{{Short description|Disorder of depression and mood episodes}} {{Hatnote group| {{Redirect2|Bipolar disorders|Manic depression|the medical journal|Bipolar Disorders (journal){{!}}''Bipolar Disorders'' (journal)|the song|Manic Depression (song)}} {{Distinguish|text=Borderline personality disorder, abbreviated as "BPD"}} }} {{Protection padlock|small=yes}} {{Use American English|date=March 2016}} {{Use mdy dates|date=May 2026}} {{cs1 config|name-list-style=vanc|display-authors=6}} {{Infobox medical condition | name = Bipolar disorder | image = P culture.svg | alt = | caption = Bipolar disorder is characterized by episodes of mania or hypomania and depression. | field = Psychiatry, clinical psychology | synonyms = Bipolar affective disorder (BPAD),<ref>{{cite journal |title=Clinical practice guidelines for bipolar affective disorder (BPAD) in children and adolescents |journal=Indian Journal of Psychiatry |date=2019 |volume=61 |issue=8 |pages=294–305 |doi=10.4103/psychiatry.IndianJPsychiatry_570_18 |doi-access=free |pmid=30745704 |pmc=6345130 | vauthors = Gautam S, Jain A, Gautam M, Gautam A, Jagawat T }}</ref> bipolar illness, manic depression, manic depressive disorder, manic–depressive illness (historical),<ref name=Shorter2005/> manic–depressive psychosis, circular insanity (historical),<ref name=Shorter2005/> bipolar disease<ref>{{cite book| vauthors = Coyle N, Paice JA |title=Oxford Textbook of Palliative Nursing|date=2015|publisher=Oxford University Press, Incorporated|isbn=978-0-19-933234-2|page=623}}</ref> | symptoms = Periods of depression and elevated mood<ref name=BMJ2012 /><ref name=DSM5 /> | complications = Suicide, Self harm,<ref name=BMJ2012/> social, legal and financial problems,<ref name=BMJ2012 /><ref name="Diler2019"/> higher risk of diabetes mellitus, heart disease and STIs,<ref name="Cloutier2018"/> cognitive impairment<ref name="Cipriani2017">{{cite journal | vauthors = Cipriani G, Danti S, Carlesi C, Cammisuli DM, Di Fiorino M | title = Bipolar Disorder and Cognitive Dysfunction: A Complex Link | journal = The Journal of Nervous and Mental Disease | volume = 205 | issue = 10 | pages = 743–756 | date = October 2017 | pmid = 28961594 | doi = 10.1097/NMD.0000000000000720 | type = Review }}</ref> | onset = 24 or 46 years old<ref name="Bolton2020">{{cite journal | vauthors = Bolton S, Warner J, Harriss E, Geddes J, Saunders K | title = Bipolar disorder: Trimodal age-at-onset distribution | journal = Bipolar Disord | volume = 23 | issue = 4 | pages = 341-356 | date = November 2020 | pmid = 33030292 | doi = 10.1111/bdi.13016 | type = Accepted manuscript | pmc = 8359178 }}</ref> | duration = | types = Bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise specified, others<ref name=DSM5 /> | causes = Environmental and genetic<ref name=BMJ2012 /> | risks = Family history, child abuse, long-term stress<ref name=BMJ2012 /> | diagnosis = | differential = Attention deficit hyperactivity disorder, autism, personality disorders, schizophrenia, substance use disorder<ref name=BMJ2012 /> | prevention = | treatment = Psychotherapy, medications<ref name=BMJ2012 /> | medication = Lithium, antipsychotics, anticonvulsants<ref name=BMJ2012 /> | prognosis = | frequency = 1% per 6-12 months;<ref name="Ferrari 2011">{{cite journal |last1=Ferrari |first1=Alize J |last2=Baxter |first2=Amanda J |last3=Whiteford |first3=Harvey A |title=A systematic review of the global distribution and availability of prevalence data for bipolar disorder |journal=Journal of Affective Disorders |date=December 2010 |volume=134 |issue=1-3 |pages=1-13 |doi=10.1016/j.jad.2010.11.007 |pmid=21131055}}</ref> 1 to 3% lifetime<ref name="Clemente 2015">{{cite journal |last1=Clemente |first1=Adauto S |last2=Diniz |first2=Breno S |last3=Nicolato |first3=Rodrigo |last4=Kapczinski |first4=Flavio |last5=Soares |first5=Jair C |last6=Firmo |first6=Joselia O |last7=Castro-Costa |first7=Erico |title=Bipolar disorder prevalence: a systematic review and meta-analysis of the literature |journal=Brazilian Journal of Psychiatry |date=May 2015 |volume=37 |issue=2 |pages=155-161 |doi=10.1590/1516-4446-2012-1693 |pmid=25946396}}</ref><ref name="Youngstrom 2017">{{cite journal |last1=Youngstrom |first1=Eric A |last2=Halverson |first2=Tate F |last3=Youngstrom |first3=Jennifer K |last4=Lindhiem |first4=Oliver |last5=Findling |first5=Robert L |title=vidence-Based Assessment from Simple Clinical Judgments to Statistical Learning: Evaluating a Range of Options Using Pediatric Bipolar Disorder as a Diagnostic Challenge |journal=Clinical Psychological Science |date=March 2018 |volume=6 |issue=2 |pages=243-265 |doi=10.1177/2167702617741845 |pmid=30263876|pmc=6152934 }}</ref> | deaths = 11.7 times higher risk of death by suicide<ref name="Biazus 2023">{{cite journal |last1=Biazus |first1=Tais B |last2=Beraldi |first2=Gabriel H |last3=Tokeshi |first3=Lucas |last4=Rotenberg |first4=Luisa |last5=Dragioti |first5=Elena |last6=Carvalho |first6=Andre |last7=Solmi |first7=Marco |last8=Lafer |first8=Beny |title=All-cause and cause-specific mortality among people with bipolar disorder: a large-scale systematic review and meta-analysis |journal=Molecular Psychiatry |date=June 2023 |volume=28 |issue=6 |pages=2508-2524 |doi=10.1038/s41380-023-02109-9 |pmid=37491460}}</ref> }}
