Expert: Ivan Goldberg, M.D. - 4/8/2009

Question
I was reading your profile and noted what you said about treatment resistant syndrome...I've never heard of that label or term in terms of a syndrome....I wonder what qualifies a patient to have that label?   My daughter is diagnosed with bipolar and has been since she was 14.  She is 19 now.  She started out on just lithium...then at 15 was prescribed lithium, lamictal and abilify.  She pretty much carried that formula until August 2008...we would change the antipsychotic...risperdal, invega, seroquel, geodon (briefly...it resulted in facial tics)...and add other things...topamax is one I remember...anyway...it seems the meds would work for about a week or maybe two...meds seem to sometimes have the opposite affect after about a month...even from the very early days when she was medicated for adhd with stimulants....they would calm her for about a month and then they would hype her up...Invega was great for one week.....To me she has had great and consistent psychiatric care...sometimes weekly adjustments of meds...but no real progress...Then last August a psychiatrist at an inpatient facility decided she had PDDNOS instead of bipolar and he took her off all her meds...When she got out in November we got into an intensive outpatient program and due to those famous cracks people fall into...she has not had a psych eval...she has her first psychiatrist appt tomorrow...she is still off meds...and has deteriorated....As a parent, I just decided no meds were ok since the meds had never really worked...so anyway your treatment resistant syndrome comment in your profile interested me.

Answer
Hi, Sheila . . .

I would consider someone to have hard-to-treat (a term i prefer to 'treatment-resistant) bipolar disorder if they were properly diagnosed and failed to improve after adequate trials of all three of the following:

1. Lithium

2. Lithium combined with two anticonvulsant mood stabilizers, and

3. The triple combination of lithium, an anticonvulsant mood stabilizer and and antipsychotic medication.

Some people would reserve the term treatment-resistant for individuals with bipolar disorder who have also not ben helped by a series of electroconvulsive treatments.

It may take a good deal of trial-and-error prescribing but most people with hard-to-treat bipolar disorder can usually be helped through the combination of psychotherapy and creative psychopharmacology.

Best regards . . .

Ivan
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