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13 Contributing Factors to Treatment-Resistant Bipolar Disorder

13 Contributing Factors to Treatment-Resistant Bipolar Disorder

  • Some clinicians find symptom checklists or scales helpful in supplementing findings on the mental status examination. Symptom recognition is especially important when medicating patients who have bipolar disorder with mixed symptoms because failure to recognize less obvious or “soft” hypomanic symptoms (insomnia, anxiety, irritability, rapid thoughts, and rumination) can lead to prescribing antidepressants, which will offer no therapeutic benefit and may even worsen activation symptoms.

  • Volitional unhealthy lifestyle behaviors can also have an adverse effect on the prognosis of bipolar disorder. Patients should be informed that controllable poor sleep habits (staying up late on the internet), predictable and avoidable stressful situations, and irregular medication compliance can neutralize or outweigh the positive effects of prescribed medications. Moreover, frequent exercise and the stability of regular routines, such as healthy eating habits and good sleep hygiene, can enhance treatment outcomes.

  • Patients who use even small or moderate amounts of alcohol or recreational drugs (including marijuana) should be informed that any continued use can interfere with the therapeutic effects of prescribed bipolar medications. Concurrent use of some psychiatric (antidepressants) and non-psychiatric (eg, steroids, opioids) mood-destabilizing medications should be discontinued to determine whether they are opposing the therapeutic effects of antimanic agents.

  • Most patients with bipolar disorder require polypharmacy. In these cases, the prescribing physician should not change more than one medication at a time because the cause of any positive or negative effects will be unclear if more than one medicine is changed simultaneously. The cost and accessibility of a bipolar disorder medication should be considered and discussed with the patient before it is initiated because some expensive brand products may not be covered by the patient’s health insurance, or the high copay may be unaffordable. Providing samples to initiate treatment can be helpful in these situations. We consider a patient with bipolar disorder treatment resistant if trials of all medications approved by the FDA for bipolar disorder have failed

  • There is no formal universal definition of treatment resistance; proposed criteria have included a specific number of failed medication trials, incomplete or unsatisfactory response to treatment (usually determined by symptom rating scales), unsuccessful response for a specified duration of treatment, failure to respond to a phase of bipolar disorder, poor response to all medication and nonmedicinal interventions, or lack of response to only “evidence-based” (usually FDA-approved) medications for bipolar disorder.

  • Medical issues, such as chronic insomnia in bipolar disorder, is associated with impaired cognition, worsening of hypomanic/manic symptoms, and increased risk of suicide.

  • For more on this topic, see Treatment-Resistant Bipolar Disorder, on which this slideshow is based.


I've tried opening this presentation multiple ways but it's not functioning correctly.

Geneva @

it wont load

Felisina @

Can't comment cause I can't see the presentation (its fixed on the first slide).

giovanni f. @

I'm having difficulties also - with both Explorer and Chrome.

Michael @

Very important and practical aspects of mood disorders!!
Walter Doege M.D.

Walter @

Message to site administration:

I had to use the Firefox browser to read this one. In the past Opera has been fine. Some site's use technicians who trained in Microsoft courses and who therefore tend to use Microsoft specific short cuts rather than programme to suit all browsers.. Firefox will mimic the M$ browser where necessary but that renders it less secure.

Ray @

Perhaps it isn’t Bipolar Disorder at all. Perhaps there isn’t enough supports or the person is unable to understand or utilize what is available. Perhaps the clinician has not engaged genuinely with the person and demonstrate caring to build a therapeutic relationship to even begin to educate or provide skills for insight into his illness. Perhaps there is time constraints that the clinician has prescribed for themselves. Perhaps there has been no early intervention before it has become chronic. Maybe the society we live in has something to do with being resistant such as spending behaviours, highs and lows and stress and stigma. Perhaps technology has done damage to our thinking and our brains. Perhaps there hasnt been enough research. There are so many viariables, but the person is still a human being and needs to be regarded with unconditional positive regard He could be teaching you something about yourself too

Brenda E @

Great post Brenda.
Talking about non-biological markers in treatment resistance is kind of weird. What are the biological markers for bi-polar disorder and what biological markers would one expect to find in treatment resistance?
Stephen Hughes

Stephen @

Brenda E,
From your comment, it seems like you think that a person who suffers from " treatment resistent bipolar disorder" means that the term is somehow saying something negative about the PERSON. It is actually just the opposite. When the psychiatric community refers to a treatment resistent disorder we are most always referring to a condition that all of the most common evidence based treatments are not alievating the patients symptoms and the patient verbalizes they feel no better. For example A patient can say after trying 4 different mood stabilizers over a year they feel no better than they did before they started. (Which is not a common occurance) That is an example of treatment resistant. It has nothing to do with the patient themselves. I agree with the power point it is imparitive to have a correct diagnosis of Bipolar 1, Bipolar 2 or neither and that does include the patient or the family needing to be reliable historians.

Susan @

Many thanks for your instructive reply Brenda. My main concern relates to a the sometimes absence of a thorough contextual analysis. A social-ecological perspective need not be at odds with the application of medical principles. I would add that when professionals refer to 'evidence-based' treatments,it is prudent to remember that evidence is can be research, contextual and experiential. Some people refer to contextual and experiential evidence as bias. They are in my view legitimate sources of evidence upon which helpful decisions can be made. Probably, in reality, they are always at play anyway.
Nice to have met you.
Stephen Hughes PhD

Stephen @

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