Depression

and Low Mood

An NHS self help guide

www.cntw.nhs.uk/selfhelp
COPYRIGHT BY NHS ENGLAND
 Page

How can this guide help me? 3

What is depression? 4
Signs and symptoms you may experience if you are 4
depressed?
What causes depression? 5
What does research tell us about depression? 6
What treatment is available for depression 7
How can I help myself? 8
Further help 28
Useful organisations 29
Useful books 32
Mindfulness downloads 36
References 36
Rate this guide 36

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These are the thoughts of two people who are
depressed:

“I feel so alone, I never see my friends now, I guess they have

dropped me. They probably don’t like me – who would? There
is no point in making any effort. It doesn’t pay off... I just hate
myself."

“I feel like crying all the time, I am so tired and can’t get
interested in anything. In fact I don’t even do the things I used
to enjoy. I can’t even do basic things that seem so easy to other
people...”

You may have had similar thoughts yourself. Depression is a

very common problem and many people feel low or down in the
dumps at times. This is often due to life stresses such as
bereavement, money or housing problems or difficulties in
relationships. For some people the problem becomes much
worse and gets in the way of normal life.

How can this guide help me?

It may seem that nothing can be done to help you feel better.
But there are things that you can do to make a difference.
There is also further help you can get if the depression does not
seem to be getting any better.

This guide aims to help you cope with depression and begin to
get better. The approach is called Cognitive Behaviour Therapy
(CBT). CBT uses methods that have been tried and tested and
found to be effective. It involves looking at the way you think
about things and what you do.

We have included pen and paper exercises in the booklet to

help you begin to understand and begin to deal with depression
practically. You should find it helpful to complete these
exercises.

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What is depression?
Depression is a common mental health problem. At least one in
ten people will experience depression at some time. In its
mildest form depression does not stop us from leading a normal
life, but the most severe depression can be extremely
distressing, with thoughts of death and suicide.

These are some of the signs or symptoms that you

may experience if you are depressed:
Emotions or feelings - (tick if you feel like this)
 Feeling sad, guilty, upset, numb or despairing 
 Losing interest and/or enjoyment in things 
Crying a lot or unable to cry when a truly sad event
occurs 
 Feeling alone even if you are in company 
 Feeling angry and irritable about the slightest thing 

Physical or bodily signs

 Tiredness 
 Lack of energy 
 Restlessness 
 Sleep problems, especially waking early 
 Feeling worse at a particular time of day - usually
mornings 
 Changes in weight, appetite and eating 

Thoughts
 Losing confidence in yourself 
 Expecting the worst and having negative or gloomy
thoughts 
 Thinking that everything seems hopeless 
 Thinking you hate yourself 
 Poor memory or concentration 
 Thoughts of suicide 

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Behaviour
 Not making decisions 
 Can’t be bothered to do everyday tasks 
 Putting things off 
 Not doing things you used to enjoy 
 Avoiding seeing people 

If you have ticked most of these boxes then you may be

experiencing depression. Most people feel some of these
symptoms from time to time. But if the feelings don't go away
after a few weeks, and are there most days for most of the time,
then it may be that you are depressed.

When you’re depressed you may feel hopeless and alone in the
world; you may blame yourself for all the faults you think you
have and feel pretty worthless. In short, you feel negative about
yourself, about the world and about the future. So you tend to
lose interest in what’s going on around you, you don’t get any
satisfaction out of the things you used to enjoy and you
withdraw even further into yourself. Eventually it can become
hard to make decisions or to carry out little tasks that you once
did no problem at all. People who are depressed often say they
don't recognise themselves they feel so different. The good
news is that there are many things that can help, and
people do recover from depression.

What causes depression?

No single cause for depression has been found. Usually there is
more than one reason and this differs from person to person.
Life is sometimes difficult and we know that things such as low
income, bereavement, loneliness, relationship problems and
loss of work can make people more likely to become
depressed, although this is not always the case. Some people
may be more vulnerable to depression, due to a family history
of depression, early experiences, personality factors or body
chemistry. Sometimes there is no obvious reason at all.

