The concept of treatment resistance in bipolar disorder is clinically familiar but lacks a standard definition. Whether the term refers to nonresponse to 1 or more standard treatments, at what dosages, and for what phases of bipolar disorder is unclear. Treatment resistance in bipolar disorder should always be based on a specific phase of treatment: mania or depression and acute or maintenance. In this article, we shall discuss the means to handle treatment-resistant bipolar disorder.
Treatment resistance is extremely common. Even under optimal maintenance conditions, almost half of the bipolar patients with symptom remission will have a recurrence in 2 years under standard care (including medication combinations).
Optimizing phase-specific evidence-based treatments is crucial. This may include raising the dosage of an initial treatment according to a response unless limited by adverse effects. Acute treatments are often continued into maintenance. Combinations are commonplace, and the number of potential combinations is large. Decisions about which medications to use first or in what combinations, as well as dosing issues, require good clinical judgment on the part of each clinician because there is little evidence to drive such decisions.
How you experience bipolar disorder is unique and may not look the same as another person’s symptoms. And while there are multiple treatment options available, not every strategy will be effective for you.
The discovery process for managing bipolar disorder can sometimes be lengthy, and you may need to try several treatment methods. Treatment plans for bipolar disorder often combine a daily balance of:
- self-care and lifestyle changes
In some cases, bipolar disorder can be resistant to common treatment methods. When the usual go-to strategies for this condition seem to have little impact, it may be time to explore options for treatment-resistant bipolar disorder.
Table of Contents
- 0.1 What is treatment-resistant bipolar disorder?
- 0.2 Symptoms of treatment-resistant bipolar disorder
- 0.3 First-line treatments for bipolar disorder
- 0.4 Psychotherapy
- 0.5 Medication
- 0.6 Coping with treatment-resistant bipolar disorder
- 0.7 Nonstandard methods
- 1 Self-Care Strategies
What is treatment-resistant bipolar disorder?
Treatment-resistant bipolar disorder is a term used when someone has a minimal or inadequate responseTrusted Source to standard treatments. This can mean that you see little to no results from first-line therapies, or your healthcare team cannot establish an effective long-term maintenance program for your bipolar disorder.
There are no formal diagnostic criteria to conclusively say when bipolar disorder should be labeled treatment-resistant. But according to 2015 research, this condition might be considered treatment-resistant when there’s an inadequate response to at least two bipolar disorder treatments.
Treatment resistance is possible across any stage or type of bipolar disorder. However, it appears that an adequate treatment for depressive episodes may be the most challenging to find.
Many treatments used during depressive episodes of bipolar disorder are also used for treating depression. Approximately two-thirds of people prescribed medication for depression don’t typically respond to their first medication.
Overall, treatment resistance affects between 20% to 60%Trusted Source of people living with mental health disorders.
Symptoms of treatment-resistant bipolar disorder
The symptoms of treatment-resistant bipolar disorder are similar to the symptoms of bipolar disorder, except the most commonly effective treatments don’t seem to help improve or reduce the severity of symptoms.
If your bipolar disorder is treatment-resistant, you may experience symptoms that:
- stay the same during treatment
- improve slightly but not enough to be clinically significant
- improve for brief periods with breakthrough manic or depressive episodes
Symptoms of bipolar disorder include:
- Mania: episodes of elevated mood, agitation, impulsivity, and excitability
- Hypomania: a milder, more easily controlled version of mania
- Depression: feelings of hopelessness, despair, and worthlessness
You may also experience:
- suicidal ideation
- weight changes
- difficulty concentrating
- sleep changes
Remember that you’re not alone, and resources are available to you. If you need to talk with someone right away, you can:
- Call the National Suicide Prevention Lifeline 24 hours a day at 800-273-8255.
- Text “HOME” to the Crisis Textline at 741741.
Not in the U.S.? You can find a helpline in your country with Befrienders Worldwide.
First-line treatments for bipolar disorder
The two most common types of first-line treatments are psychotherapy and medication. First-line treatments for bipolar disorder:
- have been tested and shown to be most effective for bipolar disorder
- are approved by the FDA
- have ample evidence backing their use
- are supported by doctors and therapists
Depending on your symptoms, your doctor may recommend a form of talk therapy, including:
- Cognitive Behavior Therapy (CBT)
- problem-solving therapy (PST)
- Interpersonal And Social Rhythm Therapy (IPSRT)
- family-focused therapy
From a medication standpoint, first-line treatments for episodes of acute mania often include:
Maintenance treatments for mania often include valproate and lithium.
