Depressive episodes plagued me during much of my younger life. There were periods of absenteeism in high school, and a blanked-out period in college that only made sense, in retrospect, as the result of an untreated mood disorder. And so, shortly after my 30th birthday, I resorted to a selective serotonin reuptake inhibitor (SSRI) to help manage my mental health, in the hopes that rebalancing my serotonin, a critical neurotransmitter, would alleviate my recurring suffering.
But nearly a decade later, my mind felt hazy and muted, and I wondered if the chemical was dampening my ability to fully experience my life. After reading studies that suggested the drug’s efficacy was little better than a placebo, I decided to stop taking it — abruptly, then and there.
I felt better than I had in years. For about two weeks, I was clear-headed, at times almost euphoric.
It didn’t last.
Like a farmer in a field watching the skies cloud over, I felt a storm of darkness descend. I spent hours sitting on the edge of my bed, unable to gather the threads of my thoughts. When I could connect with the essence of myself, the experience was repugnant. I observed thoughts of self-harm with cold detachment. I knew I had the will to survive this, but it was frightening.
The road to well-being turned out to be longer, and more complex, than I anticipated. I resumed the meds, but I also focused on diet and exercise. I entered talk therapy. I revived a long-dormant meditation practice. It was by no means a swift or linear process. But over the course of about five years, it has led me to a life of greater awareness and connected happiness — without SSRIs. It began when I learned to see my depression in an entirely new way.
Today, many health professionals are viewing mental suffering in the context of the whole person, rather than reducing it to an imbalance of brain chemicals. Along with this more complex understanding, nonpharmaceutical treatments have emerged that are changing lives and improving health from the ground up.
It starts with getting out of our heads.
A Constellation of Factors
Depression can be unbearable. The mind turns on itself, at times spiraling into self-loathing and despair or becoming glassed-off and benumbed. The World Health Organization estimates more than 300 million people suffer its effects — about 4 percent of the global population.
Its cause resists explanation, though not for lack of trying. The ancients described depression as a defect in physical essence; healers in the Middle Ages believed it to be a spiritual sickness brought on by demons.
We now understand that dysregulated neurochemicals, including serotonin, play a more crucial role than spiritual demons (not that this mitigates depression’s often-biblical intensity). As such, physicians commonly prescribe SSRIs.
Yet a growing number of healthcare professionals are viewing depression as a symptom of multiple underlying issues — including disrupted gut health, vitamin deficiencies, genetic factors, toxic exposure, thyroid imbalance, and sleep disturbances. They believe that it’s only when we get to the root causes that we can truly begin to heal.
“Many roads lead to Rome in terms of depression,” says neurologist David Perlmutter, MD, author of Brain Maker. “It’s clearly multifactorial, and we’re miles away from the Newtonian idea that a shortage of one chemical leads to depression — and that things can be fixed if we give the individual more of that chemical.”
SSRIs do work for some people, but not all. Even as more than 12 percent of Americans take an antidepressant drug, rates of depression continue to rise.
Diagnosis can be challenging. There is no reliable test for serotonin deficiency. And while most people with depression have symptoms in common, they also vary widely: Some can’t sleep; others sleep much of the time. Some are full of self-loathing; others lash out. Yet almost all sufferers are prescribed the same class of medicines.
“Our diagnostic skills with depression are not where they necessarily need to be,” says integrative psychiatrist Henry Emmons, MD, author of The Chemistry of Joy. He believes that pharmaceutical treatments can be effective in manipulating brain chemistry for short-term relief, but that more reliable, lasting effects come from rebuilding systems throughout the body and mind. Emmons and other integrative health experts recommend starting with the following strategies.
Heal the Gut
A depression-free mind hosts a healthy balance of neurotransmitters that travel freely along the major neural pathways. These include glutamate (involved in cognition, learning, and memory); GABA, which calms the fight-or-flight response; and, of course, serotonin.
Serotonin is the feel-good neuro-transmitter, and an estimated 90 percent of it is produced in the gut. Because of this, Perlmutter prefers to focus first on his depressed patients’ gut health, rather than simply adding more serotonin to the brain.
“We’re treating the smoke and ignoring the fire,” he explains. A leaky gut — triggered by food intolerances or harmful gut bacteria, among other things — can disrupt the production of serotonin. It can also create systemwide inflammation, which contributes to depression: One study found that 35 percent of patients with depression showed signs of leaky gut on blood tests.