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Whatever the cause of a person's depression, there is
something that can help. But just as the causes can vary from
person to person, so can the treatment. Some people may need
medication, others may need to make some changes in their
life. For others becoming more active may be the key, whereas
others may really benefit from changing their thoughts.
Sometimes it might be all of these. As you can see depression
can be complex!

What does research tell us about depression?

Research has helped us to understand depression much better.
Both in terms of what leads people to become depressed, and
what keeps it going. We now realise that our body, thoughts
and behaviours play an important role in depression. The way a
person is physically and emotionally, and how they think and
act when they are depressed can be very different to how they
usually are.

Here are a few examples:

 The successful business person who thinks they are
useless, stops enjoying work and withdraws from friends and
colleagues.
 The caring father who thinks he is a rubbish dad so stops
doing things with his children because of lack of confidence.
 The clever student who thinks they are stupid, tries to study
harder, can't sleep and has no energy.
 The hard working woman who thinks that she has let
everyone down because she has lost her job, then cuts
herself off from friends and family and starts drinking as a
way of coping.

Most people have low mood at times. It would be unusual if we

never felt a bit low and unmotivated to face the day. However,
when depression develops, this becomes more severe. There
may be changes in body chemistry and energy levels, leading
to lack of interest and enjoyment, which in turn leads to
withdrawing from activities mentally and physically. Once

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someone isn't doing the things they enjoy and value, their mood
drops even more. And guess what? Yes, there is much more
space in the mind for more and more gloomy thoughts to flood
in!

In summary
No one cause for depression has been found, but it is likely that
early experiences, difficult circumstances, individual differences,
body chemistry, reduced activity and gloomy thoughts can all
play an important role in depression. When someone is
depressed there are usually changes in the way they feel, their
body chemistry, what they think and how they behave.

What treatment is available for depression?

Most people are treated for depression by their family doctor.
The doctor may suggest self help (like this), a talking therapy,
antidepressant tablets or a mixture of all three. You may just
see the doctor, or be referred to a specialist. This could be a
psychological therapist, counsellor, psychiatrist or other mental
health worker.

The talking therapies are usually Counselling or Cognitive

Behaviour Therapy(CBT), although sometimes other therapies
are offered. Therapy will help you understand your own
difficulties and begin to work out ways of overcoming
depression. This can usually be offered by phone or face to
face. Quite often your therapist may suggest using a booklet
like this, but they can offer extra help and support if you have
struggled to use it on your own.

Whatever type of therapy is used, it will usually take a little time

before you begin to feel the benefits, but treatment of this kind
has helped many people and can be very effective, so don't
give up too soon.

Antidepressants are sometimes prescribed by your family doctor

or psychiatrist. They have been shown to be helpful for many

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people suffering from depression. Antidepressants work on the
chemicals in the brain to make you feel less depressed. They are
not addictive and once you begin to feel better, usually after quite
a few months, you can plan, with your doctor, to stop taking them.
This should not cause you any difficulty and your doctor will
gradually adjust and reduce the dose.

When you begin a course of antidepressants it is important to

remember that they do not work immediately. It will take 2-4
weeks before they take effect and you need to keep taking
them regularly to feel the benefit. They can have some side
effects at first but these are usually quite mild and will generally
wear off as treatment continues. Your doctor or pharmacist will
advise you about this. Although people often start to feel better
within 2-4 weeks of taking antidepressants, it is important to
keep taking them for as long as your doctor advises. This helps
stop the depression coming back. If you are taking
antidepressants it is important to consult your doctor before
taking any other tablets, drugs or alcohol.

How can I help myself?

As mentioned, the way you think about things affects the way
you feel, which affects the way you behave, and so it goes
round and round. It is difficult to change the way you feel
directly. Just telling yourself to cheer up and feel better doesn't
usually work! But you can change the things you do and the
way you think, which will then in turn change the way you feel.
This can be with or without the help of medication, depending
on what your GP and you both feel is best.

