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The standard advice you’ll hear if you express suicidal thoughts is to call a suicide hotline or check yourself into the hospital. Trained volunteers, such as those at The Samaritans, provide an invaluable service to severely depressed people who call or email them in desperation. But for some of us, suicidal thoughts can be present for many months or years, and we can’t hang out on a suicide hotline or live in the hospital psych ward indefinitely. We have to learn how to become our own trained professional who helps us tease apart our thoughts until we arrive at the truth that will keep us safe from harming ourselves.

The most difficult thing I’ve ever done in my life is to resist taking my life in the midst of severe, intense, chronic suicidal thoughts. I try to remind myself every now and then that no matter what I do from here on out, I am already a success because I am alive. I somehow managed to resist the incredibly convincing messages of my brain — the forceful urges of my psyche — to make an exit out of this world. As I mentioned in another blog, not taking your life in the midst of intense suicidal thoughts can be like not sneezing when you have an urge. Everything inside of you thinks that disappearing from this world is the only way that the pain will subside, so you listen and follow the cues without thinking.

Suicidal Thoughts Are Like Hiccups — Symptoms of a Condition

I don’t like to write about my suicidal thoughts, especially as they are happening in the present, because I am ashamed of them. They don’t fit into the Zen picture that I am trying to create for myself — all the mindfulness exercises I do, the nutritious diet and yoga, and trying to live, without judgment, in the present moment. I’m afraid they mean that I’m not aware and grateful of all the many blessings in my life — which fills me with immense guilt.

But talking about suicidal thoughts saves lives. I know this. Because people realize that other good, grateful, Zen-attempting people experience them, too. The thoughts that try to convince you to leave this world simply come with severe depression. They are mere symptoms, like hiccups, of a brain condition or fragile chemistry that feels at times too painful to endure. Just as chills, nausea, and fatigue are symptoms of the flu — and you wouldn’t blame a person inflicted with that condition — the chronic ruminations demanding a fast exit from here are symptoms of acute depression and anxiety. They mean you are sick rather than “bad.” They are not an indictment of your character.

You Want Relief From Pain, Not From Life

The best thing I have ever read on suicide is called Suicide: Read This First on Metanoia.org, hosted by Psych Central. The page has had over 23 million visitors, if that gives you any indication of how many people consider suicide. “Suicide is not chosen,” Martha Ainsworth writes. “It happens when pain exceeds resources for coping with pain.” It’s a simple formula that makes so much sense and puts things into proper perspective. She explains:

When pain exceeds pain-coping resources, suicidal feelings are the result. Suicide is neither wrong nor right; it is not a defect of character; it is morally neutral. It is simply an imbalance of pain versus coping resources. You can survive suicidal feelings if you do either of two things: (1) find a way to reduce your pain, or (2) find a way to increase your coping resources. Both are possible.

Ainsworth offers five important things to think about, like recommending that you delay your decision by 24 hours or a week, and insisting that people do get through this. She includes some great resources, including various articles, books, support groups, and websites that will help you feel less alone. Her third point involves a tweak to our thoughts that is life-saving:

People often turn to suicide because they are seeking relief from pain. Remember that relief is a feeling. And you have to be alive to feel it. You will not feel the relief you so desperately seek if you are dead.

Making that distinction has saved my life on countless occasions: I don’t want to die. I simply want a reprieve from my pain. I must trust that the relief will eventually come because all of our feelings and thoughts — and especially our most excruciating pain — are impermanent. They can’t last forever because nothing does. So taking our own life is a permanent action for a temporary problem.

Do the Thing Right in Front of You

During this past depressive episode, the suicidal thoughts have been incredibly intense — probably because I’m getting such little sleep, and sleep deprivation alters your perspective on everything. Recently while standing in line at the grocery store, I started doing “death math,” the kind of arithmetic to determine how long I have to stick it out before arriving at a natural death based on the average deaths of my ancestors. When I realized it was a good 40 years, I burst into tears in front of the cashier. I knew I absolutely couldn’t hang on for that long. In fact, I was sure I couldn’t hold on for one more day. I was filled with a crushing desire to be done right now, and that feeling of panic overwhelmed me: “How do I get out?” As if I were trapped in an airplane bathroom and the door won’t budge.

