nhs depression and low mood

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First Steps, Version 3, February 2013 - 1 - Depression and low mood

A First Steps guide to managing

Depressionand low mood



First Steps - 2 - Depression and low mood

“Feeling low”

“Feeling blue”

“Depressed”

“Feeling numb”

“Down in the dumps”

“Under a cloud”

“Fed up”

“Miserable”

…are just a few of the comments from people who are feeling low in their moodor depressed.

Using self-help tools

The strategies/tools suggested in this booklet are evidence based methods of managingemotions and reducing the effects the way that we feel has on our everyday life. We are allindividuals and respond to situations in different ways therefore not every tool will work witheveryone. For example some people find meditation and reading really relaxing, whilst forsomeone else this could be a cause of stress and their preferred relaxation method is to goto the gym. There are no set rules for managing emotions. A helpful way of thinking aboutthis could be to think “is my current method working for me?” If the answer is yes, then great,but if not, these strategies may be an alternative way that is more productive for you.

As with any new skill, self-help can take time and practice. In the same way that reading acookery book will not instantly make you a great cook, simply reading this material will notmake you instantly happy and healthy. But with time, practice and exploration it is possiblefor everybody to experience emotional well-being. Self-help alone may not be adequate for

everybody. If you feel that you need more support, it is important to discuss this with yourGP. In addition there are a number of helpful resources at the back of this booklet or youcould call our phone line or email us for more information/advice. 801 0325 or visit




What is in this booklet?

Page

What is depression and low mood? 4

Symptoms of depression 5

Why do we get depressed / low in mood 6

The cycle of low mood 9

Achieving every day emot ional well-being 12

Challenging unhelpful thinking 14

Activi ty diary 17

Setting goals 19

Lifestyle changes 20

Social supports 23

Useful contacts 24




What is depression and low mood?

The terms depression and low mood are often used interchangeably. However, depressionis a diagnosable mental illness; whereas low mood describes an emotional state.

Depression is diagnosed by the following:

If you have experienced 1 of the following symptoms, most of the time,for over 2 weeks

Low mood or sadness Loss of interest or pleasure

And at least 4 of the following symptoms:

Sleep disturbance - either falling asleep or early morning wakening

Either a loss or increase in appetite Difficulty concentrating

Slowed functioning (either thinking, talking or acting slower than usual) oragitation

Lower sex drive

Less energy

Loss of self-confidence or self-esteem

Thoughts of death or suicide

Feelings of guilt

Throughout our lives we all move through periods of happiness and sadness. It is the normal,healthy emotional reaction to events and our thoughts about these events. For many people,these feelings of sadness usually pass in a few days or when circumstances change.However, when these feelings last more than a few days, keep coming back quite frequentlyor start to affect your work, interests and/or feelings towards your family and friends, then itcould be a sign of depression. Mild depression/low mood can be improved through the use of some simple self-help techniques which are described throughout this booklet. It is importantto talk to your GP about the way that you are feeling, especially if you feel that you are

depressed or your mood is not improving through the use of self-help.

Low mood and depression in its mildest form does not stop you from leading your normal life,but it makes everything seem harder and less worthwhile. In the most severe form of depressions, it can seriously affect your ability to function on a daily basis, and some peoplefeel so bad that they find themselves feeling that life is not worth living or that other peoplewould be better off without you. Whilst these thoughts can feel very frightening it is importantto remember that sadly they are quite common. However, it is very important that you seekhelp from your GP or if you feel that you are in imminent danger, the emergency services.




