduce the drug depends on the nature of the drug,
the dose you are taking and the severity of any withdrawal symptoms you
experience. For example, paroxetine (Seroxat or Paxil) being prescribed at
20mg daily might be reduced to 10mg for one month. Each reduction would
then guide the speed at which the medication is further reduced. If
withdrawal symptoms emerge, you may have to slow down. For example:
if you experience mild or no symptoms then you need not change the
rate of reduction (for example, paroxetine from 10mg to nothing)
if you experience moderate withdrawal symptoms, the next
reduction would be smaller (for example, paroxetine from 10mg to
5mg)
if you have severe withdrawal symptoms your doctor may restore the
original dose and then start smaller dose reductions (for example,
paroxetine from 20mg to 15mg for a month). If this resulted in no or
mild symptoms, it could then be reduced to 12.5mg.
Most withdrawal symptoms can be minimized by reducing the drugs slowly
and this should be done under the guidance of your doctor. Some patients
have been advised to take the drug on alternate days, but this does not make
sense unless it is long acting like fluoxetine. It is nearly always better to
reduce the dose of an antidepressant by a small amount on a daily basis.
Further discussion on withdrawing from antidepressants can be found in the
very helpful book Coming off Antidepressants (see Appendix 4 for details).
Liquid preparations
To obtain smaller doses for a withdrawal program or to start at a lower
dose, you can either cut the tablets into smaller pieces or measure a liquid
form, which is usually easier. Alternatively, if you are simply unable to
tolerate a tablet, you may find it easier to have your medication in the form
of a liquid (elixir). The drugs available as a liquid are listed in a column in
Table 16.1 on page 209.
Use of medication in pregnancy and breastfeeding
Most of the SSRIs and tricyclics are generally considered to be safe for
pregnant women. However, as no manufacturer wants to be sued, they all
recommend ‘caution’ and say that their product should not be used in
pregnancy or breast-feeding. No mother wants to cause harm to her baby,
but in general there are no significant problems with the use of these drugs.
Fluoxetine, paroxetine, sertraline and tricyclics are the most studied in
pregnancy or breastfeeding, so these are the most widely prescribed drugs
for pregnant women. Animal and human studies suggest a very low risk but
they are not fully conclusive. The risk of spontaneous abortion
(miscarriage) may be very slightly higher than normal but the figures are
difficult to interpret. Most doctors prefer to be cautious and treat depression
with a psychological treatment where pregnancy is possible or planned.
However, if you and your doctor believe that medications are necessary
(and depression commonly gets worse during pregnancy), or if you find a
psychological approach difficult, it is nearly always better for you to be
functioning as a mother than suffering from depression, whatever the
precise risks involved, but discuss this fully with your doctor as there may
be new evidence.
What can I take if an SSRI or a tricyclic fails?
There are other options if you do not get better with two or more SSRIs or a
tricyclic. This is best discussed with a psychiatrist experienced in the
treatment of depression. For example, there is some evidence for the benefit
of combining different antidepressant drugs (for example, an SSRI with
mirtazapine). Alternatively, your doctor might recommend combining an
SSRI with certain drugs that block dopamine receptors that are normally
used for treating psychosis (see ‘Antipsychotics’ on page 227). For
example, you might be prescribed risperidone (Risperdal), quetiapine
(Seroquel) or olanzapine (Zyprexa) as an additional treatment to an SSRI,
especially if you are very agitated or have lost touch with reality. Any
benefit is likely to become apparent within one to four weeks of starting the
medication.
Tryptophan
5 Hydroxytryptophan (5-HTP) and tryptophan (5-HT) are chemicals
used by the body to make serotonin, low levels of which are linked to
depression. Tryptophan is an amino acid which is found in many foods.
A number of studies have tried to test the effectiveness of tryptophan in
treating depression but very few are of sufficient quality to be reliable.
More often, tryptophan is used in addition to an antidepressant, when it
may help.
If you are prescribed tryptophan, you should take the doses at regular
times each day. You may feel a little sick when you first start taking it,
 but this should last only a few days, and the effect can be minimized by
taking it after food. Although you should not suffer any withdrawal
effects, it is unwise to stop taking tryptophan suddenly, even if you feel
better. For it to continue working, tryptophan must be taken every day.
Side-effects are rare but you may get some in addition to nausea:
drowsiness, headache and light-headedness. These tend to wear off after
a few days. If they do not, or they cause you discomfort, you should
discuss this with your doctor. It may be possible to adjust your dose to
reduce these effects. The drug can also make you feel drowsy. You
should not drive or operate machinery until you know how tryptophan
affects you.