“I can’t. I can’t. I can’t go on,” I said to myself. Every muscle and gland in my body tensed up as I continued to bawl my eyes out in front of this poor woman scanning my items.

Then I remembered something that a friend told me the night before: I don’t have to worry about making it through an entire day. Hell, I don’t even have to tackle a whole hour. All I have to do is the thing right in front of me. In that moment, it was loading some groceries onto the belt. That’s all. If I still existed once they were all on the belt, then my next step was paying for them and hauling them to my car. “Do the thing right in front of you,” she reminded me. “Nothing else.” Everything you need is in the present moment, she said.

Your Only Job Is to Stay Alive

“All I have to do is stay alive for this moment,” I said to myself over and over again as a kind of mantra as I walked out to the car with a cart full of food, trying to be grateful for the groceries but failing once again at gratitude. That was my only job — staying alive.

That’s the only job you have if you’re wrestling with the kind of intense suicidal thoughts that accompany severe depression. Your only responsibility is to keep breathing. One long breath after another. “As long as we are breathing,” explains meditation teacher and best-selling author Jon Kabat-Zinn, PhD, in one of his sitting meditations that I listen to every day, “there is more right with us than wrong with us.”

Your only job is to keep breathing, one moment at a time. You will eventually see that the painful thoughts, as convincing as they are, are a season and won’t last forever. Like all emotions and feelings — and everything in this life — they are impermanent.

“Holding on to anger,” said the Buddha, “is like drinking poison and expecting the other person to die.”

I don’t know about you, but I feel the venom coursing through my veins when I’m ticked off, tightening all my muscles, activating the sympathetic nervous system to prepare for the gorilla that is not about to attack me, and tagging my amygdala (fear center), saying, “You’re it!”

For me, anger can be a good thing, a sign that I’m alive and I’m invested in this world. I guess I’m feeling well enough lately that unkind remarks bother me more, things that I would have never cared about back when I was doing death math all the time, not paying attention to what came out of people’s mouths because my sole focus was on getting to the grave.

But holding on to resentment is no good either, the broken record that keeps on playing the same tune over and over, and it’s not Let It Go from Frozen.

My good friend and writing mentor, Mike Leach, called me up yesterday and said, “I have never seen you use so many capitalized letters and exclamation points in apiece. Are you okay?”

I knew it was time for the Angry Octopus.

Angry Octopus is a 15-minute meditation for children, one of four stories on a CD called Indigo Ocean Dreams, by Lori Lite. My daughter and I would listen to it almost every night two years ago when she was having major sleep issues. The first time I heard it I laughed hysterically. But when I realized it could do my brain some good I paid more attention. Unlike Homer’s Odyssey, this was a story in which I could actually follow the plot.

This octopus wakes up to find his seashell rock garden is a mess. The lobsters traveling across the ocean floor have bumped into it and destroyed it. He is furious. He feels all of his muscles getting tighter and is so irate that he thinks he is going to explode. And then he does! He releases a purplish-black ink into the water.

The poor ocean creature is frustrated and doesn’t like that he is not in control of his body or feelings.

A sea child (mermaid? Still haven’t figured that out) swims by and asks him why he is so angry and why he is sitting in a dark cloud on such a beautiful day. After his five-minute psychiatric intake, which I have no doubt was not covered by insurance, she says to him, “I will show you how to be the boss of your body and your anger.”

Focus On the Breath

First they work on his breathing. She tells him to breathe in through his nose and out through his mouth, taking deep, slow breaths.

This is good advice, because of all the automatic functions of the body — cardiovascular, digestive, hormonal, glandular, immune — only the breath can be controlled voluntarily. The sea child doesn’t quite explain it that way to the octopus, or quote Richard P. Brown, MD, and Patricia L. Gerbarg, MD, but I am going to inject this part because what they write in their book, The Healing Power of the Breath, is quite interesting:

By voluntarily changing the rate, depth, and pattern of breathing, we can change the messages being sent from the body’s respiratory system to the brain. In this way, breathing techniques provide a portal to the autonomic communication network through which we can, by changing our breathing patterns, send specific messages to the brain using the language of the body, a language the brain understands and to which it responds. Messages from the respiratory system have rapid, powerful effects on major brain centers involved in thought, emotion, and behavior.

