I pick up the phone ringing in my office. The woman on the other end is softly crying. Before I can say much more than “hello,” she launches into a story that is more familiar to me than I wish.

It’s a sad story! She tells me about her years of depression that she just can’t shake and that she has been to more doctors than she can remember.

She figures she has been on “at least 20 antidepressants since the ’80s. Every new one that comes out…” but is still depressed. She’s frustrated and hopeless and doesn’t know what to do. Her latest psychiatrist has suggested ECT, which stands for Electroconvulsive Therapy. She knows ECT is the “big guns”. She flashes to the movie One Flew Over the Cuckoo’s Nest. She knows that she can’t do ECT and begins the search for other options….

Promise of the Prozac Nation

It’s 1987, and FDA has just approved Prozac to treat depression.

It was the first of a new wave of antidepressants that were supposed to be safer and more effective than previous drugs.

In that first year, 2,469,000 scripts were written for Prozac alone. A few years later, Prozac was on the cover of Newsweek magazine with the headline “A Breakthrough Drug for Depression.”

This was supposed to be a game changer!

In the years that followed other antidepressants hit the market. There was Zoloft, Celexia, Wellbutrin and so many others that were made into household names from the endless stream of TV commercials. By the mid 2000s, almost 1 in 4 woman between 35 and 40 years old were taking antidepressants.

The promise of these drugs was “the end of depression.” What we got was way more mixed.

The STAR*D study was the government’s attempt about 10 years ago to understand how well antidepressants were working. The results were disappointing to say the least. 2/3 of people still had some symptoms of depression after treatment.

That means that more than 6 in 10 people who try medications still feel some signs of depression after taking the pill that they believed would fix everything. For the people that feel better on meds, things are great. They go about their lives thankful for the little pill that gave them their life back.

But what about everybody else on antidepressants?

The Merry-Go-round of Treatment

The sad thing is that most of the people who don’t get better from antidepressants just keep on trying new ones, mostly because they don’t know what else to do. They hop from doctor to doctor with the hope that the latest antidepressants or combination of pills will make things better for them.

For these people they usually they don’t, and sometimes they make things worse.

The part that makes me the most sad (and actually more angry) is that the message that most of these people get from their doctors and therapists, is that there are NO other options. That the medications they are on, that might be making things a little bit better, is the best that the field has to offer.

In fact this was the basis of my training as a psychologist. I was taught that if you are depressed you go to therapy first, and if that does not work, you refer the person out for psychiatric medication. I wasn’t taught that any other real options existed….

But what I have learned over the last 15 years or so, has made me realize that my professional training  (7 years of graduate school) couldn’t be further from the truth! What makes things worse is that many people aren’t even given the option of therapy.

The typical scenario is that you go to your primary care doctor complaining of symptoms of depression and walk out of the 7-minute appointment with a prescription for an antidepressant (or some other psychotropic drug). Sound familiar??

Unless You Test, You’ve Guessed

The well-rehearsed line that most doctors tell their depressed patients is that depression is caused by “an imbalance in brain chemistry.” But if you actually dig into the medical literature a little, you find that there are many causes of depression (and some researchers even debate whether imbalanced brain chemistry is one of them).

Personally, I think imbalances in neurotransmitters including serotonin, dopamine, and norepinephrine, is ONE cause of depression, not THE cause.

What seems to be closest to the truth is that depression can have many different root physical causes (and of course emotional causes as well), so if you work up 5 depressed people, likely what each person needs to get better will be different. So unless we test for these underlying causes, we will just be guessing at treatments.

So from this vantage point, with so many possible root-underlying causes, what are the chances that antidepressant medications will work for every depressed person? Maybe this explains the lackluster findings on the STAR*D study described above.

The takeaway is, the more we can identify the specific and unique root causes, the more we will be able to help all the people who are literally falling through the cracks of the psychiatric system.

3 Things your doctor should test right away if you are depressed

These three tests are a good place to start a conversation with your doctor about the root cause of your depression:

Ask for a Full Thyroid Panel.

Most doctors will only test TSH (Thyroid Stimulating Hormone). This can give a misleading picture of thyroid functioning. TSH is usually high when the thyroid is underperforming. But TSH can be in the “normal range” and the active thyroid hormone, T3 can be low. If T3 is low people can have symptoms that mimic depression including low mood, fatigue, and lack of motivation. Ask for TSH, Free T3, Free T4, Reverse T3, and TPO (this last one is a marker for autoimmunity of the thyroid.)

Ask for your B12 level to be tested

Symptoms of low B12 can include: apathy, irritability, fatigue, and low mood. Be aware that the normal range for B12 can be vary widely, and some labs suggest values as low as 200 pg/ml are in the “normal” range. Most integrative mental health practitioners will suggest taking B12 supplements (either sublingual (dissolving under the tongue), Intramuscular shots or via a nasal spray) with lab values less than 500 pg/ml.

Have your C-Reactive Protein (CRP) tested

This is a test for systemic inflammation. High CRP levels are common in depressed people. If you have an elevated CRP, it may be worth trying the natural anti-inflammatory Curcumin (the active ingredient in the Indian staple Tumeric) and switching to an anti-inflammatory diet like the Whole30 (modified Paleo diet). Exploratory research has shown that 1000mg of Curcumin a day is as effective as Prozac for depression.

If you found this blog post interesting and would like to hear more about integrative care for depression and other mental health symptoms, please add yourself to my email list on my website.


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