Symptoms of depression

Depression and low mood affects us in four ways:

The way we think

Difficulty in making decisions

Difficulties in concentration andmemory

Feeling worthless

Suicidal thoughts

Self doubt

Feeling inadequate

Self criticism Negative thoughts

Ruminating (keep going over thesame thoughts in your mind)

Thoughts of death

The way we feel emotionally

Sad

Hopeless

Irritated

Angry

Numb

Guilt

The way we feel physically

Weight gain

Weight loss

Sleep disturbancesincluding earlymorning waking,waking during the night anddifficulty getting to sleep

Never feeling 100%

Aches and pains

Decreased or increased appetite

Loss of energy/ always feeling tired

Restlessness and agitation

Tearful

The things that we do

Losing interest and enjoyment inactivities you previously enjoyed

Difficulty doing everyday tasks

Withdrawal from friends/family orlife in general

Drinking/smoking more

Avoiding decisions

Poorer performance

Letting people walk over you

Agitation

Frequent crying

Irritation/aggression

Everybody is different and will react to depression and low mood in different ways.It is proven that some people, particularly men, will not feel sad or tearful and theirmain symptom may be physical or feeling angry or frustrated.




Why do we get depressed / low in mood?

Biology – Biological changes in the brain happen when we are depressed; changes in thechemicals and electrical activity are particularly responsible for the more physical symptomsof depression and low mood. Physical health problems can be both a cause of and symptomof depression, such as poor sleep, being run down, physical illness, underactive thyroid, poordiet, etc.

Traumatic experiences – Abuse or neglect, bullying, or death of a parent, for example.

Genetics – It is not clear if there is a genetic link. The chances of being depressed arehigher if other members of your family have been depressed. However, this may be causedby other common factors including the learnt ways of reacting to/coping with situations orevents. If a family member has depression it does not mean that it is inevitable that you willget it just that you may need to put systems in place (self-help techniques) to improve ormaintain your mood.

Life events – Relationship problems or break up, losing a job, bereavement, etc. Our

reaction to major life events can be a factor in developing symptoms of depression.Especially, if the feelings we experience in response to these events are not expressed orexplored.

On-going stress – Issues that seem to go on and on or seem to have no solution in sightcan lead to negative thinking and feeling helpless.

Often low mood and depression are caused by a combination of factors. The importance of each factor varies from individual to individual.

Self-help techniques can be helpful in increasing your mood regardless of the cause.




Our core beliefs Core beliefs are strongly held beliefs about ourselves that influence what we think and howwe feel. They usually influence us subconsciously and we rarely ever challenge if thesebeliefs are true.

Common negative core beliefs are:

I am not worthy I am the only person I can trust

I am unlovable

I am not good enough

Our core beliefs also relate to how we believe the world ‘should’ be and include our ethicsand values. Examples of these could be:

People should be courteous and polite

I should always do the best that I can do

Life should be fair

I must not let people down

We all hold these beliefs and they are central to our being. Quite often just awareness thatthese core beliefs may be shaping your thoughts and feelings can be helpful in challengingyour view of the situation.

Our thoughts about the situationOur thoughts about the event or situation are often closely linked to our core beliefs andoften create and maintain a large proportion of the stress we experience. It is common for a

person experiencing emotional distress to think negatively and negative thinking will createand maintain emotional distress.

I am notworthy




Case studyAmy has completed her project at work. She thought that completing it would help to lift hermood, but she is upset to find that she feels no different

Core beliefs“I am not goodenough”“I should always getthings right”“I must ensure that

people always thinkwell of me”

Importance of situation/eventAmy feels that it is veryimportant to get her work doneon time. She feels that she isnot performing well enough

Negative thoughts

“It is only what is expected of me”(discounting positives) “Its not as good as it should be”(black and white thinking)

J ulie hasn’t responded, perhapsit’s not what she wanted(jumping to conclusions)

Effects on Amy Emotional well-beingPhysical well-beingBehaviours

Thoughts about

future situations

SituationAmy has completed her project

Event The project is complete but Amy has notseen an improvement in her mood




The cycle of low mood

We already know that when a person feels low in their mood they are likely to havedecreased energy, lack of motivation and decreased interest in previously pleasurableactivities. However, imagine a time when you were generally feeling happy and healthy. Howwould you have felt if you were unable to spend time with friends/family, exercise or spendtime doing your hobbies or interests? For most people, being unable to do the things that

they enjoy leads them to feeling low and unhappy. Therefore, depression and low mood canbecome self-fulfilling. We often feel that we will do what we enjoy when we feel better.However the reality is we will not feel better until we do the things that we enjoy.

