Let’s say you twisted your ankle and it’s causing unbearable pain. You’ll likely go to a doctor, who will examine you and probably order an X-ray. If it’s just a sprain, you’ll be advised to apply ice, elevate and stay off it, and you’ll need crutches to get around for a while. If it’s a break, you might get a cast or a brace, or possibly an appointment with a surgeon, and some time off to heal.
But what happens when your unbearable pain isn’t visible, can’t easily be explained or diagnosed, and doesn’t have a commonly accepted medical treatment? For people who suffer from serious depression, there’s no one cause to pinpoint, no one way to treat it and certainly no definitive solution.
“It’s a basic human need to want a concrete explanation about an illness so it can be predicted and controlled,” says Carolyn Occhipinti, PsyD, a Portland, Oregon–based licensed psychologist in private practice. “The mind and body are intricately connected, and mental illness is related to neurochemical changes in the brain. But being told this isn’t always enough for people, or for their friends and family.”
Major depression is more than just feeling down. Mental health professionals rely on diagnostic criteria that include a persistent sad, anxious or “empty” mood; feelings of hopelessness; irritability; decreased energy or fatigue; difficulty sleeping; and loss of interest in hobbies or activities that were once pleasurable. Generally, if you meet five or more of the criteria, you’ve got some form of depression. After more than two weeks, it’s called major depressive disorder; if it lasts two years or more, it’s named persistent depressive disorder.
A combination of genetic, biological, environmental and psychological factors can cause brain changes, as can unique circumstances like grieving, a serious physical illness, or hormonal changes after childbirth or during menopause. The Journal of the American Medical Association reports that depression affects women at twice the rate as it does men, regardless of racial, ethnic or economic factors. In fact, 20 percent to 26 percent of women will experience depression in their lifetime, compared to 8 percent to 12 percent of men.
Suffering in silence
Here’s the kicker: Nearly 60 percent of those suffering from depression do not receive treatment of any kind. Barriers include lack of insurance, financial concerns and a nationwide shortage of mental health providers, but guilt and shame are also to blame, says Alicia Clark, PsyD, a licensed psychologist in Washington, D.C.
“A stigma endures about mental illness,” Clark says. “People still feel guilty about being depressed, like it’s their fault. They’re embarrassed to admit to anyone that they’re suffering, and they think others will judge them, so they’re reluctant to seek help.” Plus, she adds, depression can cause lethargy, so a depressed person often doesn’t have the energy to take action.
For example, Christine, who grew up in Chicago, didn’t get the help she needed when she was a teen, and she partially blames the stigma that persisted in the 1970s.
“I first realized there was something wrong when I was 15,” she says. “I was having bouts of crying and anxiety, and I couldn’t concentrate in school. I asked my mom if I could go to a therapist, and she said ‘No, we solve problems on our own.’ I went to the county mental health service and saw one anyway, but they told my mom and that was the end of that.”
Leaving depression untreated is dangerous, Occhipinti warns. “Ongoing depression can worsen, leading to lost work and income, strained relationships and a loss of your support network—and thus a higher risk of addiction, serious physical illness and suicidal thoughts or actions.”
Christine can attest to those dangers. “I didn’t see a therapist again until I was in my 30s, and by then it had progressed to the point where the pain was unbearable. I didn’t even want to get out of bed most days, and I attempted suicide a few times.” Today, 20 years later, she’s functioning much better, thanks to a new therapist and a highly effective medication that she says saved her life.
First, tell someone
“It doesn’t matter what the causes are,” Occhipinti says. “If you’re feeling depressed and it’s interfering with your normal functioning, then telling someone is the first step.” That could mean a pastor, a school counselor, a therapist or a primary care physician.
Tyler Friedrich, MD, a hospitalist in Denver, encourages patients to speak up. “Appointments are pretty quick, and we can’t always cover everything in one visit,” he says. “But if I have even the slightest indication that there’s a mental health issue, there’s a two-question screening tool.” That test, called a Patient Health Questionnaire 2 (PHQ-2), assesses your feelings over the past two weeks. “If you flag positive, we move to a more diagnostic test, the PHQ-9,” he says, adding that the PHQ-2 is given automatically to veterans every six months. Although primary care doctors do have some tools to help with depression, such as the ability to prescribe medications and discuss possible lifestyle changes, most will refer you to a therapist.