Increasing helpful activity

First of all in this section we will look at some practical steps to
help to overcome depressive feelings through increasing
activity. Research evidence tells us that increased activity is
very helpful in overcoming depression. In fact studies have
shown that exercise is as effective as anti-depressants in some
cases. Not only that, but withdrawing from the things and

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people we care about makes our mood much worse. Don't
expect to enjoy things as you used to straight away. This will
come later, and gradually. Just do your best to do what you
can.

It really help even if you feel your depression relates to difficult

life events.

Positive steps
 List things to do
 Mix with people
 Join in activities
 Take exercise
 Do things you enjoy and value

1. Making a daily plan

When people are depressed they often don’t feel like doing
anything, find it hard to decide what to do each day and can
end up doing very little. Hours can pass just staring into space,
or having gloomy thoughts.

Begin to tackle this by making a list of things you might usually

want to or need to do, even if you don't want to do them right
now. Then plan out an action list, start off with the easiest task
at first and don’t aim too high. Try and have a mixture of
activities, including some chores and some things you would

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usually enjoy. Work through your action list and tick off what
you’ve done. At the end of each day you’ll be able to look back
and see what you’ve achieved. Physical exercise and activity
can really help to lift your mood. Try and build a little in each
day. Classes are sometimes available to increase physical
activity for people with low mood. Your GP may be able to refer
you to these, or to other activities that may help your mood.
Mixing with friends, family, pets; anyone you feel close to, can
also help. In particular try to plan simple things you value, such
as walking in the countryside, being creative, listening to music.

List some exercise or activities that you could do. This

can be as simple as a brisk walk; or doing a crossword with
a member of your family:
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Try to fill in this action plan for a week, then continue with your
own similar plan

Mon Tues Wed Thurs Fri Sat Sun

9am -
11am

11am -
1pm

1pm -
3pm

3pm -
5pm

5pm -
7pm

2. Achievements, pleasure and gratitude diary

When people are depressed they often forget what they’ve
achieved and what they enjoy. Most people have more things
going for them than they are usually aware of. On your daily
action plan write down all events of the day, put a P next to
those which have given you pleasure and an A next to those
activities where you felt you achieved something and did well.
You can even rate this from 1 to 10 so you can see which
things please you most and can notice any changes with time.
Try not to be too modest; people who are depressed tend not to
take credit for their achievements. Don't dismiss what you
achieve by comparing with what you were able to do when you
were not depressed. Think only of your progress. Small steps
are all steps in the right direction. Try and build some pleasant

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events into your day and treat yourself. Each evening, spend a
few minutes jotting down two or three things you are grateful for
from the day. Some people find it helpful to have a nice
notebook especially for this. This is called a gratitude diary
and studies have shown improvements in mood from this
simple act.

Reducing unhelpful activity

Sometimes when people are depressed they start doing things
to try and feel better that are really quite unhelpful. For
example: drinking alcohol, staying in bed, binge eating, zoning
out in front of the TV. By noting everything you do in your daily
plan, you can start to see patterns of what helps and what
makes you feel worse. So it might be a case of increasing some
behaviours and reducing others.

It is important to get a good night’s sleep. A further booklet in

this series describes how to go about this. If you think you may
have sleep apnoea, a condition where your breathing is
affected while you sleep, please consult with your GP. This is
known to prevent improvement from depression.

Solving difficult problems

Sometimes we feel overwhelmed by the very complicated and
difficult things we have to do. One thing which helps with this
sort of problem is to write down each of the steps which you
have to take in order to complete the job – then tackle one step
at a time.

Problem solving can seem more difficult when you feel

depressed. If you have a particularly difficult problem, try and
look back to times when you may have successfully solved
similar problems and use the same approach. Or ask a friend
what they would do in a similar situation. Be clear. Write down
all your possible options - even what you think are silly solutions
can be written down and considered. Choose the best
approach.

