It is a rather common experience of depressed patients that they feel not only sad but have a rather low energy level and get tired very easily. Many clients with depressive disorder have a lack of activation (esp. in the morning). Any task costs hard effort (even reading the newspaper in the morning is distressing and hard due to additional problems of concentration or memory).

It seems to be a natural idea to reduce activity or stay in bed all day, but this does not actually help to refresh or get new energy in case of depression. The reduction of every-day activities and the social withdrawal is a severe problem for most severely depressed patients and their family.

While most patients try hard to fight this energy lack this might cause additional impairment and a complete break-down.

What does Cognitive-behavioural therapy offer for this problem? First of all the therapist will recommend the patient to keep an activity diary. What does a normal day look like? What are your normal activities on a regular day (with depression), what was your life like prior to depression?

Sometimes this will be combined with a rating of the patient's mood. (e.g. 6 very low mood, feeling deeply depressed and hopeless) to 1 (feeling fine, no symptoms of depression).

Because of the impairment due to depression we do not expect good mood or high energy at the beginning of the therapy. A "normal day" of a 45 year old woman (Maren) with major depression might look like this:

• 5.30 Mood 6 (very, very bad) was not able to sleep, feeling tired, low energy. What a terrible day to come...
• 6:30 Mood 5 tried to get up. Decided to stay in bed for a while. Listened to the radio.
• 7:00 Mood 5 should get up to prepare breakfast for my family. Feel so blue and have no energy.
• 7:30 Mood 3 My son John prepared breakfast for me. First time I got help from a family member. Low appetite, but had some coffee and a snack.
• 8:30 Mood 5 I am alone in my house. Everyone gone. Feeling sad and despaired. Is there any hope for a change?
• 10:00 Mood 4 Therapy session with my psychotherapist. She wants me to make this diary... We talk about the activities of a normal day... She might be right. I should try to include some positive activities in my day...

This is just an example of such a diary. Most patients do not include positive activities in this schedule for the day. So they will have mainly bad or sad things to write down for the diary.

Cognitive behavioural therapy will try to focus on things that are positive for you. This is a very simple but effective approach. If you try to include more positive activities you have a higher chance to feel a little bit better. But if you do not plan or schedule these activities, they will not happen. So the therapist suggested a list of some positive activities to her patient. The "homework" for the next session with the therapist was to read this list of positive activities and to try at least one of them.

Maren decided to include a daily walk with her favorite dog Teddy at least 4 times a week in the morning (11:00).