'''Bipolar disorder''' ('''BD'''), previously known as '''manic depression''', is a mental disorder characterized by periods of depression and abnormally elevated mood, lasting days to weeks, and in some cases months.<ref name="BMJ2012">{{cite journal |vauthors=Anderson IM, Haddad PM, Scott J |date=December 27, 2012 |title=Bipolar disorder |journal=BMJ (Clinical Research Ed.) |volume=345 |article-number=e8508 |doi=10.1136/bmj.e8508 |pmid=23271744 }}</ref><ref name="DSM5" /> If the elevated mood is severe or associated with psychosis, it is called ''mania''; if it does not significantly affect functioning, it is called ''hypomania''.<ref name=BMJ2012 /> During mania, an individual behaves or feels abnormally energetic, happy, or irritable,<ref name=BMJ2012 /> and often makes impulsive and reckless decisions.<ref name=DSM5 /> There is usually sleep disturbance during manic phases.<ref name="u680">{{cite journal |title=Behavioral Treatment of Insomnia in Bipolar Disorder |journal=American Journal of Psychiatry |date=2013 |volume=170 |issue=7 |pages=716–720 |doi=10.1176/appi.ajp.2013.12050708 |pmid=23820830 |pmc=4185309 | vauthors = Kaplan KA, Harvey AG }}</ref><ref name=DSM5 /><ref name="f458">{{cite journal | last1=Vieira | first1=Igor Soares | last2=Barreto | first2=Nathalia Tessele | last3=Pedrotti Moreira | first3=Fernanda | last4=Mondin | first4=Thaise Campos | last5=Simjanoski | first5=Mario | last6=Cardoso | first6=Taiane de Azevedo | last7=Kapczinski | first7=Flávio | last8=Jansen | first8=Karen | last9=Souza | first9=Luciano Dias de Mattos | last10=da Silva | first10=Ricardo Azevedo | title=Sleep alterations in individuals recently diagnosed with bipolar disorder across different mood stages | journal=Psychiatry Research | volume=299 | date=2021 | doi=10.1016/j.psychres.2021.113824 | article-number=113824 |pmid=33756207 }}</ref><ref>{{cite journal |title=Sleep disturbance in bipolar disorder across the lifespan |journal=Clinical Psychology: Science and Practice |date=2009 |volume=16 |issue=2 |pages=256–277 |doi=10.1111/j.1468-2850.2009.01164.x |pmid=22493520 | vauthors = Harvey AG, Talbot LS, Gershon A |pmc=3321357 }}</ref><ref>{{cite journal |title=The role of sleep in bipolar disorder |journal=Nature and Science of Sleep |date=2016 |volume=8 |pages=207–214 |doi=10.2147/nss.s85754 |doi-access=free |pmid=27418862 |pmc=4935164 | vauthors = Gold A, Sylvia L }}</ref> During periods of depression, the individual may experience crying, have a negative outlook, and demonstrate poor eye contact.<ref name=BMJ2012 /> People with BD are at 11.7 times greater risk of dying by suicide than the general population.<ref name=":11">{{cite journal |last1=Biazus |first1=Taís Boeira |last2=Beraldi |first2=Gabriel Henrique |last3=Tokeshi |first3=Lucas |last4=Rotenberg |first4=Luísa de Siqueira |last5=Dragioti |first5=Elena |last6=Carvalho |first6=André F. |last7=Solmi |first7=Marco |last8=Lafer |first8=Beny |title=All-cause and cause-specific mortality among people with bipolar disorder: a large-scale systematic review and meta-analysis |journal=Molecular Psychiatry |date=June 2023 |volume=28 |issue=6 |pages=2508–2524 |doi=10.1038/s41380-023-02109-9 |pmc=10611575 |pmid=37491460 }}</ref> Approximately 34% attempt suicide during their lifetime.<ref>{{Cite journal |last1=Dong |first1=Min |last2=Lu |first2=Li |last3=Zhang |first3=Ling |last4=Zhang |first4=Qinge |last5=Ungvari |first5=Gabor S. |last6=Ng |first6=Chee H. |last7=Yuan |first7=Zhen |last8=Xiang |first8=Yifan |last9=Wang |first9=Gang |last10=Xiang |first10=Yu-Tao |date=October 25, 2019 |title=Prevalence of suicide attempts in bipolar disorder: a systematic review and meta-analysis of observational studies |journal=Epidemiology and Psychiatric Sciences |volume=29 |article-number=e63 |doi=10.1017/S2045796019000593 |pmc=8061290 |pmid=31648654 }}</ref> Among adolescents with BD, 78% engaged in self-harm.<ref>{{cite journal |title=Prevalence and correlates of non-suicidal self-injury among patients with bipolar disorder: A multicenter study across China |journal=Journal of Affective Disorders |date=2024 |volume=367 |pages=333–341 |doi=10.1016/j.jad.2024.08.231 |pmid=39233245 | vauthors = Zhong R, Wang Z, Zhu Y, Wu X, Wang X, Wu H, Zhou J, Li X, Xu G, Pan M, Chen Z, Li W, Jiao Z, Li M, Zhang Y, Chen J, Chen X, Li N, Sun J, Zhang J, Hu S, Gan Z, Qin Y, Wang Y, Ma Y, Fang Y }}</ref>
The mechanisms of this mood disorder are not clearly understood, although some studies suggest areas for future clinical research. Structural and functional MRI studies have shown differences in brain regions in BD, such as regions involved in perceiving risk-reward and regulating emotions<ref name=":6">{{cite journal | vauthors = Bora E, Fornito A, Yücel M, Pantelis C | title = Voxelwise meta-analysis of gray matter abnormalities in bipolar disorder | journal = Biological Psychiatry | volume = 67 | issue = 11 | pages = 1097–1105 | date = June 2010 | pmid = 20303066 | doi = 10.1016/j.biopsych.2010.01.020 }}</ref><ref name=":8">{{cite journal | vauthors = Kempton MJ, Geddes JR, Ettinger U, Williams SC, Grasby PM | title = Meta-analysis, database, and meta-regression of 98 structural imaging studies in bipolar disorder | journal = Archives of General Psychiatry | volume = 65 | issue = 9 | pages = 1017–1032 | date = September 2008 | pmid = 18762588 | doi = 10.1001/archpsyc.65.9.1017 | doi-access = }}</ref><ref name="pmid19721106">{{cite journal | vauthors = Arnone D, Cavanagh J, Gerber D, Lawrie SM, Ebmeier KP, McIntosh AM | title = Magnetic resonance imaging studies in bipolar disorder and schizophrenia: meta-analysis | journal = The British Journal of Psychiatry | volume = 195 | issue = 3 | pages = 194–201 | date = September 2009 | pmid = 19721106 | doi = 10.1192/bjp.bp.108.059717 | doi-access = free }}</ref><ref name=":9">{{cite journal | vauthors = Selvaraj S, Arnone D, Job D, Stanfield A, Farrow TF, Nugent AC, Scherk H, Gruber O, Chen X, Sachdev PS, Dickstein DP, Malhi GS, Ha TH, Ha K, Phillips ML, McIntosh AM | title = Grey matter differences in bipolar disorder: a meta-analysis of voxel-based morphometry studies | journal = Bipolar Disorders | volume = 14 | issue = 2 | pages = 135–145 | date = March 2012 | pmid = 22420589 | doi = 10.1111/j.1399-5618.2012.01000.x | doi-access = free }}</ref><ref name="Strakowski2012">{{cite journal | vauthors = Strakowski SM, Adler CM, Almeida J, Altshuler LL, Blumberg HP, Chang KD, DelBello MP, Frangou S, McIntosh A, Phillips ML, Sussman JE, Townsend JD | title = The functional neuroanatomy of bipolar disorder: a consensus model | journal = Bipolar Disorders | volume = 14 | issue = 4 | pages = 313–325 | date = June 2012 | pmid = 22631617 | pmc = 3874804 | doi = 10.1111/j.1399-5618.2012.01022.x }}</ref> A systematic review and meta-analysis by Murri and others found that cortisol levels are "associated with the manic phase" of BD.<ref name=":10">{{cite journal |last1=Belvederi Murri |first1=Martino |last2=Prestia |first2=Davide |last3=Mondelli |first3=Valeria |last4=Pariante |first4=Carmine |last5=Patti |first5=Sara |last6=Olivieri |first6=Benedetta |last7=Arzani |first7=Costanza |last8=Masotti |first8=Mattia |last9=Respino |first9=Matteo |last10=Antonioli |first10=Marco |last11=Vassallo |first11=Linda |last12=Serafini |first12=Gianluca |last13=Perna |first13=Giampaolo |last14=Pompili |first14=Maurizio |last15=Amore |first15=Mario |title=The HPA axis in bipolar disorder: Systematic review and meta-analysis |journal=Psychoneuroendocrinology |date=January 2016 |volume=63 |pages=327–342 |doi=10.1016/j.psyneuen.2015.10.014 |pmid=26547798 |hdl=11392/2400889 |hdl-access=free }}</ref> Likewise, various other studies support an important role for hypothalamic-pituitary-adrenal axis (HPA axis).<ref name="Bender2011">{{cite journal |vauthors=Bender RE, Alloy LB | title = Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories | journal = Clin Psychol Rev | volume = 31 | issue = 3 | pages = 383–398 | date = April 2011 | pmid = 21334286 | pmc = 3072804 | doi = 10.1016/j.cpr.2011.01.004 }}</ref><ref name="Lee2013">{{cite journal |vauthors=Lee HJ, Son GH, Geum D | title = Circadian Rhythm Hypotheses of Mixed Features, Antidepressant Treatment Resistance, and Manic Switching in Bipolar Disorder | journal = Psychiatry Investig | volume = 10 | issue = 3 | pages = 225–232 | date = September 2013 | pmid = 24302944 | pmc = 3843013 | doi=10.4306/pi.2013.10.3.225}}</ref>
Risk for BD is thought to be influenced by genetics, environment,<ref name="BMJ2012" /> and ADHD. In one respect (heritability), genetic factors may account for up to 70–90% of the risk of developing BD. In another respect (concordance rate), identical twins both have bipolar disorder (or both do not) at a rate of ~40%, in contrast to dizygotic twins' ~5%.<ref>{{cite book| vauthors = Charney A, Sklar P | veditors = Charney D, Nestler E, Sklar P, Buxbaum J |title=Charney & Nestler's Neurobiology of Mental Illness|date=2018|publisher=Oxford University Press|location=New York|page=162|edition=5th|chapter=Genetics of Schizophrenia and Bipolar Disorder|isbn=978-0-19-068142-5|chapter-url=https://books.google.com/books?id=y8M9DwAAQBAJ&q=Charney%20%26%20Nestler's%20Neurobiology%20of%20Mental%20Illness&pg=PA162}}</ref><ref name="Bobo2017" /> Environmental risks include a history of child abuse and long-term stress.<ref name="BMJ2012" /> A meta-analysis and a separate critical literature review have found worse prognosis and earlier onset of BD in people with childhood maltreatment and "early emotional trauma" respectively.<ref>{{cite journal |last1=Agnew-Blais |first1=Jessica |last2=Danese |first2=Andrea |title=Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis |journal=The Lancet Psychiatry |date=April 2016 |volume=3 |issue=4 |pages=342–349 |doi=10.1016/S2215-0366(15)00544-1 |pmid=26873185 }}</ref><ref>{{cite journal |last1=Dualibe |first1=Aline Limiéri |last2=Osório |first2=Flávia L. |title=Bipolar Disorder and Early Emotional Trauma: A Critical Literature Review on Indicators of Prevalence Rates and Clinical Outcomes |journal=Harvard Review of Psychiatry |date=September 2017 |volume=25 |issue=5 |pages=198–208 |doi=10.1097/HRP.0000000000000154 |pmid=28759479 }}</ref> Likewise, traumatic bonding increases risk of BD. ADHD increases the risk of developing bipolar disorder.<ref>{{cite journal |last1=Khoury |first1=Elie |last2=Acquaviva |first2=Eric |last3=Purper-Ouakil |first3=Diane |last4=Delorme |first4=Richard |last5=Ellul |first5=Pierre |title=Meta-analysis of personal and familial co-occurrence of Attention Deficit/Hyperactivity Disorder and Bipolar Disorder |journal=Neuroscience & Biobehavioral Reviews |date=March 2023 |volume=146 |article-number=105050 |doi=10.1016/j.neubiorev.2023.105050 |pmid=36657649 }}</ref><ref>{{Cite journal |last1=Comparelli |first1=Anna |last2=Polidori |first2=Lorenzo |last3=Sarli |first3=Giuseppe |last4=Pistollato |first4=Andrea |last5=Pompili |first5=Maurizio |date=August 10, 2022 |title=Differentiation and comorbidity of bipolar disorder and attention deficit and hyperactivity disorder in children, adolescents, and adults: A clinical and nosological perspective |journal=Frontiers in Psychiatry |language=English |volume=13 |article-number=949375 |doi=10.3389/fpsyt.2022.949375 |doi-access=free |pmc=9403243 |pmid=36032257}}</ref> More research is needed to understand the nature of this association.
