Bipolar Depression: When Nothing Works - What Now?

Patient Expert

Stewart writes:

"I have been struggling with my bipolar II disorder for about 17 years. I am considered to have a refractory, treatment-resistant condition. I have been through about 25 medications singularly and in various 'cocktail' combinations, four rounds of ECT, long-term therapy, various alternative treatment, and the results have ranged from poor to terrible."

Stewart is at the end of his tether. "I am worn out and seemingly running out of options." he goes on to say. "I am a 53-year-old male and my life has been devastated ... I do not know how much more I can tolerate."

Stewart, you're my hero. I don't know how you do it. Every once in a while I slide into a one-or-two-day depression, and suddenly it's like: "Yes, now I remember what it's like." It all comes back, the indescribable hell, the constant wearing down.

Yes, I remember it all too well. Prometheus chained to a rock, the vultures gnawing at my brain. The nineties was a lost decade for me, and I nearly didn't survive it. Honest to God, Stewart, I don't think I can take that again.

Mania gets all the attention, but depression is by far the most pervasive and devastating part of our illness. According to a series of surveys by the Stanley Bipolar Foundation Network, patients with bipolar I are depressed three days for every one day manic. Those with bipolar II, of course, don't get manic, just hypomanic, at best. For them, the figure is - get this - 50 days depressed for every one day hypomanic.

Fifty days Moreover, the same studies found that virtually all of us continue to live with residual depression symptoms.

Basically, we're a depressed population with a few speed bumps. Except for one or two individuals, literally everyone I have run into with our illness has been reduced to nothing by depression. To a person, we all feel lucky to be alive. No, I take that back. A lot of us very indubitably feel less than lucky.

Okay, Stewart, I will share something personal with you. What brought me out of my suicidal depression turned out to be the worst treatment imaginable. The psychiatrist who saw me misdiagnosed me with unipolar depression and prescribed an antidepressant. The antidepressant worked uncommonly fast. Within hours, I was feeling better. For one brief shining moment I knew what it was like to feel normal, better than normal even.

I didn't sleep for two days and started hallucinating. Seeing things, starting to hear things. My heart was racing. This wasn't good. Should I stop taking my antidepressant and risk going back to being chained to a rock again? Or should I stay on the med and put my trust in this devil I didn't know?

The mania was way too frightening. I opted for the devil I knew.

As most of you know, if you have bipolar - and the same may apply for those with short unipolar depressions that cycle in and out - an antidepressant without a concomitant mood stabilizer runs a very high risk of flipping a patient into mania. Pharmaceutical companies have quietly settled a large number of cases involving patients who literally and uncharacteristically went postal soon after taking an antidepressant. Every once in a while a case goes to court, and secret and highly unflattering company documents get exposed to broad daylight.

The American Psychiatric Association in its 2002 Bipolar Treatment Guideline unequivocally advises against doctors prescribing our population antidepressants without a mood stabilizer. These days, there is an impressive body of psychiatric opinion that posits that even with a mood stabilizer, antidepressants pose too great a risk.

Believe me, Stewart, had I taken one more antidepressant, my family may well have wound up taking a drug company to court. Instead, miraculously, that antidepressant delivered me.

I was manic. I was flipping out. But I wasn't depressed. I wasn't suicidal. A crisis unit psychiatrist put me on a mood stabilizer (with a different antidepressant) and I leveled out.

Last year, I was having a conversation with a good friend of mine about making out an advance psychiatric directive should I ever get suicidally depressed again. The context of the conversation was ECT, but then I brought up my experience. Then a lightbulb went off:

Suppose, I ventured, my psychiatrist and I were to reach this kind of understanding: If I ever got suicidally depressed (which by definition is a life-or-death situation), maybe he should take me off my mood stabilizer and prescribe me an antidepressant.

Or for that matter, a stimulant or even a recreational drug. Anything to quickly get me out of my killer depression.

But with this proviso. I must be in a locked unit under constant surveillance. Inducing a mania is definitely not the sort of thing to try at home. Then, once I'm up, we put me back on a mood stabilizer.

Let me make this clear, Stewart. This was just a conversation, but you are entitled to initiate this discussion with your psychiatrist. If your psychiatrist practices good medicine, he or she is almost certain to forcefully rule out this option. The profession does tend to take that "first, do no harm" rule pretty seriously. You may reject the idea as out of hand, yourself, but you are also entitled to keep badgering your psychiatrist.

Right now, the only treatment to get an individual quickly out of depression is ECT, which did not work for you. We need to get serious about coming up with other options. I know from personal experience the pain you are in, Stewart. Believe me, for your sake - and for the rest of us - we need to start putting ideas on the table.