Q: Is Med Resistant Bipolar Possible?
Hi Dr. Phelps,
I have bipolar 1 disorder, and I'm currently doing pretty well on 600mg seroquel,
125 imipramine, 30 remeron, and 1 mg. klonopin. The klonopin is for a "movement
disorder" that may be from the seroquel (when I'm too tired my legs and arms
will start jerking quite violently, but this started before seroquel, when I was
Anyway, in my support forum for bipolar, people are talking about "med
resistant" bipolar. Someone's new pdoc told her, after their initial 30 min.
session, that she was med resistant to bipolar meds.
I've never heard of that. Is it possible for us to build up a resistance so
that *no* mood stabilizers or APs will work for us anymore?
Dear Shannon --
The sky is falling. The Day of Judgment is coming soon. If you do certain
things you'll go blind. Proclamations of doom are easy to issue. The hard part
is providing evidence to match.
Just as there is some reason to worry about the sky
falling (or warming, anyway), there is some reason to worry about bipolar
disorder -- in some few people -- becoming difficult to treat, as indeed
there are people whose symptoms seem to continue to "evolve" over time requiring
more medications to maintain remission of the illness. But how many people have
I got in my practice, where I've been treating many of the same folks for over
10 years, who have reached the point having "no" medications work? Just about
zero. I have a couple who have awful symptoms that are difficult to control but
for most of them, the symptoms have been hard to control all the way along. I
have a few people who have worsened rather steadily despite our efforts to treat
the illness, and yet one of them comes to mind immediately: one of the most
recent medications we've tried has turned the calendar back so far, he's
thinking about trying to go to work again after having been completely disabled
(wanting desperately to work all the while to support his family better but
unable to, because of severe anxiety symptoms that would worsen every time he
went to do something, even things he'd done 100's of times before). He's so much
better he's working on small jobs with friends trying to get his confidence back
(which disappeared when his symptoms were worst; a guy who used to be the boss
of a large crew).
I hesitate to mention this next idea; I'd rather just
leave you with that hopeful note (that is, that if "resistance" occurs it is
uncommon, and that even people who have tried a lot of things can still later
find a treatment that really helps). But I've written in many places, on this
website and my own (PsychEducation.org), about my concern that antidepressants
can make bipolar worse and that one of the possible risks, not proven by
any matter of means but a possibility I think we all must consider, is
that antidepressants could be one of the factors that could push some versions
of bipolar disorder along some sort of timeline faster. In other words,
perhaps in some people whose bipolar disorder can indeed "progress" over time
toward a more treatment-resistant form, antidepressants might make that happen
quicker. This is the "kindling" hypothesis reviewed on my website, where you'll
notice there is very little evidence supporting this concern (though none that
I'm aware of which stands clearly against this concern either. Here's a link to
Antidepressant Controversy (see #2b; and the thoughtful "opposing view"
which follows it).
In that essay (and more briefly here) I too run the
risk of being a proclaimer of doom where very little direct evidence exists to
support my view. Please take this with a huge grain of salt, and above all,
do not stop your antidepressant(s). You and your psychiatrist must make any
such decision together, as there are many factors which should be considered and
stopping antidepressants can easily lead to worse outcomes. Be careful. Keep
asking questions and looking for evidence-based answers. Good luck to you.
Published Sept., 2006