The condition is classified as bipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and as bipolar II disorder if there has been at least one hypomanic episode (but no full manic episodes) and one major depressive episode.<ref name="DSM5" /> It is classified as cyclothymia if there are hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes.<ref name="Van Meter 2012" /> If these symptoms are due to drugs or medical problems, they are not diagnosed as BD.<ref name="DSM5">{{cite book|author=American Psychiatry Association|title=Diagnostic and Statistical Manual of Mental Disorders|date=2013|publisher=American Psychiatric Publishing |location=Arlington |isbn=978-0-89042-555-8 |pages=123–154 |edition=5th}}</ref>
Mood stabilizers, particularly lithium, and anticonvulsants, such as lamotrigine and valproate, as well as atypical antipsychotics are used for treatment.<ref name="Lancet2016" /> Atypical antipsychotics are used for acute manic episodes or when mood stabilizers are ineffective or not tolerated, with long-acting injectables available for patients who struggle to maintain a medication regimen.<ref name="Lancet2016" /> There is evidence that psychotherapy improves the course of BD.<ref>{{cite journal | vauthors = Goodwin GM, Haddad PM, Ferrier IN, Aronson JK, Barnes T, Cipriani A, Coghill DR, Fazel S, Geddes JR, Grunze H, Holmes EA, Howes O, Hudson S, Hunt N, Jones I, Macmillan IC, McAllister-Williams H, Miklowitz DR, Morriss R, Munafò M, Paton C, Saharkian BJ, Saunders K, Sinclair J, Taylor D, Vieta E, Young AH | title = Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology | journal = Journal of Psychopharmacology | volume = 30 | issue = 6 | pages = 495–553 | date = June 2016 | pmid = 26979387 | pmc = 4922419 | doi = 10.1177/0269881116636545 | quote = Currently, medication remains the key to successful practice for most patients in the long term. ... At present the preferred strategy is for continuous rather than intermittent treatment with oral medicines to prevent new mood episodes. }}</ref> Use of antidepressants in depressive episodes is controversial: they can be effective, but certain classes of antidepressants increase the risk of mania.<ref>{{cite journal | vauthors = Cheniaux E, Nardi AE | title = Evaluating the efficacy and safety of antidepressants in patients with bipolar disorder | journal = Expert Opinion on Drug Safety | volume = 18 | issue = 10 | pages = 893–913 | date = October 2019 | pmid = 31364895 | doi = 10.1080/14740338.2019.1651291 }}</ref><ref>{{cite journal |title=Induction of Mania with Selective Serotonin Re-uptake Inhibitors and Tricyclic Antidepressants |journal=British Journal of Psychiatry |date=1994 |volume=164 |issue=4 |pages=549–550 |doi=10.1192/bjp.164.4.549 |pmid=8038948 | vauthors = Peet M }}</ref> The treatment of depressive episodes, therefore, is often difficult.<ref name="Lancet2016">{{cite journal | vauthors = Grande I, Berk M, Birmaher B, Vieta E | title = Bipolar disorder | journal = Lancet | volume = 387 | issue = 10027 | pages = 1561–1572 | date = April 2016 | pmid = 26388529 | doi = 10.1016/S0140-6736(15)00241-X }}</ref> Past studies have found that electroconvulsive therapy (ECT) is effective in acute manic and depressive episodes, particularly with psychosis or catatonia;{{efn|1=Catatonia is a syndrome characterized by profound unresponsiveness or stupor with abnormal movements in a person who is otherwise awake.<ref name="DSM-5-introduction">{{cite book| last=American Psychiatric Association| year=2013| title=Diagnostic and Statistical Manual of Mental Disorders| edition=Fifth| publisher=American Psychiatric Publishing| location=Arlington, VA| pages=[https://archive.org/details/diagnosticstatis0005unse/page/119 119–121]| isbn=978-0-89042-555-8| url=https://archive.org/details/diagnosticstatis0005unse/page/119}}</ref>}}<ref name="Lancet2016" /> likewise, past guidelines have recommended admission to a psychiatric hospital if someone is a risk to themselves or others, and/or involuntary treatment if someone refuses treatment.<ref name="BMJ2012" /> However, the Committee on Rights of Persons with Disabilities (CRPD) of the United Nations has recommended the abolition of institutionalization and forced treatments "such as sedatives, mood stabilizers, electro-convulsive treatment, and conversion therapy".<ref name=":14">{{Cite web |title=Guidelines on deinstitutionalization, including in emergencies (CRPD/C/5; 10 October 2022) |url=https://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=5eTssQxle4DLdIUqKzyP4UW%2BN3TrKLeY1iWLwXPm%2B3QxETYQnze8MKgcI5n6W7WGX29qEjh53jkdJBjGC5IfiA%3D%3D |access-date=March 22, 2026 |website=United Nations Office of the High Commissioner for Human Rights}}</ref>
The 6-12 month prevalence of bipolar disorder is 1%,<ref>{{cite journal |last1=Ferrari |first1=Alize J. |last2=Baxter |first2=Amanda J. |last3=Whiteford |first3=Harvey A. |title=A systematic review of the global distribution and availability of prevalence data for bipolar disorder |journal=Journal of Affective Disorders |date=November 2011 |volume=134 |issue=1–3 |pages=1–13 |doi=10.1016/j.jad.2010.11.007 |pmid=21131055 }}</ref> while the lifetime prevalence is between 1 and 3%.<ref>{{cite journal |last1=Clemente |first1=Adauto S. |last2=Diniz |first2=Breno S. |last3=Nicolato |first3=Rodrigo |last4=Kapczinski |first4=Flavio P. |last5=Soares |first5=Jair C. |last6=Firmo |first6=Josélia O. |last7=Castro-Costa |first7=Érico |title=Bipolar disorder prevalence: a systematic review and meta-analysis of the literature |journal=Revista Brasileira de Psiquiatria |date=May 2015 |volume=37 |issue=2 |pages=155–161 |doi=10.1590/1516-4446-2012-1693 |pmid=25946396 }}</ref><ref name=":3" /> The prevalence of pediatric bipolar disorder is 3.9%, although study estimates are higher with "broad bipolar criteria" and "older minimum age".<ref>{{cite journal |last1=Van Meter |first1=Anna |last2=Moreira |first2=Ana Lúcia R. |last3=Youngstrom |first3=Eric |title=Updated Meta-Analysis of Epidemiologic Studies of Pediatric Bipolar Disorder |journal=The Journal of Clinical Psychiatry |date=April 2, 2019 |volume=80 |issue=3 |doi=10.4088/jcp.18r12180 |pmid=30946542 }}</ref> The most frequent ages of onset are 24 or 46; the distribution of onset age is bimodal.<ref>{{Cite journal |last1=Bolton |first1=Sorcha |last2=Warner |first2=Jeremy |last3=Harriss |first3=Eli |last4=Geddes |first4=John |last5=Saunders |first5=Kate E. A. |date=October 8, 2020 |title=Bipolar disorder: Trimodal age-at-onset distribution |journal=Bipolar Disorders |volume=23 |issue=4 |pages=341–356 |doi=10.1111/bdi.13016 |pmc=8359178 |pmid=33030292}}</ref> An earlier onset is associated with worse depression and more frequent co-diagnosis of anxiety and substance use.<ref>{{cite journal |last1=Joslyn |first1=Cassandra |last2=Hawes |first2=David J |last3=Hunt |first3=Caroline |last4=Mitchell |first4=Philip B |title=Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review |journal=Bipolar Disorders |date=August 2016 |volume=18 |issue=5 |pages=389–403 |doi=10.1111/bdi.12419 |pmid=27530107 }}</ref> Around 40-60% of people with BD are employed and over 80% "may take time off work for psychiatric reasons in a five year period."