Depression can negatively impact all areas of your life, and when you’ve been living with it for years, it can feel like there’s no way out of it.

Have you had problems with side effects from antidepressants?

Do you feel like your treatment hasn’t helped your symptoms?

You could have Treatment-Resistant Depression (TRD). TRD is depression that doesn’t get better, even with treatment. From a clinical perspective, it is generally accepted that if you have depression that does not improve with at least 2 trials of antidepressants, you have TRD.

Symptoms of treatment-resistant depression are the same as for depression and include (but are not limited to):

• Low mood for an extended period of time
• Lack of enjoyment from hobbies and activities you used to enjoy
• Trouble connecting with friends and family
• Feeling disconnected
• Avoiding socialising
• Feelings of dread or hopelessness about the future
• Disturbed sleep
• Anxiety
• Difficulty concentrating
• Irritability
• Poor short-term memory

Do I Have Treatment-Resistant Depression (TRD) Or Is It Actually Bipolar Disorder?

Do you actually have TRD? It is important to reconsider this diagnosis even before giving rTMS or any other treatment, because bipolar disorders are very often misdiagnosed as treatment-resistant depression. For example, one study in the US found that 40% of people diagnosed with major depressive disorder also had symptoms of subthreshold hypomania. Another study of 43,000 people found more than 7 out of 10 of those who are eligible for randomised controlled trials for antidepressants with “pure major depression” have subthreshold bipolar disorder. In another study of 5,635 people, 16% of those with a major depressive episode fulfilled the criteria for bipolar type I or II. In addition, about a third of those with major depressive disorder convert to bipolar disorder with time.

Treatment for depression normally involves talking therapy and antidepressants. But for those with bipolar disorder misdiagnosed as TRD, the use of antidepressants can make their condition worse in the long run and increase mood cycling. Research has shown that the use of antidepressants weather short-term or long-term can worsen bipolar symptoms and be counter productive,  even harmful. With that in mind, we recommend that antidepressants should not be used for bipolar – even with mood stabilisers and antipsychotics. This is in keeping with current guidelines and follows on from the landmark STEP - BD study n bipolar treatment. CBT is not the answer either. Indeed, in the largest and longest study  of CBT in bipolar disorder  (which excluded rapid cyclers), CBT was found to be no more effective than treatment without it, and may actually make the condition worse.

In short, bipolar disorder is different to depression and requires different treatment. So if you have been diagnosed with depression or TRD, have tried multiple antidepressants but have not improved, or have gotten worse, it may be time to ask if you could have a bipolar spectrum disorder.

A couple of good books to read to help understand this are Why am I still depressed?  and Bipolar not so much by Jim Phelps.