Research has identified a number of factors associated with causing and continuing the depressed state.
The diagram below shows the five major factors: situation; thoughts; emotion; physiology; and action.
Each of these areas of your life can play a role in the development of depression, and depression itself can have an impact on all of them.
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:
- Major life events, particularly involving loss. Events such as the death of a loved one, moving, divorce, financial setbacks, or job loss are major disruptions in one’s life.
- Lack of contact with other people. Social isolation is a significant risk factor for depression.
- Relationship conflict. Times of conflict in personal relationships, whether marital or family, are extremely stressful and can contribute to the onset of depression.
- Stress related to your job. This can take the form of employment uncertainty (not knowing whether your job will continue), friction with supervisors and co-workers, or overwork (human beings were never designed to work 16 hours a day, either in an occupation or around home).
- Stress related to your physical health. This is especially true for health problems that are chronic, cause a lot of pain or disability, and only get partly better with treatment. Some physical illnesses or their treatments can trigger depression by their effects on the body. For example, hypothyroidism (a condition in which the thyroid gland secretes too little thyroid hormone) is often associated with fatigue and depression.
That doesn’t mean people only get depressed when things are going badly.
Some people get depressed when their life has been going smoothly: depression just seems to come out of nowhere.
Each of us is affected differently by outside events, depending on how we think about those events.
Imagine two people walking into a party.
-One person is naturally outgoing, anticipates enjoying herself a great deal, and sees the group of partygoers as friendly and receptive.
-The other dreads social gatherings, anticipates feeling miserable, and sees the other people as judgmental and rejecting.
Each person’s thoughts determine how the event is experienced. (Our experiences, especially our early relationships, lay the blueprint for how we interpret and make meaning of social interactions and behavior).
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.
1. Unrealistic, negative thoughts about the situation.
You see the situation in an unrealistically pessimistic way, emphasizing its negative or threatening aspects and ignoring more positive or promising aspects.
2. Unfair, negative thoughts about yourself.
You think about yourself in a very critical fashion, judging yourself in a harsh and unfair manner.
3. Unrealistic, negative thoughts about the future.
You anticipate a future that is bleak and disappointing, exaggerating the likelihood of very negative outcomes.
Taken together, we call this the Negative Triad: thinking in an unfair and unrealistic, negative way about your current situation, yourself, and your future.
These ways of thinking often start in childhood.
Some people grew up in families where only negative and critical comments were made. In other families, children were discouraged from saying positive things about themselves and rewarded for being self-critical.
Whether these negative thinking styles are caused by the depression or started in childhood, they have enormous influence on your experience of the world.
Not surprisingly, these ways of thinking about the world increase the negative impact of difficult life situations and predispose people to emotional pain. A person with depressive thinking can become discouraged or hopeless even when things are going well.
Depression is accompanied by a variety of physical symptoms.
One of the most powerful physical changes accompanying depression is impaired sleep.
Usually, this involves an inability to get enough sleep, whether because the person has difficulty falling asleep, repeatedly wakes during the night, or awakens much too early. Sometimes the person may sleep too much, caused by a desire simply to hide away in sleep or a fatigue so pervasive that there never seems to be enough sleep. When sleep is “non-restorative” – that is, the person does not awake feeling refreshed and rested – it becomes harder to face the day and deal with problems.
Depressed people often feel that they lack energy and are exhausted by everyday activities.
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.
The physiological changes of depression make it harder to cope with life problems or even to follow the steps of a depression management program like this one.
Antidepressant medication can often be quite helpful in restoring sleep and regaining your sense of physical energy.
It can allow you to actively learn and try out the new skills needed to overcome depression.
Depression usually has a significant impact on a person’s behaviour.
Here are some of the main areas affected:
Not doing rewarding activities.
Hobbies, crafts, sports, reading, and travel may all suffer. Depressed people often feel too tired or unmotivated to pursue these activities, and the less they participate in them, the less they feel able to do so. Most depressed people suffer from anhedonia, reduced ability to have fun or get enjoyment from things. Why would you go to the movies, engage in hobbies, or do the things you used to enjoy if you didn’t think you would enjoy them? Inactivity becomes a habit. As a result, the depressed person no longer receives the personal satisfaction provided by these activities, further contributing to the sense of discouragement.
Not taking care of yourself.
Activities designed to maintain one’s body and appearance are frequently neglected. Depressed individuals may take less care in personal grooming or dress than usual. In addition, exercise is often reduced, whether this involves formal fitness activities such as jogging or simply walking around the neighbourhood. Eliminating exercise contributes to depression by removing a powerful source of physical well-being and increased selfesteem. As well, the depressed person often has disrupted eating habits, whether this means inadequate intake (“forgetting to eat”) related to a lack of appetite, or overeating as a form of self comfort.
