Depression

• Conduct a routine psychological assessment.
• Assess for the presence of depressive symptoms e.g., low mood, crying, negative thoughts, sleep disturbance, appetite disturbance, psychomotor retardation, trouble concentrating, fatigue, feelings of guilt, hopelessness/helplessness, suicidality.
• Assess behaviour-specific depression symptoms: disengagement in social activities, disengagement in physical activities, and disengagement with activities of daily living.
• Assess for other stress or anxiety symptoms that may be contributing to reduced engagement in social activities.
• Administer Depression Anxiety Stress Scale (DASS-21).
• Complete the Pleasant Events Schedule (PES).
• Consider the need for a referral to a general practitioner or specialist mental health practitioner.
• Consider the need for a suicide risk assessment.

Encourage completion of Behavioural activation monitoring form. This monitoring form charts daily mood and engagement with activities associated with both pleasure and mastery e.g., a sense of competence. Completed along with the Pleasant events schedule, it allows for nomination of a range of activities that may help lift mood. Encouraging monitoring throughout the intervention period to gauge the success or otherwise of the strategy. Adjust interventions or consider referral if improvement does not occur. If mood deteriorates refer to a general practitioner or specialist mental health practitioner.

1. Psychoeducation

• About depression: Explain that following a disaster, it is not uncommon for people to experience lowered mood, and sometimes clinical depression. Provide a general description of depression. It might be appropriate to use the Understanding depression and its symptoms handout as the basis for a discussion on the topic. Invite the individual to consider which of the symptoms they may be experiencing by completing the “Your symptoms of depression” handout.
• About the relationship between mood and activity: Initially, activity can fall away after disaster because people are too busy just coping with the problems caused by the disaster e.g., securing accommodation, attending medical appointments, dealing with insurance issues. Later, activities can fall away because people just don’t feel like doing them anymore, they may be avoiding places or situations because they cause distress, or because locations for activities may have been destroyed in the disaster. Regardless of the reasons, it is known that people become depressed, down, or apathetic when they no longer engage in pleasurable activities. When diminished interest in activities and negative feelings become long lasting, they begin to interfere with life. For some people, depression results from, and is maintained by, having more negative experiences than positive ones. To improve mood, increased positive experiences are needed alongside decreased negative experiences. Engaging in activities again will help reduce feelings of low mood and depression and enable the re-establishment of a sense of control, confidence, mastery and connectedness with others.
• Changing behaviours can produce changes in feelings. In the thought-feeling-behaviour relationship, it is easier to change mood for the better at a behavioural level through activities, rather than at the feelings level where most people try to change, but do so unsuccessfully.
• It might be appropriate to use the “The vicious cycle of depression” handout as the basis for a discussion on the topic.
• About strategies to increase activity levels: Describe ways in which engaging in activity may assist with an improvement in mood. Inform the disaster impacted individual that some activities may not be as enjoyable as before. Often it takes time to feel better when increasing one’s level of activity so be careful not to create the expectation that these activities will have a quick impact on mood. Prepare the individual for the possibility they may feel disappointed if they do not enjoy activities as much as they might have expected. Emphasise that it is still important to do activities as part of their efforts to rebuild a sense of control and wellbeing. Remember that the term ‘enjoyment’ should be used with some caution with disaster survivors with prevailing experiences of loss, sadness or hopelessness. Present experiences of enjoyment may be quite different from those prior to the disaster. Further, for individuals with ongoing mood problems such as depression or grief, ‘enjoyment’ can be too strong an expectation. It may also be necessary to address concerns that doing something enjoyable is, in some way, wrong or disrespectful to those who have died or suffered severe loss. It is important to emphasise that looking after themselves, and getting their life back on track, is their first responsibility. Staying miserable will not help others.
• Present a variety of rationales for increasing activity as a way of improving mood. Examples include:
  • Activity helps you to feel better – “At the very least, when you start engaging in some activity, it gives your mind something else to think about. Doing things, even a little at a time, can help to give you a sense that you are moving forward, taking control of your life again, and achieving something. You may even find enjoyment in the activities you do.”
  • Activity helps you to feel less tired – “Usually, when you are physically tired, you need rest. However, when your mood is low or you are depressed, the opposite is true. Sleeping more and sitting around doing nothing will cause you to feel more lethargic. Also, doing nothing leaves room for your mind to ruminate on depressive thoughts, which will contribute to a lowering of your mood.”
  • Activity can help you think more clearly – “Once you get started, you may find that you take a different perspective on particular problems in your life. Also, because your mind takes a different focus as a result of the activity, your thoughts may become clearer.”

2. Identify and plan two or more activities

Ask the disaster impacted individual to generate a list of activities they currently engage in, to get a sense of how much ‘fun’ and/or satisfaction they are gaining at present. Probe for activities that the individual has not engaged in since the disaster for whatever reason e.g., they were depressed or traumatised, too busy or local venues have been destroyed etc. Also explore those activities they have not tried but might like to.