Perlmutter treats patients suffering from almost any brain-related disorder with a healing protocol for the gut and microbiome. It includes eating fermented foods to add good bacteria to the gut, as well as prebiotics (such as onions and garlic) to fertilize those bacteria; lowering sugar consumption to avoid blood-sugar crashes; increasing the intake of high-quality fats; and consuming moderate amounts of coffee, tea, and wine. (For more on how a healthy microbiome can protect the brain, see “Healthy Gut, Healthy Brain.”)
Address Vitamin Deficiencies
A lack of key nutrients can exacerbate or even trigger depression. In his book Unstuck: Your Guide to the Seven-Stage Journey Out of Depression, psychiatrist James S. Gordon, MD, singles out nutritional deficiencies from a host of contributing factors.
“The majority of people in the United States are deficient in one or more of the essential micronutrients,” Gordon notes. He believes depression is “powerfully affected” by our nutrient consumption — or lack thereof.
B vitamins, in particular, are crucial to mood regulation. Low levels of B-6, B-9 -(folate), and B-12 have all been correlated with depressive symptoms. This could be due to the role B vitamins play in methylation, which supports the body’s energy production, detoxification, and creation of beneficial neurotransmitters.
Omega-3 fatty acids are another key player. “Because the brain needs a steady supply of omega-3s to function properly, people who don’t eat enough of these fats are at greater risk of developing mental illness,” notes University of Kansas psychology professor Stephen Ilardi, PhD, author of The Depression Cure: The 6-Step Program to Beat Depression Without Drugs. He adds that populations who consume the highest levels of omega-3s, such as the Japanese, show the lowest levels of depression.
In his Therapeutic Lifestyle Change (TLC) protocol, Ilardi recommends daily dosages of omega-3 fats for depressed patients: at least 1,000 mg of EPA and 500 mg of DHA.
Gordon advises taking a daily B-vitamin complex that contains 15 to 50 mg of B1, 10 to 50 mg of B2, 50 to 100 mg of B6, 400 to 1,200 mcg of B9, and 1,000 mcg of B12.
Minimize Toxic Exposure
Depression is sometimes a chemical problem — but not a neurochemical one. A study of farmers who used pesticides found that those with the greatest exposure were 50 percent more likely to be diagnosed with clinical depression than those with the least. That risk increased to a staggering 90 percent if they used a class of toxic insecticides and herbicides that includes organophosphates — banned for home use but still allowed in commercial agriculture.
Research has also shown that toxicity from heavy metals, such as lead and mercury, can cause a variety of disorders, including anxiety, panic attacks, and major depression.
Because there are often pesticides in our food, lead in our water pipes, and airborne toxins from nearby roadways, limiting exposure can be tough, but lifestyle adjustments can help. Even simple measures — replacing commercial cleaning products with vinegar and water, for example, and avoiding chemical lawn treatments — make a difference. You can also support the body’s own detoxification systems by eating plenty of organic, whole foods and exercising regularly.
Check Your Thyroid
Weighing less than an ounce, the thyroid gland nevertheless has a big role in physical and mental health. It secretes hormones that affect every part of the body, including the brain.
When levels of these essential hormones are low, organs and body-system functions slow as well, leading to a variety of symptoms that can include decreased sexual desire, weight gain, and depression. Called hypothyroidism, it’s often triggered by an autoimmune condition in which the body attacks thyroid tissue as if it were an invasive enemy. It affects up to one in five women by the age of 60 — many of whom are mistakenly given antidepressant medications instead of thyroid treatment. Men are affected as well, but at a lesser rate.
Thyroid imbalance is a common reason why the body resists a multifaceted treatment approach to combating depression, according to Ilardi. Resetting this gland typically involves a combination of diet and lifestyle interventions — beginning with eliminating gluten, which can imitate thyroid tissue in the body and provoke an autoimmune reaction.
Consider Your Genes
When I first attempted to quit my SSRI, there was little discussion of how a genetic predisposition to depression might work, and I always assumed there was nothing I could do about my family history. But recent research has revealed some new paths of intervention.
Single nucleotide polymorphisms (SNPs, pronounced “snips”) are gene variations passed through generations; they affect various functions in the body. Up to 40 percent of us (including me) carry a SNP called MTHFR that impairs the processing of B vitamins. This hampers the methylation process, which is part of the clearing of ordinary toxins and production of neurotransmitters needed for mood stabilization and mental health. So what gets passed down is not a gene for depression, but a SNP for methylation issues that can precede it. And methylation issues are treatable.
San Rafael, Calif., functional physician Myrto Ashe, MD, uses genetic markers as part of a multipronged approach to depression. She emphasizes the importance of treating depression as a symptom rather than a disease.
