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I thought I had it all figured out.

I even had a book title picked out: Whole-ish — On Healing Myself Naturally from Depression and My Messy Path to Well. And I had outlined some of the chapters:

• Why restoring your gut health and generating good intestinal bacteria will improve mood
• The science behind optimal nutrition and how certain foods reduce inflammation of the brain, while others (sugar) send a message of distress to your immune system, affecting your entire nervous system
• How green smoothies help eliminate disease states
• The therapeutic faculties of yoga and how it primes our parasympathetic system
• Mindfulness meditation and neuroplasticity

And then the floor beneath me dropped out and I fell into a dark, ominous abyss — a life-threatening place that was more frightening than any depressive episode of my past, where the suicidal thoughts were so intense and so constant that I was absolutely sure I wouldn’t be around to celebrate my daughter’s 13th birthday. In the last five months, I have never been so scared for my life, positive that I was going insane and that I was destined to follow the path of my aunt (who was also my godmother), who took her own life.

What started out as a good and right endeavor became a dangerous dance in which I made a few critical mistakes that almost cost me my life.

Doing Everything Right

Two-and-a-half years ago, I was frustrated that I couldn’t get rid of my death thoughts after being on so much medication for so many years. So I dove into the world of integrative and holistic medicine.

I took every saliva, blood, and stool test that exists to measure my cortisol, hormones, gut status, nutrients, and food intolerances.

I transformed my diet and eliminated gluten, sugar, caffeine, and dairy (I’d already cut out alcohol).

I did extensive research on which supplements to take and added vitamins B-12, C, D, and E; probiotics; turmeric; omega-3 fatty acids; alpha lipoic acid; amino acids; magnesium; coconut oil; and iron.

I drank two green smoothies every day.

I took the eight-week intensive Mindfulness-Based Stress Reduction (MBSR) program based on Jon Kabat-Zinn‘s work at the Stress Reduction Clinic at the University of Massachusetts Medical School in Worcester, and started to meditate each day.

I immersed myself in hot yoga, practicing five or six times a week .

I committed myself to helping others, trying to transcend my pain that way, creating two online forums dedicated to people struggling with treatment-resistant depression.

I attached myself to the new science called epigenetics, the study of genetic changes that aren’t caused by a change in DNA sequence. Pamela Peeke, MD, best-selling author of The Hunger Fix, explained it to me this way: “If you can change certain key choices — your diet, how you handle stress, your physical activity — it’s like writing notes in the margin of your genome, and you can flip the switch to support and protect your health.”

Epigenetics is closely related to the concept of neuroplasticity that says we aren’t stuck with the brain that we were born with: We have more room than we think we do to direct our health toward healing and wholeness.

Thinking in Black and White

I wanted to believe more than anything that I could cure myself of my bipolar disorder and my treatment-resistant depression with the right diet, exercise, stress reduction tools, and meditation.

All of my actions over the course of nine months were able to deliver me to a place where the death thoughts ceased.

So I assumed that the medications I had been taking really didn’t do anything but cause or contribute to a host of chronic illnesses I had developed over the course of 10 years: connective tissue issues (Raynaud’s phenomenon), thyroid disease(nodules), a pituitary tumor, inflammatory bowel disease (small intestine bacteria overgrowth, or SIBO), and heart disease.

That’s where I went wrong.

Black-and-white thinking.

Raised in an alcoholic home, I have always struggled to achieve a nuanced perspective.

I stopped working with my psychiatrist because I believed I could naturally heal from my mood disorder with the help of a holistic doctor. An excellent integrative physician, he has successfully guided my general health (all of the conditions mentioned above). But a mood disorder as complex and severe as mine requires psychiatric expertise, which he is without. I began to taper off of my psychotropic medications too aggressively. The tapering coincided with some other stressors.

And I fell into the abyss.

I fell harder than I ever have.

A New Perspective From My Daughter

Resolved to find a non-drug solution, I tried transcranial magnetic stimulation (TMS), a non-invasive procedure that stimulates nerve cells in the brain with short magnetic pulses. Approved by the FDA in 2008, TMS involves a large electromagnetic coil that’s placed against your scalp. The coil generates focused pulses that pass through your skull and stimulate the cerebral cortex of your brain, a region that regulates mood.

While I did feel an initial lift from my depression following TMS treatment, my anxiety worsened, creating suicidal thoughts that were even more intense and compulsive — as if there was a very thin veil between life and death, and I didn’t know how long I could muster the self-control to stay on the right side. The series (45 sessions in all) sent me into a dangerous, mixed state of mania and depression — something that can happen if a bipolar person does the treatment without enough of a mood stabilizer.

At one point halfway through the series, I was crying when I picked my daughter up from school. I couldn’t quiet my painful ruminations even when I was with her.

“I feel like you are never going to get better,” she said, starting to cry herself.

She paused and then said, her breathing broken, “I just feel like someone is going to die.”

She began to wail.

As much as I didn’t want her to be right, I knew she was.

My little girl has always been extremely intuitive, and she could feel it in her soul that I was not far away from the grave. Two weeks after she said that, we lost a family member to suicide.

His death forced a new perspective.

Living With a Life-Threatening Illness

I realized I had to do absolutely everything I could to protect my life. In a pursuit toheal myself naturally, I had been flirting too closely with death, and I couldn’t say how long I could survive doing this dance. I was finally ready to accept chronic illnesses and tumors and nasty side effects in order to stay alive.

For the first time since my aunt and godmother took her life 30 years ago, I saw the life-threatening angle of my illness and knew that, while I can certainly improve my symptoms with natural remedies and possibly reduce the amount of medication I need, there is no escaping entirely from my mood disorder.

In the harrowing months since Thanksgiving, I’ve learned three key things that I hope I never forget as long as I’m battling bipolar disorder:

• It is absolutely critical to be under the right care.
• Medication can be lifesaving and is sometimes necessary.
• While we can all hope to heal ourselves in the wider sense of the word, some of us simply can’t cure ourselves entirely of our conditions; at best, we can manage them with a variety of treatments, both natural and traditional.

I returned recently to my former psychiatrist who had managed to keep me stable for 10 years, as well as to my therapist, whom I’ve worked with for nine years. Feeling a little bit like the prodigal son, I thanked her for her excellent care in years past and asked for her help in getting well once more.

