Professional Documents
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S CDP Antidepressants Kills
S CDP Antidepressants Kills
2ND EDITION
ANTIDEPRESSANT
SKILLS WORKBOOK
Randy is a psychologist,
director of Changeways
Clinic, and author of the
book, Your Depression Map.
Funding for this book was provided through grants from the Ministry of Health,
and BC Mental Health and Addiction Services, An Agency of the Provincial Health
Services Authority, Province of British Columbia, Canada.
Vancouver, Canada
Copies of this book can be downloaded at no cost from:
www.bcmhas.ca or www.carmha.ca/publications
Note This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is provided with the understanding that the
publisher is not engaged in rendering psychological or other professional services. If
expert assistance or treatment is needed, the services of a competent professional
should be sought.
ANTIDEPRESSANT
SKILLS WORKBOOK
TABLE OF CONTENTS
Introduction
What is depression?
14
16
Antidepressant Skills
18
19
30
39
49
53
Suggested reading
54
Useful information
55
Diet
Physical activity
Sleep
Caffeine
Drugs and Alcohol
Worksheets
56
57
58
60
61
63
INTRODUCTION
INTRODUCTION
Take a moment now to ask yourself three questions. Mark your answers on the scales below. On a scale of 0 to 100:
How much of a negative effect has low mood had on my life?
50
100
NO EFFECT
50
100
EXTREMELY IMPORTANT
50
100
If you scored less than 50 on two or three scales, you may be considering change, but still feel uncertain.
If thats the case, read the workbook and think it over.
If you scored 50 or more on two or three scales, youre ready to change. Youve had enough and youre
prepared to dedicate some time each day to getting better.
WHAT IS DEPRESSION?
ost times when you feel down, youre not depressed. Feeling sad or low
is a big part of life and cant be avoided. When something goes wrong in
your life, whether its an argument with your partner, conflict with your
boss, or a physical illness, your mood might drop.
Depression is not
If you feel especially sad or irritable because of this
situation, maybe with poor sleep, not wanting to see
friends or family, eating too much or not enough then
youre probably experiencing low mood. Low mood will
typically go away in a week or two, especially if theres
an improvement in the situation that started it.
Depression is
2. if you have other problems like:
big changes in weight or appetite;
not being able to sleep enough or sleeping
too much;
feeling that you are always restless or
slowed-down;
thinking that you are worthless or guilty;
feeling really tired much of the time;
feeling numb or empty;
having a lot of trouble concentrating
or making decisions;
thinking about death or suicide.
WHAT IS DEPRESSION?
The two most common types of depression are called mild depression
and major depression.
mild kind. Your family physician, a psychiatrist
or a psychologist can tell you whether you have
a depression.
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WHAT IS DEPRESSION?
Remember, things
SITUATION
loss
isolation
conflict
stress
ACTION
social withdrawal
reduced activity
level
poor self-care
PHYSIOLOGY
altered sleep
low energy
changes in brain
chemistry
THOUGHTS
EMOTION
negative thinking
habits
harsh self-criticism
unfair & unrealistic
discouragement
sadness
despair
numbness
anxiety
Situation
Depression is often triggered by very stressful life situations. If your attempts to cope with these situations by
improving or accepting them have not been successful,
you may begin to feel overwhelmed and hopeless. Then
the risk of a depressive episode increases. Some situations that can be associated with depression include:
Thoughts
anticipates feeling miserable, and sees the other people
as judgmental and rejecting. Each persons thoughts
determine how the event is experienced. Research
evidence has shown that depressed individuals often
have distorted ways of thinking about the world that
can trigger or worsen the experience of depression.
Emotion
Depression often begins with feelings of discouragement
and sadness after unsuccessful attempts to deal with
a difficult life situation. However, as the depression
continues, these feelings of unhappiness give way to
more severe and painful kinds of emotional experience.
The depressed individual is overcome by a sense of
despair, a pervasive mood of hopeless misery. A feeling
of intense anxiety (physical tension, worry, and a
sense of impending doom) often accompanies these
depressed feelings.