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Try this way of problem solving yourself.
What is the problem? (write it down – be as specific as
possible):
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Try the following:
List all sorts of solutions. Remember how you may have
solved similar problems in the past. What would your
friends advise? Or how would you advise a friend with a
similar problem.
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Choose the best of the above. (write it down)

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 Steps to tackle it:

Step 1: ……………………………………………………………

Step 2: ……………………………………………………………

Step 3: ……………………………………………………………

Step 4: ……………………………………………………………

Step 5: ……………………………………………………………

Depression can be a signal that something is wrong in your life. If

you feel that your relationship is part of the problem then talk to
your partner or consider couples therapy. Couples therapy is often
available through local mental health services.

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Understanding depressive thinking
As we have said depression not only affects our behaviour but
also our thoughts. Sometimes negative thoughts can stop you
from doing the things that you would normally do. You might
say to yourself 'what's the point' 'I can't face it' and this will have
a real effect on your activity levels. As a result, you may then
get self-critical thoughts about being lazy, or irresponsible,
which make you feel even worse, and able to do less and less.
In other words, you get caught up in a vicious cycle which looks
something like this:

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Has a similar cycle happened to you? Try and draw it out.

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What do gloomy, depressive thoughts look like?
Suppose you are walking down the street and you see a friend
who appears to ignore you completely. Normally this wouldn't
bother you too much. You might wonder why your friend didn't
speak and feel a little disappointed maybe. Next time you see
them you might mention the incident to your friend, and they
might tell you that they were preoccupied at the time and didn’t
even see you. If you’re depressed, you probably believe your
friend has rejected you. ”They don't like me. What have I done
to upset them?” may pass through your mind. You may not
even ask about the incident, and then the mistake goes
uncorrected. The next time you spot your friend, perhaps you
ignore them and walk straight by. If you’re feeling depressed
you’re more likely to make mistakes like this over and over
again.

When you are feeling low the gloomy thoughts may be so

familiar and happen so often to you that you just accept them
as fact.

Gloomy thoughts are often about yourself, and are usually self
critical; for example:

“I’m no good”
“People don’t like me”
“I’m a bad mixer”
“I look ugly”

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 Do you have any gloomy thoughts about yourself? – jot
them down:
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These thoughts are sometimes about other things such as the

world around you or the future.

For example:

“All people are unkind”

“The world is a horrible place”
“Nothing will work out well”

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 Do you have any gloomy thoughts about other things? –
jot them down:
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What more should I know about these gloomy

negative thoughts?
We have given some examples of the negative thoughts people
have when they are depressed. It is important to remember that
most people have some of these sorts of thoughts even when
not depressed. This is normal. The difference is that we would
generally dismiss them from our mind. When you are
depressed, however, these thoughts are around all the time and
are hard to dismiss. Let's look at negative thoughts in more
detail so you might begin to recognise them. You may notice
some of the following unhelpful thinking styles if you are feeling
depressed:

1. Catastrophising
This means we think things are much worse than they really are
by jumping to the worst conclusion. For example you make a
small mistake at work and fear that you may be dismissed
because of it, or you may spend a long time worrying that you
have upset and lost a friend by something you have said only to
find later they didn’t even remember the comment.

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 Do you ever catastrophise? Think back over the last two
weeks and list:
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2. Over-generalising
This is when we generalise from one small thing. For example,
if someone isn't friendly to you, you may think “No one likes me,
I'm a waste of space” or if one of your daily tasks hasn’t been
finished you may think “I’ve achieved nothing, today has been
pointless”.

In other words from one thing that has happened to you, you
draw a negative conclusion which is much bigger and covers all
sorts of things.

Do you ever over-generalise? Think back over the last

two weeks and list examples:
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3. Ignoring the positive
People who are depressed tend to focus their thinking on
negative or bad events and ignore positive or good events. For
example, you might have had a game of pool and missed the
shot once, but played well in general. After the game you just
think about that one missed shot and not the rest of the game
played well. Or you may have many good friends who you have
known for years but you concentrate and worry about one that
has fallen out with you rather than remembering all the other
good friendships.