Drugs for bipolar disorder

Antidepressants are used with more caution for bipolar disorder as
theoretically they may trigger an episode of mania or induce ‘rapid cycling’
between ups and downs in mood. However, the overall risk of triggering
mania with an antidepressant is low. Tricyclic antidepressants may carry
slightly greater risk of inducing mania compared to an SSRI. It is usually
recommended that if you have bipolar disorder and need to take an
antidepressant, it should be an SSRI. You should also be on a mood
stabilizer (which could consist of lithium, valproate or carbamazepine).
Mood stabilizers may be prescribed to treat mania or depression in bipolar
disorder.
Lithium (Priadel, Camcolit)
Lithium carbonate is a natural salt that is extracted from rock. It has been
used for many years as a mood stabilizer and treatment for mania. Lithium
can also be added to an antidepressant for the treatment of depression. You
will need a blood test at least every three months to check whether the
lithium level is too low (when it is ineffective) or too high. Common side-
effects are thirst, passing water more often than usual and slight weight
gain. Some people may experience a slight tremor, diarrhoea or slurred
speech, which may be a sign of the dose being too high. You should be
careful about not becoming dehydrated and inform a pharmacist or doctor if
you are taking lithium as another drug may increase the level of lithium in
the blood. Lithium may affect the thyroid gland and this should be tested
with your kidney function at least once a year.
Valproate (Depakote)
This is a drug used for treating epilepsy but it can also be prescribed for a
manic episode in bipolar disorder. About half of patients respond to
valproate alone within three weeks. When you recover, it is usually
recommended that you remain on the valproate to reduce the risk of a
relapse. Possible unwanted side-effects include weight gain, dizziness,
drowsiness, nausea, vomiting, tremor and reduced libido. In rare cases
valproate affects blood cells and liver function, so it is best to have your
blood count and liver function checked periodically during treatment.
Carbamazepine (Tegretol, Carbatrol)
This drug is widely used in treating epilepsy, but it is also for treating mania
and to a lesser extent used as a mood stabilizer in bipolar disorder. Common
side-effects usually in the first few weeks include nausea, dizziness, double
vision and a feeling of unsteadiness. A rash may occur which you must
report to the prescribing doctor as you may have to stop taking your
medication. In rare cases carbamazepine may cause a reduction in white
blood cells, so you should report any fever to the prescribing doctor. It may
also interfere with the effectiveness of a contraceptive pill.
Lamotrogine
This is another antiepileptic drug used as a mood stabilizer for reducing the
risk of relapse (especially in rapid cycling) and for treating depression in
bipolar disorder. Lamotrogine may on rare occasions cause a rash which is
potentially fatal. You should seek medical attention if you develop a skin
rash and will usually be advised to discontinue the drug.
Antipsychotic drugs
Antipsychotic drugs may be prescribed during an acute episode of mania or
as an additional treatment for agitation or for psychosis in depression. They
are also used for the treatment of schizophrenia, paranoia, mania and tics.
Antipsychotics include olanzapine (Zyprexa), ziprasidone (Geodon),
risperidone (Risperdal), aripiprazole (Abilify), haloperidol (Haldol),
quetiapine (Seroquel), sulpiride, trifluoperazine and chlorpromazine.
Olanzapine (and to a lesser extent risperidone) is more likely to cause
weight gain and sedation. With a very high dose or if you are especially
sensitive, antipsychotic drugs may cause abnormal movements such as a
tremor and you may need other tablets to counteract this. They may also
reduce libido. In general, an antipsychotic drug is not recommended in the
long term for unipolar depression. In a higher dose it can emotionally numb
you and prevent you from experiencing pleasure. If your main diagnosis is
of unipolar depression and are taking an antipsychotic drug, you may want
to ask your doctor to review it. Sometimes antipsychotic drugs are required
in the long term to prevent mania in bipolar disorder.
Tranquillizers
Tranquillizers are drugs that aim to reduce anxiety or are sedative. The most
common are a group of drugs called benzodiazepines (diazepam or Valium,
nitrazepam, lorazepam, clonazepam). Others which are prescribed for sleep
are discussed in Chapter 12. Tranquillizers used to be prescribed very
commonly in the past but are less used now because of the risks of
addiction. They are used for managing severe agitation in depression for the
short term. The main side-effects are slower reaction times, so they should
not be used when operating machinery or driving. The main problem is of
dependence, so that a sudden withdrawal can lead to a short-term increase
in anxiety, insomnia, irritability, headaches and many other possible
symptoms. Withdrawing from such drugs therefore needs to be managed
carefully.
Electroconvulsive therapy
Electroconvulsive therapy (ECT) is popularly known as ‘electric shock
therapy’. It is recommended only in very severe depression which has not
responded to medication or an evidence-based psychological treatment. The
way it works is not known although it may be similar to antidepressants in
enhancing certain brain pathways.
Behavioral activation (described in this book) has been shown to be as
effective as an antidepressant for severe depression in outpatients and could
be offered as an alternative or in combination with medication. Always
discuss your wishes with your doctor about the alternatives that can be
offered.
ECT may be life-saving in some cases, when someone is severely suicidal
or is neglecting themself to a high degree. However, treatment may create
only a short-term benefit, with other treatments being needed to maintain
the improvement. A typical course of ECT may consist of eight to twelve
sessions over a period of four to six weeks. It is used less frequently now
than in the past because other treatments are more effective. Although ECT
has a very negative image generally, and people visualize those having it as
thrashing around wildly, it is nothing like this. It is given under controlled
conditions by an anaesthetist and a psychiatrist. Patients are given a general
anaesthetic and do not feel anything during the treatment. Some people
experience a headache and a loss of memory for the period they receive
ECT; this is usually a transient problem. Some find that their memory of
recent events may be upset, and that they temporarily forget dates, names of
friends, public events, addresses and telephone numbers. In most cases this
memory loss goes away within a few days or weeks although sometimes
patients continue to experience memory problems for several months.
When you receive ECT, it is not usually possible to have a psychological
therapy at the same time, as you tend to forget what you have covered in the
therapy. Sometimes it works if it’s kept simple as in the behavioral
activation program described in this book and the sessions are recorded so
you can listen to them repeatedly.
ECT does not generally have any long-term effects on memory. A few
patients report experiencing longer-lasting memory problems but
fortunately this is uncommon. More research is needed as it is difficult to
untangle memory problems from what might occur in the absence of ECT.
ECT is generally among the safest procedures carried out under general
anaesthesia. It is about ten times safer than childbirth and carries the same
risk as any other procedure done under anaesthesia. As in all procedures
involving general anaesthetic, the greatest risks are in people with severe or
unstable medical conditions. You can refuse to have ECT and you may
withdraw your consent at any time before the first treatment has been given.
The consent is only a record that an explanation has been given to you and
that you understand what is going to happen to you. Withdrawal of your
consent to ECT will not in any way alter your right to continue treatment
with the best alternative methods available. Always discuss your concerns
with your relatives and your psychiatrist. The only situation in which you
cannot refuse ECT is in the rare event of you being detained by law and
another independent doctor agreeing that it in your best interests that you
should have ECT. If you are in such a situation, and you really do not want
ECT, in most countries you have the right to legal representation.
Summary
Medication can be an effective treatment for moderate to severe
depression.
It can be used either alone or with a psychological treatment, like
cognitive behavior therapy or behavioral activation.
Nowadays, ECT would be offered only in severe depression in an
emergency or when the patient has not responded to medication or a
psychological treatment.
Appendix 1 Am I Overweight?
Everyone’s body shape is different, but there are general guidelines for a
healthy weight. A problem for some people with depression is being
overweight as a result of eating unhealthily or comfort-eating and being
inactive. Some antidepressants may also be a factor in weight gain. You
may be a normal weight but your depression may lead to you feeling bad
about your appearance and becoming more self-conscious.
First, make an objective assessment about whether you are overweight
and then decide what to do. If you are using scales, it’s best not to weigh
yourself more than once a week as there are always natural fluctuations in
fluid loss or retention that are not relevant for your long-term weight loss or
gain. Use an objective measure rather than how tight you might feel in your
clothes. It’s also important to wear clothes for the size you are now rather
than feel too tight in clothes that don’t fit you. If you have clothes that do
not fit, get rid of them.
Body mass index
The first method for deciding whether you are overweight, which takes into
account your height, is to calculate your body mass index (BMI). Divide
your weight (in kilos) by your height (in metres) squared. For example, if
you weigh 96kg and are 1.8 metres tall, your BMI is 96 ÷ (1.8 x 1.8) = 29.6,
which would be regarded as overweight (see Table A.1). An easy way of
calculating body mass index is to use the calculator on the website
http://www.globalrph.com/bmi.cgi.
Table A.1: Interpretation of body mass index
Adults Women Men

