have i been secretly bipolar this whole time?
mood disorders, mood stabilsers + the prevalence of misdiagnosis
I’ve got some stuff to figure out, so I’m going to write through it. Let’s go.
my silly little story 🤸♂️
In December, I started mood stabilisers for the first time. I have been on some type of antidepressant, non-stop, since I was 17. I’m 28 now. But I had never tried mood stabilisers.
Previously, I had tried 5 or 6 SSRIs – with little success. None of them helped significantly, and at least two of them threw me into a manic episode. I only remember one of these episodes but it was prominent enough that my friends and family noticed a marked difference in my behaviour. We figured out it was caused by the new medication and I was back to normal after I came off it. No one questioned this episode further. Ever. But maybe they should have.
Eventually I was labelled with “treatment-resistent depression” and prescribed an SNRI that might work better. And it did. For quite a while. By the time I noticed it wasn’t working as well anymore, I know longer had access to a public psychiatrist. And because by now I had amassed a number of chronic health conditions and medications to treat them, combined with my “complicated” history, my GP was reluctant to do much more than increase my current dose. I ended up in this cycle for years. My meds weren’t working, so I went to the doctor. The doctor couldn’t change my meds, so she did what she could and increased them. The increased meds didn’t help (or straight out made things worse) and the side effects got more bothersome, so I went back to the doctor. Rinse and repeat.
Naturally, I ended up on a pretty high dose of the SNRI and still ended up in crisis. My GP tried to work with a consulting psychiatrist who suggested adding anti-psychotics in. I tried a few different ones, but that didn’t work either and the side effects were incredibly distressing.
Eventually I found a private psyhchiatrist in Hamilton last year who I booked in to see over zoom. After quite a lot of discussion, research and consulting, we decided to lower the dose of the SNRI (gotta keep some of those anti-anxiety properties to manage my OCD, obsessive thinking and anxiety 🥴) and try a mood stabiliser. Given how tangled and uncategorised my psychiatric conditions have become, it’s sometimes hard to figure out exactly what is going on. The psychiatrist thought I may have underlying bipolar and a mood stabiliser could treat that. And if there is no bipolar, mood stabilisers can be helpful in managing BPD emotional disregulation anyway.
the results are in 🥁
Here’s the thing, I don’t recall having a prolonged period of being this consistently stable ever. This mood stabiliser has…………………stabilised my mood????? Consistently???? I’ve been tracking my mood since mid-December and I was shocked at the results (I have a terrible memory so I had forgotten how I felt 🤪). I don’t want to get ahead of myself. It is also summer and I struggle a lot more in the winter. That is undoubtly partly contributing, but it can’t be all of it.
So why did it take 10 years, eight psychiartrists, two therapists, two psychologists, two inpatient stays, one hospital admission and countless assessments to try a mood stabiliser? Especially, when SSRIs were not helping. Especially, when SSRIs triggered a manic episode that was witnessed by two psychiatrists and two therapists. Especially, when I have BPD, which is often comorbid with bipolar or even impossible to separate.
the evidence 🕵️♀️
Bipolar, especially bipolar 2 is often misdiagnosed as depression for a number of reasons.
People are more likely to seek help when they are feeling depressed, even if it’s part of a bigger picture.
People are less likely to report manic/hypomanic symtpoms as they might not realise it is a symptom. They might not see it as anything abnormal. Mania/hypomania can look vastly different from person to person. They may not fit in to their own understanding of what bipolar is.
People are less likely to seek help for mania/hypomania (even if they are aware of what it is) because they might like how they feel.
People may feel more shame and anxiety about reporting mania/hypomania, especially if it results in behaviours they are embarrased about (hypersexuality, overspending, anger, substance use and so on).
People seeking help may have experienced only depression. The only way to tell the difference between bipolar depression and unipolar depression is mania/hypomania. If they haven’t expereinced that yet, there is no way for anyone to know if the real problem is bipolar. And after unipolar depression has been diagnosed and medicated or treatment has started, it’s unlikely for people to review this diagnosis, even if antidepressants aren’t helping.
One survey reported 69% of people diagnosed with bipolar are initally diagnosed with another mental health condition, mostly with unipolar depression, and more than 30% of those misdiagnosed are still misdiagnosed after 10 years.
Another study found that misdiagnosed bipolar causes a lower quality of life than both major depression and accurately diagnosed bipolar.
It’s also not a new idea that SSRIs are unhelpful and maybe dangerous for treating bipolar depression. There are many differing opinions on this, but overall the evidence is weak. It looks like SSRIs may be helpful in conjunction with a mood stabiliser. They may be better in the short term. They may be better at treating bipolar 2 depression over bipolar 1. They may work for some people and not at all for others. Given how many conflicting opinions there are, I would guess it would be smart to, at the least, be aware of these risks and watch out for them when treating someone for depression.
Research for this post took me very little time. A quick google search will bring up multiple studies and surveys regarding misdiagnosed bipolar. It’s equally easy to find information on SSRIs triggering mania in people with underlying bipolar. All of this information at the tip of my fingers and still, here I am 10 years later.
bring it all back to me 💃
Maybe I don’t have bipolar and am just benefitting from the mood stabiliser treating the rollercoaster of BPD. Maybe the summer is really helping my mood and I will look at this all differently in a few months time. All I can write about is right now. And right now I can’t get past the fact that there was this whole category of medication right there for years. There was clear evidence that I might benefit from it. And instead I was labelled “treatment-resistent”. Instead I was loaded with unhelpful medication even when I said I wanted to come off it and it wasn’t helping. If this medication continues to be this beneficial, I can’t help but think how my life might have been different, been easier, if I had tried this years ago.
My current psychiatrist was so surprised to hear I had a documented manic episode after starting an SSRI and I was never assessed for bipolar after that. (Reacting to an SSRI like this doesn’t automatically mean you have bipolar, but it is at least worth looking at.)
self-validation 🤗
Despite all the murkiness of diagnosis here, all the unanswered questions, I still need to validating what I am feeling. I don’t need to have concrete answers to warrant feeling upset and mad and disappointed and hopeful.
Of course I feel frustrated that key signs that a different medication could be more helpful were missed by the people I trusted with my care. Almost every one would feel like that in this situation.
It makes sense that I felt embarrased and shameful and broken at having been referred to as “treatment-resistent” after one course of treatment had been tried. It makes sense that I’m still upset and angry about being labelled “treatment-resistent” or complicated and difficult when I wasn’t the problem, the treatment was.
It’s understandable that I am anxious and even scared about being stable after such a long period of instability. Change is always scary, especially after such a long and consistent pattern. And also it makes sense that I’m scared of losing the stability I have now because I have waited so long and worked so hard for it.
It’s understandable that I’m thinking about this in terms of diagnosis and labels because humans instinctively want things to be easily recognised and categorised. And also my oldest wisest self knows it is just as valid to treat symptoms without a diagnosis. I deserve an easier, more stable life regardless.
It makes sense that I am feeling conflicted and confused and muddled because this situation is and my mental health treatment has been conflicting and confusing and muddly. And also I am a human being and we are inherently conflicted and confusing and muddly.
Thanks for being here and reading my muddled musings. See you next week.