For depressive episodes, first-line medications typically include:
- anti-anxiety medications
- mood stabilizers
Coping with treatment-resistant bipolar disorder
Trying to manage treatment-resistant bipolar disorder can feel disheartening. You might even start to wonder whether anything will ever make a difference.
In this case, your doctor may opt for second-line and combination therapies, such as:
- thyroid hormone T3
- ketamine therapy
If these treatments are still ineffective, nonstandard methods of addressing treatment-resistant bipolar disorder are often used.
These include Electro Convulsive Therapy (ECT), which uses electric currents to stimulate the brain while under anesthesia to encourage improved neural connections, and clozapine, an antipsychotic medication.
A 2020 meta-analysis of 17 studies found that ECT and clozapine showed promising results in treatment-resistant bipolar disorder.
Also, a 2014 reviewTrusted Source revealed clozapine not only improved the symptoms of treatment-resistant bipolar disorder, but it was also relatively safe with a low occurrence of negative side effects.
The effectiveness of ECT is recognized by the American Psychiatric Association (APA) and has been shown to benefit approximately 80% of patients with uncomplicated, severe major depression.
Other therapiesTrusted Sources for treatment-resistant bipolar disorder continue to be investigated, including the use of:
- glutamatergic agents
- dopamine agonists
In addition to clinical treatment, you could also consider self-care strategies.
Learning about treatment-resistant bipolar disorder can help you and your loved one better understand breakthrough symptoms.
You may be able to speak with your doctor before episodes of mania or depression impact your life severely once you know how to better recognize the signs.
Meditation methods, such as mindfulness meditation, can help you break free from intrusive thoughts and cycles of emotion.
A 2015 research article suggests aerobic exercise can positively impact your brain when living with bipolar disorder. This exercise may lessen the damage from long-term stress and encourage stress-response suppression.
According to a 2015 review, people with bipolar disorder who exercise experienced improved:
- depressive symptoms
- quality of life
In a 2015 study on sleep, women living with bipolar disorder who believed they had poor sleep quality were more likely to experience worse mood outcomes in the severity and frequency of episodes.
While men generally didn’t report worse outcomes from their perceived sleep quality, there is a link between sleep and wellness.
Drug and alcohol abstinence
Substance use can cause changes in the brain, often in the areas related to behavior and mood. These changes can make bipolar symptoms worse and can even cause a form of bipolar disorder over time.
Maintaining creative hobbies can keep your brain engaged while providing a sense of accomplishment and relaxation.
But if you suddenly lose the desire to spend time on your hobbies, it may be an early indication that you’re experiencing a breakthrough symptom of a bipolar depressive episode.
Spending time with pets
Pets can provide emotional support and comfort. They can bring you joy and help you maintain a sense of responsibility.
A 2016 study suggests healthy eating can help reduce comorbidities for people living with bipolar disorder.
Discovering what helps you relax can help you manage symptoms of agitation and anxiety that may come with bipolar disorder.
While participating in breathing exercises or yoga can be a great way to destress, relaxation techniques could be as simple as indulging in a bubble bath or a cup of coffee on the porch.
Surrounding yourself with people who understand and support you can be a big help when you have breakthrough bipolar disorder symptoms.
When you feel lost or unsure about how your treatment is going, finding an online or local support group can help provide insight.
You can learn a lot from other people also living with bipolar disorder. You can also offer them support as they work through their bipolar disorder.
Journaling may allow you to see patterns in your emotions and behaviors. You can express your thoughts freely with the ability to look back on them before you make any major decisions.
A journal may also be beneficial to your doctor or mental health professional as you evaluate your treatment options.
Following treatment protocols
Treatments are the most successful when they are followed as prescribed. Skipping medications or therapy sessions may impact how well you respond to your treatment plan.
Even an effective treatment plan won’t improve your symptoms if it is practiced infrequently.
In summary, treatment-resistant bipolar disorder can impact your life in many ways. You may start to feel frustrated or anxious if your symptoms don’t seem to improve.
If you live with treatment-resistant bipolar disorder, you are not alone, and your feelings are valid.
When first-line treatments don’t seem to help, treatment plans may include:
- second-line or combination therapies
- nonstandard options
- self-care and lifestyle changes
Finding the best treatment plan for bipolar disorder can take time. You may need to try multiple strategies or a combination of options before finding what works best for you.
There is hope for people living with treatment-resistant bipolar disorder. If you are ready to get help but don’t know where to begin, you can check out Psych Central’s guide to mental health support.