Do you sometimes ignore the positive? Jot down some

examples from the last two weeks:
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4. Taking things personally and being self-critical

Often if our mood is low we blame ourselves for anything that
goes wrong, even if things have nothing to do with us in reality.
For example, you go into a local shop and the assistant who
knows you is ‘off-hand’, your automatic thought is "she doesn’t
like me... have I done something wrong?”, but the most likely
reason is that she’s tired or upset or has had a ‘bad day’. In this
example you have taken the blame personally. You may also
be self-critical and put yourself down with thoughts such as “I
am an idiot” “I never get things right”. Insert here box to collect
self critical thoughts.

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 “Are you sometimes self critical?”Jot down some
examples from the last two weeks
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5. Mind reading or fortune telling

We sometimes believe we know what others are thinking and if
our mood is low we may expect that they are thinking badly of
us. For example if a friend is quiet you may think “that is
because she thinks I am boring”. Or we may predict the future
by imagining a negative outcome before it even happens. So
you may think “I know it’s not going to be good enough so I'm
not going to even bother trying.”

Do you find that you ‘mind read’ or 'fortune tell'? Jot down
some examples from the last two weeks:
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Did any of these look familiar? If so, don't worry. Once you have
begun to recognise them in yourself, there is plenty you can do
to stop depressed thoughts affecting your mood. The following
simple techniques might help:

1. The ABC of changing thoughts and feelings

Most people who are depressed think their lives are so awful
that of course they feel sad. In fact our feelings come from what
we think about rather than just facts.

Try to think about a recent event which had upset and

depressed you. You should be able to sort out three parts of it:

A. The event.
B. Your thoughts about it.
C. Your feelings about it.

Most people are normally only aware of A and C. Let's look at

an example:

Suppose someone at work criticises you for a piece of work you

have done.

A. The event – criticism of your work.

B. Your thoughts – what might you be thinking? You may
need to concentrate to discover this.

“He thinks I’m no good and

he’s right, I’m hopeless”

C. Your feelings – hurt, embarrassed.

How depressing! No wonder you feel bad! The important point
about trying to become aware of these three stages A, B and C

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is that you can change what you think about an event and
therefore you can change how you feel about it.

2. Balancing
A useful technique to try is called balancing. When you have a
negative, critical thought, balance it out by making a more
accurate and positive statement to yourself. For example:

The thought: “I’m no good at my job”, could be balanced with:

“my boss said how much he appreciated the piece of work I did
yesterday”.

Negative Positive
thought thought

3. The double column technique

Another thing you could do is to write down your negative
automatic thoughts in one column, then opposite each one,
write down a more balanced positive thought. Like this:

Negative automatic thought: Balancing thought:

John hasn’t called, he doesn’t He is very busy and thinks I am
like me. doing better than I was last
week, so he doesn’t need to
worry about me.

It may be helpful to keep a diary of events, feelings and

thoughts a bit like the table below. Use the approaches
described to gain more balanced thoughts and look out for
unhelpful thinking styles.

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 Feeling or Thoughts in Other more
Event
emotion your mind balanced thoughts
Example

A neighbour Low and She doesn’t She’s probably got

ignored me depressed like me, no something on her
one does. mind. I am jumping
to a conclusion that
she doesn’t like me.

Your
example

4. Try and remember details

Research tells us that people who are depressed don't remember
details of events but tend to think in general statements, such as
“I’ve never been any good at anything”. Try and train yourself to
remember specific details so that good times and experiences are
easy to recall. A daily diary can help you to do this. Make lists of
actual achievements and good aspects of yourself such as “I’m
always on time”, “I helped my friend on Tuesday” or “My partner
complimented me on my work last week”. Listing past
achievements and pleasurable activities in detail can also be
helpful, as can the gratitude diary described earlier.

