Treating Depression Through Cognitive-Behavioural Therapy (CBT)


1 in 4 Canadians has depression significant enough to warrant treatment at some point in their life.

Yes, 25% of Canadians struggle with depression. It's that significant of an issue.

As a matter of fact, according to the World Health Organization, depression is the leading cause of disability worldwide.

More specifically, over 300 million people worldwide struggle with depression.

However, there are effective treatments for depression.

But before we get to them, let’s talk about what depression is.


What is depression?

Typically, when looking at definitions for psychological disorders, we’d start with the DSM, which is the Diagnostic and Statistical Manual of Mental Disorders and is essentially the final word on mental health diagnoses.

For our purposes, I’m going to borrow a relatively brief definition of depression from the American Psychiatric Association, as they’ve summed it up wonderfully.

Depression: A common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and or a loss in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.

And to further borrow from the APA, symptoms are as follows:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite – weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g. hand-wringing or pacing) or slowed movements and speech (actions observable by others)
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

These symptoms must last at least 2 weeks (for a diagnosis of depression) and must not be accounted for by a medical condition.

Typically, a depression measure, such as the Beck Depression Inventory, is used to evaluate symptom severity.

Now that you have a better understanding of what depression is let’s take a closer look at depression treatment strategies.

Strategy #1: Start with a plan for the day

When mood is low, there is a tendency to get stuck and do the bare minimum of what needs to get done.

If nothing needs to get done, well, probably very little is going to happen until you “feel like it.”

If you fall prey to that type of thinking, you could be waiting a long time! Not to mention, there’s an increased chance that your mood could dip further.

Instead, you want to make a plan for the next day before you go to bed. It doesn’t need to be overly ambitious, but it should provide some structure to your day.

If you’re working or going to school, this will help you to maintain structure and routine during the week. If not, it’s likely going to be harder to get moving.

One of the worst things that can happen with mood is sitting idle for too long. We are happier when we are busier.

As Isaac Newton said:

So, if you are inactive for too long, it’s very hard to get moving again.

The body was meant to move and the mind was meant to think and both body and mind should be active fairly consistently.


Strategy #2: Take care of the basics

The basics are never fun or sexy and often overlooked. But they are essential and definitely not worth skipping over.

What are the basics I’m referring to? Drinking water, eating regular meals, and getting exercise.

Let me make a quick analogy here. If you were a car (yeah I know it’s weird to be compared to a car, but I’m sure you’ve been called worse!), you wouldn’t run well if you didn’t have oil, gas, transmission fluid, etc.

Humans are no different. To think that we can run properly without water, food and exercise is pretty unrealistic.

Let’s take a quick look at each of these areas and see what’s needed to maintain and promote a healthy mood:

Water

So understated, yet so important.

Up to 60% of your body is water and even 31% of your bones are water.

Not surprisingly, having adequate water intake and avoiding dehydration is vital if you hope to function properly.

The amount of water you need varies from person-to-person depending on the demands of your daily life, but according to the National Academies of Sciences, Engineering and Medicine, adult males should drink an average of 3.7 litres per day and adult women should drink an average of 2.7 litres per day.

That’s a lot of water needed to function properly!

And at the risk of getting too high up on my soapbox, be sure to get your water from the cleanest source possible. Personally, I’m a fan of both Reverse-Osmosis and Distillation.

Food

Without digging too deep into this topic, our purpose here is to establish food basics. Keeping that in mind, you want to consume multiple, small meals (e.g., 4-6 meals) throughout the day.

Diets high in fibre, fruits and vegetables are also important.

Lastly, it is very important to avoid inflammatory foods, as these foods serve to make feelings of depression worse.

Exercise

The general rule of thumb for exercise is that it’s pretty much great for everything!

And when it comes to mood, it all helps. To put it simply, you just need to get moving in some way, shape or form to benefit mood.

However, it appears likely that the more demanding the exercise, the greater the impact on mood (Gordon et al. 2018).


Strategy #3: Chunk time to get started

So, you know you need to get moving as an initial cornerstone of any depression treatment plan. But simply put, you don’t want to move.

What do you do?

Chunk time.