Tense One Muscle At a Time

Next the sea child tells the octopus to tense and squeeze his toes and feet as hard as he can, to hold the tension as he inhales, and then to release the muscles as he exhales through his mouth.

Next he tightens his legs, then his hips, stomach, and back — always tensing with the inhale and releasing with the exhale.

He tightens his shoulders and neck, then his arms and hands, and finally his jaw, lips, nose, and the rest of his face.

The sea child then helps the octopus to repair the seashell garden. This makes himvery happy. You are left with a few minutes to just breathe deeply with the octopus and the sea child, and it is very peaceful. You wish you had fins.

Dig Deeper

Progressive muscle relaxation techniques and deep breathing do have the power to change our thought process. However, if we still keep getting stuck, it can be helpful to do some prodding at what lies beneath the anger. For example, ever since I’ve had to fundraise for my foundation, I have become an angrier person. Yesterday I realized what it is. I’m going beyond my comfort zone, which is not a good thing. It’s hard enough to post articles about my struggle with depression on this blog and on Facebook where people other than my depression community can read them. But by getting in people’s faces and asking for money, I am left way too vulnerable. The rejection or lack of response hurts too much. So what I need to do is scale back the vision for the foundation to fit within what I can do without having to write to friends and family for money.

Return to the Second Agreement

Yesterday, as I was spouting off to my mentor about the hurtful remark that triggered all this rage, he said very calmly, “But who he thinks you are has nothing to do with who you really are.” It was a reminder of the second agreement of Don Miguel Ruiz’s classic, The Four Agreements, which is, Don’t Take Anything Personally.

Ruiz writes: “Whatever happens around you, don’t take it personally … Nothing other people do is because of you. It is because of themselves. All people live in their own dream, in their own mind; they are in a completely different world from the one we live in. When we take something personally, we make the assumption that they know what is in our world, and we try to impose our world on their world.”

Even when a situation seems so personal, even if others insult you directly, it has nothing to do with you. What they say, what they do, and the opinions they give are according to the agreements they have in their own minds.

And if all of that fails, just think to yourself how lucky you are not to be an octopus who inks outside his seashell garden.

How embarrassing.

A new study from the University of Oxford finds that mindfulness-based cognitive therapy (MBCT) is just as effective as antidepressants for preventing a relapse of depression. In MBCT, a person learns to pay closer attention to the present moment and to let go of the negative thoughts and ruminations that can trigger depression. They also explore a greater awareness of their own body, identifying stress and signs of depression before a crisis hits.

The study is wonderful news because the relapse rate for major depression disorder is as high as 50 percent for persons who have experienced one episode and as high as 80 percent for people who have experienced two episodes of depression. As my psychiatrist said in our last session, it usually takes less medicine to keep someone well than to get someone well. So that means people can wean off antidepressants with a kind of security net under them, without the high risk of relapse.

However, I’m going to risk the backlash of readers and go against popular opinion when I say that I don’t think mindfulness is a cure-all for depression. It has gotten so much buzz lately that I fear that some severely depressed people out there may make the same mistake I did.

Last year this time, I was immersed in an eight-week intensive Mindfulness-Based Stress Reduction (MBSR) program at Anne Arundel Community Hospital. The course was approved by and modeled from Jon Kabat-Zinn’s incredibly successful program at the University of Massachusetts. I was familiar with Zinn’s writings and had read about the many miracles that mindfulness had brought to his patients, from helping with diabetes and arthritis to heart disease and chronic pain. People with insomnia were sleeping through the night, and diabetics were improving their blood sugar.

I salivated over his pages.

I wanted a miracle, too.

I had been unable to break free of chronic “death thoughts” (“I wish I were dead”) for over five years, and was growing disillusioned with traditional psychiatry, as I had tried countless medication combinations that didn’t seem to do much beyond gift me with lovely side effects, and had been in therapy off and on for 20 years. The only thing that did help was aerobic exercise, so I was swimming more than 300 laps some days to escape the thoughts.

There were three people in our small group of 15 that were clinically depressed at the time, or at least were willing to talk about it. During the sixth class, when the instructor was talking about how to let your thoughts be, I became a little agitated and raised my hand. “Are there ever times when your thought process is so distorted that mindfulness and meditation can’t help you?” I asked.

“You can always shift to another object of attention, like from your breath to sound,” she replied.

