Finding Answers for Treatment-Resistant Bipolar Disorder

The history of pharmacological bipolar disorder treatment dates back to late 1949, when Australian psychiatrist John Cade published an article on the efficacy of lithium in the treatment of mania. Since that time, we have witnessed the emergence of an ever-growing number of pharmacological options—from anticonvulsants to atypical antipsychotics—for treating bipolar disorder symptoms. And yet, as Dr. Michael Gitlin, Professor of Clinical Psychiatry at the UCLA School of Medicine, says, “Treatment resistance remains a central problem in bipolar disorder.”

Treatment resistance doesn’t have a standard definition, but it is generally taken to mean that at least two trials of first-line treatment options have not been successful in fully resolving symptoms. For many, however, two trials is only the tip of the iceberg; it is not uncommon for people to try over a dozen medications in their search for relief from mood disturbances. Additionally, while treatment resistance has historically only referred to effect on clinical symptoms, the mental health community is increasingly starting to consider functionality when it comes to defining treatment resistance. Dr. Gitlin notes that people with bipolar disorder often struggle with “inadequate responses” to pharmacological interventions and continue to experience chronic symptoms, recurrence, and “marked functional disability” even when taking medication that provides partial improvement.

The reason treatment resistance is so prevalent amongst people with bipolar disorder lies partially in the complexity of the illness itself. Mania, hypomania, and depression may all require different kinds of interventions that vary depending on illness presentation, and balancing the changing needs of each person can be challenging.

For example, some will respond well to first-line medication for acute symptoms, but struggle to find medication that prevents cycling during maintenance. Others quickly find treatment the resolves their manic or hypomanic states, but relief from bipolar depression eludes them. In fact, bipolar depression often one of the most difficult phases of bipolar disorder to treat. Contrary to historical understanding, bipolar depression appears to be distinct from unipolar depression, does typically not respond well to SSRIs, and requires more complex interventions while guarding against mood switching. All of these factors together can make finding effective pharmacological treatment a difficult and time-consuming process that usually involves multiple medications.

While medication is typically the cornerstone of bipolar disorder treatment, psychotherapy and skill building are also important components of the treatment picture. Ideally, medication will resolve most clinical symptoms, but learning how to effectively manage residual symptoms, cope with stressors to prevent symptoms from recurring, and improve overall functionality are vital pieces of the recovery picture. This includes developing lifestyle habits that support healthy function and nurturing independent living skills. In the absence of these interventions, your loved one is more likely to struggle with breakthrough symptoms and functional difficulties even when appropriately medicated.

Treatment efficacy can also be impacted by substance use, including the use of alcohol. Additionally, co-occurring illnesses such as anemia, posttraumatic stress disorder, hyperthyroidism, and personality disorders should all be ruled out.

If your loved one is struggling with treatment-resistant bipolar disorder, you may feel that you are running out of options. However, long-term residential treatment programs offer new solutions to people who have not achieved their desired outcomes in other treatment environments. The benefits of these programs include:

Diagnostic Clarity

Long-term residential treatment programs can offer in-depth psychological assessment in order to develop a complete picture of your loved one’s needs. This includes not only clinical interviews and testing, but ongoing observation that gives clinicians the opportunity to create diagnostic clarity. This is critical to confirming that your loved one truly has bipolar disorder and identifying their bipolar subtype as well as discovering any co-occurring disorders that will need to be treated. You may also be referred to outside physicians to rule out physical or neurological conditions.

Comprehensive Pharmacological Care

With a detailed picture of your loved one’s psychological health as well as their treatment history, their psychiatrist will design a personalized medication plan targeted at resolving their immediate symptoms. The close monitoring made possible by a residential environment allows clinicians to observe both efficacy and side-effects and gives your loved one the ability to provide continuous feedback about their medication response. This affords clinicians the opportunity to rapidly develop effective and well-tolerated medication protocols tailored to your family member’s needs. These plans go beyond first-line options and include judiciously formulated medication combinations based on cutting-edge research.

The residential treatment environment also ensures that your loved one’s adherence is monitored and that they are not taking harmful substances that can interfere with treatment efficacy.

Psychotherapeutic Supports and Skill Building

The importance of psychotherapeutic supports cannot be overstated when it comes to bipolar disorder treatment. Too often, treatment providers rely solely on medication while ignoring the complex, nuanced emotional and behavioral challenges people with bipolar disorder face, challenges that go unaddressed by medication alone. Engaging in a comprehensive curriculum of therapies designed to help your loved one explore their inner selves, give expression to their feelings, and disrupt damaging patterns can be a powerful experience. By deepening your loved one’s self-awareness and creating strategies for coping with their symptoms, these therapies can promote profound transformation and reduce the chance of relapse.

Additionally, developing the concrete skills necessary to improve day-to-day functionality is essential to fostering confidence and self-efficacy. The duration of long-term residential treatment programs ensures that your loved one as the time and space necessary to deeply integrate these skills through continuous practice.