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  • Writer's pictureTom Robinson

The importance of a thorough diagnosis in bipolar disorder and major depression with mixed features

Updated: Jan 29, 2022

Yesterday I outlined a chronological history and progression of my bipolar illness as it happened over the last twenty years, and today I'm going to fill in more of the story.

I finally left the NHS in 2019 (after going round in circles and having my condition much worsened), and I eventually went to see Dr Andy Zamar at the London Psychiatry Centre, on the recommendation of a friend. She had successfully reached remission from her own frightening experience of bipolar disorder and was insistent that this doctor could help me too.

It was obvious from the very first moment that I would be getting far better treatment this time since Dr Zamar asked so many detailed questions about my symptoms and experiences than had ever been asked before.

I explained that if I had to be somewhere the following day I would be unable to sleep because of sheer panic and fear at the self-doubt over whether I would be able to perform even the simplest of tasks of leaving the house or meeting a friend for lunch.

At other times I explained that I could not get going at all, thought of nothing but death and dying, and would sleep for anything up to seventeen hours a day.

I also explained (when asked) that in other episodes I would be severely depressed but also restless and anxious and suffer for days at a time with acute insomnia, my mind racing with suicidal thoughts and intentions.

There was also the physical pain that I would experience where I felt a deep inner unrest in my abdomen with my heart twinging constantly - my only remedy being hours and hours of sitting in a darkened room, deep breathing and desperately trying to resist my suicidal thoughts.

When I explained all of this to Dr Zamar he immediately identified that I was rapid cycling between these ‘mixed states’ where I would have manic symptoms such as racing thoughts and insomnia, but all in a negative (depressed) way.

Not one psychiatrist on the NHS had ever mentioned ‘mixed state’ to me in twenty years, I had just been labelled ‘depressed’ or ‘manic’ and 'bipolar type 1'. The reality was that there was so much more to it than that.

Doctor Zamar explained that the physical pain and unrest that I was experiencing was in fact ‘agitated depression’ which gave me some insight into why I was suffering so intensely and felt like I was constantly at risk of having a heart attack.

The DSM 5 (diagnostic and statistical manual of mental disorders 5th edition) gives the following definition of mixed affective state:

Depressive disorder with mixed features (also referred to as "mixed episode," "mixed state," or "agitated depression" is a mood disorder in which a person has symptoms of both depression and mania or hypomania at the same time.

The times where I would be completely stunted by depression and asleep for seventeen hours a day was ‘simple depression’ and although there was certainly nothing 'simple' about it, knowing what it was helped me to be able to identify the difference between the 'mixed' and 'simple' episodes as they presented themselves.

Doctor Zamar also explained that ‘depression with flight of ideas’ can also occur when the mind is jumping from thought to thought as it does in mania, but this time in a negative way. This was familiar to me too as I had experienced this horrifying state on several occasions throughout my illness.

Knowing all of this didn’t lessen the intensity of the illness, but being able to interpret my episodes in an educated way was the first essential step I took in getting better. I was now able to understand my mind in a different way – Dr Zamar had enlightened me to something that had been completely overlooked by all of my previous psychiatrists.

The importance of a thorough diagnosis cannot be overstated but (as I know from experience) the limits and time constraints involved in the current NHS system do not allow for this to happen. The results can be catastrophic.

I must point out before I go any further that I am not a psychiatrist! I have just read some of the research papers and learnt through my own lived experience. What I write next is my interpretation of what I've read....

There is a concern that prescribing antidepressants to patients with bipolar disorder and/or major depression with mixed features can cause suicide.

This is so obvious to me since my condition was so much worsened when taking the likes of fluoxetine (Prozac) and citalopram (Celexa). My thoughts of death, dying and suicide were all so much heightened, intensified and amplified on these traditional antidepressants.

This is why doctors often say this ridiculous and terrifying statement to patients when they hand them an antidepressant:

"This might make you feel worse before you feel better"

The poor patient thinks "What?! I'm going to feel worse than this? I'm already suicidal, how the hell am I going to be able to survive?" - The reality of what is going on in psychiatry is truly terrifying.

People with depression and mixed features (or already diagnosed bipolar disorder) should NEVER be given antidepressants. The implications in all of this are huge and this is why people need to be thoroughly and properly diagnosed as soon as their first episode presents itself.

Clinicians need to know how to treat those who present with major depression with mixed features. The following paper discusses this:

The current recognised treatment for bipolar mixed states and major depression with mixed features, consists of a combination of a mood stabiliser like lithium or sodium valproate, and an antipsychotic like quetiapine or olanzapine. However, some psychiatrists are still prescribing antidepressants in conjunction with mood stabilisers to people who have mixed features. I know lots of bipolar patients who are unwittingly taking antidepressants that are making their condition so much worse.

The problem with the alternative - (antipsychotics like quetiapine, olanzapine, aripiprazole and paliperidone - to mention a few of the ones I've been prescribed), is that they come with many complications and side effects and are in many cases (including my own) completely ineffective in combatting depressive symptoms!

Mood stabilisers like lithium and sodium valproate are not even approved for use in treating depression and I know from experience that neither drug has ever made even the tiniest dent in the depressive side of my illness.

The paper that I've added above states that:

No mood stabiliser (lithium and divalproex (Sodium Valproate) is actually approved for use in depression of any kind (unipolar, mixed, bipolar), except lamotrigine, which is approved for maintenance treatment in bipolar I disorder”

The problem with lamotrigine is that is completely ineffective too!

All of this is an absolute MINEFIELD for the patient! We go to our doctor to get better yet we're constantly seeing our conditions worsened, some of our friends are DYING because of these medications and we've all now got side effects and new conditions that have been CREATED by these drugs!

So, what is the answer to all of this and how the hell do we treat this effectively and safely?!

Well, within the medical literature there are references to research that shows that treatment with levothyroxine and rTMS (repetitive transcranial magnetic stimulation) can be a safe and effective way of treating bipolar disorder and major depression with mixed features.

This is the treatment that has finally brought me to full remission from a disorder that I have battled for twenty years.

It is painless and comes without risks like memory loss (ECT) or stroke (antipsychotics can increase stroke risk!) or side effects like head-spins, cold sweats, hallucinations, sleep paralysis, mania, mixed state, racing suicidal thoughts, physical pain, panic, fear, and anxiety (thanks antidepressants!)

I will be discussing the safe and effective alternative to all of this in detail tomorrow!

Thanks for reading,

Speak to you soon,


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