“No, I mean, like sometimes if you simply get too frustrated trying to meditate, isn’t it better to go watch a movie or do something that will distract you?” I was thinking of the introduction to The Mindful Way through Depression, when authors Kabat-Zinn, Mark Williams, John Teasdale, and Zindel Segal write:

“It may be wise to not undertake the entire program while in the midst of an episode of clinical depression. Current evidence suggests that it may be prudent to wait until you have gotten the necessary help in climbing out of the depths and are able to approach this new work of working with your thoughts and feelings, with your mind and spirit unburdened by the crushing weight of acute depression.”

I finally quoted Zinn, the Dalai Lama of the MBSR world, to get my point across, and then she agreed with him. But I was relieved when one of my other classmates who had experienced the same kind of debilitating depression I had whispered to me, “I don’t think she has ever been depressed like we have.”

He confirmed what I was thinking during that moment and what has been my experience: mindfulness is better at keeping a person from getting depressed than from pulling a person out of depression.

I say this because I gave the program everything I had. I meditated everyday for 45 minutes for more than eight weeks, read everything I was supposed to for the class, went to a weekly three-hour class, and participated in a retreat. But, upon graduating from the program, I drove home still fighting those damn death thoughts.

I felt like a complete mindfulness and MBSR failure.

What went wrong?

In hindsight, I wish there was more than one paragraph in Zinn’s book about when mindfulness isn’t the solution, about when it’s better to swim laps or ride your bike into town or call a friend you haven’t talked to in a while. I still would have taken the course — and I do feel like I benefited immensely from it — but I would have been more forgiving of myself that it didn’t “work” like everyone else’s magic.

Today I am more aware of my stress reactions and am proactive about reducing my stress before I start wilting. I can identify the thinking patterns that lead to depression, like the inner critic and jumping to the future. Especially beneficial is locating tension in a certain region of my body, and trying to relax it. All of this I learned from the class. And I still meditate — actually it has morphed into prayer, which is a more natural form of meditation for me, and more beneficial (for me).

Mindfulness and meditation may very well keep me from relapsing from depression, now that I am finally without the death thoughts.

I hope so anyway.

But I don’t attach to it the magical properties that I did before, and I think we need to be careful in our optimism.

There are many, many tools to help those of us who are at risk for depression relapse.

Mindfulness is one.

Stuck thoughts. Painful ruminations. Unrelenting obsessions. They are the curse of depression — among the most excruciating symptoms, in my opinion. “When a child gets lost, he may feel sheer terror,” explains Byron Katie in her bestseller Loving What Is. “It can be just as frightening when you’re lost inside the mind’s chaos.” I can usually gauge the severity of my depression based on the intensity and frequency of my stuck thoughts. Sometimes they can outright debilitate me. One seemingly benign thought — often a rumination about a decision I have made in the past, a regret of one form or another, or sometimes something that makes no sense at all — is packed with panic and plays over and over again in my mind, keeping me awake at night and besieging me with anxiety during the day. More than any other symptom of my depression — more so even than unrestrained tears and bawling my eyes out in public — the stuck thoughts make me feel truly insane, scared to be living inside my body and mind.

In my post 9 Ways to Let Go of Stuck Thoughts, I offer some tools to deal with obsessions. But since I’ve been imprisoned by this insanity as of late, I thought I’d share more of them with you that have helped me escape, if only for a few minutes, to a place of peace.

1. Rely on Other Brains

In the state of severe ruminations, your brain is toast. You have to fully admit that — it’s the first step of most 12-step programs. You can’t rely on your logic or any of the content that’s streaming through your neurons, because it’s all inaccurate. You need to rely on other brains to help you sort out the stuck thought and tease it apart until you arrive at the truth. Fortunately, I have a handful of friends who know the insanity of ruminations and have walked with me through this in the past. They know it’s what I do when I get depressed. I get hooked on one thought and use it to beat myself to the ground until I feel absolutely worthless. So I have to believe in their logic. They remind me of why I made certain decisions, why they were the right ones, and why that decision has absolutely nothing to do with the panic that is raging through my body.

When I’m on the phone with them, I write down everything they say like a newspaper reporter, because I will need that information handy for when the thoughts come — and I can’t afford to bother them again. I have a journal filled with the reasonable logic of my friends, and sometimes (not always) accessing their truth calms me down as if I’m talking to them again. I try to trust them because I know I can’t trust my own brain.