<ref>{{cite journal |last1=Marwaha |first1=S. |last2=Durrani |first2=A. |last3=Singh |first3=S. |title=Employment outcomes in people with bipolar disorder: a systematic review |journal=Acta Psychiatrica Scandinavica |date=September 2013 |volume=128 |issue=3 |pages=179–193 |doi=10.1111/acps.12087 |pmid=23379960 }}</ref> Occupational therapies appear cost-effective at returning people with BD to work.<ref>{{Cite journal |last1=Johanson |first1=Suzanne |last2=Gregersen Oestergaard |first2=Lisa |last3=Bejerholm |first3=Ulrika |last4=Nygren |first4=Carita |last5=van Tulder |first5=Maurits |last6=Zingmark |first6=Magnus |date=November 2023 |title=Cost-effectiveness of occupational therapy return-to-work interventions for people with mental health disorders: A systematic review |journal=Scandinavian Journal of Occupational Therapy |volume=30 |issue=8 |pages=1339–1356 |doi=10.1080/11038128.2023.2200576 |pmid=37119175 |url=https://research.vu.nl/en/publications/3c48f951-e840-4ba4-85ce-7b64378d8e0c |hdl=1871.1/3c48f951-e840-4ba4-85ce-7b64378d8e0c |hdl-access=free }}</ref> Social cognition is moderately impaired in people with BD, regardless of mood state.<ref>{{cite journal |last1=Gillissie |first1=Emily S. |last2=Lui |first2=Leanna M. W. |last3=Ceban |first3=Felicia |last4=Miskowiak |first4=Kamilla |last5=Gok |first5=Sena |last6=Cao |first6=Bing |last7=Teopiz |first7=Kayla M. |last8=Ho |first8=Roger |last9=Lee |first9=Yena |last10=Rosenblat |first10=Joshua D. |last11=McIntyre |first11=Roger S. |title=Deficits of social cognition in bipolar disorder: Systematic review and meta-analysis |journal=Bipolar Disorders |date=March 2022 |volume=24 |issue=2 |pages=137–148 |doi=10.1111/bdi.13163 |pmid=34825440 |url=https://researchprofiles.ku.dk/da/publications/76357baa-e8f3-4541-bec9-e98a57851438 }}</ref> 16% of people with BD are high functioning.<ref>{{cite journal |last1=Akers |first1=Nadia |last2=Lobban |first2=Fiona |last3=Hilton |first3=Claire |last4=Panagaki |first4=Katerina |last5=Jones |first5=Steven H. |title=Measuring social and occupational functioning of people with bipolar disorder: A systematic review |journal=Clinical Psychology Review |date=December 2019 |volume=74 |article-number=101782 |doi=10.1016/j.cpr.2019.101782 |pmid=31751878 |doi-access=free }}</ref> As of 2021, people with BD accounted for 183 Years Lived with Disability (YLDs) per 100,000 people in the Americas (ranking 20th out of all conditions).<ref name=":12">{{Cite web |title=Leading causes of death, and disability - PAHO/WHO {{!}} Pan American Health Organization |url=https://www.paho.org/en/enlace/leading-causes-death-and-disability |access-date=April 16, 2026 |website=www.paho.org |language=en}}</ref> Risk of death due to unnatural and natural causes is 7.3 and 1.9 times higher respectively.<ref name=":11" /> On average, life expectancy is 12.9 years shorter.<ref>{{cite journal |last1=Chan |first1=Joe Kwun Nam |last2=Tong |first2=CoCo Ho Yi |last3=Wong |first3=Corine Sau Man |last4=Chen |first4=Eric Yu Hai |last5=Chang |first5=Wing Chung |title=Life expectancy and years of potential life lost in bipolar disorder: systematic review and meta-analysis |journal=The British Journal of Psychiatry |date=September 2022 |volume=221 |issue=3 |pages=567–576 |doi=10.1192/bjp.2022.19 |pmid=35184778 |doi-access=free }}</ref> {{TOC limit|3}}
== Signs and symptoms == Bipolar symptoms usually begin in adolescence or early adulthood.<ref name="Christie88">{{cite journal |vauthors=Christie KA, Burke JD, Regier DA, Rae DS, Boyd JH, Locke BZ | title = Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults | journal = The American Journal of Psychiatry | volume = 145 | issue = 8 | pages = 971–975 | year = 1988 | pmid = 3394882 | doi=10.1176/ajp.145.8.971}}</ref>{{sfn|Goodwin|Jamison|2007|p=1945}} The condition is characterized by intermittent episodes of mania, commonly (but not in everyone) alternating with bouts of depression, with an absence of symptoms in between.<ref name="Chen2011">{{cite journal | vauthors = Chen CH, Suckling J, Lennox BR, Ooi C, Bullmore ET | title = A quantitative meta-analysis of fMRI studies in bipolar disorder | journal = Bipolar Disorders | volume = 13 | issue = 1 | pages = 1–15 | date = February 2011 | pmid = 21320248 | doi = 10.1111/j.1399-5618.2011.00893.x }}</ref><ref name="Reus_2022">{{cite book | vauthors = Reus V |title=Harrison's Principles of Internal Medicine |date=2022 |publisher=McGraw Hill |isbn=978-1-264-26850-4 |edition=21st |location=New York |chapter=Chapter 452: Psychiatric Disorders}}</ref> During these episodes, people with bipolar disorder exhibit disruptions in normal mood, psychomotor activity (the level of physical activity that is influenced by mood)—such as constant fidgeting during mania or slowed movements during depression—circadian rhythm and cognition. Mania can present with varying levels of mood disturbance, ranging from euphoria, which is associated with "classic mania", to dysphoria and irritability.<ref name=akiskalsadock>{{cite book| vauthors = Akiskal H | veditors = Sadock B, Sadock V, Ruiz P |title=Kaplan and Sadock's Comprehensive Textbook of Psychiatry|date=2017|publisher=Wolters Kluwer|location=New York|edition=10th|chapter=13.4 Mood Disorders: Clinical Features}}{{ISBN?}}</ref>
Psychotic symptoms such as delusions or hallucinations may occur in both manic and depressive episodes; their content and nature are consistent with the person's mood.<ref name="BMJ2012" /> Approximately 60–75% of people with bipolar I disorder have experienced psychosis.<ref>{{cite journal |last1=Aminoff |first1=S. R. |last2=Onyeka |first2=I. N. |last3=Ødegaard |first3=M. |last4=Simonsen |first4=C. |last5=Lagerberg |first5=T. V. |last6=Andreassen |first6=O. A. |last7=Romm |first7=K. L. |last8=Melle |first8=I. |title=Lifetime and point prevalence of psychotic symptoms in adults with bipolar disorders: a systematic review and meta-analysis |journal=Psychological Medicine |date=October 2022 |volume=52 |issue=13 |pages=2413–2425 |doi=10.1017/S003329172200201X |pmc=9647517 |pmid=36016504}}</ref><ref>{{cite journal |last1=Grover |first1=Sandeep |last2=Avasthi |first2=Ajit |last3=Chakravarty |first3=Rahul |last4=Dan |first4=Amitava |last5=Chakraborty |first5=Kaustav |last6=Neogi |first6=Rajarshi |last7=Desouza |first7=Avinash |last8=Nayak |first8=Omkar |last9=Kumar Praharaj |first9=Samir |last10=Menon |first10=Vikas |last11=Bathla |first11=Manish |last12=Subramanyam |first12=Alka A. |last13=Nebhinani |first13=Naresh |last14=Ghosh |first14=Prasonjit |last15=Lakdawala |first15=Bhavesh |last16=Bhattacharya |first16=Ranjan |title=Prevalence of psychotic symptoms and their impact on course and outcome of patients with bipolar disorder: Findings from the Bipolar Disorder Course and Outcome study from India (BiD-CoIN study) |journal=Journal of Affective Disorders |date=May 2022 |volume=305 |pages=233–239 |doi=10.1016/j.jad.2022.02.070 |pmid=35248664 }}</ref> Psychotic symptoms are more common in bipolar type I than in bipolar type II, though people with bipolar type II can also experience psychosis.<ref name=":7">{{cite journal |last1=Chakrabarti |first1=Subho |last2=Singh |first2=Navdeep |title=Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review |journal=World Journal of Psychiatry |date=September 19, 2022 |volume=12 |issue=9 |pages=1204–1232 |doi=10.5498/wjp.v12.i9.1204 |doi-access=free |pmc=9521535 |pmid=36186500 }}</ref>
