I have spent years of my life without bipolar medication working, or at least without bipolar medication working to the extent that one would like. I know this is not the common refrain around medications (the common refrain is to take medication for bipolar disorder and get better), but it is a reality that many of us live with. So the question is, what do you do when bipolar medication doesn’t work? What do you do when you have treatment-resistant bipolar disorder?
Why don’t bipolar medications work? Why do some people resist treatment?
I don’t know why bipolar medication sometimes doesn’t work. I actually don’t know why bipolar medication works; nobody knows; It is one of the mysteries that medicine currently faces. What I do know, however, is that there are more medications that don’t work for me than those that do, and I know that’s true for many of us. That’s why you have to go from one medication to another until you find the right one for you. (If you’re lucky enough to not have gone through that, you’re in the minority.)
But if we know that bipolar disorder is a disease of the brain and we have medications that treat it effectively, as studies show, why do bipolar medications so often not work for certain people? I am intensely frustrated by this question. And I am deeply frustrated by the fact that 25% of people with bipolar disorder fall into the category of treatment-resistant bipolar depression. (People who resist bipolar disorder treatment tend to manifest it as persistent depression.)
What is treatment-resistant bipolar depression? What does “the medicine doesn’t work” mean?
It is difficult to even define treatment-resistant bipolar depression. This is because the definition of treatment resistance differs between studies. Studies not only differ on how many treatments one must fail to be considered treatment resistant, but they also differ on what they consider a successful treatment. One could say that a 50% reduction in symptoms is a successful treatment, while others may use a different measure. (And, as a patient, I can say that I don’t necessarily agree that a 50% reduction in symptoms is a “success.” As we know, we should aim for zero symptoms.)
All that said, it is usually the failure of two treatments that indicates treatment resistance. But when I say two-treatment failure, I mean the failure of two treatments that were given at an appropriate dose for long enough to really rule them out (many people give up before that happens).
(There is actually an even more severe concept that has been conceptualized called multitherapy-resistant bipolar depression. It is like treatment-resistant bipolar depression, with the addition of failure in psychotherapeutic treatment, at least one trial with an antidepressant and electroconvulsive therapy. (ECT). I fall into this category myself.)
For me, the definition of treatment-resistant bipolar depression is this: you cannot achieve anything close to remission after you have tried two or more therapies. This is a vague definition, of course, but I think it better represents the patient’s point of view.
When you resist treatment and your bipolar medication works well enough, know this
There are many things to know about treatment-resistant bipolar disorder. The first, and perhaps most important, is this: just because your bipolar medication isn’t working enough doesn’t mean it isn’t working at all. In other words, it can always get worse. You can’t assume that just because you’re still depressed your medications aren’t doing anything. It is very possible (and perhaps probable) that without it you would be worse off. Carefully consider the ramifications of this when deciding to make medication changes. (I’m not saying that a medication switch is a misstep, just that you should do it with this knowledge in mind.)
Second, while it sounds scary to have treatment-resistant bipolar depression, it doesn’t mean you can’t or won’t get better. I had a period of remission after trying everything I could think of (including electroconvulsive therapy). Remember that hope still exists.
Third, understand that bipolar disorder is extremely difficult and complicated to treat. This is evidenced by the fact that most people with bipolar disorder take two or more medications. This is known as polypharmacy. Polypharmacy is the rule in bipolar disorder and not the exception. Obviously, if your wellness comes from multiple medications, it will take longer to achieve than if it were just one.
Fourth, you may have to live with bipolar medications that don’t work well for some time. I know this is horrible and unfair, but it’s true. You can overcome this pain. It won’t last forever. You may find yourself in a holding pattern for a variety of reasons, one of which is accessibility to the treatment you need.
Finally, don’t lose hope. Treatment-resistant bipolar disorder is not a life-threatening diagnosis. People move from treatment-resistant to successfully treated all the time. It’s hard, painful and long, but it happens. Believe me, I’ve been there. (Don’t lose hope even if your doctor gives up.)
I’m so sorry your bipolar medication isn’t working; You’re not alone
As I said, a significant number of people are considered treatment resistant, and even more people are taking medications that are not successful enough. I’m sorry if it’s you. I’m sorry this is me. But this doesn’t mean it’s over. That doesn’t mean you’ll always live this way. The suffering seems like an eternity. And sometimes it’s very, very long. But change happens every day. New medications become available every day. Wait. Better days are coming.
- Díaz, AP, Fernandes, BS, Quevedo, J., Sanches, M. and Soares, JC (2022). Treatment-resistant bipolar depression: Concepts and challenges for novel interventions.. Brazilian Journal of Psychiatry, 44(2), 178-186. https://doi.org/10.1590/1516-4446-2020-1627
- Weinstock, L.M., Gaudiano, B.A., Epstein-Lubow, G., Tezanos, K., and Miller, I.W. (2014). Medication burden in bipolar disorder: a review of the medical records of patients admitted to a psychiatric hospital. Research in psychiatry, 216(1), 24. https://doi.org/10.1016/j.psychres.2014.01.038
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