Psychologist Peter Lewinsohn discovered in the 1970's that depressed people suffered from a deficit of positive, pleasurable experiences in their daily life. He developed a behavioural treatment for depression described in the book "Control Your Depression". This treatment was designed to help depressed people increase the number of pleasurable events in their lives. Later, psychologists like Neil Jacobson, further developed behavioural treatments for depression and expanded the concept to something called "behavioural activation". The idea was that depression is largely a disorder of inaction. Due to lowered energy levels, pessimism and other factors, depressed people simply do less than non-depressed people and as a result experience far less pleasure. Furthermore, often the things they actually choose to do are not behaviours that result in pleasurable results.

At the same time these behavioural therapies were being developed, the whole cognitive approach to treating depression was flourishing. Ultimately the two approaches were combined into Cognitive Behavioural Therapy, but the behavioural component has always been the poor cousin. It seems more appealing to try to change the way we think and view the world, than to simply change our behaviour. However, there is compelling evidence that changing the way we think is harder than changing the way we behave. The evidence suggests that changing behaviour is just as effective as changing our cognitive world in helping us feel better.

Let's talk about some ways to make antidepressant behavioural changes. Start by taking an inventory of all the things you do in a day from the moment you wake up and rate how you feel while (or just after) doing these things (scale 1-10 – one is lowest pleasure, 10 is highest pleasure). This will give you an idea of how many positive moments you have in the day, what activities have positive results and what activities have aversive results.

Also, rate your level of depression three times per day, morning, dinnertime and bedtime. While it may seem like a pain, keeping charts is a very important component of therapy. It helps you determine what to change and helps you assess your progress. I have found that clients who structure their day do better than clients who take an open ended approach. One good example of this is a client who discovered that his depression was lowest in the morning when he woke up. On the weekend, would lie in bed for an hour or two ruminating before getting up and would feel more intensely depressed. He found that getting up immediately upon waking even on the weekends and getting busy exercising, reading the paper or doing other constructive tasks significantly improved his mood throughout the day.

There seem to be certain kinds of activities that deliver more positive effect than others. Activities that make you feel physically better (like exercise and eating well), activities that make you feel competent (like achieving a goal or learning a skill) and activities that get you in contact with positive people are extremely effective at combating depression.

Conversely, watching TV, surfing the internet, sleeping for long periods of time, misusing substances or hanging out with critical, negative people can worsen depression. You may be able to design your own individual program for behavioural activation.

However, some people find that they do better with a mental health professional to help coach them and be a source of encouragement and accountability in changing depressive behaviour. The professional can help with goal-setting, creating activity charts, behavioural practice, problem-solving and interpersonal skills/choices. For example, a person may be involved in a negative relationship with a friend and not realize the effect this is having on their mood. Sometimes an outside objective observer can provide a fresh perspective and encourage a positive change in how they spend their social time.

Depressed people spend more time dwelling on the negative than do non-depressed people. This "dwelling on the negative" activity appears to happen automatically for depressed people. One popular exercise to counter negative rumination is the Gratitude List. Once a day, usually at the end of the day, the person writes down at least five things for which they are grateful that day and reviews the list. This simple activity can go a long way towards countering the pessimism of depression.

Behavioural activation changes should be small enough to be successfully accomplished and should be individually tailored for the person’s unique interests and tastes. If you start small and have successes, you will want to continue to do yourself out of that depression!

Dr. Jim Browning