In some people with bipolar disorder, depressive symptoms predominate, and the episodes of mania are always the more subdued hypomania type.<ref name="Reus_2022" /> According to the DSM-5 criteria, mania is distinguished from hypomania by the duration: hypomania is present if elevated mood symptoms persist for at least four consecutive days, while mania is present if such symptoms persist for more than a week. Unlike mania, hypomania is not always associated with impaired functioning.<ref name="Lancet2016" /><!-- cites 2 previous sentences --> The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood.<ref name="Salvadore2010">{{cite journal | vauthors = Salvadore G, Quiroz JA, Machado-Vieira R, Henter ID, Manji HK, Zarate CA | title = The neurobiology of the switch process in bipolar disorder: a review | journal = The Journal of Clinical Psychiatry | volume = 71 | issue = 11 | pages = 1488–1501 | date = November 2010 | pmid = 20492846 | pmc = 3000635 | doi = 10.4088/JCP.09r05259gre }}</ref>
=== Manic episodes === {{Main|Mania}}
thumb|left|An 1892 color lithograph depicting a woman diagnosed with ''hilarious mania''
Also known as mania, a manic episode is a period of at least one week of elevated or irritable mood, which can range from euphoria to delirium. The core symptom of mania involves an increase in energy of psychomotor activity. Mania can also present with increased self-esteem or grandiosity, racing thoughts, pressured speech that is difficult to interrupt, decreased need for sleep, disinhibited social behavior,<ref name=akiskalsadock/> increased goal-oriented activities and impaired judgement, which can lead to impulsive or high-risk behaviors, such as excessive spending.<ref name="Barnett2009" /><ref name="Tarr2011">{{cite journal|vauthors=Tarr GP, Glue P, Herbison P|date=November 2011|title=Comparative efficacy and acceptability of mood stabilizer and second generation antipsychotic monotherapy for acute mania—a systematic review and meta-analysis|journal=J Affect Disord|volume=134|issue=1–3|pages=14–19|doi=10.1016/j.jad.2010.11.009|pmid=21145595}}</ref><ref name="Beentjes2012">{{cite journal|vauthors=Beentjes TA, Goossens PJ, Poslawsky IE|date=October 2012|title=Caregiver burden in bipolar hypomania and mania: a systematic review|journal=Perspect Psychiatr Care|volume=48|issue=4|pages=187–197|doi=10.1111/j.1744-6163.2012.00328.x|pmid=23005586|doi-access=}}</ref> To fit the definition of a manic episode, these behaviors must impair the individual's ability to socialize or work.<ref name="Barnett2009" /><ref name="Beentjes2012" /> If untreated, a manic episode usually lasts three to six months.<ref>{{cite journal | author = Titmarsh S | title = Characteristics and duration of mania: implications for continuation treatment | journal = Progress in Neurology and Psychiatry | date = May–June 2013 | volume = 17 | issue = 3 | pages = 26–27 | doi = 10.1002/pnp.283 | doi-access = }}</ref>
In severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood.<ref name="Beentjes2012" /> They may feel unstoppable, persecuted, or as if they have a special relationship with God, a great mission to accomplish, or other grandiose or delusional ideas.<ref name="Knowles2011">{{cite journal |vauthors=Knowles R, McCarthy-Jones S, Rowse G | title = Grandiose delusions: a review and theoretical integration of cognitive and affective perspectives | journal = Clin Psychol Rev | volume = 31 | issue = 4 | pages = 684–696 | date = June 2011 | pmid = 21482326 | doi = 10.1016/j.cpr.2011.02.009 }}</ref><ref>{{cite journal | vauthors = Baethge C, Baldessarini RJ, Freudenthal K, Streeruwitz A, Bauer M, Bschor T | title = Hallucinations in bipolar disorder: characteristics and comparison to unipolar depression and schizophrenia | journal = Bipolar Disorders | volume = 7 | issue = 2 | pages = 136–145 | date = April 2005 | pmid = 15762854 | doi = 10.1111/j.1399-5618.2004.00175.x }}</ref> This occasionally results in hospitalization in an inpatient psychiatric hospital,<ref name="Tarr2011" /><ref name="Beentjes2012" /> but a systematic review and meta-analysis showed that bipolar disorder, by itself, does not increase criminally violent behavior.<ref name=":13">{{cite journal |last1=Verdolini |first1=Norma |last2=Pacchiarotti |first2=Isabella |last3=Köhler |first3=Cristiano A. |last4=Reinares |first4=Maria |last5=Samalin |first5=Ludovic |last6=Colom |first6=Francesc |last7=Tortorella |first7=Alfonso |last8=Stubbs |first8=Brendon |last9=Carvalho |first9=André F. |last10=Vieta |first10=Eduard |last11=Murru |first11=Andrea |title=Violent criminal behavior in the context of bipolar disorder: Systematic review and meta-analysis |journal=Journal of Affective Disorders |date=October 2018 |volume=239 |pages=161–170 |doi=10.1016/j.jad.2018.06.050 |pmid=30014956 |hdl=2445/148126 |hdl-access=free }}</ref> The severity of manic symptoms can be measured by rating scales such as the Young Mania Rating Scale, though questions remain about the reliability of these scales.<ref>{{cite journal | author = Furukawa TA | title = Assessment of mood: Guides for clinicians | journal = Journal of Psychosomatic Research | volume = 68 | issue = 6 | pages = 581–589 | year = 2010 | pmid = 20488276 | doi = 10.1016/j.jpsychores.2009.05.003 }}</ref>
Authors of a chapter for a "clinical textbook" posit that mania is a medical emergency.<ref>{{cite book |last1=Jauhar |first1=Sameer |last2=Alexandre Wong |first2=Sui Liem |title=Clinical Textbook of Mood Disorders |chapter=An Update on the Treatment of Manic and Hypomanic States |date=2024 |pages=206–212 |doi=10.1017/9781108973922.021 |isbn=978-1-108-97392-2 }}</ref> Two other authors (Kane and Director) in the Journal of Medical Ethics have debated the medical decision-making capacity of people with mania.<ref>{{cite journal |last1=Kane |first1=Nuala B |title=What it is like to be manic: a response to Director |journal=Journal of Medical Ethics |date=October 2024 |volume=50 |issue=10 |pages=716–717 |doi=10.1136/jme-2024-110032 |pmid=38688687 }}</ref><ref>{{cite journal |last1=Director |first1=Samuel |title=Defending manic competence: a reply to Kane |journal=Journal of Medical Ethics |date=September 2025 |volume=51 |issue=9 |pages=653–654 |doi=10.1136/jme-2025-110744 |pmid=39965908 }}</ref> In a study of fifty inpatients with mania, 38% were found to have capacity to make their own treatment choices.<ref>{{Cite journal |last1=Beckett |first1=Jonathan |last2=Chaplin |first2=Robert |date=November 2006 |title=Capacity to consent to treatment in patients with acute mania |journal=Psychiatric Bulletin |volume=30 |issue=11 |pages=419–422 |doi=10.1192/pb.30.11.419 |doi-access=free }}</ref>
