Ever since I started an online community and foundation for treatment-resistant depression—depression and anxiety that doesn’t respond to psychotropic medications—I’ve been inundated with mail from desperate people who have tried 30 and 40 different kinds of antidepressants and feel no relief. I repeatedly hear from family members of folks who have tried everything and are not getting better. I sense the utter frustration and despair in their words and it pains me. I, too, felt hopeless after trying countless medication combinations and sitting through years of psychotherapy sessions only to continue my death obsessions.
I wish I could respond to each person individually—spend an hour on the phone with them, begging them not to give up because they won’t always feel this way. Unfortunately, I can’t (step six). So the next best thing is to outline these nine basic steps for people who are treatment-resistant because these actions, more than any medication I have tried in the last seven years, have helped me emerge from the other side of depression. I’m not anti-medication by any means. Drugs serve an important purpose. However, with so many people not responding or only partially responding (myself included), I felt compelled to list the other parts of my recovery that have been critical to my wellness—things that most doctors don’t discuss. These steps didn’t fix me for good. I have still have a lot of work ahead of me, and I have plenty of bad days. However, I have now been one year without the constant death thoughts that stalked me for a good five years. And that is truly miraculous to me.
I believe everyone has a chance at recovery, even those who have been depressed and anxious most of their lives.
I wish you good health with all my heart.
1. Identify Any Underlying Conditions
I would venture to say that most persons with treatment-resistant depression are also suffering from undiagnosed conditions. My list was long: Crohn’s disease, small intestine bacteria overgrowth (SIBO), hypothyroidism, low stomach acid (Hypochlorhydria), adrenal fatigue, Raynaud’s phenomenon and connective tissue problems, pituitary tumor, aortic valve regurgitation, and certain nutrient deficiencies (iron, vitamin D, and vitamin B-12).
It’s really best to work with an integrative or functional doctor. Many are listed on the website for the Institute of Functional Medicine. However, you need to proceed with caution because some of them are very expensive and will run unnecessary tests if you’re not careful. At the very least, I would ask your primary care physician or psychiatrist to run these four blood tests: a complete blood count (CBC); comprehensive metabolic profile (CMP); a thyroid full panel, including TSH, free T4, free T3, and thyroid antibodies (read Dana Trentini’s important blog on this); and the 25-OH vitamin D test as well as B-12 levels. It may also be worth finding out if you have a Methylenetetrahydrofolate reductase (MTHFR) gene mutation (present in 15 to 40 percent of the general population) because we need the MTHFR enzyme to convert folate to its active form, methylfolate and folate deficiencies make it difficult for antidepressants to work. In fact, many studies link low folate levels of depression.
I have actually learned more about my various conditions from the people on my depression forums and in books and articles than I have from sitting in doctors’ offices. The folks on Project Beyond Blue and Group Beyond Blue are working with nutritionists, integrative doctors, gastrointestinal specialists, and other experts and are experimenting with new things all the time and willing to share their experience with you for free. From them I have learned about certain supplements, protocols, and resources that have really helped mitigate some of my symptoms.
2. Eliminate Triggers of Inflammation
Certain foods and substances create inflammation in our bodies, including our brains, which leads to depression. Here are the usual suspects: sugar, gluten, dairy, caffeine, and alcohol. Some people, like my daughter, may have more dramatic reactions to dairy; whereas others, like my son, are more affected by gluten. Me? I can’t go near sugar if I don’t want the death thoughts to return. You won’t really know until you do an elimination diet and get rid of everything for a few weeks, and gradually add them back in (that is, if you tolerate them fine). I will warn you, though: You can’t cheat for those few weeks because your system has to be totally clean for you to identify the problem. A spike in cytokines, proteins that are pumped into our blood stream when our immune system is fighting off a foreign agent, happens when people are depressed. The process looks the same as when a person is fighting an infection of any kind. Unfortunately a lot of fun, processed foods that taste really good like Twinkies and Doritos can cause inflammation, but clearly some people are more sensitive to others. Here’s an easy rule to follow: if a food comes in a nicely marketed package (even with the words “gluten free,” “dairy free” and ESPECIALLY “sugar free”) and its ingredients contain a bunch of words that you don’t know how to pronounce, it’s not going to make you any saner.
And not to be a total killjoy, but it’s worth examining what other kinds of toxins you are immersed in daily. Those could be causing inflammation too. Not until three months ago did I realize swimming in chlorine a few times a week was probably contributing to my gut problems and my thyroid issues, both of which are critical to establishing a stable mood. So I switched to hot yoga (step five), and I began to feel better.