2. Investigate the Thought

“I have never experienced a stressful feeling that wasn’t caused by attaching to an untrue thought,” writes Katie. “Depression, pain, and fear are gifts that say, ‘Sweetheart, take a look at what you’re thinking right now. You’re living in a story that isn’t true for you.’” In her book, she explains what she calls The Work, a way of inquiring or investigating your thought with four simple questions:

It it true?

Can I absolutely know that it’s true?

How do I react when I think that thought?

Who would I be without the thought?

Then you turn the thought around. You rewrite your statement as the opposite. If you said, “I am a failure,” your turnaround might be, “I am a success.” And you find three genuine, specific examples of how the turnaround is true in your life.

If my ruminations are severe, this strategy doesn’t always work. As I mentioned in my other piece, sometimes it’s better not to analyze the thought. But just asking myself the first question, “Is this true?”, can sometimes forge a little distance between the rumination and my symptoms of anxiety or be a reminder that I’m caught in a story that isn’t accurate.

3. Visualize the Thoughts as Hiccups

Ruminations are symptoms of depression just as nausea or fatigue are symptoms of the flu. If my fever spiked or I developed a bad case of hiccups, I wouldn’t berate myself for those symptoms. Yet I feel totally at fault for my stuck thoughts, as if they are a weakness of my character, which further pushes me down the rabbit hole of despair. One of my friends recently yelled at me over the phone, “THEY ARE NOT YOUR FAULT!!” when I told him that all the mindfulness exercises I had been doing were making me feel even worse — as though I were creating the ruminations by not being able to let go or detach in the right way. He reminded me that when they reach a certain intensity — when they are making me hyperventilate over the phone to a friend as I was doing, or they totally disable me — mindfulness doesn’t work. At this point, I’m better off imagining them as physical symptoms of an illness and say, “Here they are again .…” rather than to constantly try to meditate them away or release them in the zen fashion that I would like.

4. Use a Mantra

“When my thoughts become intense,” a friend told me recently, “I will use a mantra as a kind of racket to hit the ball back.” Repeating a mantra helps her be prepared for the thoughts when they come. She told me to look through Scripture and find something that resonates with me. I chose “Be not afraid,” as it appears throughout the Bible more than any other phrase, and is also my favorite hymn — one that I would sing all the time as a young girl when I was scared — based on my favorite psalm. A mantra doesn’t have to be religious, of course. It can just be a simple phrase, like “Peace be with me.” Or “I am okay.” Or “This will pass.”

5. Do the Thing in Front of You

I said this recently in my piece on suicidal thoughts. When I’m battling severe ruminations, my head is usually trapped in the past or in the future, fretting a decision I’ve made a month ago or worrying about something a week or a year from now that may never even come to be. The thoughts engulf me in a world that is not real and spin panic everywhere I look. At this point, I can’t handle a day’s worth of concerns, or even 15 minutes of them. What helps immensely is to concentrate only on the task in front of me. If I’m working, this means trying my best to craft a sentence that makes sense. If I’m with the kids, it means helping with their math problems or making a snack. Sometimes it helps to have an anchor to the present moment, such as concentrating on my breath or tuning into my senses. But when mindfulness doesn’t work, I try to tell myself that all I have to do is the thing I am already doing.

Major mental illnesses such as schizophrenia or bipolar disorder rarely appear “out of the blue.” Most often family, friends, teachers or individuals themselves begin to recognize small changes or a feeling that “something is not quite right” about their thinking, feelings or behavior before one of these illnesses appears in its full-blown form.

Learning about developing symptoms, or early warning signs, and taking action can help. Early intervention can help reduce the severity of an illness. It may even be possible to delay or prevent a major mental illness altogether.

Signs and Symptoms

If several of the following are occurring, it may useful to follow up with a mental health professional.