The onset of a manic or depressive episode is often foreshadowed by sleep disturbance.<ref name="McKenna2012">{{cite journal |vauthors=McKenna BS, Eyler LT | title = Overlapping prefrontal systems involved in cognitive and emotional processing in euthymic bipolar disorder and following sleep deprivation: a review of functional neuroimaging studies | journal = Clin Psychol Rev | volume = 32 | issue = 7 | pages = 650–663 | date = November 2012 | pmid = 22926687 | pmc = 3922056 | doi = 10.1016/j.cpr.2012.07.003 }}</ref> Manic individuals often have a history of substance use disorder developed over years as a form of "self-medication".<ref name="Post2013">{{cite journal|vauthors=Post RM, Kalivas P|date=March 2013|title=Bipolar disorder and substance misuse: pathological and therapeutic implications of their comorbidity and cross-sensitisation|journal=Br J Psychiatry|volume=202|issue=3|pages=172–176|doi=10.1192/bjp.bp.112.116855|pmc=4340700|pmid=23457180}}</ref>
=== Hypomanic episodes === {{Main|Hypomania}}
thumb|An 1858 lithograph captioned "Melancholy passing into mania"
Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania,<ref name="Beentjes2012" /> but does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features, and does not require psychiatric hospitalization.<ref name="Barnett2009" /> Overall functioning may increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some.<ref name="Bowins2013" /> Hypomanic episodes rarely progress to full-blown manic episodes.<ref name="Bowins2013" /> Some people who experience hypomania show increased creativity,<ref name="Beentjes2012" /><ref name="pmid20936438">{{cite journal|vauthors=Srivastava S, Ketter TA|date=December 2010|title=The link between bipolar disorders and creativity: evidence from personality and temperament studies |journal=Current Psychiatry Reports|volume=12|issue=6|pages=522–530|doi=10.1007/s11920-010-0159-x|pmid=20936438 }}</ref> while others are irritable or demonstrate poor judgment.<ref name="Bobo2017">{{cite journal | vauthors = Bobo WV | title = The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update | journal = Mayo Clinic Proceedings | volume = 92 | issue = 10 | pages = 1532–1551 | date = October 2017 | pmid = 28888714 | doi = 10.1016/j.mayocp.2017.06.022 | type = Review | doi-access = }}</ref>
Hypomania may feel good to some individuals who experience it, though most people who experience hypomania state that the stress of the experience is very painful.<ref name="Beentjes2012" /> People with bipolar disorder who experience hypomania tend to forget the effects of their actions on those around them. Even when family and friends recognize mood swings, the individual will often deny that anything is wrong.<ref>{{cite web|url=http://www.pueblo.gsa.gov/cic_text/health/bipolar/bipolar.htm |title=Bipolar Disorder: NIH Publication No. 95-3679|publisher=U.S. National Institutes of Health|date=September 1995 |archive-url = https://web.archive.org/web/20080429204140/http://www.pueblo.gsa.gov/cic_text/health/bipolar/bipolar.htm |archive-date = April 29, 2008}}</ref> If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic unless the mood changes are uncontrollable or volatile.<ref name="Bowins2013">{{cite journal | author = Bowins B | title = Cognitive regulatory control therapies | journal = Am J Psychother | volume = 67 | issue = 3 | pages = 215–236 | year = 2007 | pmid = 24236353 | doi = 10.1176/appi.psychotherapy.2013.67.3.215 | doi-access = free }}</ref> In individuals with bipolar II disorder, depressive symptoms typically overlap with hypomania symptoms. These individuals may not be able to identify these specific symptoms as hypomania, rather they view them as typical depression with slight alterations in mood.<ref>{{cite book |last1=American Psychiatric Association |title=Diagnostic and Statistical Manual of Mental Disorders |date=2022 |doi=10.1176/appi.books.9780890425787 |isbn=978-0-89042-575-6 |publisher=American Psychiatric Association}}</ref>{{page needed|date=January 2026}} Most commonly, symptoms continue for time periods from a few weeks to a few months.<ref>{{cite web|url=http://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder|title=Bipolar II Disorder Symptoms and Signs|publisher=Web M.D.|access-date=December 6, 2010|url-status=live|archive-url=https://web.archive.org/web/20101209213147/http://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder|archive-date=December 9, 2010}}</ref>
=== Depressive episodes === {{Main|Depression (mood)}}
[[File:'Melancholy' by W. Bagg Wellcome L0022594.jpg|thumb|left|''Melancholy'' by William Bagg, after a photograph by Hugh Welch Diamond]]
Symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger, loss of interest in previously enjoyed activities, excessive or inappropriate guilt, hopelessness, sleeping too much or not enough, changes in appetite or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide.<ref name="Muneer2013" /> Although the DSM-5 criteria for diagnosing unipolar and bipolar episodes are the same, some clinical features are more common in the latter, including increased sleep, sudden onset and resolution of symptoms, significant weight gain or loss, and severe episodes after childbirth.<ref name=Lancet2016/>
The earlier the age of onset, the more likely the first few episodes are to be depressive.<ref name="Bowden">{{cite journal | author = Bowden CL | title = Strategies to reduce misdiagnosis of bipolar depression | journal = Psychiatr Serv | volume = 52 | issue = 1 | pages = 51–55 |date=January 2001 | pmid = 11141528 | doi = 10.1176/appi.ps.52.1.51 }}</ref> For most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes.<ref name="Carvalho">{{cite journal |vauthors=Carvalho AF, Firth J, Vieta E |title=Bipolar Disorder |journal=N. Engl. J. Med. |volume=383 |issue=1 |pages=58–66 |date=July 2020 |pmid=32609982 |doi=10.1056/NEJMra1906193 }}</ref> Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and treated with prescribed antidepressants.<ref name=Muzina2007>{{cite journal |vauthors=Muzina DJ, Kemp DE, McIntyre RS | title = Differentiating bipolar disorders from major depressive disorders: treatment implications | journal = Ann Clin Psychiatry | volume = 19 | issue = 4 | pages = 305–312 | date = October–December 2007 | pmid = 18058287 | doi = 10.1080/10401230701653591 }}</ref>
=== Mixed affective episodes === {{Main|Mixed affective state}}
In bipolar disorder, a mixed state is an episode during which symptoms of both mania and depression occur simultaneously. Individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while simultaneously experiencing depressive symptoms such as excessive guilt or feeling suicidal. They are considered to have a higher risk for suicidal behavior as depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control. Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania. Substance (including alcohol) use also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance use.<ref name="Swann2013">{{cite journal |vauthors=Swann AC, Lafer B, Perugi G, Frye MA, Bauer M, Bahk WM, Scott J, Ha K, Suppes T | title = Bipolar mixed states: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis | journal = Am J Psychiatry | volume = 170 | issue = 1 | pages = 31–42 | date = January 2013 | pmid = 23223893 | doi = 10.1176/appi.ajp.2012.12030301 }}</ref>