Not doing small duties.
A depressed person often neglects or procrastinates doing small, necessary duties, like running errands, taking out the garbage, cleaning house, or caring for the garden. Failing to complete these chores adds to the depressed person’s sense of inadequacy and lack of control over life. It also creates friction with others and places further stress on relationships.
Withdrawing from family and friends.
Social invitations are refused, phone calls are ignored, and habitual get-togethers with family or friends somehow just don’t happen. Social isolation is a strong contributor to depressed mood, taking you away from the warmth and sense of connection to others, basic to all of us. Depressed people often believe that others have no interest in their company, given how miserable or emotionally flat they are feeling.
Three steps towards feeling better
Depressive thoughts are unfair and unrealistic. They are distorted because they are inaccurate reflections of how the world is or how you are. The table below (and continued on the next page) describes some common forms of distorted thinking in depression1:
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.
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, you’ll fail every time. But realistic thinking recognizes that one disappointing situation does not determine how other situations will turn out.
All or Nothing Thinking.
You see the world in terms of extremes. You are either fat or thin, smart or stupid, tidy or a slob, depressed or joyful, and so on. There is no in-between. Gradual progress is never enough because only a complete change will do. “Who cares that I did half of it? It’s still not finished!” But realistic thinking sees people and events as falling somewhere between the extremes, towards the middle, where most things are found.
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.
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 doesn’t use these kind of insults because they are not fair, you wouldn’t talk to anyone else that way, and they are unnecessarily discouraging.
You feel as though you know what others are thinking about you, and it’s always negative. So you react to what you imagine they think, without bothering to ask. But realistic thinking recognizes that guessing what others think about you is likely to be inaccurate, especially when you are depressed.
You feel as though you know what the future will bring, and it’s negative. Nothing will work out, so why bother trying? But realistic thinking recognizes that you don’t know how things will turn out: by staying open to the possibility of positive results, you’ll be more hopeful and more likely to make things better.
It’s only good enough if it’s perfect. And because you can’t make most things perfect, you’re 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.
You think that you know how the world should be, and it isn’t like that. You know what you should be like, and you aren’t. 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.
Most thinking is so quick and so automatic that we don’t even realize we are doing it.
We must learn to become aware of depressive thinking as it occurs. An excellent strategy is to carry around pencil and paper for a week.
Although depression can seem like a constant dark cloud, it actually varies over the course of the day. Every time your mood sinks, ask yourself this important question:
“What was going through my mind just then?”, What were you thinking about? What were you reacting to? Write this down.
You may find that you take the depressive thoughts less seriously once you know where they come from.
When you become aware of depressive thoughts you may feel tempted to attack yourself. “How could I think such stupid thoughts?” Depression causes you to be self-critical, and recognizing depressive thinking can give you one more way to beat up on yourself. Don’t. Instead, remind yourself that depressive thoughts are the product of low mood and of your personal history. You are not stupid for having them. They are normal during depression.
Challenging depressive thoughts involves deliberately rethinking the situation that got you upset.
To do this you can use a strategy called Challenging Depressive Thoughts. Take a piece of paper and divide it into columns, like the example below.
Challenging Depressive Thoughts
Situation: Friend cancels lunch date.
|DEPRESSIVE THOUGHT||REALISTIC THOUGHT|
|She doesn’t like me.
|I don’t know why she cancelled; maybe something urgent came up. It’s only lunch.|
|No one likes me. I’m unlikable.
|Some people do seem to like me, so I must be likable.|
|The world is a cold and rejecting place.
|This lunch doesn’t mean much about the world as a whole. I’ve been accepted before.|
|I’ll always be alone.
|I can’t tell the future. One lunch doesn’t mean no one will ever like me.|
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 don’t have enough information to know for certain what’s happening. “I don’t know why she cancelled lunch; there might be hundreds of possible reasons.”
Calling yourself insulting names like “idiot” will cause you to feel more discouraged; as a result, you may give up on a task. But giving yourself encouragement and fair evaluation is likely to result in trying harder, which increases the odds of a successful outcome.
When you’re down or depressed, it’s not easy to come up with fair and realistic thoughts. Here are some questions that will help you do this.
Depression is often the result of life problems that have become overwhelming. The strategies for solving them have been ineffective, or may even have made them worse.
Why is it that as people get depressed, their ability to solve problems declines? There are several reasons:
- Solving problems takes energy. As depression worsens, the energy level declines.