Anorexia nervosa <17.5

Underweight <19 <20.5

Normal range 19–26 20.5–26.5

Slightly overweight 26–27.5 26.5–28

Overweight 27.5–32 28–31

Obese >32 >31

Severely obese 35–40

Morbidly obese >40

You can use Table A.1 to interpret your BMI. The table does not apply if
you are aged under 18 (for which you should use a chart related to your age
and sex), are pregnant or breast-feeding, elderly or have a lot of muscle. If
you are over 65, you can allow an extra 4.5kg (or 10lb). Being overweight
or obese is linked to many different health problems, from diabetes to heart
disease, and increased mortality. If your BMI is 17.5 or under and you are
restricting your diet, you may be suffering from anorexia nervosa which is a
serious illness. You need to seek medical attention.
Waist-to-hip ratio
Another method of calculating your health risks is to measure your waist-
to-hip ratio. Stand with your stomach relaxed and use a tape-measure in
centimetres.
1. Measure the narrowest section of your waistline. Don’t pull the tape
measure too tight or hold it too loose.
2. For a man, measure your hips at the tip of the hip bone; for a
woman, measure at the widest point between the hips and buttocks.
The waist-to hip ratio is calculated by dividing your waist measurement by
your hip measurement.
If you are female, your waist-to-hip ratio should be 0.8 or less. Men
should have a waist-to-hip ratio of 0.95 or less. Too much fat around the
waist and upper body (an ‘apple’ body shape) is associated with greater
health risk than fat located more in the hip and thigh area (a ‘pear’ body
shape). A ratio higher than this is linked to an increasing risk of developing
health problems such as diabetes, heart disease and high blood pressure.
Whether you are overweight or not, you may already be following a diet
that restricts the amount you eat. However, the problem with many diets is
that they often make you feel hungrier and make your health worse. The
key is not just in the amount of food but the type of foods you eat, and
combining healthy eating with an exercise program.
Keep a record of the activities you do in the Weekly Activity Schedule.
There is a blank provided in Appendix 5.
Appendix 2 Resources
UK
Child Death Helpline
Great Ormond Street Hospital
Great Ormond Street
London WC1N 3JH
Helpline: 0800 282 986
Fax: 020 7813 8516
Email: contact@childdeathhelpline.org
Website: www.childdeathhelpline.org.uk
The Child Death Helpline offers befriending and emotional support to
anyone affected by the death of a child, teenager or young adult. The
helpline is staffed by trained volunteers, all of whom have suffered the
death of their own child.
Childline
Freepost 1111
London N1 0BR
Telephone 0800 1111
www.childline.org.uk
Helpline to children and young people under 18 providing confidential
counselling over the telephone.
Cruse Bereavement Care
126 Sheen Road
Richmond
Surrey TW9 1UR
Tel: 0870 167 1677
Email: info@crusebereavementcare.org.uk
Website: www.crusebereavement.org.uk
Cruse is a registered charity providing advice, counselling and information
on practical matters for anyone bereaved.
Depression Alliance
212 Spitfire Studios
63–71 Collier Street
London N1 9BE
Tel: 0845 123 2320
Email: information@depressionalliance.org
Website: www.depressionalliance.org
Depression Alliance is the leading UK charity for people with depression. It
provides information, support and understanding to those who are affected
by depression.
Depression Alliance Scotland
3 Grosvenor Gardens
Edinburgh EH12 5JU
Tel: 0845 123 2320; 0131 467 3050
(10am–2pm, Mon, Tues, Thurs & Fri)
Fax: 0131-467 7701
Email: info@dascot.org
Website: www.dascot.org
Depression Alliance Scotland is the Scottish branch of Depression Alliance,
a national charity and provides the same services as stated in the UK.
MDF – The Bipolar Organisation
Castle Works
21 St George’s Road
London SE1 6ES
Tel: 08456 340 540
Fax: 020 7793 2639
Email: mdf@mdf.org.uk
Website: www.mdf.org.uk
The Bipolar Organisation provides support, advice and information for
people with manic depression, their families, friends and carers.
Bipolar Fellowship Scotland
Studio 1016
Mile End Mill
Abbeymill Business Centre
Seedhill Road
Paisley PA1 1TJ
Tel: 0141 560 2050
Fax: 0141 560 2170
Website: www.bipolarscotland.org.uk