5. Challenge long term beliefs

Sometimes people have long held views about themselves that
are very self-critical. For example, “I’m not a very clever person” or
“I’m not a very lovable person”. These beliefs are often a product
of our past experience and may hold no truth in present reality. Try
to challenge this self-criticism, stop knocking yourself down and
look for evidence that disproves the beliefs. What would you say to

25
a good friend if they held that belief about themselves? Again
writing things down can be really helpful. Improving your self-
esteem is very important to recovering from depression.
6. Dealing with rumination
When people are depressed they may ruminate. That means
they go over an upsetting thought again and again without
finding a solution. This can become an unhelpful habit. One
way of dealing with this is to try and notice what’s going on
when this sort of thinking starts, and try to do something
different. So for example, if the rumination is bad when sitting
watching TV, then try to do something else, such as: getting
active, practicing relaxation, reading or doing a puzzle. If you
can interrupt the habit, then you may be able to reduce the time
given to these unhelpful ruminations.

7. Mindfulness and acceptance

Sometimes no matter how hard we try, our thoughts will not be
changed. If you find yourself getting in to endless arguments
with your thoughts, this can then become part of the problem.
You may start to feel useless for not being able to challenge
your thoughts well enough and before you know it there are a
whole host of more negative, self-critical thoughts in your mind.
This can be the case particularly if you have had a few bouts of
depression.

Research has shown that a form of meditation called

mindfulness can be really helpful. Mindfulness is about paying
attention to the present moment, in a non- judging way.
Because depressed thinking is almost always about the past or
the future, focusing on what is happening in the here and now is
incredibly helpful. A good place to start is with some mindful
breathing. The goal of mindful breathing is calm, non-judging
awareness, allowing thoughts and feelings to come and go
without getting caught up in them. Follow these instructions:

Sit comfortably, with your eyes closed or lowered and your back
straight.

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Bring your attention to your breathing. Don't try and change it.
Just notice what it feels like.

Notice where you feel the breath. In your nose and your throat
and your chest. Notice your chest and stomach rising with the
in-breath, and falling with the out-breath. Just as though you
were observing a wave, coming in and going out.

Thoughts will come into your mind, and that’s okay, because
that’s just what the mind does. Just notice those thoughts, then
bring your attention back to your breathing. You may notice
sounds, physical feelings, and emotions, but again, just bring
your attention back to your breathing.

Don’t follow your thoughts or feelings, don’t judge yourself for

having them, or analyse them in any way. Just accept them. It’s
okay for the thoughts to be there. They are just thoughts. You
can notice them, and let them drift on by; bring your attention
back to your breathing.

Whenever you notice that your attention has drifted off and is
becoming caught up in thoughts or feelings, simply note this
without judgement, and then gently bring your attention back to
your breathing. Thoughts will enter your awareness, and your
attention will follow them. No matter how many times this
happens, just keep bringing your attention back to your
breathing. The more you can practice this exercise the more it
will help you not to get caught up in your negative thoughts.

There are many books and websites about mindfulness for

depression, some of which are listed at the end of this booklet.

27
Further help
We hope you will use the exercises suggested in this booklet.
They should help you to begin to overcome your depression
and get back in control of your thoughts, your depression and
your life.

If you feel that you are making little progress then as mentioned
other help may be available to aid you in overcoming your
problem, and your family doctor is usually the best person to
talk to.

If you feel so depressed that thoughts of harming yourself

or taking your own life have been in your mind then visit
your doctor as soon as possible and talk about how you
are feeling.

28
Written by Dr Lesley Maunder and Lorna Cameron, Consultant
Clinical Psychologists. This guide has been developed from an
earlier manual by Sheila Sharkey and Kevin Gibson.

Many thanks to local voluntary sector groups, service users and

healthcare staff who have contributed to the review of this guide.

Further information about the content, reference sources or

production of this leaflet can be obtained from the Patient Information
Centre. If you would like to tell us what you think about this leaflet
please get in touch.

This information is available in audio, larger print, easy read and

BSL at www.cntw.nhs.uk/selfhelp It can also be made available
in alternative formats on request (eg Braille or other languages).
Please contact the Patient Information Centre Tel: 0191 246 7288

Published by Cumbria, Northumberland, Tyne and Wear NHS

Foundation Trust
2020 Copyright PIC/90/0220 February 2020 V4
Review date 2023

www.cntw.nhs.uk @cntwnhs CNTWNHS