And the self-talk around chunking time should go something like this:

Once you get started, momentum will be on your side and you’ll be more likely to keep going. Dealing with too big of a chunk of time can feel overwhelming and is more likely to shut you down.

But what if you can’t even commit to getting started at all?

It’s important to dig into your self-talk a bit further. I’d suggest something like this:

And herein lies the brutal truth about mood. If you wait until you “feel good to do something,” you’ll probably be waiting a while, especially if you already feel depressed.

In actuality, you need to commit to doing whatever it is you need to do, even if it’s for a short time if you intend to kick-start your depression treatment program.

So, with that in mind, your self-talk should be more along the lines of this:


Strategy #4: Be aware of how you carry your body

How you carry and move your body is wired into your cerebral cortex.

The cerebral cortex is responsible for higher-level cognitive processes in the brain, such as thinking, language, decision-making, etc.

And making simple adjustments with your body, especially when done consistently, can serve to improve mood.

We are going to look at 3 of them right now:

1. Smiling

This one seems so simple… and it works. Smiling is universal. It doesn’t matter who you are or where in the world you live. It feels better to smile.

Science has known the benefits of smiling for some time. Strack et al. (1988) completed a pretty ingenious study in which they had study participants put pens in their mouth. I’m going somewhere productive with this!

Half of the group put a pen in their mouth in a manner that activated the same muscles you use when you smile, while the other group put the pen in their mouth in a different way.

Results showed that study participants who had their smile muscles activated by the pen rated cartoons as funnier when compared to the control group.

And the point of including the pen in the study?

Simply activating smile muscles made people feel better. So, faking a smile, as phoney as it might feel, will still cause you to feel better.

2. Tone of your voice

When you think about this one simply from a common-sense perspective, the idea has merit. If you talk in a low, uninspired, monotone fashion, it stands to reason that you probably won’t feel very good.

If you talk in a higher tone and show a little excitement, perhaps with a bit of intonation to your voice as well, it seems logical we should feel better.

But, let’s look to science for some support on this theory.

Aucouturier et al. (2015) conducted a study in which they recorded the voices of their study participants. Afterwards, they manipulated the sound of their voice to either sound happier, more sad, etc. (the participants were unaware that the researchers were manipulating their voices).

When their voices were played back, the tone of voice was found to impact people’s emotional states.

In other words, a happier tone of voice, made people feel happier, while a sadder tone of voice made people feel more sad, etc.

So indeed, the tone of voice matters in your quest to improve mood.

3. Posture

Take a moment here to picture the posture of someone who is struggling with mood. When I do this, I envision someone slouched over with their body in a loose, self-defeated stance.

And the posture of someone who is happy?

I picture a person sitting or standing upright in a confident, self-assured manner.

Once again, let’s turn to science to see if this is helpful.

Nair et al. (2015), in the journal Health Psychology, conducted a study in which they had participants either sit up straight or slouch when completing a mock job interview.

Study participants who were asked to sit up straight reported feeling more enthusiastic, excited and strong. They also found that people reported better mood and improved sleep when simply asked to sit up straight.

Proper posture helps!


Strategy #5 – Prioritize time to focus on what’s going well

Generally speaking, most people are in the habit of thinking about what they have to do and focusing on things that aren’t going well.

Very little time, if any, is spent thinking about what’s going well.

Not surprisingly, mood is negatively impacted by a thinking pattern like this.

To help rectify this problem, I’d suggest spending at least 5-10 minutes/day focusing on what’s going well in your life.

When doing this, I like to start with the most important areas in life and then work my way towards the smaller ones. Here’s my list below. Feel free to add to it or modify it to better suit you.

  • Health – Physical, mental and cognitive
  • Freedom
  • Relationships – Family and friends
  • Purposeful Daily Activity – Job, School, Volunteer, Child-Rearing, etc.
  • Hobbies
  • Miscellaneous (could be anything – e.g., favourite Netflix series, the release of a new song, an upcoming vacation, etc.)

And remember to always have something out in front of you to look forward to in the future.

What you are focused on helps to determine how you feel.


Strategy #6 – Challenge negative thoughts

I imagine some of you might be thinking that this could be a new full-time job, especially if your mood has dipped notably.