Bipolar Fellowship Scotland provides similar services to the Bipolar
Organisation but specifically for people living in Scotland.
MDF – The Bipolar Organisation Cymru
22–29 Mill Street
Newport
Wales NP20 5HA
Tel: 01633 244 244
Helpline: 08456 340 080
Email: info@mdfwales.org.uk
website: www.mdfwales.org
Association For Postnatal Illness
146 Dawes Road
Fulham
London SW6 7EB
Tel: 020 7386 0868
Fax: 020 7836 8885
Email: info@apni.org
Website: www.apni.org
Association for Postnatal illness is a countrywide network of phone and
postal volunteers who have had and recovered from postnatal depression.
SAD Association (Seasonal Affective Disorder)
PO Box 989
Steyning BN44 3HG
Website: www.sada.org.uk
SAD is a voluntary organization providing support and advice to SAD
sufferers.
Samaritans
Addresses of the 202 branches in the UK and Ireland can be found in local
telephone directories and on the Samaritans website.
Tel: 08457 909 090 (UK)
Tel: (1850) 609 090 (ROI)
Website: www.samaritans.org.uk
Samaritans is a registered charity which offers confidential support to
anyone passing through a crisis or thinking of taking their own life.
The Befrienders website (www.befrienders.org) gives details of similar
organizations worldwide.
Sane & Saneline
1st Floor
Cityside House
40 Adler Street
London E1 1EE
Helpline: 0845 678 000
Email: info@sane.org.uk
Website: www.sane.org.uk
Saneline is a national mental-health helpline providing information and
support with a database of local and national services.
Australia
The Black Dog Institute
Hospital Road
Prince of Wales Hospital
Randwick NSW 2031
Community/Consumer enquiries:
(02) 9382 4523
Fax: (02) 9382 8208
Email: blackdog@unsw.edu.au
Website: www.blackdoginstitute.org.au
The Black Dog Institute is dedicated to advancing the understanding,
diagnosis and management of depression.
Canada
Mood Disorders Society of Canada
3–304 Stone Road West, Suite 736
Guelph, Ontario
N16 4W4
Canada
Phone: (519) 824 5565
Fax: (519) 824 9569
Email: info@mooddisorderscanada.ca
Website: www.mooddisorderscanada.ca
MDSC is a registered charity run by volunteers committed to improving the
quality of life for people affected by mood disorders.
Ireland
Aware
72 Lower Leeson Street
Dublin 2
Helpline: (1890) 303 302
Tel: (01) 661 7211
Website: www.aware.ie
Aware provides information and support to people affected by depression in
Ireland and Northern Ireland.
South Africa
South African Depression and Anxiety Group
Tel: (011) 783 1474/76
Email: anxiety@iafrica.com
Website: www.anxiety.org.za
South African Depression and Anxiety Group provides a helpline with
trained counsellors, as well as information on depression and various
anxiety disorders that you can download.
Mental Health Information Centre (and MRC Unit on Anxiety
Disorders)
PO Box 19063
Tygerberg 7505
South Africa
Tel: (021) 938 9229
Fax: (021) 931 4172
Email: mhic@sun.ac.za
Website: www.mentalhealthsa.co.za
USA
AARP Grief and Loss Programs
601 E Street NW
Washington DC 20049
Tel: (202) 434 2260
Fax: (202) 434 6474
Email: griefandloss@aarp.org
Website: www.aarp.org/griefandloss
AARP Grief and Loss Programs offers a wide range of resources and
information on grief and loss issues to adults who are bereaved and their
families.
Depression and Bipolar Support Alliance (DBSA)
730 N. Franklin Street, Suite 501
Chicago
Illinois 60610-7224
Tel: (800) 826 3632
Fax: (312) 642 7243
Website: www.dbsalliance.org
The Depression and Bipolar Support Alliance (DBSA) is the nation’s
leading patient-directed organization focusing on the most prevalent mental
illnesses – depression and bipolar disorder.
GriefShare
250 S. Allen Rd
PO Box 1739
Wake Forest, NC 27587
Tel: (800) 395 5755; (919) 562 2112
Fax: (919) 562 2114
Email: info@griefshare.org
Website: www.griefshare.org
GriefShare is a network of support groups to assist any person who is
grieving the loss of a loved one. Offers information, referrals, literature,
help in starting groups.
Rainbows
2100 Golf Rd, Suite 370
Rolling Meadows
Illinois 60008-4231
Tel: (800) 266 3206
Fax: (847) 952 1774
Email: info@rainbows.org
Website: www.rainbows.org
Rainbows establishes peer support groups in churches, schools or social
agencies for children and adults who are grieving a death, divorce or other
painful transition in their family.
Professional Associations

