Monitoring activities

Lowered activity levels and loss of interest and pleasure are often central features of depression. The goal of early behavioural interventions is to maximize engagement in activities providing a sense of pleasure and mastery. This has a direct impact on mood, and also provides an opportunity to begin countering negative thoughts that block engagement and, perhaps in a more global sense, prevent recovery (e.g. 'I can't do anything to change how I feel').

Patients record what they do, hour by hour, on a weekly activity schedule or diary, which looks something like a school timetable ( Fig...2). Each activity is rated out of 10 for Pleasure (P) and Mastery (M). P ratings indicate how much they enjoyed the activity, and M ratings how much of an achievement the activity was. P ratings are usually fairly straightforward, but M can present difficulties. Depressed people often feel as though nothing they do is an achievement, perhaps because most of their activities are routine ('What's so special about that?') or do not meet their standards ('I should have done more'). M therefore needs to be explained as 'an achievement, given how you felt at the time'. This means that simple activities (such as making a cup of tea) can be seen as real achievements now that the patient is hampered by low mood and loss of energy. Ratings should be made immediately after each activity, since retrospective ratings may be distorted by negatively biased recall. In addition, it is helpful for the patient to undertake a review of each day, asking questions like: 'What worked for me?' 'What did not work?' 'What do I need more of? Less of? Different?' These questions provide useful information for the next stage.

Planning activities

Once self-monitoring is mastered, the schedule is used to plan each day in advance on an hour-by-hour basis. This:

• provides a structure to the day and helps with setting priorities

• averts the need to keep making decisions as to what to do next

• reduces what may seem like chaos to a manageable list

• increases the chances that activities will actually be carried out

• enhances the patient's sense of control.

A pattern of activities is sought in which mastery and pleasure are balanced and maximized. So the plan is likely to contain a blend of obligations (e.g. doing the ironing) and pleasures (e.g. listening to music). Tasks that have been avoided can be included, broken down into manageable steps ('graded task assignment'). Again, it is helpful for patients to review each day in detail. The schedule also provides further opportunities to identify and deal with unhelpful thoughts (e.g. 'If I can't complete the task, I might as well not bother at all'). That is, the cognitive element is present throughout activity scheduling, even when it is not a primary target.

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