• “I will do what I enjoy when I feel better”

• “I will feel better when I do what I enjoy”

Our thoughts, feelings (physical and emotional) and behaviours also feed in to each other. The following model is a useful way of looking at the different aspects of your low mood.

Life event

Behaviours

Emotionalsymptoms

Physicalsymptoms

Thoughts




The way J ane spends her evening is as a result of her thoughts and the way that she isfeeling. However her mood is unlikely to improve as she has avoided going out with herfriends (the thing that usually helps her to feel relaxed and happy) and has also notchallenged her thoughts. J ane is at risk of becoming stuck in the cycle of low mood.

Can you think of a situation that has caused you to feel low in your mood? Try using yourown example to fill in the blank boxes on the next page. The aim of managing and improvinglow mood is to break this cycle. This could be by challenging your thoughts or changing yourbehaviours.

EventBad day at work having too much to do andfeeling that you have not done your best

Behaviours

Cancels going out as notfeeling up to it

Stays at home alone

Goes to bed early but cannotsleep due to racing thoughts

Emotional symptoms Frustrated

Guilty

Sad

Physical symptoms Tired

Headache

Tearful

Thoughts I have let my team down

I should be able to do this

I’m not good enough to domy job

Jane’s example




Did your way of coping improve or decrease your mood?

Event

Thoughts

Physical symptoms

Behaviours

Emotional symptoms




Achieving every day emotional wel l-being

J ust as achieving physical fitness takes time, practice and commitment, so too doesachieving mental fitness. There are three basic principles in obtaining emotional well-being:the first is to maximise the things that make you feel good, and minimise the things that makeyou feel bad; second is valuing yourself; and third is to recognise that you can change.

Maximise the things that make you feel good, and minimise (as far as practical) thethings that make you feel bad.

Some feel good factors include:

Making time for relaxation

Being able to express your feelings

Having achievable goals to aim for

Making time for the things you enjoy

Maintaining a healthy diet

Starting a sport or exercise you enjoy Work you find rewarding

A comfortable balance between work and leisure

Time to yourself, to do the things that interest you

Time for friends and family

Some things to minimise:

Unnecessary stress, at home or at work

Feelings of rage or frustration

Expecting too much of yourself and negative thoughts and feelings

What things could you increase or need to decrease?




Valuing yourself

Valuing yourself will help you to recognise the things in your life that you value and deserveand help you to build your life on a secure foundation. Everyone deserves to have a lifewhere you feel happy and secure. If you value yourself enough, you will know when to takeaction and make changes in your life and when to let go of problems that you cannot changeor are not yours.

Recognising that you can change

Change is part of life. We are all products of our environment and experience, but are neverfated to live or feel the same way forever. There are three conditions for long-lasting change:

a. Understand the present: Don't hide from reality, but see the present clearly.

b. Do not be burdened by the past: The past cannot be changed. Do not allow it to weighyou down. Choosing to let go of the past does not mean that you accept or agree with

what has happened; just that you recognise that thinking about it is not helpful to you.

c. Accept the uncertainty of the future: Much of the future is not under our control. It is in ourbest interest to accept uncertainty and learn how to face the future with confidence.




Challenging unhelpful th inking

Events themselves do not cause us to feel upset or depressed. It is our beliefs about theseevents that determine our emotional reaction. We have a tendency to think “If I think thesethoughts, they must be true”.

However, when we feel low in mood we are more likely to focus on negative things from the

past. We become really good at ignoring any of the positive, and then wonder why we aredepressed.

Unhelpful thoughts pop into our minds so quickly that it is often difficult to spot them. Think of it this way, we don’t get to choose whether or not a bird lands on our heads. We do get tochoose, though, whether or not it makes a nest.

This is true of our thoughts as well. J ust because we think a thought, does not mean that wehave to believe it or continue to think about it!

When we experience depression, we tend to think in any or all of the following ways. How

many apply to you?

