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Antidepressants Not Working? Here's Why.

Antidepressants Not Working? Here’s Why

Are your antidepressants not working, or even making your symptoms worse? Have you tried treatments for depression only to find them at best ineffective and at worst aggravating? If this is you, your situation is more common than you may think. In fact, research has shown that of people with moderate to severe depression symptoms, around half have experienced antidepressants not working.

Thankfully though, science is getting to grips with why. Read on to find out more.

The surprising reason antidepressants are not working for millions of people

Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) are a first line treatment for major depressive disorder (MDD).

Serotonin is a neurotransmitter that delivers messages between nerve cells throughout your brain and body. It is often referred to as the ‘feel good’ chemical, because at optimum levels it promotes happiness, calm, emotional regulation and a feeling of wellbeing.

Selective serotonin reuptake inhibitors (the most commonly prescribed antidepressant medications) work to raise levels of serotonin in the brain. They do this by obstructing (‘inhibiting’) its reabsorption (‘reuptake’) by the nerve cells, so more of it remains to send messages in the brain. For millions of people with depression around the globe, SSRIs have been life-saving.

However, for a significant proportion of people thought to have depression, SSRIs have been found to be ineffective, and in many cases actually harmful. When this happens, patients are often told they have treatment-resistant depression – a crushing verdict that may leave a sufferer deeply frustrated and baffled as to what to do next.

In many cases however, what is thought to be treatment-resistant depression is actually undiagnosed bipolar spectrum disorder. Far more common than you may think, and frequently misdiagnosed, bipolar disorders almost never respond to conventional treatments for depression.

Depression treatment usually incorporates antidepressants and talking therapies like CBT. But for people who have bipolar disorder, studies have demonstrated that antidepressants can actually worsen their symptoms long-term and increase mood cycling (bipolar transition from mania/hypomania to depression, and vice versa). CBT isn’t the solution for bipolar disorder either, as the most expansive study of CBT in bipolar disorders confirms (indeed CBT was discovered to be no more helpful than treatment without it and could indeed aggravate the condition).

Simply put, bipolar disorders are distinct from major depression and they call for different treatment. So, if you have found your antidepressants not working or making things worse, it could be time to ask if you actually have a bipolar disorder. Read on to find out more.

Is it treatment-resistant depression or is it bipolar disorder?

If you have been diagnosed with depression but are experiencing ongoing problems such as:

  • Antidepressants not working
  • Talking therapies not improving your condition
  • Antidepressants seeming to make you more anxious
  • Burdensome side effects from medication
  • Antidepressants seeming to make your depression worse

You may actually be suffering from a form of bipolar spectrum disorder.

After the failure of first-line depression treatments, it is common to be told you are suffering from treatment-resistant depression. While some people do indeed suffer this problem, here at The London Psychiatry Centre, as experts in successfully treating both treatment-resistant depression and bipolar spectrum disorder, one of the things we recommend when conventional depression treatments haven’t worked is considering if the original diagnosis is in fact appropriate.

This is because many people diagnosed with depression in fact have undiagnosed bipolar disorder – a condition much more common than people realise. For instance, one USA-based study found that nearly 40% of respondents diagnosed with depression had symptoms of subthreshold bipolar disorder. Other work has suggested that the true rate of bipolarity in people who’ve suffered major depressive episodes could be closer to 50%.

Dr Christos Kouimtsidis, Consultant Psychiatrist at The London Psychiatry Centre says: “At our clinic we have numerous patients that come to us after failed treatment elsewhere, quite rightly saying ‘antidepressants don’t work for me.’ If we then suggest it is possible they have an undiagnosed bipolar disorder, they’re often shocked. They may say: “I can’t have bipolar disorder – I’m not manic. I don’t experience psychosis.” But the truth is, the picture of bipolar we see in popular culture most closely aligns with only one of the three types of bipolar disorder – bipolar I (the ‘classic’ form). Often, patients are convinced they can’t have bipolar disorder because they are unfamiliar with the different ways in which bipolar actually presents. It’s more complex than you think.”

Bipolar disorder: not what you think it is

The depictions of bipolar disorder we see most frequently in the media tend to most closely resemble bipolar I (the classic form). But did you know there are actually three main types of bipolar disorder, and the most common form is in fact the least understood? This is why bipolar disorder is so frequently misdiagnosed as unipolar depression, and countless sufferers are at a loss as to why they find antidepressants not working and talking therapies ineffective. Let’s break it down.

Bipolar I (the ‘classic form’)

Bipolar I is characterised by episodes of mania for seven days or more and episodes of depression for two weeks or more (with or without psychosis). To be diagnosed with bipolar I, an individual must have suffered at least one episode of mania in their lifetime. Mania is a state in which someone experiences a change in mood, affect and behaviour that radically effects their ability to function. Generally mania includes symptoms such as extreme hyperactivity, euphoria, elevated talkativeness, much less need for sleep, grandiosity, reckless and impulsive behaviour, distractibility, irritability, rapid speaking, racing thoughts, an increase in goal-directed behaviour, and psychomotor agitation (for example pacing around or tapping).

