Depression

What Is Depression?

At some point probably all of us have said, “That’s depressing,” or “I’m so depressed.” Maybe our team lost the championship game or something else mildly disappointing happened. If you’ve had true depression, you know the difference between being disappointed and actually depressed. What distinguishes depression from the normal ups and downs that everyone experiences?

Duration. In contrast to ordinary bouts of sadness, major depressive disorder lasts for at least two weeks, and usually for several months. During that period we’ll feel down or blue for most of the day, the majority of days. 

Severity. The psychological pain of depression can feel unbearable, to the point that a person may consider suicide over continuing to feel that way.

Range of Symptoms. Whereas sadness is primarily an emotional response, depression tends to involve physical, mental, and emotional symptoms—in other words, it can be a whole-body condition. Physical symptoms can include changes in appetite (either increased or decreased), trouble sleeping (too much or too little), agitation, being physically slowed down, and persistent fatigue.

Emotional symptoms include feeling sad, empty, tearful, or hopeless, as well as having very little interest in activities, even ones the person used to find enjoyable. Finally, the mental or cognitive symptoms can include feeling completely worthless, excessive guilt, difficulty thinking or concentrating, and trouble making decision even about everyday things like what to eat or what to wear.

In short, everything can feel like a struggle when we’re depressed. We tend to have less energy and low motivation, so even getting out of bed in the morning can be a tremendous challenge. On top of the low motivation, we’re likely to be extremely self-critical, telling ourselves we’re “lazy” or in some way defective.

A Life of Its Own. When something disappointing happens and we feel sad, we can usually point to the cause of our sadness. Depression often follows a major loss or disappointment, but then can stick around even when the acute pain of the loss has passed. Thus depression can take on a “life of its own” in which it’s no longer directly connected to what may have originally triggered it. Other times there’s nothing we can point to as the cause of the depression, it just seemed to come out of the blue.

Whatever its origin, there are certain patterns of thought and behavior that we tend to see with depression, and understanding these patterns is a crucial part of treating depression in cognitive-behavioral therapy.

What Is CBT for Depression?

There are several components in effective CBT for depression. The basics include, not surprisingly, behavioral approaches, cognitive techniques, and mindfulness.

Behavioral Activation. In order to feel content and fulfilled, we need a balance of enjoyable and meaningful activities in our lives. When we’re depressed we often aren’t doing a lot that brings us a sense of reward. Maybe we’re only working and never playing, so our emotional “batteries” are run down and we ask, “What’s the point if I never enjoy my life?” Or perhaps we’re struggling to motivate ourselves to take care of our commitments, and feeling bad about ourselves as a result.

Whether the lack of positive activities came before or after depression, a straightforward approach called “behavioral activation” can be very effective in lifting mood. As the name suggests, the basic approach is to “do more.” And of course it matters what the “more” is. If it’s more of the same, or more of what others think is important or fun, it’s unlikely to be helpful. The activities we do more of need to be closely tied to what we value.

The technique often starts with identifying what we value in the major domains of our lives: relationships, physical health, work, spirituality, and so forth. For example, under physical health I might identify “following a regular workout routine” as something of value to me. Once we’ve listed our values, we can find activities that support each value—for example, “running three times a week.”

A natural and important question about this approach is, “How am I supposed to do all these activities? I can barely get out of bed.” Motivation is almost always a major challenge in depression, and so it’s crucial to find ways to ease the entry into these activities. Thus important principles of behavioral activation include:

  1. Start with activities that are easier.
  2. Plan a small number of additional activities to begin.
  3. Break down larger activities into manageable pieces.

Generally over the course of a few weeks of behavioral activation, a person starts to feel noticeably better. As we’re able to get the ball rolling and start to feel better, we can pick up momentum that feeds back into more energy and motivation to do what we want. Over time small changes can lead to a lot of progress as the process builds on itself.

Many studies have found behavioral activation by itself to be very effective, and as helpful as treatment programs that also include a focus on thoughts, which we address next.

[5 Ways to Do More Mood-Boosting Activities on Psychology Today blog]

Cognitive Therapy. As mentioned above, we often find that our thinking is different when we’re depressed, and not in a way that’s friendly toward ourselves. We’re likely to be highly critical of ourselves, to amplify our faults, to fail to see anything good in ourselves, and to feel somehow inadequate or defective. These thoughts can be part of the symptoms that maintain depression, and they tend to improve with effective treatment, even if the treatment doesn’t directly deal with the thoughts.

From a cognitive approach, we would identify what we’re telling ourselves that contributes to our poor mood and view of ourselves. For example, if I cause a slight fender bender, I might tell myself that “I never do anything right,” which obviously wouldn’t make me feel good about myself. Once I’ve identified what I’m telling myself in a situation, I can explore whether the thought is accurate. In this example, do I actually never do anything right?

If my thought is biased in some way, I can work to adjust the thought so it better fits reality. With the car accident example I might decide that “I’m usually a good driver, but this morning I got distracted and rear-ended someone.” Notice that I’m not trying to fool myself into thinking only happy thoughts. We’re smart enough to see through such self-trickery. Instead, I want to see the world closer to how it is. The truth of what happened is that I got distracted and ran into the car in front of me. Does that make me a total loser, unable to do anything right, ever? Probably not.

It’s important with both behavioral and cognitive approaches to write down our thoughts and plans. By seeing what we’re thinking and doing on paper, we can more easily make adjustments.

Mindfulness-Based Approach. Training in mindfulness has proven effective in treating many psychological conditions, and depression is no exception. The basics of mindfulness are to focus one’s attention on the present and to adopt an open and nonjudgmental attitude. It’s probably not hard to see how mindfulness could be helpful in treating depression.

It’s easy to take our thoughts at face value, mistaking what we think for Truth. If we’re thinking really negative things about ourselves, it would be easy to assume that we’re as bad as we think. One of the most useful parts of mindfulness training for the treatment of depression is learning to recognize what our minds are telling us, and not believing everything we think.

[Mind the Gap: Avoiding Destructive Trains of Thought on Psychology Today blog]

As we practice the techniques of mindfulness, we can start to see more easily what we’re thinking, and develop a different relationship with our thoughts. When we can identify a thought about ourselves as a mental event and not something that’s necessarily true, we can start to hold our thoughts more lightly and not take them so seriously.

Being more fully in our lives through the practices of mindfulness can also help us to get the most out of behavioral activation. When we’re caught up in thinking about the past or worrying about the future, as we often are in depression, we’re seldom doing what we’re doing. The scenery never changes, so to speak, when we’re always in our heads. As we practice focusing on what we’re doing, we can get the full benefit out of our activities.

Mindfulness is often combined with CBT for depression and can be especially useful in preventing relapse.

Additional Resources

Depression Information from NIMH

The National Institute for Mental Health provides information on what depression is, including subtypes like perinatal depression and persistent depressive disorder; what the risk factors are; and what kinds of treatments are available. They also describe how to find a clinical trial you might be eligible for.

Depression Information from APA

The American Psychological Association provides information on what depression is, what forms of self-care might be helpful, and how to seek treatment. They also provide links to news stories, articles, books, and web pages related to depression.

Depression Information from NAMI

The National Alliance on Mental Illness gives an overview of what depression is, describes treatments (including medication and psychotherapy), discusses how to care for oneself or others who have depression, and provides a way to connect with others via NAMI discussion groups.