The goal here isn’t to challenge every single negative thought that enters your head, but rather, to take time when it’s available to address these thoughts. If you never take time to challenge your negative thoughts, you are accepting them.

And if you get into a consistent pattern of accepting negative thoughts, it doesn’t take a PhD. in Clinical Psychology to figure out that your mood is going to suffer.

But in the spirit of evidence-based treatment, let’s take a quick look at a study which examines the effectiveness of cognitive therapy on changing negative thought patterns.

Strunk et al. (2010) conducted a study in which 60 participants who were diagnosed with major depression engaged in cognitive therapy with a therapist. Cognitive therapy involved tasks such as challenging negative thoughts and running thought experiments (i.e., testing to see if your negative thoughts are true or false).

The study also had participants engage in behavioural techniques such as participating in enjoyable activities.

Results showed that cognitive therapy led to an improvement in depressive symptoms and the improvement was superior to the benefits gained from behavioural techniques.

So, now that we’ve confirmed it works let’s establish a plan to utilize it.

Step 1: Identify negative thoughts

If you are going to challenge negative thoughts, it’s best to start by identifying them. This is where a thought record can help.

(Click the image above for a full-sized printable copy)

Over the course of several days, it’s helpful to set aside 5 minutes each day and write down the most common negative thoughts you experience, including a rating for the frequency and intensity of the thought.

Step 2: Create an operational definition for the thought

If you are going to criticize yourself in your mind, you might as well know what you’re calling yourself.

Let’s say a common negative self-talk statement is, “I’m so stupid.” Let’s ask Google what stupid means:

Stupid – "Having or showing a great lack of intelligence or common sense.”

Okay, maybe that can happen sometimes. That might not seem so bad until you dig into the synonyms (i.e., words that mean the same thing).

Hmmmmmm... now that seems a little harsh and probably inaccurate, which leads us to our next step.

Step 3: What’s the evidence for the thought being true/false?

I love the word “evidence” (not enough to ever consider becoming a lawyer, mind you!). For our purposes, evidence means:

Generally speaking, you are going to find that most negative thoughts are primarily false. On occasion, you may find there is a little truth to a negative thought.

And that’s okay, but label it as such, “It’s just a little true in this case.”

Step 4: How to manage negative thoughts that are largely true

There will inevitably be times where you examine negative thoughts and come to the conclusion, “Damn, this is true.”

For example, let’s say you were caught in a lie and you have the thought, “I’m a liar.”

Well, first and foremost, lying once doesn’t make you a liar (i.e., someone who lies all the time).

So, in this particular instance, “I lied” would be accurate. That obviously doesn’t feel great, so what do you do with this statement.

Drowning in this thought for an excessive period isn’t going to help.

There’s nothing wrong with feeling some pain (likely feelings of guilt) from the thought. Use that negative feeling to learn the lesson from this negative situation, let go of the guilt and resolve not to make the same mistake again.

And what should you do if you have a negative thought (or what you perceive to be negative) that you simply can’t change or learn a lesson?

For instance, let’s say the thought is, “I’m so short.” Well, if you’re an adult in Canada and are well under the statistical average of 5 feet 8.5 inches for males and 5 feet 3.4 inches for females, the numbers are against you on this one.

This leaves you with one positive choice – accept the thought and do your best to make peace with it.

In the case of being short, we could discuss a myriad of reasons about why being short doesn’t have to interfere with your quality of life and truly doesn’t matter in the grand scheme of things, so I’ll assume you’ve got the idea here.


Strategy #7 – Use mindfulness

Mindfulness, also known as mindfulness meditation, may bring to mind the thought of someone sitting cross-legged, arms outstretched with index fingers and thumbs creating circles, all the while chanting, “Umm” at regular intervals. Kind of like this.

For those of you who are interested in this form of mindfulness, it works.

For those of you who aren’t, we’ll go over the basics you need to do to achieve the benefits of mindfulness.

But first, let’s take a quick look at the science. More specifically, we are going to explore a meta-analysis (also known as a collection of studies, which are statistically analyzed together) by Govel et al. (2014) which examined 47 different studies.