• Withdrawal — Recent social withdrawal and loss of interest in others
• Drop in functioning — An unusual drop in functioning, at school, work or social activities, such as quitting sports, failing in school or difficulty performing familiar tasks
• Problems thinking — Problems with concentration, memory or logical thought and speech that are hard to explain
• Increased sensitivity — Heightened sensitivity to sights, sounds, smells or touch; avoidance of over-stimulating situations
• Apathy — Loss of initiative or desire to participate in any activity
• Feeling disconnected — A vague feeling of being disconnected from oneself or one’s surroundings; a sense of unreality
• Illogical thinking — Unusual or exaggerated beliefs about personal powers to understand meanings or influence events; illogical or “magical” thinking typical of childhood in an adult
• Nervousness — Fear or suspiciousness of others or a strong nervous feeling
• Unusual behavior – Odd, uncharacteristic, peculiar behavior
• Sleep or appetite changes — Dramatic sleep and appetite changes or decline in personal care
• Mood changes — Rapid or dramatic shifts in feelings

One or two of these symptoms alone can’t predict a mental illness. But if a person is experiencing several at one time and the symptoms are causing serious problems in the ability to study, work or relate to others, he/she should be seen by a mental health professional. People with suicidal thoughts or intent, or thoughts of harming others, need immediate attention.

Taking Action, Getting Help

More than a decade of research around the world has shown that early intervention can often minimize or delay symptoms, prevent hospitalization and improve prognosis. Even if a person does not yet show clear signs of a diagnosable mental illness, these “red flag” early warning symptoms can be frightening and disruptive.

Encourage the person to:

• Have an evaluation by a mental health or other health care professional.
• Learn about mental illness, including signs and symptoms.
• Receive supportive counseling about daily life and strategies for stress management.
• Be monitored closely for conditions requiring more intensive care.

Each individual’s situation must be assessed carefully and treatment should be individualized. Comprehensive treatment to prevent early symptoms from progressing into serious illness can include ongoing individual and family counseling, vocational and educational support, participation in a multi-family problem-solving group, and medication when appropriate.

Family members are valued partners and should be involved whenever possible. Learning about mental illness and what is happening in the brain can help individuals and families understand the significance of symptoms, how an illness might develop and what can be done to help.

Just as with other medical illnesses, early intervention can make a crucial difference in preventing what could become a serious illness.

There are many misperceptions about mental illness and its treatment that contribute to stigma. People may incorrectly assume that the feelings that accompany anxiety anddepressive disorders can be willed away with the right amount of discipline, or that seeking help for them is a sign of weakness. It’s important to understand that these emotional disorders are not “normal” feelings. This fact is often misunderstood, which can also lead to misunderstandings about the use of medication.

Misinformation about the role that antidepressants or medication play in the treatment of mental illness can deter people with depression or anxiety from using what may be one of their best options for recovery. The term “antidepressant” is somewhat misleading, in that these medications could easily be called anti-anxiety medications and are used to treat many other conditions. Combined treatment, which involves drug therapy, psychotherapy and lifestyle change, has proved most effective in treating depression and anxiety and in lowering relapse rates.

Antidepressants Are Not “Happy Pills”

The purpose of antidepressants is to help a patient’s mood to return to a normal state, not to alter it. Antidepressants do not make you high or work quickly – they work over an extended period of time. These medications are not sedatives, “uppers” or tranquilizers. They are not habit-forming. Generally antidepressant medications have no stimulating effect on people not experiencing depression or anxiety. Most people start to feel better two to four weeks after starting treatment. Full benefits may not be felt for two to three months, or even longer in some patients.

The purpose of antidepressants is not to “make you happy,” nor are they intended to keep you from feeling emotions. The goal of medication and combined treatment is to help you get you back to functioning as your full self. Feeling emotionally numb is a symptom of depression, a symptom that the use of antidepressants is intended to help correct. If the medication is working correctly, a patient with a depressive or anxiety disorder should be able to experience typical levels of joy, sadness, stress and the full range of emotions.

There Is No Shame in Seeking Help

Mental illnesses are illnesses like any physical ailment – they often require combined treatment to improve. Sometimes treatment involves psychotherapy, sometimes it involves medication, and it requires both – along with lifestyle changes – to be most effective. If a person requires medication to manage a mood or anxiety disorder, it is important they do so, just as it is important for a person with asthma to use an inhaler or a person with diabetes to use insulin.

As with any medication, there can be side effects when using antidepressants. Some adverse effects, like sexual dysfunction, can be difficult to talk about, but it’s important to talk with your doctor and treatment team about how you’re reacting to your medication. Doctors weigh many factors in choosing an antidepressant, such as the person’s medical status, prior bouts of depression, prior responses to antidepressants and the presence of symptoms. There is a wide variety of treatment options for depression and anxiety, including a range of medications, and the right balance of medication, psychotherapy and lifestyle changes can differ from person to person.