We’ll get there, she said.

We’ll get there.

There are four distinct types of people when it comes to weather and mood, according to a study published in Emotion in 2011.

• Summer Lovers (better mood with warmer and sunnier weather)
• Unaffected (weak associations between weather and mood)
• Summer Haters (worse mood with warmer and sunnier weather)
• Rain Haters (particularly bad mood on rainy days)

Although my mood seems to be better with more sun, I understand why a substantial number of folks get more depressed in the summer. Extreme heat is hard to tolerate. In fact, in a study published in Science in 2013, researchers reported that as temperatures rose, the frequency of interpersonal violence increased by 4 percent, and intergroup conflicts by 14 percent.

Ten percent of those diagnosed with seasonal affective disorder suffer symptoms at the brightest time of the year. The summer’s brutal heat, bright light, and long days can affect a person’s circadian rhythm and contribute to depression for the opposite reasons that winter conditions do.

If you’re a Summer Hater, or just notice that your mood is affected negatively by the heat, here are some summer depression busters that may help you better tolerate these months — maybe even enjoy them.

1. Plan Something Fun

You don’t need to plan some elaborate cross-country trip that’s going to deplete your savings. Just taking off an afternoon to have lunch with a friend or go kayaking by yourself can be a pleasant break and something to look forward to. When I was working through a severe depression, someone told me to plan something enjoyable every few weeks to keep me motivated to keep going. Scheduling fun activities sporadically throughout the summer might help carry you through some hot afternoons.

2. Be Around People

It can be as tempting to isolate yourself during the summer months as during the winter months, especially if you have body image issues and don’t like showing your legs and arms. But isolation breeds depression, especially if you’re a ruminator like I am. You don’t need to hang out poolside with a crowd of people in order to connect with friends. Sometimes just picking up the phone is enough to fend off depression and anxiety.

3. Add Some Structure

Summer is typically more relaxed, which is why some people look forward to the season all year. It’s nice not having to get the kids out of the door at 7:30 a.m., lunches packed. But those of us who are prone to depression do better when we have some structure to our day. If you don’t work outside the house, you may have to design this structure during the summer months and dig deep for the discipline to stick with it.

4. Stay on Your Sleep Schedule

Related to the last point, it’s easy to get off a regular sleep schedule in the summer if you don’t have anywhere you have to be at 7:30 in the morning. A few days of sleeping in feel great, but an aberrant sleep schedule is a slippery slope to depression for many of us. Even if the day’s events are changing from week to week, make sure to keep your sleep schedule the same: Go to bed at the same time every night, wake up at the same time every morning. Try not to sleep much less than seven hours and no more than nine hours a night.

5. Hydrate

Dehydration is one of the conditions I mentioned in my post, 6 Conditions That Feel Like Clinical Depression but Aren’t. It sneaks up on you, because by the time you feel thirsty, you’re already dehydrated. According to two studies conducted at the University of Connecticut’s Human Performance Laboratory, even mild dehydration can alter a person’s mood.

Dehydration causes a shortage of tryptophan, an important amino acid that is converted to serotonin in the brain. Our bodies can’t detoxify when there is a shortage of water, so tryptophan isn’t distributed to the necessary parts of the brain. Low levels of amino acids in the body can contribute to depression, anxiety, and irritability. A good way to make sure you’re drinking enough is to calculate how much water you should be drinking based on your weight, height, and age, and then fill up two or three containers equaling that amount of water and stick it in the fridge each night before you go to bed. Each day, try to drink enough to empty the containers.

6. Eat Mood-Boosting Foods

It’s not uncommon to eat more sweets and drink fancy, fruity drinks during the summer. But sugar is poison to depression. For one, it causes spikes and drops in glucose, and your brain does much better when it has an even supply of blood sugar. Processed foods — those that come in pretty packages listing a bunch of ingredients you can’t pronounce — aren’t going to help your depression either. During these hot months, stick with foods that can boost your mood, like turkey, pumpkin seeds, fatty fish, walnuts, turmeric, dark leafy greens, avocados, berries, and dark chocolate. I try my best to be sure and pack some nuts and seeds if I’m going to a picnic because the average American picnic is not supplied with brain food. And even one day of eating processed junk, and especially sugar, will do a number on my mood.

7. Get to the Water

Hanging out near water is one strategy for calming down your nervous system that Elaine Aron offers in her book The Highly Sensitive Person. She writes, “Water helps in many ways … Walk beside some water, look at it, listen to it. Get into some if you can, for a bath or swim.”

I find this to be especially true during the summer. I love to run by the Severn River, or walk to Back Creek at the end of my street, or have my lunch on the dock by Spa Creek. I find that being close to the water does calm me down and reminds me what I like most about summer.

8. Avoid Diet Soda

It’s easy to grab a Diet Coke when you feel hot and thirsty, but a study by theNational Institutes of Health (presented at the 2013 American Academy of Neurology meeting) showed that people who drink four or more cans of diet soda daily are about 30 percent more likely to be diagnosed with depression than people who don’t drink soda.

People with mood disorders are especially sensitive to the superficial sweeter aspartame in most diet sodas. In fact, a 1993 study conducted by Ralph Walton, MD, of Northeastern Ohio Universities College of Medicine found that there was a significant difference between aspartame and placebo in both number and severity of symptoms for people with a history of depression, but not so for persons with no history of a mood disorder.

9. Replace Your Depression Triggers

In their book Extinguishing Anxiety, authors Catherine Pittman and Elizabeth Karle explain that in order to retrain the brain from associating a negative event to a trigger that creates anxiety, we must generate new connections by exposure.

So, for me, I need to replace memories of depression relapses in the summer (which trigger anxiety for me during the summer) with positive summer events. One way I’m doing this is by getting involved in the kids’ golfing events. It gives me joy to see them learn a new activity and it generates happy memories of my dad taking my three sisters and me for a ride on the golf cart when we were young.

10. Try Something New

Summer is a great time to try a new activity. Ten years ago, when I was emerging from a severe depressive episode, I took a tennis class with about 20 other women. It was one of the best things I ever did to move past the depression. I still remember the evening that I thought to myself, in the midst of executing a volley, “I am going to beat this thing” (the depression, not the ball).

