8 Things to Consider When You’re Not Getting Better


armonkmed.comI keep getting the same email over and over again, and my heart aches each time I read it: “I have tried everything to overcome my depression, but nothing has helped. Is there anything else I can do or will I have to live the rest of my life plagued with sadness?”

First, hear these three words: there is hope. If there wasn’t any, I would not be alive writing my blog. I am one of the worst cases out there like you are. I have spent more years of my life fantasizing about death than wanting to be alive. I get it. But now I do enjoy some really good days—where I feel better than I ever have. And those good days keep me motivated to get through the harder ones. From my own 43 years of experience fighting the demon of hopelessness and from all my conversations with folks in my online depression community, Project Beyond Blue, here are some suggestions that you might try.

1. Get a Physical

The reason that you may not be getting better despite trying 20 different combinations of medication is that your symptoms of irritability, fatigue, and apathy are not caused by a lack of serotonin or norepinephrine in your brain, rather a tear in your diaphragm, or a problem with your aortic valve. A few conditions that are often misdiagnosed as depression are: hypothyroidism, Vitamin D deficiency, Vitamin B-12 deficiency, insulin resistance or blood sugar imbalances, and anemia. (See my piece, “6 Conditions That Feel Like Depression But Aren’t”). You should really get a physical and have some blood work done by an integrative or functional doctor; however, that can be costly, especially if you get a functional doctor who wants to run every test on you.

I asked my integrative doctor, Alan Weiss of Annapolis Integrative Medicine, to give me a list of the three or four most important blood tests a person with chronic depression should ask their primary care physician to do for them, if they can’t afford to go outside their insurance network for a consultation. He suggested:

  • Complete Blood Count (CBC)
  • Comprehensive Metabolic Profile (CMP)
  • Thyroid testing, including TSH, free T4, free T3, and thyroid antibodies
  • 25-OH Vitamin D, B-12 levels

2. Check Your Thyroid

I want to return to the thyroid for a moment since this is so tricky and so critical. Every person I know that suffers from chronic depression has a thyroid issue. That is no lie or exaggeration. Every person. Think. I was seeing an endocrinologist, someone who specializes in thyroid disease, for six years and she never tested me for an underactive thyroid. She was merely testing my TSH levels, not the full panel. Which is what most primary care physicians, endocrinologists, and psychiatrists do. Dana Trentini writes a great post, “The Top Five Reasons Doctors Fail to Diagnose Hypothyroidism” on her blog “Hypothyroid Mom.” If you are sluggish, gaining weight, have brain fog, need to lie down all the time, and are depressed, please have a FULL panel of your thyroid done. Your T3 and T4 levels are needed to detect slight problems that can wreak havoc with your mood and energy level. Now that I am taking natural medicine for that, I have much more energy.

3. Load Up on Vitamin D and Vitamin B-12

I was relieved that Dr. Weiss included blood tests to check vitamin D and vitamin B-12 levels, as well, because deficiencies in both of those vitamins can cause severe depression. They are included in my list of “10 Nutritional Deficiencies That Can Cause Depression.” According to a 2009 study published in the Archives of Internal Medicine, as many as three-quarters of U.S. teens and adults are deficient in vitamin D. Last year Canadian researchers performed a systematic review and analysis of 14 studies that revealed a close association between vitamin D levels and depression. Researchers found that low levels of vitamin D corresponded to depression and increased odds for depression. In another 2009 study, more than a quarter of severely depressed older women were deficient in B-12. I take each of those vitamins in liquid form so that they absorb quickly and efficiently.

4. Adjust Your Diet

If you are annoyed at this suggestion, let me say I understand. I was annoyed for the first 40 years of my life when someone would insinuate that there was a tight connection between my diet and my distorted thinking. I thought I ate well. By most American standards, I was a health freak. However, I didn’t realize how much insulin I was throwing into my bloodstream until I stopped eating all sugar cold turkey one day, as well as processed flour, dairy, and caffeine. (Alcohol is bad news too but I gave that up 25 years ago.) All those nut and fruit KIND bars that are supposed to be good for you, the honey in my tea, the cereal and pumpkin bread in the morning … all of them were creating a blood sugar nightmare that got me high only to make me crash … and hard. No street drugs were involved. Just a lame granola bar that I thought was sanctioned by Dr. Oz. Consider eliminating sugar and white flour from your diet for a few months. As much as I’d like to tell you that the effect was immediate, it took up to nine months before I really started to feel better, before I was free of death thoughts.

5. Get a Consultation With a Teaching Hospital

Before my husband begged me to make a consultation at Johns Hopkins Mood Disorders Center, I had been to six psychiatrists. One of my blogs, in fact, is called “The Psychiatric Guide to Annapolis.” Let me just say that there are a lot of people who shouldn’t be practicing medicine, like one I dubbed “Pharma King,” who was generous kickbacks from a pharmaceutical company. The reason I trust teaching hospitals like Johns Hopkins, is that they never stop researching, and they are not afraid to use the older drugs like Lithium that have proven track records but aren’t lucrative. Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins, wrote an excellent op-ed piece in the New York Times just after the death of Robin William called “Depression Can Be Treated, But It Takes Competence.” She writes: Many different professionals treat depression, including family practitioners, internists and gynecologists, as well as psychiatrists, psychologists, nurses and social workers. This results in wildly different levels of competence. Many who treat depression are not well trained in the distinction among types of depression. There is no common standard for education about diagnosis.” Go to a teaching hospital. You won’t regret it.