Al l or nothing th inking. Thinking inabsolutes, black and white, or goodand bad with no middle ground and atendency to judge people or eventsusing general labels, eg. “He’s an idiot”,“I’m a failure”

Catastrophizing. Overestimating thechances of disaster, eg. whatever cango wrong will go wrong or a set backbeing part of a never-ending pattern of defeat

Jumping to conclusions. Makingnegative interpretations even thoughthere are no definite facts. Also makingnegative predictions about the future

Negative focus. Ignoring ormisinterpreting positive aspects of asituation. Focussing on your ownweaknesses and forgetting yourstrengths

Living by fixed rules. Fixed rules andunrealistic expectations, regularly usingwords such as “should”, “ought”, “must”and “can’t”, leading to unnecessary guiltand disappointment. The more rigidthese statements are, the moredisappointed, angry and depressed youare likely to feel

Personalising. Taking responsibilityand blame for everything that goes

wrong




Challenging our thinking can be a difficult skill to learn, but for most people is an effectiveway of improving our mood. The following techniques may be helpful.

Keeping a thought record

Keeping a thought record can be helpful in identifying patterns of negative thoughts.

1. Situation: Who were you with? What were you doing? When was it? Where were you?

2. Unhelpful thoughts: What was going through your mind just before you started to feel thisway? What images or memories do you have of the situation? In which unhelpfulthought style did you engage (i.e. all or nothing thinking, catastrophizing, etc)

3. Helpful thoughts: What might be an alternative more helpful thought?

When trying to come up with a helpful thought, here are some tips to help you…

What is the evidence to support the unhelpful thought?What tells you that this thought is correct?

What is the evidence that does not support the unhelpful thought? This is the hard part, because it is often overlooked, but ask yourself thesequestions: How would someone else view the situation? How would I have viewedthe situation in the past? What might I say to a friend who was in a similar situation?

What is the effect of thinking the way I do? Does it help me or make me feelworse?

Now, is there an alternative, more helpful thought that could also be true to thatsituation……



First Steps - 16 -

What was I thinking just before Ifelt like this?

Proof that the thought is true Other possibilities, or What I would say to a friend




Activ ity diary

The activity diary is a strategy that is very helpful for people experiencing low mood and lowself-esteem. The purpose of the diary is to help you:

identify the activities you are currently doing

increase the number of tasks that will increase your mood

schedule tasks that may lower your mood in a way that they have the least negative

effect on you

Sometimes we can neglect ourselves, because we may spend all our time helping others orworking hard.

Step 1: Keeping an activity diary The first step is to look at how you currently spend your time and to consider how satisfyingyou find your daily activities and routine. You can use the diary sheet on the next page.

Try to record daily activities along with ratings of how satisfying you find each activity (senseof pleasure or sense of achievement).

It is important that there is a good balance between the things that you have to do and thethings that you want to do.

Step 2: What would you like to change?Once you have kept a diary for a week or so, it is time to reflect on how you spend your timeand consider what you would like to change. The following questions may help with this:

What was satisfying and what wasn’t? How can you make your daily activities moresatisfying?

Could you reduce the impact of activities that are necessary but are not good for your moodby following these with an activity that does increase your mood?If you were helping someone you cared about, what changes would you make?Are you striking a balance between enjoyable activities, relaxation, and things for yourself onone hand, and work, duties, things for other people on the other hand? If not, what could youdo to create a better balance?

Did negative thoughts get in the way of you doing this? If they did, write them down and tryquestioning them.



First Steps - 18 -

Step 3: Creating a diary that includes your learning from steps 1 and 2

Activity diary

Monday Tuesday Wednesday Thursday Friday

Morning

Af ternoon

Evening




Setting goals

Goals give us a sense of purpose and allow us to achieve tasks that may feel overwhelmingor unachievable. The key to effective goal setting is to be realistic. It is easy to make themistake of trying to achieve a goal that is vague and unrealistic. By setting realistic, clearlydefined goals, you can measure and take pride in the achievement of those goals. You cansee forward progress in what might previously have seemed a long pointless grind. Your self-

confidence will increase as you achieve your goals and as you recognize your ability andcompetence in your achievements.

There are five components to consider when setting yourself a goal. These goals are knownas SMART Goals. These are:

Component Ask yourself …..