For the last few summers, I’ve tried new things: kayaking, paddle boarding, and open-water swimming. Each activity has helped my mood because it not only distracts me from ruminations, but the process of learning a sport gives me confidence. Neurologists have found that trying something new essentially rewires our brain. In the process of learning, our neurons become wired together.

There’s such a thing as trying too hard.

Anyone who has ever suffered through a case of insomnia knows this well. The harder you try to sleep, the less rest you get. Sleep only comes if you can relax and let go.

It’s true for many other things, too.

Like garage-door controls.

The other day, I was trying to get into my neighbor’s house to walk his dog and pressed the code into the box outside the garage more than 20 times, but the garage wouldn’t lift.

“You’re pressing the buttons too hard,” my daughter told me.

She did the sequence one time, pressing the buttons effortlessly, and up the garage went.

And it definitely applies to managing your thoughts.

The Harder You Try, the More Negative Things Can Get

A study published in August 2007 in The Journal of Neuroscience showed that there was a breakdown in normal patterns of emotional processing that prevented depressed and anxious people from suppressing negative emotions. In fact, the more they tried, the more they activated the fear center of their brain — the amygdala — which fed them more negative messages.

In the study, Tom Johnstone, PhD, then of the University of Wisconsin in Madison, along with colleagues there and at Tufts University in Medford, Massachusetts, examined 21 adults diagnosed with major depressive disorder and 18 non-depressed people of comparable ages. Participants were asked to view a series of emotionally positive and negative images and then specify their reaction to each one. A few seconds after the presentation of each picture, participants were asked to either increase their emotional response, to decrease it, or simply to continue watching the image.

The results showed distinctive patterns of activity in the ventromedial prefrontal cortex (vmPFC) and the right prefrontal cortex (PFC), areas that regulate the emotional output generated from the amygdala: the almond-shaped group of nuclei located deep within the temporal lobes of the brain that play a primary role in the processing of memory, decision-making, and emotional reactions. The vmPFC is compromised in depression, possibly because of the inappropriate engagement of right PFC circuitry in depressed individuals.

It even applies to exercise.

Why Too Much Exercise Can Be Too Much

While regular and moderate exercise can boost longevity, cardiovascular health, and mood — and improve symptoms of all kinds of chronic conditions — long-term endurance exercise and working out too hard can actually harm our health, according to recent research, such as a study published in 2015 in the Canadian Journal of Cardiology that linked excessive exercise to heart rhythm issues.  Such exercise has been linked to pathological structural remodeling of the heart, enlargement of arteries, and increases in anxiety and depression.

Too much exercise can also exacerbate autoimmune disease, gut dysbiosis, and adrenal fatigue. According to Chris Kresser, an acupuncturist and leader in functional and integrative medicine, overtraining affects blood levels of important neurotransmitters like glutamine, dopamine, and 5-HTP, and can negatively impact the hypothalamic-pituitary axis, possibly causing conditions like hypothyroidism. Extreme exercise also increases levels of the stress hormone cortisol, which can cause sleep disturbances, digestive issues, depression, weight gain, and memory impairment.

I know consciously that trying too hard doesn’t always render the best results, but when I experience a depressive episode, I automatically start pedaling faster, thinking that I will escape the biochemical storm sooner if I just try harder.

When Self-Help Is No Help

I showed up recently to my psychiatrist appointment with another self-help book in my hands: Mental Health Through Will Training, by Abraham Low, MD, the late professor of psychiatry at the University of Illinois College of Medicine in Chicago who founded Recovery International, a self-help group for people with nervous, mental, and emotional problems. The book is an invaluable resource that has plenty of wisdom and insights for managing chronic depression, and I was using it as an adjunct to psychiatric care. But its provocative “push yourself as much as you can” philosophy was exactly what I shouldn’t be reading in a dangerous, mixed state of bipolar disorder.

“I think you should stay away from all self-help books right now,” my doctor told me, reminding me of all the times before when I’d been in this state of mind and looked for the answer in mental health literature or self-help groups or mindfulness techniques — as if I were missing some key cognitive behavioral strategy that would instantly deliver me to the land of sanity. Moreover, pushing too hard, she said, has typically led to setbacks in my recovery rather than helped me heal.

People often ask me how much they should push themselves when it comes to managing their depression: Should they go into work, or call in sick? Should they force themselves to socialize, or stay home and recover? Having read way too many self-help books, I can say there is research to support both perspectives. The right answer is going to be different for everyone, and will vary for the same person at different times.

For me, though, right now I’m learning the hard lesson of patience and trust and moderation.

I’m learning, once again, that more isn’t always better.

In fact, sometimes less is more.

Paper or plastic?

For here or to go?

Cash or credit?

These are simple questions that most people don’t think twice about. But to a person in the midst of a depressive episode, answering any one of these queries can be utter torture. I’ve sat there looking at a grocery cashier like a deer in the headlights, tormented by the choice between a paper bag and a plastic bag — as though the rest of my life depended on the decision between which kind of material would transport my eggs and granola to my car.

The inability to make a decision is one of the most infuriating symptoms ofdepression.

According to a study published in August 2011 in Cognitive Therapy and Research, a few things factor into the difficulty a depressed person has in making decisions.

For starters, good decisions happen when people have the ability to evaluate alternatives and make judgments that are free of bias. In a depressed state, strong emotions and incorrect predictions of the future negatively impact a decision; the pessimistic thinking and heightened sense of potential disappointment in the outcome cloud rational thinking.

Listlessness and passivity affect decisions, as well as a lack of confidence, an inaccurate appraisal of personal resources (“I could never do that”), and a hopelessness about the future.

Depression, Decisions, and Regrets

Several studies have shown that depressed people are especially likely to regret their decisions, so the anticipatory regret handcuffs them and they can’t make future decisions. According to the authors of the Cognitive Therapy and Researchstudy:

Anticipatory regret likely serves as a warning mechanism, protecting a decision-maker from bad decisions and prompting them to reevaluate possible alternatives. Inappropriate or excessive regret can thereby impair future decision-making.

Given the common tendency of people to experience more regret for active, rather than passive, choices, anticipatory regret may bias a person toward inaction. People may believe, irrationally, that by accepting a default choice passively they are avoiding making a decision and thereby minimizing their responsibility for the outcomes of that choice.

