Consider Bipolar depression when antidepressants are not working

One of the most common presentations to a family doctor or psychiatrist is for symptoms of depression. These symptoms include feeling low in mood, but also having sleep and appetite changes, low energy, poor concentration and a lack of interest in things that would normally bring joy like hobbies and seeing friends. When depression becomes severe, a person can become catatonic or psychotic, meaning they can stop eating, talking or moving and can even begin to believe things they normally do not. Fortunately these severe mental states are rare.

The most common medications for depression are antidepressants called selective serotonergic reuptake inhibitors or SSRIs. These include drugs like Fluoxetine, Cipralex and Sertraline. There are many other types of antidepressants with different modes of action and often patients will respond to one of these.

There are instances where despite many antidepressant trials, a patient's depression does not respond. I will not go into all of the reasons why this might be, but wanted to highlight one possibility in particular: Bipolar depression.

This kind of depression, Bipolar depression, means that the depression is not the only mood irregularity in the person's mental illness, but that this person is also prone to more energetic, elevated or irritable moods also. These episodes are called manic or hypomanic episodes and are diagnosed depending on duration of the episode as well as a set of clinical symptoms. In these cases, antidepressants should actually be avoided because they can push patients into the elevated mood states and cause disinhibited, reckless behaviors, or rapid mood cycling

It can be very difficult to confirm if a patient has bipolar depression when the person's mental health history is not clear for a manic or hypomanic episode. In mania/hypomania, a person experiences an elevated mood state that can cause a whole range of difficulties, but often are experienced by the patient as a time of more productivity, creativity, ambition and energy. A thorough psychiatric assessment therefore should always include questions asking about the presence of these different mood states because of their implications on treatment and illness course.

When I can not confirm bipolar illness, but it is a possibility, even after a thorough assessment, the conversation with the patient around treatment involves detailing the risks and benefits of treating the symptoms like a unipolar depression (ie classic depression) and the risks and benefits of treating the symptoms like a bipolar depression. Sometimes, if I believe the risk for a bipolar illness is low, I recommend trying an antidepressant first because unipolar depression is more common than bipolar depression and these treatments are quite effective and have few side effects. Also, it is not uncommon people switch between treatments too quickly, when an adequate dose of a medication has not been reached. This may be another possible reason for poor response to treatment. So I will suggest a 6-8 week trial of a therapeutic dose of an antidepressant first. Another reason for this approach is that I can monitor how the person responds to an antidepressant, which would be more information for me to work with as we hone in on the right diagnosis and treatment. Antidepressants are also very effective in anxiety disorders which accompany the depressive mood. I then warn patients to look out for symptoms that may signal a mania or hypomania and have them fill out a daily mood chart.

In patients with a history more concerning for a bipolar illness, other medications need to be discussed, usually in the drug classes of antipsychotics and mood stabilizers. It can be difficult for patients to accept they need these kinds of medications and so I take the time to tell patients that though these medications have specific labels, they are still used for all sorts of disorders. Medications that are effective for depression in a bipolar illness include Quetiapine, Lamotrigine, Lithium and Lurasidone.

Here are six questions to consider(known as the Rapid Mood Screen-II) when wondering if your depression is a unipolar or bipolar depression:
1. Have you had more than 6 different periods of time ( at least 2 weeks) when you felt deeply depressed?
2. Did you have problems with depression before the age of 18?
3. Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
4. Have you ever had a period of time (>4 days) during which you were more talkative than normal with thoughts racing in your head?
5. Have you ever had a period of time (> 4 days) during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
6. Have you ever had a period (>4 days) of time during which you needed much less sleep than usual?

If you answer yes to 4 or more of these questions, it is more suggestive of a bipolar illness and is worth following up with your doctor and getting a referral to see a psychiatrist. This may explain why your antidepressant trials have not been working.