6. Consider Transcranial Magnetic Stimulation (TMS)

Transcranial magnetic stimulation (TMS) is a non-invasive procedure that stimulates nerve cells in the brain with short magnetic pulses. A large electromagnetic coil is placed against the scalp which generates focused pulses that pass through the skull and stimulate the cerebral cortex of the brain, a region that regulates mood. The procedure was approved by the FDA in 2008. In September, I featured a story about Stephanie, a woman in Project Beyond Blue, who underwent 30 sessions of TMS and was transformed into a new person. She now moderates a group on Project Beyond Blue called “Exploring TMS.” Several other people I know have had success, as well.

7. Try Eye Movement Desensitization and Reprocessing (EMDR) Therapy

My friend Priscilla Warner first turned me on to EMDR. She devotes a chapter in her bestselling memoir “Learning to Breathe” about it, and how it was instrumental in breaking down her anxiety. It is mostly used for people with some form of Post Traumatic Stress Disorder (PTSD), but it has also been used to address generalized anxiety from a dysfunctional childhood, a bad marriage, or a boss from hell. According to the EMDR Institute, “EMDR psychotherapy is an information processing therapy and uses an eight phase approach to address the experiential contributors of a wide range of pathologies. It attends to the past experiences that have set the groundwork for pathology, the current situations that trigger dysfunctional emotions, beliefs and sensations, and the positive experience needed to enhance future adaptive behaviors and mental health.”

8. Find a Way to Lower Your Stress

I don’t mean putting a few less to-do items on your list. I’m talking about radical lifestyle changes—like changing jobs in order to work in a less toxic and stressful environment, moving into a smaller home so that you don’t have to moonlight, deciding against adopting a rescue dog or having a third child. It can be practically impossible to keep your mood resilient if you are under chronic stress because it increases the connection between the hippocampus part of your brain and the amygdala (worry central), impairs your memory retention, affects your cortisol production (making it difficult for you to handle more stress), and weakens your immune system.

There are other ways to try to lower your stress besides quitting your job, like practicing mindfulness meditation. I took the eight-week Mindfulness-Based Stress Reduction (MBSR) program at my local hospital because I read numerous studies on how mindfulness meditation can reset neural passageways and change rumination patterns. As a result of the class, I am now more aware of my thinking, and I try my best to keep coming back to the present. However, nothing beats the anesthesia from depression and the calm I experience after an intense aerobic workout. I swim and run for my sanity.

In summary, the road to my recovery has been rocky as hell. I had to throw out the old system—my belief that medication, therapy, and exercise was all I needed—that the brain lived in another solar system as my body. I now believe that you must approach the illness of depression systematically: there is nothing that you eat, say, or do in your day that doesn’t affect your mood. While that thought can be overwhelming, it also points the way to hope.

You are not a lost cause.

Join conversations like “Hypothyroidism & Depression” and “Nutrition” on “Project Beyond Blue,” a new community for persons with treatment-resistant depression.

Published originally on Sanity Break at Everyday Health.

Image: armonkmed.com

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Therese Borchard
I am a writer and chaplain trying to live a simple life in Annapolis, Maryland.

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6 Responses
  1. Therese, excellent starting points! I suspect you pared down the rough draft from a much longer list. Where would you place adjusting our expectations? I realize “it depends” – on one’s unique circumstances.
    Along with MDD, etc., I also struggle with OCD, boundary issues, self-doubt …. Rhetorically, how many resources (time, money) to invest in each effort, and for how long, and how does one know if a specific attempt is even on target, i.e. vetting the physician, understanding and prioritizing test results. Every day feels like I’m starting over, from the beginning, hopeful, but lost, different stressors, new obstacles, new priorities to weigh. I so often don’t know whether a med/combination, diet change, activity, effort, etc., is having a positive effect. I don’t even know it this makes sense…. But I believe that if I follow your blog, try your suggestions, participate in PBB, challenge my pdoc, pay closer attention to my limits, learn more about my illness, and keep pushing ahead … something better will (hopefully) happen.

    1. Carl A. Nesselbush

      Thanks for sharing, John. I just found PBB and was so moved by Therese’s honesty I contributed to her Foundation fundraising. I struggle with wakeup every day challenged to “feel better.” I have learned from her to never try explain myself to anyone not so afflicted. They can’t possibly “get it.” My therapist has also suggested I try to focus on daily “healthy” activities as you exactly mention. My new Psych has changed my meds and ordered the requisite blood tests and follow up appt. Like you, I’m following orders, not drinking and trying to live into health. Here’s hopin’ for both of us!! CAN

  2. sarah

    On my good days my partner tells me I’m manic… that it feels fake and he’s waiting for the balloon to burst. What do you do?

  3. Carl A. Nesselbush

    I went to a psychiatrist (4th one but first in a new city) who again dx’d me as B/P affective disorder and OCD. Prescribed Lithium and kept my Lamictal going. He asked me if I was irritable. I said no then came home and my brother laughed and told me I am ALWAYS irritable. He gave me several examples which I never realized were symptomatic. I’m writing him a letter correcting my answer and providing some examples (as any OCD person will feel compelled to do) and reminding myself that any OCD person will eventually start calling this CDO (alphabetized, of course!). My therapist has me concentrating on healthy activities
    eg. exercise, church, going to the library(reading), eating well and not to focus on the big issues of failure that haunt me. I need a manic day soon!