I know how painful any simple decision can be for the person who is assailed by a biochemical storm in the limbic system (the brain’s emotional center). You brace yourself for any sentence that ends with a question mark and requires a response. Panic descends. “Oh God, no, not another decision!” That’s why tasks like grocery shopping can be so laborious and humbling for a person in a depressed state.

Like the scarecrow in The Wizard of Oz, I have been without a brain for about six months now, trying my best to make decisions despite my inability to assess situations and facts accurately. I thought I’d share a few techniques that I’ve been using to help me arrive at a “yes” or “no,” “plastic” or “paper” response when my brain can’t help me.

1. Let Someone Else Decide

I know this sounds like the pansy’s way out. I reserve it for those times when I’m completely disabled by my depression.

Earlier this year, I had three weeks where any kind of minor decision incited so much panic in me that I couldn’t stop obsessing and crying. I was overwhelmed with fear and regret and therefore terrified to make even a simple decision. During this period, I removed myself as best as I could from every decision and had my husband decide for me.

This included big decisions — like starting TMS and determining how much to continue the treatment — as well as smaller decisions, like whether or not I was capable of going to my cousin’s wedding shower and how I would get there.

For three weeks, I essentially gave my husband the power to make most of my decisions, and told myself that I was going to have to trust him and then let go. Even if you’re not in crisis mode, it can be helpful to give your brain a break and have other people make decisions for you — especially if they aren’t all that important, like where to go for lunch or what day to meet up for coffee.

2. Flip a Coin

This is my standard way of making a decision when I’m depressed. I flip a coin so often when I’m in an episode that sometimes I get scared I’m turning into Rain Manand will soon be counting straws.

But it’s a clean, easy way to make a decision on just about anything when your brain won’t cooperate.

Sometimes for the bigger decisions, I will incite the help of my deceased father or God or someone else in heaven, asking for a little guidance, and then flip the coin.

Then the trick is letting it go and not continuing to flip, looking for 3 out of 5, or 7 out of 10, or 82 out of 100. Sometimes, though, you find out what you really want to do because you’re disappointed with the result — which you wouldn’t have known had you not flipped the coin.

3. Go With Your First Instinct

Researchers say that our first thought is often our best, and that we’re right to trust our gut instincts. A University of Alberta study published in January 2011 in Cognition and Emotion found that the unconscious mind is smarter than we think, and can be a great motivator in working out future goals.

Of course when you’re depressed, it can be extremely difficult to discern that voice: The whisper is usually crowded out by SOS signals. When we do hear it, though, it’s best to go with it and try to do our best to arrest the insecurities and anxiety that follow it, trusting that science says that our first decision is the best one.

4. WWXD (What Would X Do?)

In the midst of a depressive cycle, most of us have self-confidence issues. We’re quite positive that we will screw up just about anything left up to us, which then leads us to the inability to make decisions.

That’s why I sometimes have to ask myself, “What would Mike do?” Mike is one of the wisest people I know on this planet. He makes great decisions. Or “What would Eric do?” My husband is also extremely insightful, grounded, and makes good decisions. Sometimes I’ll ask myself, “What would my doctor say?”

For example, I was recently deliberating on whether or not to volunteer at an event at my kids’ school. I very much wanted to — I want to be the type of mom who can pull off being the class mom, work a full-time job, be in great physical shape, and cook a gourmet, organic meal for her family each night.

But I know that right now I’m extremely fragile, and my first priority has to be getting well. I think that Mike, Eric, and my doctor would all tell me that there will be plenty of years that I can volunteer for all kinds of activities at school, but for right now, I should concentrate on getting blood work done, swimming, trying to sleep as much as I can, and writing my column. I think they would also say that I’m fine the way I am, even if I’m never class mom or a gourmet chef.

Join Project Hope & Beyond, a new depression community.

What we eat might not be able to cure us indefinitely from depression. I learned thathard lesson earlier this year. However, researchers are compiling strong evidence that what we eat can influence our risk for developing depression and can keep persons in remission from possibly relapsing. Eating better foods has certainly helped my mood and allowed me to get by on less medication. A 2014 review published in the American Journal of Clinical Nutrition examined the link between diet and depression risk and found that a diet consisting mainly of fruit, vegetables, fish, and whole grains was significantly associated with a reduced risk of depression. There are certain foods that are especially good for augmenting mood. Here are eight of them.

1. Fish

Oily, fatty fish like salmon, tuna, and sardines are great sources of omega-3 fatty acids, which enhance aspects of brain function, including mood, and can protect against depression. In a large Norwegian study of 22,000 people, participants who took cod liver oil were 30 percent less likely to have symptoms of depression than the participants who did not take omega-3 fatty acids. Our brains are mostly fat, so we need enough omega fatty acids for optimal growth, development, and function of brain tissue. When the brain doesn’t have enough omega fatty acids, the structure of brain cell membranes and nerve connections are inferior, which leads to cognitive and emotional disorders.

2. Nuts

Nuts are loaded with important minerals that aid mental health such as selenium, copper, magnesium, manganese, and zinc. Walnuts are one of the richest plant-based sources of omega-3 fatty acids. They also help replace B vitamins, critical for mood. Brazil nuts have lots of magnesium, which helps calm the nerves, as well as zinc, an antidepressant element that combats anxiety. Almonds are very good sources of manganese and copper, two trace minerals that defuse free radicals produced within the mitochondria, the “powerhouse of the cell,” protecting us against disease and providing us with energy.

3. Yogurt

All dairy can be beneficial for depression because milk, cheese, etc. are rich in calcium, vitamin D, and specific peptides that promote relaxation. However, yogurt is especially beneficial because of its probiotics. In a 2013 study by UCLA researchers, participants who ate yogurt twice daily for a month showed lower levels of activity in the areas of the brain associated with pain and emotion and more increased activity in areas associated with decision making. I find the brain-gut connection fascinating. The 100 trillion bacteria housed in our gut, known collectively as our microbiome, can play an important role in our mental health. John F. Cryan, Ph.D. of University College Cork in Ireland, has conducted several studiesthat show that when the microbiome of mice is disrupted, they mimic human anxiety and depression. I drink Kefir every morning, which contains many probiotics, and I do think it has improved my mood.