Some depressed people experience a general sense of
emotional numbness, an inability to feel anything. It
is as though the psychological pain has become so
intense that your mind simply switches off your
emotions, like a circuit breaker.
10
Physiology
One theory of depression is that it is caused by changes
in brain function, a chemical imbalance. There is
research showing that, for some depressed people,
certain neurochemicals in the brain are less active.
It is unclear, however, whether these changes in brain
chemistry commonly cause depression. All we know is
that depression is often associated with changes in
brain chemistry.
11
Action
Depression usually has a significant impact on a persons behaviour. Here are some of the main areas affected:
12
13
MILD DEPRESSION
Talking to family and trusted friends about how
youve been feeling is usually a good thing to do.
They can help you figure out solutions to some of the
problems youve been dealing with; besides, just
knowing that people care about you is helpful.
Write about problems youre facing, your feelings and
thoughts, and possible solutions. This can help you
understand what youre going through and what
choices you have.
Speak to a family physician, psychiatrist or psychologist. A professional can help you figure out whats
been going on and can make useful suggestions.
In some cases, antidepressant medications can be
helpful in overcoming Mild Depression. But for most
individuals with Mild Depression, the answer does not
lie in medication.
14
MAJOR DEPRESSION
(CBT). CBT is a talking therapy that teaches new skills
for thinking and acting more effectively. This guide is
based on CBT methods.
Yet another effective treatment is interpersonal
therapy (IPT), a talking therapy that teaches new
skills for dealing with partners, friends and family.
For long-lasting or recurrent depression, the most
powerful approach is to combine antidepressant
medication with one of these kinds of talking
therapy.
Learning and practicing the antidepressant skills in this guide is likely to help in overcoming
Major Depression. BUT remember that the skills taught in this guide will not be enough by
themselves to fix something this serious. If you have a Major Depression, you should seek
professional help.
15
can give you the energy and mood lift you need to
make changes (such as starting a regular exercise
program, learning assertiveness skills, or defining
and working toward your life goals).
16
17
ANTIDEPRESSANT SKILLS
n this section, you will learn three skills that can stop your mood from
sliding down, lessen your depression and help prevent it from happening
again. The skills are:
Thinking Realistically
Solving Problems
18
DEPRESSION
INACTIVITY
19
Your ideas:
20
Self-Care
Examples:
Getting dressed each day. Taking time to shower and get cleaned up. Exercising. Eating breakfast. Eating more
nutritious food. (Lifestyle factors associated with reducing depression are discussed in the information sheets
at the back of the book.)
Your ideas:
21
Small Duties
Examples:
Opening the mail. Paying bills. Housecleaning. Grocery shopping. Running errands.
Your ideas:
22
Your ideas:
23
Activity 1:
Activity 2:
24
Realistic
You may find it tempting to set your goals based on how much you think you should be able to accomplish. Dont.
Keep in mind that depression slows you down and makes things more difficult. Your goals should be easy enough
to be achievable even if you feel very depressed in the coming week. Sometimes it seems overwhelming to think
of starting a new activity. In that case, try setting the goal of gathering information related to the activity: for
example, finding out what sorts of exercise activities are available in your local community centre.
Scheduled
You should have a clear idea when and how you are going to carry out your activation goal. Take a walk
Thursday evening for 15 minutes is much better than Walk more.
25
ACTIVITY
HOW OFTEN?
WHEN EXACTLY?
Walk, 15 minutes
Thursday evening
He used his appointment book to write in each of these activities. After he did each activity,
he checked it off in his book.
26
HOW OFTEN?
WHEN EXACTLY?
1.
2.
Think of your activity goals as appointments with yourself. Treat these goals as respectfully as you would an
appointment with your physician. If you must cancel
one of these appointments with yourself, reschedule
immediately and dont miss it.
Its a good idea to buy an appointment book to keep track of your goals.
When you've done the goal, check it off in the book to show yourself what you've
accomplished in the early stages of getting better, that's the reward.