Bipolar II

To meet the diagnostic criteria for bipolar II, an individual will have experienced episodes of hypomania for at least four days at a time and episodes of depression for two weeks at a time. Hypomania is a state of elevation less extreme and less obvious than mania, and it generally does not render a person unable to function socially and occupationally. Indeed many people with bipolar II can be misdiagnosed with major depressive disorder because they do not recognise their episodes of hypomania and clinicians don’t ask about it.

Subthreshold bipolar disorder (also known as unspecified bipolar disorder or bipolar disorder not otherwise specified)

Bipolar disorders that fit within this bracket are those that do not meet the threshold for either bipolar I (7+ days mania/2 weeks+ depression) or bipolar II (4+ days hypomania/2 weeks+ depression). Whilst they have historically often been overlooked in the study of bipolar and are frequently misdiagnosed, people with a subthreshold bipolar disorder are actually in the majority (55-60%).

There are all kinds of bipolar presentations that can come under subthreshold – for example a person who experiences 5 days of mania and 1 week of depression, or 3 days of hypomania and three days of depression. Rapid cycling (4 or more mood changes within a year) tends to plague subthreshold bipolar disorders. In fact in some forms, a person’s mood can cycle within hours or even minutes.

A common form of subthreshold bipolar disorder is manic symptoms coexisting with depression (for example racing thoughts, impulsivity, high libido, irritability and agitation in the presence of depression).

Why does bipolar disorder so often go misdiagnosed as depression?

Bipolar disorders are plagued by misdiagnosis – particularly subthreshold bipolar disorders. Here in the UK, clinicians are not trained to spot the signs of subthreshold bipolar disorders.

Indeed, the National Institute for Health and Care Excellence (NICE) rolls out advice and guidelines for healthcare workers in the UK. While NICE acknowledges the concept of ‘bipolar spectrum’, it has published no guidance on how to recognise and treat it, offering advice only on bipolar type I and bipolar type II. In practice, this deficit leaves those suffering the myriad other forms of bipolar disorder – who can be equally debilitated by the condition – at a loss or misdiagnosed with major depression and put on ineffective or harmful treatments.

Bipolar disorder is a serious illness and misdiagnosis is a risky business. Indeed a World Health Organisation (WHO) investigation reported that across a lifetime, the disability burden of bipolar spectrum disorder is heavier than all types of cancer, epilepsy, and all known neurological diseases (Alzheimer’s included). What’s more, bipolar disorder is linked to early death from heart disease in almost 40% of cases and an 18% suicide rate.

Here in the UK bipolar disorder diagnosis takes 13 years on average, and 85% of cases suffer misdiagnosis. The standard across Asia, the USA and Europe is also subpar. But research has shown that early intervention in bipolar disorder could be crucial in averting or mitigating some of its potential worst outcomes. So if you find your antidepressants not working or seeming to aggravate your symptoms, it’s worth considering if you could in fact have an undiagnosed bipolar disorder.

Antidepressants not working – now what?

Has your depression not improved with at least 2 trials of antidepressants? Ask yourself – Is it possible that what I suffer from may be bipolar disorder?

Take the HCL-32 bipolar disorder self-report questionnaire.

Only a qualified mental health professional can diagnose bipolar spectrum disorder, however:

  • If you score 14 or above the positive predictive value is 73%, which means there is a 73% chance (high probability) that you have bipolarity. You should be assessed by a specialist psychiatrist.
  • If you score below 14 you have a negative predictive value of 61% meaning that there is still a probability of bipolar disorder in 39% of cases. We recommend you are assessed by a specialist psychiatrist.

Revolutionary treatment for bipolar disorder

Good treatment is essential for bipolar disorder. Unfortunately, a condition characterised by mood cycling has historically been very hard to treat because of the necessity of addressing both polarities (mania/hypomania plus depression). Sadly, ineffective treatment and poor quality of life for bipolar sufferers tends to be the norm the world over. Traditional bipolar treatment normally involves a combination of three or four different drugs with a host of unpleasant side effects. Indeed, WHO research found the disability burden of bipolar to average 7.4 out of 10 on the Sheehan Disability Scale.

Thankfully though, a movement for better bipolar treatment is afoot – and here at The London Psychiatry Centre, our Bipolar Clinic is at the forefront.

At The London Psychiatry Centre, our exclusive bipolar treatment programme combines precision medicine, mitochondrial treatment, High-Dose Levothyroxine (HDL), and non-invasive treatment rTMS (Repetitive Transcranial Magnetic Stimulation).

Backed by extensive research following patients for two years after treatment commences, our programme boasts a 96.4% remission rate.

Indeed, 33% of our bipolar treatment programme patients now have a disability score of 0, and the average disability rating on the Sheehan Disability Scale is 1.29 out of 10. These results have been described by patients as ‘life-changing’, as acknowledged by the Care Quality Commission (CQC).

You can learn more about our treatment programme here. Make an appointment by calling 020 7580 4224 or email info@psychiatrycentre.co.uk.

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