3. Go Green
Dark, leafy greens like spinach, Swiss chard, and kale fuel every system in your body more completely than any other kind of food. They are nutrition powerhouses, packed with vitamins A, C, E, K, and folate; minerals like iron and calcium; carotenoids; fiber; antioxidants; omega-3s; and phytochemicals. They are also a major source of chlorophyll, which, according to Green for Life author Victoria Boutenko, “heals and cleanses all our organs and even destroys many of our internal enemies, like pathogenic bacteria, fungi, cancer cells, and many others.”
I started to feel a little better when I swapped my sandwich at lunch for a salad full of greens and made a conscious effort to eat mood-lifting foods during the day; however, I began to really heal when I started drinking green smoothies. I realize I sound like an infomercial at this point, but the only way my body was able to easily absorb and process all the nutrients in the greens was when they were blended into very small pieces. Like most people who have been on medications for decades, my stomach acid was very low, so eating lots of raw vegetables and greens was producing bloating and gas. I was not happy when my husband spent $500 on a refurbished Vitamix, but it has proven to be one of the smartest investments we’ve ever made. Now I try to drink two smoothies each day and I really believe it has made a substantial impact on my health.
4. Heal Your Gut
Embedded into the walls of our intestines is an intricate enteric nervous system, consisting of some 100 million neurons that is often referred to as our second brain. In fact, the nerve cells in our gut manufacture 80 to 90 percent of our body’s serotonin. There’s also a complex collection of bacteria living in our guts that a substantial volume of research says impacts our mood. It’s fascinating stuff for people like me who have always suffered from gastrointestinal problems and never before connected the dots. In my article, 10 Ways to Cultivate Good Gut Bacteria and Reduce Depression, I outline some of the steps I have taken to clean up my gut. Among them I believe it’s important to consume prebiotic foods like garlic, onions, artichokes, leeks, and dandelion greens and probiotic foods like active-culture yogurt, kefir, pickles, and fermented foods. It’s also good to avoid the use of antibiotics as much as possible.
5. Do Yoga
Any kind of workout or movement lifts your mood—boosting our brain’s dopamine levels and providing endorphins –but some kinds of exercises are much healing than others, especially for people who have been depressed for decades, or have stress-related conditions like adrenal fatigue. Unlike other aerobic workouts like running or CrossFit that raise cortisol levels and essentially wear out your body, yoga lowers levels of this stress hormone that is critical to the maintenance of homeostasis and regulating immune responses, blood sugar, and central nervous system functions. Several studies illustrate how yoga tames the stress response by priming the parasympathetic nervous system and is therefore an effective therapy for depression and anxiety. I have tried different types of yoga, but the one in which I feel the most benefit is Bikram yoga, a sequence of 26 Hatha yoga positions and two breathing exercises designed to engage and heal all of the systems of your body. It’s not for everyone, as you’re stuck for 90 minutes in a room heated to 105 degrees (sweating helps flush out the toxins). But when I can get there on a regular basis (at least four times a week), I feel a profound, calming effect, and I have heard this from several other people who struggle with chronic anxiety and depression.
6. Reduce Stress
Depression is ultimately a stress disorder, a disease where stress is poorly managed by our bodies. It’s as if many of us with depression and anxiety have a new intern sitting at command central of our nervous system and she keeps categorizing stress responses incorrectly, sending them to the wrong department in our body. Moreover, she sits right next the fire alarm and keeps ringing it every time there is a hint of panic. However, new research from the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital has found that by eliciting the relaxation response we can immediately alter our gene expression tied to inflammation, metabolism, and insulin production—all of which impact our mood. We engage the parasympathetic nervous system by practices like meditation, yoga, deep breathing, massage, and prayer. Even a few long, deep breaths when you start to feel panicky can message the intern not to sound the fire alarm.
However, I have found that doing a “stress inventory” is also critical to getting well, an exercise where you list on one side of a sheet of paper everything that stresses you out and list on the other half everything that helps you feel better. Next you sit with all those things on the left side of the paper (what stresses you out) and have a brutally candid talk with yourself about why you are doing them (people-pleasing hang-ups? ego? confused priorities?) followed by a session where you find creative solutions to cross out as many as you can. I had a stress inventory with myself a few months ago, where I finally conceded that my health is not worth my trying to become a blogging superstar and bestselling author like Gretchen Rubin like I’ve always wanted to be or running a formidable nonprofit like BringChange2Mind. It was an epiphany moment when I realized that I don’t have to be anyone else in order to be okay. By working at my own snail pace I have enough time to do more of the things on the right side of the paper that make me feel good.