27
28
Do you want to increase the goals slightly or keep doing them at the same level until it feels pretty comfortable?
Its your choice.
This is a good time to add another goal. Pick one from another area. For example, if you had Self-Care and
Personally Rewarding Activities goals before, choose one from Involvement with Family & Friends or from Small
Duties.
New Activity:
ACTIVITY
HOW OFTEN?
WHEN EXACTLY?
Write the new goal into your schedule along with the 2 continuing goals. Remember, check off the activity goal as
you do it and praise yourself for completing it.
29
THINKING REALISTICALLY
30
THINKING REALISTICALLY
Filtering.
In this kind of depressive thinking, you only look at the bad, never the good. Because all you see is the negative
side, your whole life appears to be negative. But realistic thinking equally considers positive and negative
aspects of your life.
Overgeneralization.
In this kind of depressive thinking, one negative event seems like the start of a never-ending pattern. If one
friend leaves, they all will. If you fail the first time, youll fail every time. But realistic thinking recognizes
that one disappointing situation does not determine how other situations will turn out.
Catastrophizing.
A small disappointment is seen as though it were a disaster. For example, you were slightly late in completing
a small project, so your entire month is ruined: you react to the imagined catastrophe (a terrible month) rather
than to the little event (a late project). But realistic thinking sees events in their true importance, not
overemphasizing negative events.
Labeling.
You talk to yourself in a harsh way, calling yourself names like idiot, loser, or whatever the worst insults are
for you. You talk to yourself in a way you would never talk to anyone else. But realistic thinking doesnt use
these kind of insults because they are not fair, you wouldnt talk to anyone else that way, and they are
unnecessarily discouraging.
These types of distorted thinking are described in an excellent book, Feeling Good by David Burns (Avon, 1992).
31
THINKING REALISTICALLY
Fortune-telling.
You feel as though you know what the future will bring, and its negative. Nothing will work out, so why bother
trying? But realistic thinking recognizes that you dont know how things will turn out: by staying open
to the possibility of positive results, youll be more hopeful and more likely to make things better.
Perfectionism.
Its only good enough if its perfect. And because you cant make most things perfect, youre rarely satisfied
and can rarely take pride in anything. But realistic thinking gives credit for accomplishments, even if the
result is less than perfect. Few of us reach perfection in what we do, but our achievements are meaningful.
Shoulds.
You think that you know how the world should be, and it isnt like that. You know what you should be like, and
you arent. Result: You are constantly disappointed and angry with yourself and with everyone around you.
But realistic thinking understands the limitations of the world and of yourself trying for improvement but
also accepting how things are.
There are other types of depressive thinking, but these are some of the most common ones. When you catch
yourself thinking depressively, it can be useful to look at this list to see if you are using one of them.
32
THINKING REALISTICALLY
33
THINKING REALISTICALLY
DEPRESSIVE THOUGHT
REALISTIC THOUGHT
First, make a brief note of the situation. Some examples: Talking to daughter, Walking to work, Planning to
make dinner. Next, write down the negative thoughts that seem related to how you feel. If you like, you can try
to classify the type of distortion involved (as shown above).
Finally, think about the situation and try to come up with a more fair and realistic assessment of the situation.
Hint: Depressive thinking often goes way beyond the facts. Often the fair and realistic thought is simply to remind
yourself that you dont have enough information to know for certain whats happening. I dont know why she
cancelled lunch; there might be hundreds of possible reasons.
34
THINKING REALISTICALLY
Depressive Thought:
Can I get more evidence, like asking someone about the situation?
Would most people agree with this thought? If not, what would be a more realistic thought?
We are often much more realistic about other people than about ourselves.
What would I say to a friend in a similar situation?
35
THINKING REALISTICALLY
Situation:
DEPRESSIVE THOUGHTS
REALISTIC THOUGHTS
36
THINKING REALISTICALLY
Try to think of a few situations where you often have depressive thoughts.
Write them here:
1.
2.
3.
