I have spent years of my life with bipolar medication not working — or, at least, bipolar medication not working to the extent that one would want. I know this isn’t the common refrain around medication — the common refrain being, take bipolar medication and get better — but it is a reality that many of us live with. So, the question is, what do you do when the bipolar medication isn’t working? What do you do when you have treatment-resistant bipolar disorder?
Why Doesn’t Bipolar Medication Work? Why Are Some People Treatment Resistant?
I don’t know why bipolar medication sometimes doesn’t work. Actually, I don’t know why bipolar medication ever works — no one does; it’s one of the mysteries with which medicine currently grapples. I do know, though, that more medications don’t work for me than do, and I know it’s like that for many of us. That’s why you have to cycle from medication to medication to find the right one for you. (If you happen to be lucky enough not to have gone through that, you’re in the minority.)
But if we know that bipolar disorder is an illness of the brain and we have medications that effectively treat it, as borne out in studies, why, so often, does bipolar medication not work for certain people? I’m intensely frustrated by this question. And I’m intensely frustrated by the fact that 25% of people with bipolar disorder fall into the category of treatment-resistant bipolar depression. (People who are treatment-resistant in bipolar disorder tend to manifest it as persistent depression.)
What Is Treatment-Resistant Bipolar Depression? What Does ‘Medication Not Working’ Mean?
It’s difficult to even define treatment-resistant bipolar depression. That’s because the definition of treatment resistance differs among studies. Not only do studies differ regarding how many treatments one must fail to be considered treatment resistant, but they also differ in what they consider successful treatment. One might 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 “success.” As we know, we need to aim for zero symptoms.)
All that being said, it’s usually a failure of two treatments that indicates treatment resistance. But, when I say a failure of two treatments, I mean a failure of two treatments that were given at an adequate dose for long enough to truly rule them out (many people give up before that happens).
(There is actually an even more severe concept that has been conceptualized called multi-therapy 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 can’t achieve anything close to remission after you’ve really given two or more therapies a shot. This is a loose definition, of course, but I think it represents the patient’s point of view better.
When You’re Treatment Resistant and Your Bipolar Medication Does Work 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 medication is doing nothing. It’s quite possible (and perhaps likely) that without it, you would be worse. Consider the ramifications of this carefully when deciding to make medication changes. (I’m not saying that a medication change is the wrong move, only that you do so with this knowledge in mind.)
Secondly, while it sounds terrifying to have treatment-resistant bipolar depression, it doesn’t mean that you can’t or won’t get better. I had a spell of remission after trying everything I could think of (including electroconvulsive therapy). Please remember that hope still exists.
Thirdly, understand that bipolar disorder is extremely difficult and complicated to treat. This is evidenced by the fact that most people with bipolar disorder are on two or more medications. This is known as polypharmacy. Polypharmacy is the rule in bipolar disorder rather than the exception. Obviously, if your wellness is going to come from multiple medications, it’s going to take longer to dial that in than if it was just one.
Fourth, you may have to live with bipolar medication that doesn’t work well for some time. I know this is horrible and unfair, but it’s true. You can get through this pain. It won’t last forever. You may be in a holding pattern for a variety of reasons, not the least of which being accessibility to the treatment you need.
Finally, don’t give up hope. Treatment-resistant bipolar disorder is not a death diagnosis. People move from the category of treatment-resistant to successfully treated all the time. It’s hard and painful and long, but it happens. Believe me, I have been there. (Don’t give up hope even if your doctor gives up on you.)
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 on medication that isn’t nearly successful enough. I’m sorry if this is you. I’m sorry that this is me. But this doesn’t mean that it’s over. That doesn’t mean you will always live this way. Suffering feels like forever. And sometimes it’s very, very long. But change happens every day. New medications become available every single day. Hold on. Better days are coming.
Sources
- Diaz, A. P., Fernandes, B. S., Quevedo, J., Sanches, M., & Soares, J. C. (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., & Miller, I. W. (2014). Medication burden in bipolar disorder: A chart review of patients at psychiatric hospital admission. Psychiatry Research, 216(1), 24. https://doi.org/10.1016/j.psychres.2014.01.038
One huge piece of advice… especially if you have repeated medication “failures” or you’ve been on something that poops out… blood work. And most importantly, ferritin and B12. Both of which need to be ABOVE what’s considered normal when it comes to mental health and psych meds.
While the whole “not enough serotonin/dopamine” is way over-simplistic, psych meds mostly do work by modifying the behaviour of neurotransmitters in your system. If you, for some reason, don’t have enough neurotransmitters in your system, the meds have nothing to work on so aren’t going to work well. Our body builds neurotransmitters from smaller building blocks and requires various other compounds to fuel that process (cofactors). Sufficient levels of iron (measured by ferritin) and vitamin B12 are two of them.
Deficiencies of either (and many other things) can decrease the production of neurotransmitters (to say nothing of mimicking many symptoms of anxiety and depression). And that can affect how well your meds work. Doctors are quick to bump doses or switch meds and then label people treatment-resistant without always looking at things like this. Many family doctors and psychiatrists miss this—frequently. And these are some of the easiest (and quickest) things to correct, once detected.