Association for Behavioral and Cognitive Therapy USA

Website: www.aabt.org

Australian Association of CBT

Website: www.aacbt.org

European Association of Cognitive Behavior Therapists

Website: www.eabct.com
British Association of Behavioural and Cognitive Psychotherapies
(BABCP)
Website: www.babcp.com
Appendix 3 Finding Professional Help
When to consider professional help
A self-help book can be all that is required for some people to overcome
depression. After all, even with professional help, it is likely to be your own
efforts between sessions that make the biggest difference. You might
consider using this book with the aid of a professional; this is called ‘guided
self-help’. In this case the book can offer a shared way of understanding
your problems, and the strategies to improve the way you feel.
Professional help, with an appropriately trained practitioner, is often the
most effective approach. This involves working with a psychologist,
psychiatrist, therapist, counsellor or nurse therapist. Evidence-based
psychological treatments help most people and rarely make symptoms
worse. We suggest that you seek professional help if your depression is in
the moderate to severe range, and especially if your attempts at self-help are
not bearing fruit after a few weeks. If you are feeling hopeless about the
future and are having thoughts about ending your life, seek professional
assistance immediately.
Getting the right kind of help
If you are prescribed a dose of medication for depression, such as Prozac,
you can virtually guarantee that any pharmacy you go to will give you the
right dosage and that the Prozac will be of the same quality. Unfortunately,
this is not always true of getting the optimum psychological therapy. Only a
few types of therapy have been shown to work for moderate to severe
depression: cognitive behavior therapy (CBT), behavioral activation (BA)
and inter-personal therapy (IPT). CBT or BA is likely to be the treatment of
choice and the most widely available
In choosing a suitable therapist for moderate to severe depression, the
alarm bells should start ringing for therapists who:
do not tell you what type of therapy you are receiving
keep asking ‘How does that make you feel?’
spend most of the time wanting you to discuss your childhood and
the cause of your depression
do not share their understanding of what maintains your depression
do not problem-solve with you
do not negotiate relevant homework between sessions
do not monitor your progress in overcoming your symptoms.
If you are not sure, ask what type of therapy or counselling you are
receiving. There is no evidence that general counselling, psychodynamic
therapy, psychoanalytical therapy, hypnotherapy or transactional analysis is
of any benefit in moderate to severe depression. People may have found
such approaches supportive or helpful for other issues, but they are rarely
helpful by themselves for overcoming depression. Counselling and other
psychological therapies may help people in mild depression to some extent.
Similarly, beware of a doctor who offers medication only, without also
recommending a psychological treatment, unless you are very severely
depressed; even then behavioral activation can help. There may be
problems of obtaining psychological therapies in state medicine because of
the lack of funding, but this is not the fault of the doctor. This is an issue
that requires political action and takes a long time to solve. In the
meantime, seek support, use the principles outlined in this book (or other
CBT-based self-help material), and consider using medication.
Fears about seeking help
You may have a number of worries about seeking help such as:
‘What if it doesn’t help?’
‘It will be too embarrassing to tell them.’
‘They’ll think I’m mad and want to keep me in hospital.’
‘What if they pass the information on to social services or my
employer?’
If you find it difficult to talk about some of your worries, it’s usually helpful
to say you are embarrassed or ashamed. Remember that worrying is normal
and any health professional with the slightest experience in depression will
be sensitive to your difficulties. They will not consider you mad or want to
keep you in hospital against your will. Individuals are assessed for
detention only in extreme circumstances: if you are a danger to yourself or
others (for example, if you are actively suicidal or neglecting yourself
badly). Such information is kept confidential and cannot be shared with
other agencies or your employer without your permission. It does not go on
any employment records or to social services. Only in extreme
circumstances would a therapist ask someone to assess the impact of a
person’s depression on their family and children.
Treatment may not help initially as it can take a few weeks to take effect,
but, if nothing is risked, nothing is gained and your depression is likely to
persist for some time. Furthermore, CBT or medication very rarely make
depression worse.
In teaching centres, you may be asked if a student or trainee may sit in. It
is important to continue training others in psychological treatment but you
are entitled to refuse without it affecting your treatment.
Remember, as with all other negative thoughts, try to treat negative
thoughts about seeking help as ‘just thoughts’ which are likely to be quite
common under the circumstances. Rather than trying to ignore them, or
debating them in your mind, take your thoughts with a pinch of salt and act
consistently with pursuing your goal of overcoming your depression.
Getting the most from a psychological therapy
You will get most from a psychological therapy if you:
keep your appointments
are honest and open with your therapist
tell your therapist if you feel very embarrassed or ashamed about
your symptoms
attempt the homework agreed between you and your therapist during
therapy sessions. Having a good relationship with your therapist is
important, but adherence to daily homework is the single predictor
of success in therapy
act as if the problem is a thinking problem, act against the way you
feel and do the homework you negotiate daily
do the homework and tolerate the uncertainty and discomfort for as
long as is necessary
have clear goals that you want to achieve and you can agree on with
your therapist
regularly monitor your progress with the therapist by using rating
scales
record the sessions in some way so you can listen to them again
give the therapist feedback.
You might find that you are not ready for CBT or BA and it may be better
to return when you feel more committed to change and able to do the
homework regularly. Don’t believe you are a ‘hopeless case’ – change is
nearly always possible. Then you can build on it. Don’t be afraid to seek a
second opinion or a referral to a specialist centre.
Types of professional offering help
There is a range of mental health professionals who will offer help for
depression. Most mental health teams are multidisciplinary, which means
that they include people from different professional backgrounds.
Psychiatrists are medical doctors who specialize in mental disorder.
They can prescribe medication for depression and will probably be
more knowledgeable about dosage and other issues required for
depression and anxiety than your family doctor. A few psychiatrists
are trained in CBT or BA.
Clinical psychologists have a basic training in psychology and have
then trained in the clinical application of psychological assessment
and therapies. They do not prescribe medication. Many will offer
CBT or BA but may not have had the specialist training and
supervision required.
Counselling psychologists have a basic training in psychology and
are then trained in counselling and therapy. They do not prescribe
medication. Some may offer CBT or BA but may not have had the
specialist training.
Nurse therapists are originally trained in psychiatric nursing and in
the UK most have specialized in CBT.
Psychotherapists and counsellors come from a broad range of
therapies. Most will listen to you and help you to work through
issues in your life. They do not prescribe medication. They are not
usually trained in CBT or BA.
It is important to realize that there is nothing to stop anyone calling
themself a counsellor or psychotherapist, whether they are properly trained
or not. No therapist with a recognized professional qualification is going to
mind you asking about their relevant training and qualifications. It is very
important that you satisfy yourself about these things as well as the type of
therapy used. What experience have they got of treating depression (for