37
THINKING REALISTICALLY
You will probably find that, for the first while, the
realistic thinking sounds false to you. For example:
youve been thinking in a perfectionistic way about
your work, telling yourself that my work has to be
100% or else its worthless, but you are given very
little time to complete each task, so you often feel
like a failure. You realize that this is unrealistic thinking
and come up with the fair and realistic thought that
achieving 80% is acceptable in this job, given the
time I have; thats all anyone else accomplishes. At
first, this realistic thought will seem false, as though
you are just fooling yourself. Only with time and
repetition does realistic thinking the truth begin
to feel true to you. Eventually you will come to
accept realistic thoughts.
38
39
40
Here is an example:
It was done by Amy, employed as executive secretary to a senior manager.
The Problem:
My workload is overwhelming files are piling up in my tray and, even though I work long hours, I keep
getting further behind. Ive told my boss that the workload has been growing quickly, but she doesnt do
anything about it. The whole situation seems out of control and Im starting to feel pretty depressed.
Possible Actions:
1. Just keep going, maybe my boss will notice how overloaded I am and she will get another employee
to take over some of the work.
2. March in to my bosss office and let her know that Ive had enough, ask her to stop making
unreasonable requests.
3. Write down all the jobs that are on my desk, then note which ones are urgent to do today, and which
ones need to be done this week, this month or this century. That way, Ill be focusing my energy on the
highest priority tasks and I can plan ahead a little more effectively.
41
Possible Actions:
1.
2.
3.
42
ACTION
ADVANTAGES
DISADVANTAGES
3. Prioritize my jobs
43
ADVANTAGES
DISADVANTAGES
1.
2.
3.
44
45
Your plan of action should follow four rules that can be abbreviated as M.A.S.T.
In other words:
Manageable. Even if you dont feel any better in the coming week than you did last week (even if you feel a little
worse), you could do it anyway. Its better to accomplish a goal that is too small than to fail at an ambitious one.
Heres a bad example: For my first time out, run a marathon. Better example: Walk one block.
Action-oriented. Make a plan for what you will do, not how you will think or feel while you are doing it. You
have a certain amount of control over what you do, but you have less control over your emotions and thoughts.
Bad example: Spend a pleasant hour with my children. Better example: Spend one hour with my children.
Specific. It should be very clear what you need to do. Bad example: Get in shape. Better example: Phone the
community centre to find out whether they teach yoga.
Time-limited. Your plan should take only a short time to carry out. Dont plan to change your style forever.
Bad example: Keep up regular exercise for the rest of my life. Better example: Walk 20 minutes three times a week,
review after two months.
46
Step 6: Evaluate
Come back to this section when a week has passed or when you have achieved your goal.
What was the outcome? What went right? What went wrong?
47
Step 7: Move On
Use this experience to plan your next step.
Take a new approach. Perhaps you learned something useful from your first effort that suggests another way
of handling the issue. Example: Talking face to face with Aunt Sarah didnt work, so write her a letter instead.
Keep working on this issue in a step-by-step manner. Record your efforts on paper. Keep reminding yourself about the
progress you make.
48
49
Lighten up on ongoing responsibilities. If you are taking a night school course, for example, give yourself
permission to eat out more often or have a slightly less tidy home.
Keep up your self-care. How do you keep yourself balanced? Dont give these things up when you need them the
most. If a weekly lunch with a close friend is important to you, keep doing it. If exercise helps a lot, do everything you
can to keep exercising during stressful times.
50
Get professional help. Consider giving permission to a few friends or family members to tell you (or perhaps your
doctor) when they notice your mood seems to be sliding.
Get support. Who could help you and what kinds of help would you need? Perhaps you need someone to talk to, or
maybe you would prefer practical help like assistance with grocery shopping.
Manage your lifestyle. A mood decline is no time to stop exercising, or getting out of the house, or eating
properly, or keeping a good sleep schedule. What are the lifestyle factors that help your mood the most?