7. Take the Right Supplements
It can be overwhelming trying to figure out which supplements you need and how to distinguish between quality brands. ConsumerLab.com lists third-party tested supplements which should be safe to take. I’ve done a bit of research and found these manufacturers to be reputable: Prothera, Klaire Labs, Pure Encapsulations, Douglas Labs, Nature Made, Orthomolecular Products, Metagenics, Vital Nutrients, Truehope.com, OmegaBrite.com, and Carlson Labs.
In my post 12 Patient-Approved Natural Supplements for Depression, I list various vitamins and minerals that are good to take for your mood. However, here are the critical ones that I would start with: an omega 3 supplement, a probiotic, vitamin D, vitamin B-12, and a multivitamin. Because I have low stomach acid (as do many people who have been on medication for years), I find better results when I take a powder or liquid. I get my vitamin D and B-12 as a liquid from pureprescriptions.com. Blogger Lisa Richards has compiled an excellent list of the best commercial probiotics, her favorite being Health Origins 30 Billion or Prescript Assist. I take Ther-Biotic Complete Powder because it contains all of the different strains of bacteria that I need for my unique gut situation (Crohn’s plus significant intestinal bacteria). A few months ago I started taking a multivitamin called EmpowerPlus Powder from TrueHope.com after I read through all the research studies using this specific micronutrient to help treat different mood disorders and watching Julia Rucklidge’s inspiring TEDx Talk about nutrition and micronutrients. Finally, I get my Omega 3 supplement from OmegaBrite.com because their capsules contain 70 percent EPA (eicosapentaenoic acid) in a 7:1 ratio of EPA to DHA (docosahexaenoic acid). New research has confirmed the positive effects of EPA on mood, even more so than DHA, as it provides a natural balance to omega-6 arachidonic acid. Nordic Naturals is also a reliable brand. If you do have a MTHFR gene mutation, it’s a good idea to supplement with l-methylfolate, the bioavailable form of folate.
8. Protect Your Sleep
From all my research on mood disorders over the last ten years and conversations with people who can’t get well, I’d say that chronic stress and disrupted sleep cycles are the two biggest factors that prevent a person from climbing out of the depths of depression. Unfortunately where there is depression, there are usually sleep issues. Volumes of studies have documented the devastating effects of sleep on mental health, like the one by the American Academy of Sleep Medicine that found that the heritability of depressive symptoms in twins with very short sleep was nearly twice the heritability in twins sleeping seven to nine hours per night.
Because I am such a fragile creature, I have had to move up sleep on my priority list from about no. 7 to no. 1. I protect it with everything I have. This means I no longer wake up at 5 a.m. to work out. I sleep in, exercise later, and am much less productive during the day (step six). However, by sleeping eight hours a night, I am more resilient to mood swings. I have had to adopt strict sleep hygiene rules to ensure that I don’t end up with the kind of miserable insomnia I had two years ago: I shut off the computer at 7 p.m., leave my phone downstairs (not next to my bed) and don’t check messages after 8 p.m., and try to be in bed by 10 p.m. every night. I also have started to use lavender oil, and take melatonin and a combination of magnesium and calcium at night, which does seem to calm me.
9. Find a Purpose
Nietzsche said, “He who has a why to live for can bear almost any how.” Last summer, when I began to think that I would never be without debilitating death thoughts, I clung on to that logic and to the inspiring words of Holocaust survivor and famous psychiatrist Viktor Frankl, MD, PhD. If a person has found a purpose in life, he explains in his classic Man’s Search for Meaning, “even the helpless victim of a hopeless situation facing a fate he cannot change, may rise above himself, may grow beyond himself, and by doing so change himself.” Upon finishing that book, I had no doubt about my purpose in life: to help persons who have been battling depression and anxiety for most of their lives … those that, like me, have spent years in the offices of psychiatrists trying so many drugs and yet dream of a flattened pulse. So I started my two forums and a nonprofit dedicated to treatment-resistant depression. They haven’t cured me of my symptoms, but I can honestly say that committing to a purpose last summer is what brought me hope in a period of desperation. For the first time I could see myself living a meaningful life despite the persistent ruminations clogging up my brain. When I began to help another person off the ledge, I often forgot about my own obsession to jump. I think Nietzche and Frankl are right. Meaning and purpose can serve as a kind of anesthesia to pain; focusing on your small role to make the world a better place positions your suffering into a larger perspective that leads to peace.
Join ProjectBeyondBlue.com, the new depression community.
Originally published on Sanity Break