4. Dark Leafy Greens

“Greens are the primary found group that matches human nutritional needs most completely,” explains Victoria Boutenko in her book Green for Life. They are nutrition powerhouses, packed with vitamins A, C, E, K, and folate; minerals like iron and calcium; carotenoids; antioxidants; omega-3s; and phytochemicals. Greens provide insoluble fiber, which is like a miraculous sponge, helping us to eliminate pounds of toxins regularly. They balance our pH levels, leaving our body more alkaline, and are a major source of chlorophyll, which, according to Boutenko, “heals and cleanses all our organs, and even destroys many of our internal enemies, like pathogenic bacteria, fungi, cancer cells, and many others.” Dark leafy greens like kale, Swiss chard, and spinach also fight against all kinds of inflammation, and according to a new study published in JAMA Psychiatry, severe depression has been linked with brain inflammation.

5. Seeds

Seeds are some of Mother Nature’s best mood boosters. For example, pumpkin seeds are chock-full of zinc (containing 23 percent of our daily recommended value in just one once), which promotes emotional resilience because zinc deficiencies have been shown to be a factor underlying depression. They are also rich in magnesium, the calming nutrient known as the original chill pill. Sunflower seeds are nutrient-dense foods, as well. They also contain lots of magnesium—a quarter cup provides 25 percent of the recommended daily value—and the specific kind of magnesium (magnesium sulfate) found in sunflower seeds has been known to havebeneficial effects on patients with depression dating back 100 years. In his bestsellerThe End of Dieting, Joel Fuhrman, MD, includes seeds among his G-BOMBS (Greens, Beans, Onions, Mushrooms, Berries, Seeds)—the foods with the most powerful immune-boosting and anticancer effect.

6. Green Tea

Green tea has been used for centuries by the Chinese and Japanese to promote digestion, regulate blood sugar, and for relaxation and mood benefits. It contains an amino acid, theanine, that calms the nervous system. A study published in the November 2009 issue of American Journal of Clinical Nutrition showed that people who drink at least five cups or more of green tea daily experience less psychological distress. In another study published in 2011 of Phytotherapy, researchers reported the antidepressant effect of L-theanine in mice undergoing a forced swim test and tail suspension test. The antidepressant effect “may be mediated by the central neurotransmitter system,” says the abstract.

7. Eggs

In her book Gut and Psychology Syndrome, Dr. Natasha Campbell-McBride, MD, writes, “Eggs are one of the most nourishing and easy-to-digest foods on this planet. Raw egg yolk has been compared with human breast milk because it can be absorbed almost 100 percent without needing digestion.” Eggs are loaded with essential amino acids, omega-3 fatty acids, vitamins (A, D, biotin), as well as minerals like zinc and magnesium that help anxiety. They are a great source of B vitamins, especially vitamin B-12, which promotes development of the nervous system. Eggs also contain choline, an amino acid that serves as a building block for a neurotransmitter called acethylcholin, which aids cognitive and learning processes. Because they are high in protein, they stabilize blood sugar, which is critical for good mood, and keep you satiated longer.

8. Dark Chocolate

In a 2013 randomized, double-blind study published in the Journal of Psychopharmacology, researchers found that participants who consumed a dark chocolate drink mix for 30 days had “significantly increased self-rated calmness and contentedness relative to placebo.” In another 2009 study published in the Journal of Proteome Research, dark chocolate was found to reduce the stress hormone cortisol and help normalize stress-related differences in energy metabolism and gut microbial activities. Dark chocolate contains large amounts of tryptophan, an amino acid that works as a precursor to serotonin, and theobromine, another mood-elevating compound. It also has one of the highest concentrations in magnesium in a food, with one square providing 327 milligrams, or 82 percent of your daily value. The higher percentage of cocoa, the better. Aim for at least 70 percent.

Join Project Hope & Beyond, a depression community.

Photos: iStock.com; Daniel Hurst/Stocksy; Getty Images; Corbis

The American Journal of Psychiatry has just published a meta-analyses of supplements, or nutraceuticals, that, used in adjunction to antidepressants, have evidence of reducing depressive symptoms. The primary positive results were found with SAMe (adenosylmethionine) methylfolate, omega 3 (primarily EPA or ethyl-EPA), and vitamin D. Positive isolated studies were found for creatine, folinic acid, and an amino acid combination. Mixed results were found for zinc, folic acid, vitamin C, and tryptophan. With all the supplements available on the market today for depression, it is important to know which ones are supported by evidence. I would start with these four:

1. SAMe

SAMe has been available in in Europe by prescription since the 1970s for the treatment of various conditions, including depression. It became available in the United States in 1999. In a 2010 double-blind randomized clinical study, participants with major depressive disorder who had not responded to a serotonin reuptake inhibitor (SRI) continued to take their SRI treatment for six weeks. Some of the patients were treated with adjunctive SAMe and some placebo. At the end of the study, the remission rates were higher for patients treated with SAMe than placebo.

In a 2013 open-label, fixed dose, single-blind study published in The Scientific World Journal, researchers evaluated 33 outpatients with major depressive episode who failed to respond to at least eight weeks of treatment with two antidepressants. They were given 800 mg of SAMe for 8 weeks, in addition to their existing medication. At eight weeks, 60 percent of the patients had a significant decrease in Hamilton Rating Scale for Depression (HAM-D) scores, and remission was achieved by 36 percent.

“SAMe may improve depressed mood through enhanced methylation of catecholamines and increased serotonin turnover, reuptake inhibition of norepinephrine, enhanced dopaminergic activity, decreased prolactin secretion, and increased phosphatidycholine conversion,” says the article.

2. Methylfolate

As I explained in another blog, research has linked folate deficiencies to depression. The B vitamin is important for stabilizing our mood. Many of us are folate deficient because up to 40 percent of the general population can’t convert folate to its active form, methylfolate. Lots of folks have a gene mutation in their methylenetetrahydrofolate reductase (MTHFR) enzyme that prevents the conversion.

Supplementing with L-methyfolate, a bioavailable form of folate that plays a role in neurotransmitter synthesis, can improve a person’s response to antidepressant medications. In fact, several studies have documented the enhanced efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) when taken with L-methyfolate.