Take some time to think about how you could get to work early in a depressive episode to prevent it from
getting worse. What would have helped this time? Use the list above as a starting point and make up a clear
plan of action.
51
Margaret is a married teacher in her mid30s who came to her family physician with
symptoms of depression. She had recently
transferred to an inner city school, attracted
to the challenge of the work. But she found
she could not accomplish what had been
normal for her, although she worked long
hours. She began to sleep poorly and to
worry almost all the time. She criticized
herself in a harsh manner for not doing as
well as she expected. Her mood began to
drop until she felt miserable. This made
it more difficult to perform her job and
she became even more self-critical
and depressed.
53
SUGGESTED READING
ON DEPRESSION AND RELATED TOPICS
Burns, David D. Feeling Good (1992, Avon Books) or The Feeling Good Handbook (1999,
Plume Books). Extremely successful self-help books on depression and anxiety. The
emphasis is on specific exercises to carry out.
Catalano, Ellen Mohr (1990). Getting to Sleep. Oakland: New Harbinger Publications. A
useful book that describes a variety of sleep problems and offers concrete suggestions
for dealing with them.
Paterson, Randy (2002). Your Depression Map: Find the Source of Your Depression and
Chart Your Own Recovery, New Harbinger Publications, Inc. A guide to developing
individualized strategies for recovering from depression.
Greenberger, Dennis and Padesky, Christine (1995). Mind Over Mood. Guilford Publications,
Inc. A hands-on workbook for therapy clients suffering from depression, panic attacks,
anxiety, eating disorders, substance abuse, and relationship problems.
Cronkite, Kathy (1994). On the Edge of Darkness. New York: Delta. First-person accounts
from well-known people who have been through serious depression.
Seligman, Martin E. P. (1992). Learned optimism. New York: Simon and Schuster.
How to overcome a sense of helplessness in your life.
54
USEFUL INFORMATION
AND WORKSHEETS
DIET
56
PHYSICAL ACTIVITY
Regular physical activity is related to improved mental and physical well-being. Recent
research indicates that physically fit people are less vulnerable to depression, and that
regular exercise can markedly reduce symptoms of depression for many people.
Exercise affects mood in four ways. First, it can produce a brief runners high just after
exercising in some people (during depression this effect may not occur). Second, after a
few weeks of regular exercise (three to four times a week, at least 20 minutes at a time),
a general improvement in mood tends to begin. Third, improvements in physical fitness
are associated with improved energy, which can enable you to do more. Finally, exercise
can be a good way of burning off stress when you are feeling tense.
Stretch and warm up first. Learn how to do stretching exercises properly, then
make sure to do them before each exercise session. This can help reduce the likelihood
of exercise-related pain or injury.
Focus on enjoyment. People who exercise for enjoyment and challenge seem to show
bigger mood improvements than people who exercise mainly to look better. Try to put an
emphasis on how you will feel rather than how you want to look.
Nothing changes overnight. Use goal-setting when developing a fitness program, and
be sure to pick something achievable. For example, aim to swim once for five minutes
rather than starting off by committing yourself to a daily 70 laps.
SELF-CARE DEPRESSION PROGRAM
57
SLEEP
Stress, anxiety, and depression often disrupt sleep, but this sleep disruption can lead to
even more anxiety and depression. In other words, sleep difficulties are a cause and an
effect of mood problems. Regardless of which came first, it can be worth the effort to
work on getting a good nights sleep.
Set a standard bed-time and rising time. Your body operates on a 24-hour cycle
that can be disrupted by going to bed and getting up at different times. This is what causes
jet lag: not the air travel, but the change in sleeping hours. Having regular hours for going
to bed and getting up can help to set your internal clock.
Dont go to bed too early. If you never get to sleep before 1 a.m., dont go to bed
before 12. Want to get to sleep earlier? Start by setting your bed-time between 30 minutes
and an hour before the time you have normally been getting to sleep. Then gradually begin
going to bed earlier (by, say, a half-hour a week).
