Several non-biological factors often contribute significantly to treatment resistance.
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.