Finding the best treatment plan for depression can take some trial and error. Here’s how to tell if your current treatment isn’t working and what to do about it.

When it comes to major depression, there’s no one treatment that works for everyone. Because each person may respond differently to treatment, finding the most effective treatment plan for you can sometimes take several attempts. But with time and effort, major depression can be treated successfully.

“People with major depression need to be patient,” says David Schilling, MD, an associate professor of psychiatry at Loyola University Health System in Maywood, Ill. “Serious depression usually requires medication and may need other types of treatment as well.”

Research shows that the combination of medication and talk therapy (psychotherapy) works better than either of these types of treatments alone for treating major depression. However, making lifestyle changes — including eating well, exercising regularly, and maintaining a strong support system — can also be important. Because finding the right combination of depression treatment options can be tricky, it’s important to know the signs of an ineffective treatment regimen so your doctor can recommend alternatives as soon as possible.

5 Signs Your Depression Treatment Isn’t Working

Here are five warning signs that your depression treatment might not be working and what you can do if it isn’t:

1. You’ve been taking an antidepressant medication for four to six weeks, and you’re not feeling better.

Major depression causes a mood so depressed that you can no longer enjoy life. If your treatment is working, you should feel that most depression symptoms — such as changes in sleep, energy, and appetite — are starting to lose their intensity, Dr. Schilling says. “Although antidepressants take time to work, if you’re not starting to feel better within four to six weeks, your doctor may want to increase your dose, change your medication, or add another medication,” he says. “Another option is to add psychotherapy if you’re only taking medication.”

2. You’ve been trying psychotherapy for several weeks, and you’re not feeling better.

Research shows that people with moderate to severe depression can benefit from a type of psychotherapy called cognitive behavioral therapy, especially if a therapist immediately focuses on techniques to help you break out of negative thought patterns and see life events more realistically. But if talk therapy isn’t working for you, it’s important to evaluate why. Be honest with your therapist so together you can figure out what needs to happen to get you where you need to be in your treatment progression. “Your therapist may suggest seeing a psychiatrist who can prescribe an antidepressant,” Schilling says.

3. You feel less depressed, but you’re also feeling very high and excited.

If this happens, you may have bipolar disorder and not major depression. “Most of the time, people with bipolar disorder are depressed, so it’s not uncommon to be misdiagnosed,” Schilling says. “If you start to feel the opposite of depressed, or if you start to feel invincible, you need to let your doctor or therapist know.” Treatment for bipolar disorder also involves a combination of medication and psychotherapy, but it differs from treatment for major depression.

4. Your treatment is reducing some depression symptoms but not others.

Different types of depression may need different types of treatment. For instance, one type of major depression called psychotic depression may cause you to have false beliefs or see, feel, or hear things that aren’t real. Psychotic depression requires more aggressive treatment than antidepressants alone. Other disorders can also exist along with depression, including substance abuse, anxiety, and post-traumatic stress disorder. These conditions may need to be addressed along with depression to enhance your overall treatment.

5. Side effects of antidepressant medication are affecting your overall treatment.

All antidepressants can have side effects, such as nausea, vomiting, diarrhea, sleepiness, weight gain, and sexual problems. “Side effects can keep treatment from going well, and you need to let your doctor know about them,” Schilling says. If you’re plagued by side effects, you might need to switch to a different antidepressant medication. Or your doctor may lower your dose until side effects fade, which is common. Some side effects, like trouble sleeping or sexual difficulties, may be treated with other medications. But you shouldn’t stop taking medication on your own. Always talk to your doctor first.

About Treatment for Major Depression

Treatment for major depression takes time to work, and you may need to change treatments at some point. “Treatment works for most people with major depression,” Schilling says. “But giving up or avoiding treatment leads to longer and more serious depression symptoms.”

To help boost treatment effectiveness for and speed recovery of major depression, learn as much as you can about depression and work closely with your doctor to find the right combination of treatment options for you.

You don’t have to tell people about your major depression. But you don’t have to keep it to yourself, either. Before you share your diagnosis, consider the following facts.