In a 2012 study published in the American Journal of Psychiatry, researchers conducted two randomized, double-blind, parallel sequential trials to evaluate the effect of L-methylfolate augmentation in the treatment of major depressive disorder in patients who had a partial response or no response to selective serotonin reuptake inhibitors (SSRIs). Adjunctive L-methylfolate at 15 mg/day showed significant improvement in response rate and degree of change in depression scores as compared to continued SSRI therapy plus placebo.

3. Omega 3

The American Journal of Psychiatry meta-analyses evaluated eight studies of Omega 3 that were double-blind randomized controlled trials. The trials involved both eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) combinations; however analysis showed that the data was stronger when studying EPA-inclusive studies (removing the DHA-only trials). Per the meta-analyses:

The findings from the omega-3 meta-analysis demonstrates this augmentation approach significantly reduces depressive symptoms beyond placebo and thus has potential clinical and public health significance. As detailed in a recent general meta-analysis, it is advised that EPA or ethyl-EPA dominant formulas be used, as DHA may not be effective.

In a 2013 study published in European Neuropsychopharmacology, researchers conducted a randomized, double-blind trial comparing the efficacy of EPA versus DHA as adjuncts to maintenance medication treatments for mild-to-moderate depression. Patients receiving the EPA showed significantly lower scores on the Hamilton Depression Rating Scale (HDRS) than did those receiving DHA or placebo.

I order my Omega 3 from OmegaBrite because their capsules contain 70 percent EPA in a 7:1 ratio of EPA to DHA. I noticed a difference in switching from a brand of mostly DHA to mostly EPA.

4. Vitamin D

As I said in my post, “6 Conditions That Feel Like Depression But Aren’t,” a deficiency in vitamin D will feel very much like depression. Lots of studies have found a close association between depression (or increased odds for depression) and vitamin D deficiencies. And as many as three-quarters of U.S. teens and adults are deficient, according to a 2009 study published in the Archives of Internal Medicine.

In a 2013 study published in the Australian and New Zealand Journal of Psychiatry, researchers compared the therapeutic effects of vitamin D3 plus fluoxetine and fluoxetine alone in patients with major depressive disorder. Patients received either 1500 IU vitamin D3 plus 20 mg fluoxetine or fluoxetine alone for eight weeks. Depression was assessed at two week intervals using the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI). Depression scores of the group who took the vitamin D in addition to their antidepressant were significantly better than those just taking fluoxetine from the fourth week of treatment.

Per the meta-analyses:

Vitamin D can be considered a neurosteroid, with vitamin D receptors being identified in areas involved with depression, such as the prefrontal cortex, hypothalamus, and substantia nigra. Vitamin D has been revealed to increase the expression of genes, encoding for tyrosine hydroxylase (precursor of dopamine and norepinephrine). Further, a major dopamine metabolite in the striatum and accumbens has been found in methamphetamine-treated animals administered vitamin D.

“To be nobody-but-yourself—in a world which is doing its best, night and day to make you everybody else,” wrote American poet E. E. Cummings, “means to fight the hardest battle which any human being can fight; and never stop fighting.”

According to a recent survey by the charityAction for Happiness, in collaboration with online behavior change program Do Something Different, self-acceptance, or “being comfortable with who you are,” was the factor that best predicted life satisfaction (out of 10 “happy habits”). However, for the 5,000 respondents, it was also the most difficult to do.

Living authentically is not for the weak. The average person does not like to stand out in the crowd, risking rejection and mockery. Perhaps that’s why public speaking is our number one fear, followed by death. As Jerry Seinfeld pointed out, “That means to the average person if you have to be at a funeral, you would rather be in the casket than doing the eulogy.”

Being comfortable with yourself—liking yourself enough not to want to change in order to better blend with the crowd—takes guts, integrity, stamina, and the inner calm of a Tibetan monk.

In her book “Being Perfect,” Anna Quindlen writes:

Nothing important, or meaningful, or beautiful, or interesting, or great, ever came out of imitations. What is really hard, and really amazing, is giving up on being perfect and beginning the work of becoming yourself.

More difficult because there is no zeitgeist to read, no template to follow, no mask to wear. Terrifying, actually, because it requires you to set aside what your friends expect, what your family and your co-workers demand, what your acquaintances require, to set aside the messages this culture sends, through its advertising, its entertainment, its disdain, and its disapproval, about how you should behave.

This is especially true when you have “the little man”—the voice of disapproval or the echo of negative intrusive thoughts, hanging over your every sentence and action during a depressive episode.

Being okay with yourself when you’re depressed is well near impossible because your self-esteem is so far below sea level. It’s all we can really do to force ourselves out of bed in the morning and get three meals a day, right? Forget about aiming for a confident stride.

I haven’t done a good job of writing authentically on this blog, “Sanity Break.” I have wanted to fit in with the site, which is very different from the spirituality site I came from (Beliefnet.com). Because Everyday Health does a great job of covering all kinds of health conditions, offering current research on various illnesses, I thought I should concentrate on all the new studies on different mood disorders and new trends in psychology and neuroscience. I left out much of my story, my frustrations, my insights, and my breakthroughs. Impressed by the other health bloggers on the site, I swapped my voice for one of theirs.

Writing from the heart is terribly difficult when you are not feeling well, and, as I’ve mentioned in places, I have really wrestled with the “black dog” (as Winston Churchill referred to his depression) this last past year. I am gradually getting better, but the journey has been exhausting, and I can see now that I have been without a sense ofhumor—something that I know readers appreciate!—and other trademarks of my writing style for too long.

Next week will mark the one-year anniversary of this blog. I am excited to share with you all what I have learned during this arduous year—my journey to functional (integrative or holistic) medicine, to an eight-week intensive mindfulness-based stress reduction program, to a new nutritional plan that has me drinking kale for breakfast, and to many unusual places that are leading to healing and health.

When I was six months pregnant, I attended a birthing preparation class with my husband and about 12 other expectant parents. During the fifth session, the instructor asked the mothers whether or not they were going to use medication to get through the pain of childbirth labor.

“Everyone who wants to try for a natural birth, stand over here,” she said. “And everyone who plans on having an epidural or taking other pain medication, stand over here.”