It may also be helpful to use the Activity Menu below (inset link) to aid the identification of possible activities, particularly if the individual struggles to come up with any they used to enjoy or could try. If they still find it difficult to come up with activities, consider using the Pleasant Events Schedule (insert link), which provides a much more detailed list of possible activities.

Allow some time for the individual to review the activities generated through this process. Highlight the difference between categories of activities that are pleasure based and those that are responsibility/task based. The distinction is made with the aim of ensuring a balance between the two, to encourage participation in activities that, if completed, might produce feelings of pleasure as well as mastery. In considering this balance, it can be helpful to plan for activities that

• Allow for ‘downtime’ or relaxation
• Foster a sense of safety
• Encourage opportunities for closeness to loved ones
• Permit coping with new situations
• Afford social time with others or
• Increase opportunities for physical exercise

Your role in helping the disaster impacted individual select activities is to encourage a choice of activities that the individual might enjoy (pleasurable), might actually be able to do (achievable) and will be relatively easy to set up (practical). It may be necessary to be creative and flexible, and to problem-solve around possible barriers like transportation, money, or safety concerns. It may also be useful to include activities that provide a breather from everyday stressors, as well as activities that foster family time if possible, noting that the concept of family can also extend beyond blood ties – for example, to ‘community’.

Further, be mindful of potential safety issues surrounding activities. Individuals may be aware of the pre-existing risks in their environment, but their surroundings may have changed greatly since the disaster. For example, after a bushfire it would be wise to exercise caution when walking in bush land where damaged trees might fall over after being burnt.

Once activities are identified and discussed, work towards helping the individual select five activities and operationalising at least two of these in a plan for the week. These are written down in the Activity Monitoring Sheet (link). Encourage commitment to the two activities. Explain that scheduling the activities into the monitoring form can help “unstick” and motivate behaviour. Encourage awareness of mood before and after the activity, and ascribe SUDS ratings. This will allow the individual to observe the benefits or otherwise of having performed the activity. It also allows for barriers or issues to be explored if they do not experience any change in mood or increase in pleasure while completing the activity, with an eventual view to selecting different activities.

Also be aware that making time and creating space for activities can be quite challenging. When determining a time and place for activities, be sensitive to the impact of disaster-related reminders. Some activities may involve locations linked to the disaster or may bring up memories of a person who used to do the activities with the individual.

3. Follow up the activity scheduling

Follow up the activity scheduling exercise with the individual in the following session. You need to determine whether the activity was attempted, and if so, what happened and what was the impact on mood. The discussions should include:

• A review of each activity in turn: What did they do? How did they feel before and after the activity?
• What activities did they try out? If they did not try anything, explore reasons for the lack of follow through.
• When no improvement in mood is reported, revisit the rationale – that is, it may take time for pleasurable effects to emerge, that the effects are gradual/cumulative, that with effort, they will learn what activities help.
• How activities can be modified or assign/schedule new activities.
• How the activity schedule should be modified – If the individual reports improved mood, reinforce and encourage further activity. If no improvement in mood was noted, explore what happened and what got in the way. Often initial efforts to participate in potentially rewarding activities do not result in large changes in mood – rather, the effect of activity involvement is gradual or cumulative – so you need to reinforce the small gains or continued efforts towards these gains.
• Build on successes and continue to plan for an increase in participation in potentially rewarding activities over time.
• Consider accessing a published Behavioural activation treatment manual (Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised treatment manual. Behavior Modification, 35(2), 111–161. org/10.1177/0145445510390929)

Monitor the effectiveness of the intervention by tracking changes in mood relative to activities initiated. Increase engagement in satisfaction/mastery and pleasurable activities gradually. Continue monitoring, reassess as necessary and consider other interventions or referral to mental health specialists if increase in activity does not result in improvements in mood, or if mood deteriorates.

Recommended reading list:

• Jakupcak, M., Wagner, A., Paulson, A., Varra, A., & McFall, M. (2010). Behavioral activation as a primary carebased treatment for PTSD and depression among returning veterans. Journal of Traumatic Stress, 23(4), 491–495. doi.org/10.1002/jts.20543
• Lejuez, C. W., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised Treatment Manual. Behavior Modification, 35(2), 111–161. doi.org/10.1177/0145445510390929Wong, S. Y. S., Sun, Y. Y., Chan, A. T. Y., Leung, M. K. W., Chao, D. V. K., Li, C. C. K., Chan, K. K. H., Tang, W. K., Mazzucchelli, T., Au, A. M. L., & Yip, B. H. K. (n.d.). Treating Subthreshold Depression in Primary Care: A Randomized Controlled Trial of Behavioral Activation with Mindfulness. Annals of Family Medicine, 16(2), 111–119. doi.org/10.1370/afm.2206