S Specific What exactly do I want to achieve?

M Measurable How will I know when I have completed the goal?

A Achievable Is this possible given more current situation/ performance?

R Relevant The goal has to make sense to you and be something youfeel is worthwhile and that applies to your views and lifestyle

T Time bound When do I plan to finish the task?

Once you have set your goal, you then need to break the main goal down into achievable

‘steps’ called sub goals. You are far more likely to be successful if you plan a series of smallstages which will help you to reach your ultimate goal. By working on and achieving smalltargets, your confidence will increase far more than if you are trying to achieve goals whichare too difficult, and where you run the risk of failing.

Once your time frame has expired you should then add a further 2 components to your goal,making it a SMARTER goal:

Component Ask yourself …..

E Evaluate What have I achieved so far? Have I completed my goal?

R Re-doWhat further stages should I set for myself or is this goal nowfully achieved? What is my next goal?




Lifestyle changes

Physical activity and healthy eating

There is a strong link between emotional well-beingand general good health. Your general emotionalwell-being is an important part of how well you get

by on a day-to-day basis. Feeling emotionally andphysically well may mean that you feel moreinclined to socialise and spend time with otherswhich can reduce feelings of low mood and loneliness.

We often say to ourselves that we will do what we enjoy when we feel better. More oftenthan not, though, we feel better when we do what we enjoy.

As part of this, it can be useful to look at your eating and activity patterns. A balanced,healthy diet can make you feel better about yourself as well as being beneficial to your bodyand immune system. A balanced diet will help your body and mind work more efficiently.

Regular exercise is good for us in many ways: it increases our confidence and self-esteem; itstimulates "feel good" chemicals in our bodies; it provides an outlet for tension andfrustration; it relieves anxiety; helps us relax; helps us sleep better and helps to preventphysical illness, such as heart disease and osteoporosis.

The type of activity that you do will vary according to your physical health, fitness, theamount of time you have and how much you enjoy it. It is recommended that you do 150minutes of moderate intensity activity across a week; this can include shopping, gardening,housework, etc. You might find that it is easier to break this into three ten minutes bursts, or

thirty minute sessions, on five days of the week.

It is important to try to focus on things that you are able to do rather than the things that youcannot.

Healthy eating tips

Base your meals on starchy (carbohydrate) foods for energy eg. wholegrainbread/cereal/pasta, brown rice, jacket potatoes

Eat lots of fruit and vegetables

Eat more fish – including one portion of oily fish per week

Cut down on saturated fat and sugar – sugary and processed foods can increaseirritability and emotional fragility, plus reducing these foods reduces the risk of highblood cholesterol and cardiovascular disease

Try to eat less salt – 6g max for adults – the effects of excess salt, sugar andcaffeine can mimic stress responses

Drink plenty of water or other fluids

Cut down on caffeine as it can increase mood swings, symptoms of anxiety andinterfere with sleep – try herbal teas instead

Do not use alcohol, drugs or cigarettes to cope

Don’t skip breakfast




How to get a good night ’s sleep

People may worry about not getting enough sleep, butworrying only makes it worse. It’s easy to overestimatehow much sleep you need, or not to realise that it is normalto wake briefly each night. The occasional bad patch isharmless and usually rights itself. It is only of concern if

your sleeping difficulties have been lasting for longer thana month.

The average amount of sleep is seven to eight hours a night, but we all need differentamounts, and the amount we need decreases as we get older.

We pass through cycles of light and deep sleep at night. Every 90 minutes comes a period of dream sleep (REM), which is vital for our well-being.

If we miss out on sleep on a regular basis we may incur a ‘sleep debt’, making us tired andirritable, unable to concentrate or to function properly. It stops once the ‘debt’ is paid off.

Long-term sleep problems may cause physical or mental health problems.