I looked at the two groups, which held about the same number of people. My head went from one to the other, much like a puppet with a tic. Like most decisions in my life (including which dressing I want on my salad), I had analyzed the hell out of this one — done all the research on both sides — and still couldn’t commit.

“What a feeling of triumph to be able to do it without drugs,” I thought to myself. “I could wear a T-shirt for the rest of my life that says, WOMAN WARRIOR: I GAVE BIRTH NATURALLY.” But I also knew that acute pain — just like severe depression — has devastating effects on the body, and that white-knuckling it isn’t always the heroic thing to do. Plus, I’m not a huge fan of pain. I try not to bring it on when I don’t have to. I could see myself wearing another T-shirt, too: PAIN IS NOT MY FRIEND: I CAVED TO THE EPIDURAL.

I walked up to the two groups and stood in the middle of them.

Alone.

“I’m undecided,” I explained to both camps, who glared at each other with disdain.

I’ve tried my best to stay in that spot — in the middle, gazing at the opposing sides from my peripheral vision — for most of my time as a mental-health blogger. I believe that the center is by far the most interesting place to be, because you get to read the memos from each group and decide whether or not you agree.

But it also gets lonely.

And that’s because the world of medication is so divisive, especially when it comes to using antidepressants or any kind of psychotropic medication to treat depression and anxiety. There is the camp that believes anyone who uses them is avoiding the hard work that has to be done to move beyond sadness — that the meds are agents of evil, poisoning our systems with harmful toxins. And then there is the camp that believes that medication is the one-and-only way of treating depression, that mood disorders are strictly biological and can’t benefit from any introspective work, and that the disorders are in no way influenced by one’s diet or lifestyle habits.

For the first 10 years of my blogging life, I was publicly pummeled for “copping out” and popping pills. People called me irresponsible for disseminating harmful information to the public, accused me of sleeping with Big Pharma (even though I never saw any cash), and also of being weak, small-minded, and caving to a popular culture that says good health is only one prescription away. I’ve never believed that medication alone will heal you from depression — that a script is all you need to get to sanity. But that’s what some people heard.

Now I’m getting lambasted from the other side. I’m getting the “Shame on you” a lot for pursuing natural therapies to treat depression, and thereby supposedly influencing people to go off of their meds, which could “kill 20 people.” The tragedies that are so often attached to mental illness in the news are the fault of people like me who encourage folks to mistrust psychiatry.

Let me say this about medication:

I would not be alive today without it.

I credit my psychiatrist for saving my life in March of 2006.

I believe that antidepressants and mood stabilizers are agents of healing.

There is absolutely a place for medication, and I would never say otherwise.

When I was holed up in my bedroom closet, sobbing in fetal position with a bag of prescriptions that I intended to use to flatten my pulse, I was incapable of pursuing the steps I am now — Bikram yoga, helping others, working with an integrative doctor — to deliver me from that hell. Rarely did I have the stamina to make it to the grocery store, let alone to blend green smoothies and learn how to cook nutritious meals. It was through the intervention of a skillful doctor, and the right combination of meds, that I stabilized.

Being on meds was absolutely the right thing to do.

But over the last seven years, I have not responded to the medications as I did earlier in my life. They have failed to bring relief from my death thoughts. Plus, their side effects compromised my health in ways that were keeping me depressed.

For example, I believe (after reviewing some research) that my experimentation with antipsychotics, or possibly my long-term use of Zoloft (sertraline), is what caused my pituitary tumor, which completely throws off the hypothalamic-pituitary-adrenal axis that is critical to mood. If the tumor gets big enough, it can affect your vision and even render you blind (the pituitary gland pushes up next to the optical nerve). To manage the growing tumor, I went on a medication called Cabergoline, which, according to research, is linked to aortic valve regurgitation, which I now have — andthe connection between cardiovascular disease and depression has long been established. At the same time, I developed hypothyroidism and some expanding nodules in my thyroid gland that can happen with Lithium use. As I’ve written in the past, the thyroid is a delicate and powerful gland that governs so many essential activities in our body related to hormones and mood. Finally, many of my medications have gastrointestinal side effects, which I suspect have something to do with my current inflammatory bowel disease. Our gut is our second brain, so problems there leak into anxiety and depression.

Therefore, I was forced to look into other kinds of therapies to treat my symptoms.

If I’ve been inching closer to the tree-hugger camp in my writing as of late, it’s only to make these two points:

1. Diet and lifestyle are more effective than I previously thought to managesymptoms of depression, if you know what you’re doing: some adjustments COULD help reduce the amount of medication you need to take.
2. Medications aren’t risk-free. Their side effects can inadvertently contribute to your depression and negatively impact your health for years to come, so do your homework.

Ultimately, though, it’s about doing a cost-benefit analysis.

I would live with blindness and a goiter the size of a football if that’s what I had to do to stay alive. Chronic illness isn’t fun, but it’s better than being dead. And if I felt some relief from the medications, I would tolerate a host of side effects. I believe a person should take the course he or she needs in order to relieve the most suffering. So in my case, when the negatives began to outweigh the positives, I knew it was time to take my health in a different direction.

That’s not to say I don’t support the use of medication for people who struggle with depression.

My son’s birth ended up being a traumatic one. I held off on the epidural until the very last moment, but was glad I had taken it, because when his heart rate began to plummet, the doctors performed an emergency C-section. Had I opted to do it naturally, they would have completely knocked me out for the surgery, and I would have missed the entire birth.

Modern science saved little David’s life, much like my own.

Fifteen years later, if I were in that birthing class, I’d stand in the same place.

Consider these statistics:

• Nearly 50 percent of asthma patients have symptoms of depression.
• At least 40 percent of people with Parkinson’s disease experience depression, and anxiety is often reported.
• 45 percent to 65 percent of people who have had a heart attack live with depression.
• The lifetime risk for depression in people with multiple sclerosis (MS) is 40 percent to 60 percent.
• Nearly 30 percent of stroke patients develop depression.

A 2009 study published in Archives of Gerontology and Geriatrics confirms that “when pain is severe, impairs function, and/or is refractory to treatment, it is associated with more depressive symptoms and worse depression outcomes. Similarly, depression in patients with pain is associated with more complaints and greater functional impairment.” The study goes on to explain that there is growing evidence that “depression and pain share genetic factors, biological pathways, and neurotransmitters. Thus, the most promising area of future research is elucidating the neurobiological alterations in pain pathways that intersect with those involved in depression.”