If you see a therapist, she or he will first conduct a thorough assessment by delving into your medical history, family medical history, possible childhood trauma and daily lifestyle—including diet, exercise, prescriptions, job stress and relationship issues. Then you and the therapist will discuss what to do, which may include new or changed habits and a specific therapy (there are hundreds, including cognitive behavioral therapy and emotion-focused therapy). “The best therapist will assess how you function and what works for you in your life,” Clark says.
Confidence in your therapist is essential, so if you aren’t comfortable with the one you choose, keep trying, says Clark. Many organizations (see Online Resources) offer advice on choosing a therapist. The Anxiety and Depression Association of America (adaa.org) offers a list of questions you should ask potential counselors, including practical ones (“Do you accept my insurance?”) and more clinical ones (“What is your treatment approach?”).
Occhipinti, Clark and Friedrich all agree: Overall attention to your health is crucial to overcoming depression.
The first line of defense: correcting any nutritional deficiencies, particularly those that increase inflammation in the body. “If depression is viewed as a chronic, low-level inflammatory disorder or a lack of certain nutrients, then it makes sense to focus on lifestyle changes that replenish nutrients and reduce inflammation, such as avoiding sugar and processed foods, taking minerals and B vitamins, and eating omega-3 fats and antioxidant-rich foods like turmeric, green tea, kale and broccoli,” says Robert Rountree, MD, Delicious Living’s medical editor. Nutritionists also recommend salmon, leafy greens and lentils as research- backed “mood boosters” (check out our delicious good-mood recipes).
In addition, solutions might include getting back to the gym or getting out of a toxic relationship, Clark says. Self-medicating with booze, which may seem to offer temporary relief, can actually worsen depression symptoms and can also prevent antidepressants from working as they should.
Numerous studies show the benefits of regular exercise on mood because it releases brain endorphins, neurotransmitters related to an enhanced sense of well-being. In fact, a 2013 study at Harvard Medical School showed that, for some people, exercise is just as effective as antidepressants at treating depression—although the report cautioned that exercise alone isn’t enough for someone with severe depression.
If you’re not ready to get out and run a mile, don’t worry; endorphins also release when you laugh, have sex, dance, get acupuncture and eat your favorite foods.
Meds might help
According to the National Alliance on Mental Illness (NAMI), supplemental vitamins and minerals have been shown to lessen mental illness symptoms in some people, whether taken instead of or in addition to antidepressants. Some vitamins, like folic acid and vitamin B6, can even improve antidepressants’ effectiveness. Talk to your doctor about the options.
But if you’ve been stuck in major depression for a while, don’t discount the real benefit that gentle, nonaddictive medications can provide. Talk to your doctor, psychiatrist or nurse practitioner about the options (psychologists and licensed therapists cannot prescribe medications). “In my experience, a combination of the nutritional approach with medication often works better than either one alone,” says Rountree. “For example, research shows that folate can enhance the effects of SSRIs [antidepressants].”
If you choose medication, give it time; doses are intentionally low, and effects are gradual. Because of this, many people—more than 50 percent, according to NAMI—decide to stop taking meds before they see any results. Reasons include fears about becoming addicted (even though antidepressants are not addictive or habit-forming), lack of insurance or money to pay for meds, or a temporary improvement that leads people to believe they don’t need meds any longer.
Some people also stop taking antidepressants after experiencing normal, minor side effects, Occhipinti says, especially in the first two weeks. “The side effects in the beginning, like dry mouth and upset stomach, can be unpleasant, but those usually subside. It’s important to stay on most meds for a full four weeks [to start].” If symptoms haven’t improved by then, talk to your prescribing physician about adjusting the dose or switching to a different medication.
Use more than one tool
In the broadest sense, Occhipinti says, depression is a response to stress and the anxiety of coping with everyday life. That means you’ll need to learn new ways to think and identify feelings and actions that can lead to greater well-being. The most effective treatment for depression is a comprehensive plan that includes all the tools that work for you: personalized lifestyle and diet changes, therapy, supplements, medication if necessary and more.
Most of all: Be kind to yourself. Overcoming depression takes time and effort. Don’t expect immediate improvement. “An ‘all or nothing’ plan can cause anxiety,” says Occhipinti, “so I don’t recommend drastic changes. Take tangible, small steps every day, like exercising more, adding vegetables to your diet or getting out and enjoying nature.”