Things that may disrupt your sleep pattern

Snoring that interferes with breathing

Too much stress

Ill health or physical pain

Emotional difficulties, including anxiety and depression J et lag or shift work that disrupts our internal body clock

Traumatic events, such as a divorce, redundancy, or bereavement

Going into hospital, a residential home or a hotel

Medicines, such as water pills, steroids, beta-blockers, and some painkillers,antidepressants, slimming tablets and cold remedies

Withdrawing from certain drugs, such as tranquillisers or antidepressants

Taking street drugs such as ecstasy, cocaine and amphetamines

Overusing alcohol, tobacco and caffeine




Tips to help you sleep

1. Establish a regular routine. Go to bed only when you're tired and get up at the sametime each day. Avoid napping during the day

2. Check your sleeping arrangements. Think about comfort, temperature, light andnoise levels

3. Learn to de-stress before bed. Dismiss nagging thoughts by writing them down andleaving the list away from your sleeping area

4. Have a warm bath, practise a relaxation technique, or listen to a relaxation tape. (Butdon't read or watch television in bed)

5. Don’t eat late. Avoid rich, spicy or sugar-rich foods, red meat and cheese. Choosingwholemeal, low-fat, magnesium-rich foods (green salads, broccoli, nuts and seeds)may encourage sleep, as may drinking hot milk and honey

6. Get enough exercise. Fit people are proven to generally sleep better

7. Don't stay in bed. If you can't sleep, get up after 20 minutes and go through your

relaxation routine again8. Try out complementary remedies. Yoga, meditation, homeopathy or herbal

remedies, such as lavender or valerian, may help

9. Keep a sleep diary. This helps you identify potential causes for your sleeplessness

10. Try some reverse psychology: keep your eyes open and tell yourself to resist sleep

11. Interrupt unwanted thoughts: repeat a soothing word to yourself. Visualise a sceneor landscape that has pleasant memories for you

12. Talk to your GP. Using sleeping tablets on a long term basis may present problems,but a brief course is sometimes appropriate especially if nothing else is working for

you

Night-time relaxation routine

Relaxing before bed is a good way of de-stressing and getting the body and mind ready forsleep. People relax in different ways and it is important to find a method that suits you. Thesecould include:

Breathing exercises

Muscle tension and relaxation exercises

A warm bath

Reading a non stimulating book

Guided/non guided visualisation exercises

For more information on relaxation exercises look at our website www.firststeps-surrey.nhs.uk or call our help line.




Social supports

Social supports (friends, families etc) can be an important way of increasing our mood. Whena person feels low in their mood it is not uncommon for them to reduce their contact with theirfriends/family which can lead to social isolation and the associated negative effects on well-being.

Increasing our social support is not simply a case of increasing our contact with more peopleas not all social contacts are positive. For example, only meeting up with somebody who isvery low and has a number of difficulties of their own may have an adverse affect on yourmood. It is possible to feel lonely even when surrounded by others.

Increasing our positive social contact could be through a number of ways including:

Pushing ourselves to meet up with friends, family or colleagues

Contacting friends via the telephone, internet or email

Doing activities which provide us with the opportunity to meet and choose new friends

Sharing our experiences with the people around us



Useful contacts

First Steps 0808 801 0325Monday and Wednesday 10am to 4.30pm and Thursday 11am to 5.30pm. The helpline willbe open on a Tuesday following a Bank [email protected]

www.firststeps-surrey.nhs.uk

Depression Alliance 0845 123 23 20 National self-help organisation for depression and low mood www.depressionalliance.org

SANELine 0845 767 8000 www.sane.org.uk

MindInfoline 0300 123 3393 www.mind.org.uk

NHS Direct 0845 46 47www.nhsdirect.co.uk

Living Life to the Fullwww.llttf.com

Cognit ive Behaviour Therapy Self-help Resourceswww.getselfhelp.co.uk

Books

The Surrey County Council library has a very helpful list of self-help books that can beaccessed from the following libraries:

Camberley, Dorking, Epsom, Farnham, Godalming, Guildford, Horley, Oxted, Redhill,Staines, Walton-on-Thames, Woking

You can find the list at www.surreycc.gov.uk if you search “Read Yourself Well”.

Many of these libraries also have a self-checkout option, which means you can take out abook without anyone knowing the book that you choose.

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