Results showed that mindfulness meditation was not only effective at treating mood, but it also happened to be just as effective as taking an antidepressant medication.

But doesn’t mindfulness involve sitting still for long periods?

Not necessarily.

Studies by Norris et al. (2017), Tashani et al. (2017) and Xu et al. (2017) show that as little as 10 minutes of mindfulness can improve learning, reduce pain and reduce worrying.

And based on the research I've seen to date, I’m willing to bet that as little as 10 minutes of mindfulness would help to reduce depressive symptoms as well.

Now, let’s look at the primary components of mindfulness:

Step 1: Get comfortable and focus on your breathing

Mindfulness doesn’t need to involve sitting. Studies have been done which show that mindfulness can be effective with people standing, jogging and even washing dishes.

The key is to get into a comfortable position and breathe slowly from your diaphragm.

Step 2: Have something to focus on

To maximize the benefits of being mindful, you are going to need an anchor. An anchor can be just about anything as long as you are locked onto it. It could be a picture on the wall, an image in your mind, focus on your breathing, etc.

Step 3: Free your mind

Now that you are comfortably breathing and locked onto something, it’s time to let go of your thoughts. This can be tough, given we are always thinking.

The goal here is to allow thoughts to come in and simply not to judge or engage them in any manner. Simply treat them as if they were thought bubbles showing up in a foreign language that you can’t understand.

For those of you struggling to stay focused, quickly remind yourself that you likely have 16 waking hours in a day to deal with your thoughts. You can afford to take 10 minutes off.

If you catch yourself drifting or engaging with your thoughts, no worries. Simply acknowledge that you are doing this and return your focus to slow, deep breathing and locking onto your anchor.


Strategy #8 – Get a good night's sleep

Proper sleep may be the single-most overlooked aspect of mental health in my humble opinion.

And it appears that the good people in the United Kingdom might agree with me.

Fang et al. (2017), in the journal SLEEP, conducted a survey of 30,500 people in the U.K. over the course of 4 years.

Results showed that improved sleep quality led to dramatic improvements in mental and physical health.

As a matter of fact, Fang et al found that better sleep for their study participants was equivalent to winning $250,000 in the lottery! Yay for sleep!

For the sake of brevity, I’m going to outline some of the core components of a good night’s sleep:

    • Have a sleep routine that includes at least a 1-hour “wind-down period” before bed
  • Go to bed and wake up at the same time every day (weekends included!)
  • Keep it dark
  • Keep it quiet (use white noise, or a fan if needed to block out distracting noise)
  • Keep it cool (within reason, I’m looking at you, Jennifer Sullivan!)
  • Avoid ruminating (excessive thinking about your past or upcoming day)
  • Have an interesting thought to focus on (if you don’t fall asleep right away, you will need something to think about)
  • Don’t toss and turn (if you aren’t asleep within 30-45 minutes, get up for 5-10 minutes to break-up the inevitable pattern of frustration that has likely set in)
  • Do not check your phone (the world won’t stop turning)
  • Do not do mental math (to determine how much sleep you’ll get if you fall asleep this instant)
  • Do not put too much pressure on falling asleep (this will take you further away from relaxation, which you need to fall asleep)

And lastly, let’s look to Dr. Barah, Medical Director of the Valley Hospital Center for Sleep Medicine in Ridgewood, New Jersey, for guidelines on how much sleep you should be aiming for each night.


Conclusion

When you don’t feel good emotionally and your mood is low, little else can seem to matter.

This article outlines 8 strategies you can use in a depression treatment plan. I’ve listed these strategies in an order you can utilize from the time you get up to the time you go to bed.

Begin by outlining a plan for the day and don’t forget the basics you need to fuel your body. Chunk time to help get you moving and remember that how you carry your body impacts your mood.

Prioritize time to focus on what’s going well and challenge negative thoughts. Reboot the mind with mindfulness and end the day with a good night’s sleep.

Follow these strategies and it will put you on the fast-track to improving your mood.


Are you surprised by how many people struggle with mood?

What strategies do you find helpful for improving mood?

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Article by

Trevor Sullivan, MA, RP

Registered Psychotherapist

September 9, 2019