This is important to know since, according to research published by the Robert Wood Johnson Foundation, the number of people with chronic illnesses will increase 37 percent, or 46 million people, between 2000 and 2030. That means those of us who are predisposed to depressive episodes to begin with would be wise to familiarize ourselves with those illnesses that are most often associated with depression and can exacerbate our symptoms. The following 10 are a good start.

1. Parkinson’s Disease

The National Parkinson Foundation’s Parkinson’s Outcomes Project, the largest clinical study of Parkinson’s disease ever conducted, shows that depression is the most important factor influencing the health status of people with Parkinson’s. According to the study: “A clear finding from our study is that, taken together, mood, depression, and anxiety, have the greatest effect on quality of life, even more than the motor impairments commonly associated with the disease. Further, our analysis found that QII [quality improvement initiative] participants who receive care from clinics with the most active approach to psychological counseling report the lowest rates of depression.”

2. Heart Disease

Depression is three times more common in people after a heart attack than in the general public, with 15 to 20 percent of heart attack victims qualifying for a diagnosis of major depression disorder and many others experiencing depression symptoms. “Depression after a heart attack is bad not only because of the accompanying emotional distress and suffering,” says Redford B. Williams, MD, professor of psychiatry at Duke University Medical Center in Durham, North Carolina, “it also increases one’s risk of having another heart attack or dying over the ensuing months and years.” People with heart disease who are depressed tend to have more cardiac symptoms than those who are not depressed. Depression and anxiety affect heart rhythms, increase blood pressure, elevate insulin and cholesterol levels, and raise levels of stress hormones.

3. Stroke

Nearly 30 percent of stroke patients develop depression, either in the early or in the late stages after a stroke, according to a study published in the medical journalNeuropsychiatric Disease and Treatment. It is so common that the Diagnostic and Statistical Manual (DSM)-5 categorizes “post-stroke depression” as a mood disorder (due to a general medical condition, i.e., stroke). Stroke causes physical damage to the brain, affecting brain cells that monitor mood and mental function. It’s also a frightening experience that can cause trauma. Although depression may affect functional recovery and quality of life after stroke, it is often ignored. In fact, only a minority of patients are diagnosed and even fewer are treated in the common clinical practice.

4. Dementia

Up to 40 percent of people with Alzheimer’s disease may also experience severe depression according to the Alzheimer’s Association. In fact, a new study published in the journal Neurology found that for people who develop Alzheimer’s disease, depression and other “noncognitive” changes can happen before any of the hallmark symptoms like memory and thinking problems associated with the disease. Another report in the British Journal of Psychiatry found that depressed older adults (over the age of 50) were more than twice as likely to develop vascular dementia and 65 percent more likely to develop Alzheimer’s disease than people who weren’t depressed. It can be difficult to distinguish depression in persons with dementia because the symptoms are similar: a lack of interest in hobbies and activities, difficulty communicating, weight loss, and difficulty sleeping.

5. Hypertension

High blood pressure can impact depression; however, it is more likely that depression affects high blood pressure. Stress hormone levels are raised during depressive episodes, which, in turn, elevates blood pressure. Acute stress and severe depression will elevate blood pressure to the point where damage to blood vessels is caused.

6. Diabetes

I was shocked to find out how many people in my depression communities, Project Beyond Blue and Group Beyond Blue, have diabetes. In a 2010 study published in the Archives of Internal Medicine, it was determined that the diabetes-depression relation is, in fact, “bidirectional,” meaning that just as people with diabetes have a higher risk for developing depression than those without the condition, people who have depression are more likely to develop diabetes, at least type 2 diabetes. “We can say that the two conditions are linked to each other and are both the causes and the consequences of each other,” says the study’s senior author, Frank Hu, MD, PhD, professor of nutrition and epidemiology at Harvard School of Public Health.

7. Cancer

The prevalence of mood disorders among persons with cancer can vary depending on the type of cancer and its clinical stage. In an older 1983 study published in theJournal of the American Medical Association, 47 percent of the patients were diagnosed with a kind of psychiatric disorder — most of them adjustment disorders. However, a more recent study published in the journal Cancer shows that 53.7 of people with terminal cancer were diagnosed with a psychiatric disorder: delirium, dementia, adjustment disorders, major depression, or generalized anxiety disorder.

8. Multiple Sclerosis

Depression is the most frequent psychiatric diagnosis in people with MS, according to a study published in the Journal of Rehabilitation Research & Development. The lifetime risk for depression in people with MS ranges from 40 to 60 percent. Depression could be a result of the disease process, since MS damages the myelin and nerve fibers deep within the brain — areas involved in emotional expression and control. Depression may also be associated with changes that occur in the immune and neuroendocrine systems. According to the study, “the etiology of depression is multifactorial and likely associated with psychosocial stress, focal demyelinating lesions, and immune dysfunction.”

9. Asthma

I was surprised to learn that nearly 50 percent of people with asthma may experience clinically significant depressive symptoms. The stress involved in having this particular illness and the disruptive symptoms seem to be what contribute most to psychiatric diagnoses. For example, those who experience dyspnea and nighttime awakening are at increased risk for major depression according to a study published in the Medical Journal of Australia. Asthma has also been associated with anxiety in a study of children and adolescents. In general, the depression and anxiety is worse among persons whose asthma is difficult to control: 87.5 percent of people with frequent asthma attacks experienced mood disruptions, compared to 25 percent of people with less frequent attacks, according to other research.

10. Arthritis

A study from the Centers for Disease Control and Prevention published in the journal Arthritis Care & Research indicates that one third of Americans aged 45 years and older with arthritis have either anxiety or depression. Interestingly enough, anxiety was almost twice as common as depression. Most people who had depression (85 percent) also had anxiety. But only half (50 percent) of the people who had anxiety also had depression. The study suggests that everyone with arthritis may be at risk for mood disruptions, and that screening all adults with arthritis for anxiety and depression is more important than ever, especially since the results found that only 50 percent of those with anxiety and depression sought help in the past year.