Save your bedroom for sleep. Avoid associating this area with activities that are
inconsistent with sleep like working, eating, arguing, exercising, using the telephone,
watching television, and so on. Sex, though, is fine.
58
SLEEP
Create a good sleep environment. The best bedroom temperature for most
people is 18 to 21 (65F to 70F). If noise is a problem, some options include earplugs,
soundproofing the room (cloth hangings can help a bit), and devices that emit white noise
(e.g., fans or special noise machines). Eliminate hourly watch beepers or clocks that gong.
If a restless bed partner is a problem, consider a larger bed, special mattress, or even twin
beds for a time.
Avoid napping during the day. Unless, that is, you are a great 20-minute napper.
Longer daytime naps can disrupt your ability to get to sleep at night.
Prepare for sleep. Avoid strenuous activity, exercise, heavy meals, and bright light for
at least one hour before going to bed.
59
CAFFEINE
Caffeine stimulates the sympathetic nervous system, which governs the stress response.
If your depression comes with a lot of anxiety, the last thing you need is a chemical
that makes the stress response system more active. Caffeine can also aggravate tension
headache, irritable bowel syndrome, chronic pain, and other physical problems.
Substance
Amount in mg
Coffee
Drip (5 oz.)
Instant freeze-dried (5 oz.)
Decaffeinated (5 oz.)
Espresso drinks (1 shot)
Tea
5-minute steep (5 oz.)
3-minute steep (5 oz.)
Other
Hot cocoa (5 oz.)
Regular or diet cola (12 oz.)
Most other soft drinks (12 oz.)
Small chocolate bar
Total
SELF-CARE DEPRESSION PROGRAM
# per day
Total
130
70
3
90
x
x
x
x
_______
_______
_______
_______
=
=
=
=
60
35
x
x
_______
_______
= _______
= _______
10
45
0
25
x
x
x
x
_______
_______
_______
_______
=
=
=
=
=
60
_______
_______
_______
_______
_______
_______
_______
_______
_______
One of the reasons that depressed people use recreational drugs and drink alcohol is that
these substances can make them feel better in the short run. But, in the long run, they
can make depression worse:
Problems are avoided rather than dealt with.
Performance at work, at home, and in social situations is impaired.
Psychological and/or physical dependence can develop.
Physical health can be impaired.
During periods of depression, alcohol and drug use may seem particularly tempting. But, at
these times, using such substances is a bad idea. Your tolerance for their effects and your
ability to control your use may both be lower than usual. The situation usually requires
concrete, constructive action rather than a retreat into substance use. As well, drugs and
alcohol interact with many prescription medications, including most of the medications
prescribed for anxiety and depression. In general, then, it is best to follow these
guidelines for a sustaining and sustainable lifestyle:
Avoid using alcohol or recreational drugs during periods of depression or severe stress.
Avoid using alcohol or recreational drugs if you have a personal or family history
of substance abuse.
Even if you are feeling fine and have no history of abuse, adopt a personal policy to
use these substances only in moderation.
The prospect of eliminating alcohol and drug use from your life can be a daunting one.
Remember that while using none is best for some people, reducing your intake is better
than becoming overwhelmed and giving up. Use the principles of goal-setting to help
you examine the problem and overcome it a bit at a time.
If your use of drugs or alcohol is altogether out of your control, you are in good company:
many people have had this problem. A number of organizations exist that can help you to
regain control. Ask your physician for more information.
61
Situation:
DEPRESSIVE THOUGHTS
REALISTIC THOUGHTS
Depressive Thought:
Can I get more evidence, like asking someone about the situation?
Would most people agree with this thought? If not, what would be a more realistic thought?
We are often much more realistic about other people than about ourselves.
What would I say to a friend in a similar situation?
PROBLEM SOLVING
ACTION
1.
2.
3.
ADVANTAGES
DISADVANTAGES
GOAL SETTING
ACTIVITY
HOW OFTEN?
WHEN EXACTLY?
Illustration
Karen Cowl
Designer
Stripe Graphics Ltd.
Vancouver, BC