- Everyday problems take a backseat to a bigger problem – the depression itself. Because the person becomes so concerned about the mood problem, other problems slide and get worse.
- Depression causes difficulties in concentration, memory, decision-making ability, and creativity. Most problem-solving requires all of these skills.
Given all of these factors, it is no great surprise that problems don’t get solved and instead pile up.
Recognize that your problem-solving ability may not be as good as it usually is. Don’t beat yourself up over this.
It is a normal symptom of depression, and it does get better.
Plan ahead for stress
We all have difficult times in our lives – some of us more than others.
For the person who has recently recovered from depression, stressful times may be a risk factor for relapse. The solution is not to avoid all possibility of stress (which none of us can do), but to plan ahead to manage the stress effectively.
Some stressful events can be predicted. Perhaps you know that on a certain date you will go back to work. Perhaps Christmas is always stressful for you, and December is coming. Perhaps a stressful family gathering is scheduled. Perhaps you are expecting a baby, whose birth will bring many demands. You can plan ahead for these events to make them less difficult.
Here are some strategies:
When possible, introduce the stress gradually. If, for example, you are returning to work soon, you might check to see if you could go back part-time at first.
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? Don’t 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.
Create a Mood Emergency Action Plan
If you plan ahead for a relapse, you may be able to get help faster than last time. As a result, the depression may not become as severe, last as long, or be as difficult to recover from.
By planning a course of effective action ahead of time, you may not be as anxious, and you may actually reduce the possibility of a return of the depression.
If you were to become depressed again, what are some of the things that you could do to help yourself and get better as quickly as possible?
Here are some areas to think about:
Increase rewarding activities.
Reduce your obligations.
Get professional help.
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.
Food, fuel, must eat!
Food is the most obvious source of our energy. When we are depressed, however, our diet often suffers. Some people overeat.
A more common problem is lack of appetite.
If this occurs, it is important to remember that although you may not feel particularly hungry, your body’s need for fuel continues.
Here are some tips on keeping up adequate nutrition during difficult times.
Eat regular meals. It is usually easiest to eat (and to control what you eat) if you keep to a routine. Try to have three set mealtimes per day. Ensure that you have enough food at home for all three.
Eat by the clock, not by your stomach. If you have lost your appetite, push yourself to eat at mealtimes anyway. If you have been overeating, try to eat only at mealtimes while sitting at the table.
Make it easy. The important thing is to eat, not to cook. Buy foods that are easier to prepare (but keep an eye on their nutritional value).
Make extra. You can cut your preparation time by making larger amounts and refrigerating or freezing certain dishes for reheating later.
Make it healthy. Stock up on nutritious food and snacks using the Canada Food Guide (see the box).
Watch your sugar intake. Avoid eating too much refined sugar. Complex carbohydrates are generally preferable (particularly whole grain products, brown rice, and potatoes).
Avoid dieting. Avoid strict diets, even if you wish to lose weight. It is much better to adopt healthy (rather than restrictive) eating habits and increase your activity level. Ask your physician for advice before attempting to lose weight. (Information here is NOT a substitute for medical advice).
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 “runner’s 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.
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 night’s sleep.
Here are some tips:
Avoid over-the-counter sleeping medication. Although it may help you to fall asleep, the type of sleep you get will usually not be as helpful as normal sleep. Instead, take sleeping medication only as directed by your physician. If you do take sleep medication, remember that the mark of its success is how you feel during the day, not whether it actually puts you to sleep. Report the results to your physician.
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.
Don’t go to bed too early. If you never get to sleep before 1 a.m., don’t 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.
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.
Caffeine is an addictive drug. Heavy users can become psychologically dependent on it, develop tolerance (meaning that more caffeine is needed to get the same effects), and undergo withdrawal if they don’t get it. Withdrawal symptoms include headache, drowsiness, irritability, and difficulty concentrating. Many people discover that they are dependent on caffeine when they go for a day or two without coffee and develop splitting headaches.
How much caffeine does it take to become dependent on it? Estimates vary, but 450 milligrams per day is about average. Some people are more sensitive, others less. Use the table below to calculate your average daily consumption. Notice the small serving sizes. Your coffee cup may hold three or four of these!
If you decide to try reducing your caffeine intake, do so slowly to avoid the withdrawal symptoms. Drop your intake by about half for 4-6 days, then half of the remainder, then half again until you are drinking no more than 2 cups per day.
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.
Information on this website is not a replacement for professional counseling. If you are in crises, please call 911 or the Multnomah County Crises line at 503.988.4888.