example, the number of patients or clients they have treated)? What are
their expectations for change at the end of therapy and do these match your
goals? Do you get on with the therapist? Of course you will want someone
who is experienced in depression but, if they are not, try to judge whether
they are willing to learn more.
If you have problems with your therapist
If you want to complain about any professional, think clearly about the
nature of the problem – for example, is it the type of treatment, the
therapist, the location, or something else?
Are there contributing factors – for example, the personality of your
therapist or you feeling more depressed? Can you sort it out with the
therapist or another member of the team? Can you think of possible
solutions to discuss with the professional? If the professional is refusing
further therapy, listen to their reasoning and write down their explanation. If
the reasons are financial (for example, it costs too much), don’t give up as
you may have to persist to get another opinion.
Finding professional help in the UK
If you would like professional treatment in the UK, your family doctor or
general practitioner is the best place to start. They will usually be aware of
what services are available locally. If you are worried about seeing your GP,
take a relative or friend with you. If you find it difficult to talk to your GP,
write a letter and give it to the doctor. At your consultation, write down the
key points that you want answered. You can always change your GP if you
think you might be better understood or treated by another.
The information that you tell your GP is confidential and cannot be shared
without your permission. If your local mental health service is unable to
assist, it may refer you to a national service. Unfortunately, getting referred
to a specialist service can be a minefield and usually depends upon the
support of your local mental health team. Communicate clearly that you
need cognitive behavior therapy or behavioral activation from a trained
practitioner. Unfortunately, for many public services, you can be referred
only to a department and not to a particular individual. Despite this, you
may find it helpful to do your own research and find out the names of
recommended therapists from your local depression support group or
national charity.
In the UK, it is usually quicker to obtain help privately but it does not
necessarily mean that the treatment will be any better. Good and bad
treatment can occur in both the public and the private sectors. It is best to
do your homework and to ask for recommendations from your local support
group or national charity (see Appendix 2 for contacts), which may keep a
directory of practitioners. You can also try searching for a private accredited
therapist on the website of the British Association of Behavioural and
Cognitive Psychotherapists (www.babcp.com) in the ‘Find a Therapist’
section. Not all cognitive behavior therapists bother to become accredited
and there are many from psychiatry, psychology or nursing backgrounds
who are excellent cognitive behavior therapists.
Finding help in the USA
In the USA finding a cognitive behavior therapist may be difficult and
depend on where you live. You could ask for a referral from your family
doctor or recommendation from an academic psychiatry or psychology
department. The best recommendation may come from your local support
group or charity. It is likely to be a member of the Association for
Behavioral and Cognitive Therapies, which maintains a directory of
therapists who can be contacted (www.aabt.org). As in the UK, it is usually
quicker to obtain help privately but it does not mean you will necessarily
get any better treatment. Good and bad treatment can occur in both the
public and the private sectors.
Finding help in the rest of the world
In Appendix 2 we have included contact details of other national depression
charities around the world which may be valuable resources of
recommended professionals.
Charities and support groups
In addition to professional help, national charities and local support groups
can be invaluable. By joining and supporting them you can help them. In
the UK, for example, support Depression Alliance; in the USA, the
National Foundation for Depressive Illness. By joining a charity, you will
receive a newsletter and help put depression on the national agenda. They
also have information on local resources and support groups, which provide
a forum for mutual acceptance, understanding and setting of goals. They
will also be able to recommend local therapists or psychiatrists. People new
to depression can talk to others who have learned successful ways for
coping. Reading books about depression and searching on the Internet are
useful ways of getting further information or support (see Appendix 4). The
more you know about depression and the more you can become your own
therapist, the better equipped you will be to overcome it. And when you
recover from depression, you can help raise funds for research into better
treatments for depression and campaign for better services and for training
for more cognitive behavior therapists in public medicine. Unfortunately,
many of the charities in depression are too small and unable to focus
enough energy on raising funds for research compared with the big charities
in cancer or heart disease.
Appendix 4 Further Reading
Blaszczynski, Alex (1998) Overcoming Compulsive Gambling. Constable
& Robinson.
Burns, David (2000) Feeling Good: The New Mood Therapy. Avon Books.
Butler, Gillian (1999) Overcoming Social Anxiety and Shyness. Constable &
Robinson.
Crowe, Michael (2005) Overcoming Relationship Problems. Constable &
Robinson.
Dimidjian, S., Hollon, S.D., Dobson, K.S. et al. (2006) ‘Randomized trial of
behavioral activation, cognitive therapy, and antidepressant medication in
the acute treatment of adults with major depression’. Journal of
Consulting and Clinical Psychology 74(4): pp.658–70.
Gavin, Jim (2005) Lifestyle Fitness Coaching. Human Kinetics Europe Ltd.
Gilbert, Paul (2000) Overcoming Depression. Constable & Robinson.
Glenmullen, Joseph (2006) Coming off Antidepressants. Constable &
Robinson.
Hayes, S.C., Strosahl, K.D. & Wilson, K.G. (2003) Acceptance and
Commitment Therapy: An Experiential Approach to Behavior Change.
Guilford Press.
Herbert, Claudia & Wetmore, Ann (1999) Overcoming Traumatic Stress.
Constable & Robinson.
Jacobson, N.S., Martell, C.R. & Truax, P.A. (1996) ‘A component analysis
of cognitive behavioral treatment for depression’. Journal of Consulting
and Clinical Psychology 64(2), pp.295–304.
Kennerley, Helen (1997) Overcoming Anxiety. Constable & Robinson.
Martell, C., Addis, M. & Jacobson, N.S. (2001) Depression in Context:
Strategies for Guided Action. W.M. Norton.
Ottenbreit, N.D. & Dobson, K.S. (2004) ‘Avoidance and depression: the
construction of the cognitive-behavioral avoidance scale’. Behavior
Research and Therapy 42(3): pp.293–313.
Papageorgiou, C. & Wells, A. (2004) Depressive Rumination: Nature,
Theory and Treatment. Wiley.
Rosenthal, Norman (2005) Winter Blues. Guilford Press.
Scott, Jan (2001) Overcoming Mood Swings. Constable & Robinson.
Silove, Derrick & Manicavasagar, Vijaya (1997) Overcoming Panic.
Constable & Robinson.
Veale, David & Willson, Rob (2005) Overcoming Obsessive Compulsive
Disorder. Constable & Robinson.
Williams, Christopher (2006) Overcoming Depression and Low Mood.
Hodder Arnold.
Zigmond, A.S. & Snaith, R.P. (1983) ‘The hospital anxiety and depression
scale’. Acta Psychiatrica Scandinavica 67(6): pp.361–70.
National Institute of Clinical Excellence (NICE) guidelines on depression:
Depression: management of depression in primary and secondary care
(2003) http://www.nice.org.uk/page.aspx?o=cg023
Depression in children and young people: identification and management in
primary, community and secondary care (2005)
http://www.nice.org.uk/page.aspx?o=cg028
The management of bipolar disorder in adults, children and adolescents, in
primary and secondary care – NICE guidance (2006)
http://www.nice.org.uk/page.aspx?o=CG38
Appendix 5 Blank Charts and Forms
The Hospital Anxiety and Depression (HAD) scale
Please read each group of statements carefully, and then pick the one that
comes closest to how you have been feeling in the past week. Write that number
in the box. Don’t take too long over your replies: your immediate reaction to
each item will probably be more accurate than a long thought-out response.
Anxiety Depression
1 I feel tense or ‘wound up’:
0 Not at all
1 Time to time, occasionally
2 A lot of the time
3 Most of the time