“That’s where functional medicine shines,” Ashe says. “We say: ‘Let’s look under the hood rather than focus on a warning light on the dashboard.’ We are not machines, after all. We are intelligent, self-healing organisms.”
Ashe orders genetic tests for patients with family histories of suicide, alcoholism, and homelessness. She notes that nearly all are positive for a variation in MTHFR; this helps shape her treatment approach. Her protocol for depression includes methylated B vitamins and increased exercise, which has a proven track record of relieving depressive symptoms.
Get Plenty of Sleep
Sleeplessness or oversleeping is not just an inconvenient side effect of depression; it can also be a trigger.
“I think the quality of one’s sleep is the absolute most important lifestyle factor in being able to fully recover from depression, and in preventing a recurrence of it,” says Emmons.
Every cell in the human body is essentially a molecular machine that has evolved to function on 24-hour rhythms. The circadian sleep cycle is tied into neurochemistry, and it evolved under conditions that are often contradicted by modern life. Our bodies work best if we go to sleep when it’s dark and wake when it’s light, but our lifestyles generally don’t allow for this.
Ilardi encourages his patients to revise their schedules as best they can to favor better sleep — which means a regular bedtime and about eight hours of sleep a night.
“Depression manifests in so many distinct ways from one patient to the next,” he says. “One patient’s main driver might be sensitivity to light deprivation. For somebody else, it’s an anxiety level so great that they have horrific insomnia with the loss of restorative slow-wave sleep at night reinforcing their depressive illness.”
While each patient will need different approaches in an overall treatment plan, Ilardi prescribes light exposure for 30 minutes a day, ideally in the morning, as a vital tool for restoring disrupted circadian rhythms. (A walk outdoors or a 10,000 lux lightbox both work.)
“I believe that if people just protected their sleep, they could do a lot of other things wrong and stay pretty mentally healthy,” says Emmons. “People who improve their sleep and normalize it double their chances of recovering from depression.”
The Basics of Getting Better
My initial attempt to stop taking an SSRI failed; I returned to it after a hiatus of just a couple of weeks. Several years later, I was still taking it. But even with a daily dose of chemicals in my system, I had a prolonged depressive tailspin. I felt alternately numbed (whether from the medication or the depression, I’m unsure to this day) and agitated, my mind spiraling with a high-speed rumination I couldn’t stop.
I was fortunate to discover a talented psychotherapist who, in addition to finding a knowing, insightful groove in our talk sessions, was an avid student of integrated health strategies. Many of the behavior changes he advised me to try are becoming more mainstream today.
These included the dietary modifications Perlmutter outlines for gut health, along with supplements such as B vitamins and omega-3 fats. Consistent exercise was another. Getting adequate amounts of daily sunlight and focusing on regulated sleep rounded out his body-based recommendations.
It didn’t stop there. Any integrative approach also acknowledges that depression has a social and spiritual component. Humans evolved as social creatures, yet today more people than ever live alone, and even such basic communal activities as shopping are disappearing in an increasingly digital economy.
Gordon says social interaction is as essential as diet and exercise. He recalls one depressed patient who simply checked in with her best friend on the phone for five minutes every day. Along with other experts, Gordon also emphasizes a mindfulness or meditation practice to reduce stress and provide perspective on troubling thoughts and feelings.
He advances the provocative notion that depression can be an opportunity of sorts: an imbalance that is summoning the sufferer to move onto the next phase of life.
“[The capacity for depression] is built deep into human DNA and our earliest understanding of aboriginal healing,” he says. “When people get into states of depression, illness, and trauma, these states have the potential — if understood rightly — to lead to a new stage in our development. We have to accept them, and embrace them for that possibility, and then be willing to sit with them, experience them, and learn from them in a way that opens these doors.”
Indeed, if our diet, our environment, and our way of life are harming our mental health, depression might be a crucial wake-up call.
For my part, about a year after I began psychotherapy and implemented lifestyle changes that included dietary modification, daily exercise, and meditation, I was finally able to stop taking my SSRI — this time under a careful tapering-off plan advised by my physician.
I haven’t had a depressive episode in the two-plus years since.
I can feel it sometimes, a flash of despair, a strange voice in my head, pointing the way back into the darkness. But properly fortified, and thanks to a daily mindfulness practice, I have learned to let those clouds pass like the weather. As many others have done, I’ve found an integrated way to retain the memory of depression as the spark that compels me to work toward a more balanced and sustainable existence.
This originally appeared as “It’s Not All in Your Head” in the March 2018 print issue of Experience Life.