2 I still enjoy the things I used to enjoy:

0 Definitely as much
1 Not quite so much
2 Only a little
3 Hardly at all

3 I get a sort of frightened feeling as if something awful is about to

happen:
0 Not at all
1 A little, but it doesn’t worry me
2 Yes, but not too badly
3 Very definitely and quite badly

4 I can laugh and see the funny side of things:

0 As much as I always could
1 Not quite so much now
2 Definitely not so much now
3 Not at all

5 Worrying thoughts go through my mind:

0 Only occasionally
1 From time to time but not too often
2 A lot of the time
3 A great deal of the time

6 I feel cheerful:
 0 Most of the time
1 Sometimes
2 Not often
3 Not at all

7 I can sit at ease and feel relaxed:

0 Definitely
1 Usually
2 Not often
3 Not at all

8 I feel as if I have slowed down:

0 Not at all
1 Sometimes
2 Very often
3 Nearly all the time

9 I get a sort of frightened feeling like butterflies in the stomach:

0 Not at all
1 Occasionally
2 Quite often
3 Very often

10 I have lost interest in my appearance:

0 I take just as much care as ever
1 I may not take quite as much care
2 I don’t take so much care as I should
3 Definitely

11 I feel restless, as if I have to be on the move:

0 Very much indeed
1 Not very much
2 Quite a lot
3 Very much indeed

12 I look forward with enjoyment to things:

0 As much as I ever did
1 Rather less than I used to
 2 Definitely less than I used to
3 Hardly at all

13 I get sudden feelings of panic:

0 Not at all
1 Not very often
2 Quite often
3 Very often indeed

14 I can enjoy a good book, or radio or TV program:

0 Often
1 Sometimes
2 Not often
3 Very seldom

TOTAL
If you score 9 or more on the depression sub-scale, you are probably
experiencing depression. If you score 9 or more on the anxiety sub-scale, you
are probably experiencing an anxiety disorder. Higher scores (15 or more on the
depression sub-scale) may mean that a self-help book is not suitable for you,
and you may need to seek additional professional help.
Disability Ratings
Please rate how far your problems have held you back in various areas of your
life in the past week. Circle the number that best describes how badly you were
affected:
a Because of the problems, my ability to work or study or my role as a
homemaker is affected.
(Note: please rate this even if you are not currently working; you are rating your
ability to work or study):

b Because of the problems, my home management (e.g. cleaning, shopping,

cooking, looking after my home or children, paying bills, etc.) is affected:

c Because of the problems, my social life activities (with other people, e.g.
parties, pubs, outings, visits, dating, home entertainment, etc.) are affected:
d Because of the problems, my private leisure activities (done alone, e.g.
reading, gardening, hobbies, walking alone, etc.) are affected:

e Because of the problems, my general relationship with my partner (e.g.

affectionate feelings, number of arguments, enjoying activities together, etc.) is
affected:

f Because of the problems, my sexual relationship (enjoyment of sex, frequency

of sexual activity, etc.) is affected:

Summary of HAD and Quality of Life scores

 Cognitive and Behavioral Avoidance Checklist
I avoid social activities
I make excuses not to attend social events
I ignore the phone and texts or emails from friends
I limit myself to events where the people are familiar
I tell myself that I prefer to be alone
I leave social gatherings early
I keep to myself or stick to someone I know at a social gathering
I avoid socializing with people of the sex to which I am attracted
I have reduced or stopped my leisure activities (for example, visiting
pub, cinema, theatre, club, restaurant, gallery, football match)
I have reduced or stopped solo hobbies (for example, fishing, playing a
musical instrument, DIY, reading, painting, gardening, running)
I do not take as much care of myself as I used to (for example,
washing, hair care, regular clean clothes and sheets)
I have reduced or stopped paying attention to my role as a
parent/partner/son or daughter
I have reduced time spent cooking and live on junk food
I have given up tidying or cleaning my home
I have stopped opening or replying to letters, and paying bills
Instead of acting as a good student or employee, I accept what I think
are my limits at school or at work
I am not following up what I want to achieve at college or work
I am sticking with the things I know rather than developing new
interests (whether at college or work or in my spare time) where I may
fail
I quit activities early where I feel that they are too challenging even
though others do not agree with me
I try not to think about problems in any of my relationships but just let
things go on as they are
I do not think about what I really want in life
I avoid communicating with my partner/parents/children
I am not getting serious about college or work
I am trying to find a reason for the way I feel
I am constantly thinking about why I acted in the past in the way I did
I am trying to answer ‘What if?’ questions in my mind
I am turning down opportunities to further my education or career
 I am fantasizing ‘If only’ situations (for example, if only I had not
acted in the way I did, or if only such and such had not happened)
I avoid making important decisions about my future
I distract myself when I think about work or education, or my role as
parent or partner
The following are relevant only when you do them excessively to stop
yourself thinking or to numb yourself emotionally or to avoid doing
something else
I comfort eat or binge-eat
I watch excessive amounts of TV
I listen to a vast amount of music
I spend a large portion of my day on the computer/Internet
I binge-drink alcohol
I stay in bed in the morning or have frequent naps in the day
I exercise excessively
I use illegal substances

Valued Directions Form

Area Valued direction

1 Intimacy _________________________________________
(What is _________________________________________
important to you _________________________________________
in how you act _________________________________________
in an intimate
relationship?
What sort of
partner do you
want to be? If
you are not
involved in a
relationship at
present, how
would you like
to act in a
relationship?)

2 Family _________________________________________
relationships _________________________________________
(What is _________________________________________
important to you _________________________________________
in how you want
to act as a
brother/sister;
son/daughter;
father/mother or
in-law? If you
are not in
contact with
some of them,
would you like
to be and how
would you act in
such a
relationship?)

3 Social _________________________________________
relationships _________________________________________
(What is _________________________________________
important to you _________________________________________
in the way you
act in the
friendships you
have? How
would you like
your friends to
remember you?
If you have no
friends, would
you like to have
some and what
role would you
like in a
friendship?)

4 Work (What _________________________________________

is important to _________________________________________
you at your _________________________________________
work? What sort _________________________________________
of employee do
you want to be?
How important
to you is what
you achieve in
your career?
What sort of
business do you
want to run?)

5 Education _________________________________________
and training _________________________________________
(What is _________________________________________
important to you _________________________________________
in your
education or
training? What
sort of student
do you want to
be? If you are
not in education,
would you like
to be?)

6 Recreation _________________________________________
(What is _________________________________________
important to you _________________________________________
in what you do _________________________________________
to follow any
interests, sports
or hobbies? If
you are not
following any
interests, what
would you
ideally like to be
following?)

7 Spirituality _________________________________________
(If you are _________________________________________
spiritual, what is _________________________________________
important to you
in the way you
want to follow a
spiritual path? If
you are not,
would you like
to be and what
do you ideally
want?)

8 Voluntary _________________________________________
work (What _________________________________________
would you like _________________________________________
to do for the
larger
community? For
example,
voluntary or
charity work or
political
activity.)

9
Health/physical _________________________________________
well-being _________________________________________
(What is _________________________________________
important to you
in how you act
for your
physical
health?)

10 Mental _________________________________________
health (What is _________________________________________
important to you _________________________________________
generally in
how you act in
your mental
health?)

11 Any other _________________________________________

valued _________________________________________
directions that _________________________________________
are not listed _________________________________________
above?

Problem list Severity rating

0–10
1. ____________________________________________
____________________________________________
____________________________________________
2. ____________________________________________
____________________________________________
____________________________________________
3. ____________________________________________
____________________________________________
____________________________________________
4. ____________________________________________
____________________________________________
____________________________________________
5. ____________________________________________
____________________________________________
____________________________________________
6. ____________________________________________
____________________________________________
____________________________________________
 Goals
Progress rating (0–10)
Short term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________
Medium term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________
Long term
1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
6. ____________________________________________
 Functional Analysis

Activating event (situation or

context of event or ruminating)

Behavior (including ruminating,

worrying and self-attacking)
Consequences (immediate) which
provide a payoff. What happens
next? What effect does it have on
your thoughts and feelings?

Unintended consequences (in the

long term) which cause handicap.
What effect does it have on yourself
and others? What effect does it have
on your thoughts and feelings?

Valued directions What directions

could you take that would be in
keeping with your values and give
you better feelings?

Effect of valued direction What

effect does taking the valued
direction have on yourself, others
and the community in the long term?
 Daily Activities Record Sheet

Day/date:

Time Activity Time Activity

7am 4pm

8am 5pm

9am 6pm
10am 7pm

11am 8pm

12pm 9pm

1pm 10pm

2pm 11pm

3pm 12am

Daily Activities Record Sheet

Day/date:

Time Activity Time Activity

7am 4pm

8am 5pm

9am 6pm

10am 7pm

11am 8pm

12pm 9pm

1pm 10pm

2pm 11pm

3pm 12am

Planned Timetable
Day/date:

Time Planned Actual What was the Did it contribute towards

activity activity effect of what I my goals and valued
did on my directions in life? Rate it
emotions or the from 0–10 where 0 is not
context in at all and 10 is extremely
which I live?

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm

9pm

10pm
11pm

12–7am
 Cost–Benefit Analysis Form
Option:
________________________________________________________
Costs – for you and other people. Benefits – for you and other people.
Consider short- and long-term Consider short- and long-term
costs. benefits.

For self in the short term For self in the short term

For self in the long term For self in the long term

For others in the short term For others in the short term

For others in the long term For others in the long term
 Food Diary
Day ______________ Date ____________________________________
Time Context Food/drink and
(for example, thoughts, emotion, amount consumed
activity or situation)

Food Diary
Day ______________ Date ____________________________________
Time Context Food/drink and
(for example, thoughts, emotion, amount consumed
activity or situation)