=== Psychosis === Most people with bipolar disorder experience psychosis during their lifetime, with one half to two-thirds of people experiencing it.<ref name=":7" /> Symptoms of psychosis include delusions, hallucinations, or both. Delusions are more common than hallucinations in bipolar disorder. Psychotic symptoms occur more often during manic or mixed episodes. Having psychotic episodes indicates a more severe illness. People with psychosis have poor insight and more agitation, anxiety, and hostility. Psychosis is more common in bipolar type I than in bipolar type II.<ref name=":7" />
=== Cycling === {{Distinguish|Rapid cycling}} Predictable timing of mood switches is possible though uncommon in bipolar disorder. A systematic review by Geoffroy and others (2014) found seasonal pattern mania in 15% of patients.<ref>{{cite journal |last1=Geoffroy |first1=Pierre Alexis |last2=Bellivier |first2=Frank |last3=Scott |first3=Jan |last4=Etain |first4=Bruno |title=Seasonality and bipolar disorder: A systematic review, from admission rates to seasonality of symptoms |journal=Journal of Affective Disorders |date=October 2014 |volume=168 |pages=210–223 |doi=10.1016/j.jad.2014.07.002 |pmid=25063960 }}</ref>
== Causes == The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear.<ref name="Nierenberg2013">{{cite journal |vauthors=Nierenberg AA, Kansky C, Brennan BP, Shelton RC, Perlis R, Iosifescu DV | title = Mitochondrial modulators for bipolar disorder: a pathophysiologically informed paradigm for new drug development | journal = Aust N Z J Psychiatry | volume = 47 | issue = 1 | pages = 26–42 | date = January 2013 | pmid = 22711881 | doi = 10.1177/0004867412449303 }}</ref> Genetic influences are believed to account for 73–93% of the risk of developing the disorder indicating a strong hereditary component.<ref name="Bobo2017" /> The overall heritability of the bipolar spectrum has been estimated at 0.71.<ref name="Edvardsen2008">{{cite journal |vauthors=Edvardsen J, Torgersen S, Røysamb E, Lygren S, Skre I, Onstad S, Oien PA | title = Heritability of bipolar spectrum disorders. Unity or heterogeneity? | journal = Journal of Affective Disorders | volume = 106 | issue = 3 | pages = 229–240 | year = 2008 | pmid = 17692389 | doi = 10.1016/j.jad.2007.07.001 }}</ref> Twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For bipolar I disorder, the rate at which identical twins (same genes) will both have bipolar I disorder (concordance) is around 40%, compared to about 5% in fraternal twins.<ref name="Barnett2009" /><ref name="Kieseppa_2004">{{cite journal |vauthors=Kieseppä T, Partonen T, Haukka J, Kaprio J, Lönnqvist J | title = High Concordance of Bipolar I Disorder in a Nationwide Sample of Twins | journal = American Journal of Psychiatry | volume = 161 | issue = 10 | pages = 1814–1821 | year = 2004 | pmid = 15465978 | doi = 10.1176/appi.ajp.161.10.1814 }}</ref> A combination of bipolar I, II, and cyclothymia similarly produced rates of 42% and 11% (identical and fraternal twins, respectively).<ref name="Edvardsen2008" /> The rates of bipolar II combinations without bipolar I are lower{{Em dash}}bipolar II at 23 and 17%, and bipolar II combining with cyclothymia at 33 and 14%{{Em dash}}which may reflect relatively higher genetic heterogeneity.<ref name="Edvardsen2008" />
The cause of bipolar disorders overlaps with major depressive disorder. When defining concordance as the co-twins having either bipolar disorder or major depression, then the concordance rate rises to 67% in identical twins and 19% in fraternal twins.<ref name="McGuffin2003">{{cite journal |vauthors=McGuffin P, Rijsdijk F, Andrew M, Sham P, Katz R, Cardno A | title = The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression | journal = Archives of General Psychiatry | volume = 60 | issue = 5 | pages = 497–502 | year = 2003 | pmid = 12742871 | doi = 10.1001/archpsyc.60.5.497 | doi-access = }}</ref> The relatively low concordance between fraternal twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.<ref name="Edvardsen2008" />
=== Genetic === {{See also|Epigenetics of bipolar disorder}} Behavioral genetic studies have suggested that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility with each gene exerting a mild to moderate effect.<ref name="Kerner2014">{{cite journal|author=Kerner B|date=February 2014|title=Genetics of bipolar disorder|journal=Appl Clin Genet|volume=7|pages=33–42|doi=10.2147/tacg.s39297|pmc=3966627|pmid=24683306 |doi-access=free }}</ref> The risk of bipolar disorder is nearly ten-fold higher in first-degree relatives of those with bipolar disorder than in the general population; similarly, the risk of major depressive disorder is three times higher in relatives of those with bipolar disorder than in the general population.<ref name="Barnett2009" />
Although the first genetic linkage finding for mania was in 1969,<ref>{{cite journal|author2-link=Paula Clayton|author3-link=George Winokur | vauthors = Reich T, Clayton PJ, Winokur G | title = Family history studies: V. The genetics of mania | journal = The American Journal of Psychiatry | volume = 125 | issue = 10 | pages = 1358–1369 | date = April 1969 | pmid = 5304735 | doi = 10.1176/ajp.125.10.1358 }}</ref> linkage studies have been inconsistent.<ref name="Barnett2009">{{cite journal | vauthors = Barnett JH, Smoller JW | title = The genetics of bipolar disorder | journal = Neuroscience | volume = 164 | issue = 1 | pages = 331–343 | date = November 2009 | pmid = 19358880 | pmc = 3637882 | doi = 10.1016/j.neuroscience.2009.03.080 }}</ref> Findings point strongly to heterogeneity, with different genes implicated in different families.<ref>{{cite journal |vauthors=Segurado R, Detera-Wadleigh SD, Levinson DF, Lewis CM, Gill M, Nurnberger JI, Craddock N, DePaulo JR, Baron M, Gershon ES, Ekholm J, Cichon S, Turecki G, Claes S, Kelsoe JR, Schofield PR, Badenhop RF, Morissette J, Coon H, Blackwood D, McInnes LA, Foroud T, Edenberg HJ, Reich T, Rice JP, Goate A, McInnis MG, McMahon FJ, Badner JA, Goldin LR, Bennett P, Willour VL, Zandi PP, Liu J, Gilliam C, Juo SH, Berrettini WH, Yoshikawa T, Peltonen L, Lönnqvist J, Nöthen MM, Schumacher J, Windemuth C, Rietschel M, Propping P, Maier W, Alda M, Grof P, Rouleau GA, Del-Favero J, Van Broeckhoven C, Mendlewicz J, Adolfsson R, Spence MA, Luebbert H, Adams LJ, Donald JA, Mitchell PB, Barden N, Shink E, Byerley W, Muir W, Visscher PM, Macgregor S, Gurling H, Kalsi G, McQuillin A, Escamilla MA, Reus VI, Leon P, Freimer NB, Ewald H, Kruse TA, Mors O, Radhakrishna U, Blouin JL, Antonarakis SE, Akarsu N | title = Genome Scan Meta-Analysis of Schizophrenia and Bipolar Disorder, Part III: Bipolar Disorder | journal = The American Journal of Human Genetics | volume = 73 | issue = 1 | pages = 49‑62 | year = 2003 | pmid = 12802785 | pmc = 1180589 | doi = 10.1086/376547 }}</ref> Robust and replicable genome-wide significant associations showed several common single-nucleotide polymorphisms (SNPs) are associated with bipolar disorder, including variants within the genes ''CACNA1C'', ''ODZ4'', and ''NCAN''.<ref name="Kerner2014" /><ref name="Craddock2013">{{cite journal |vauthors=Craddock N, Sklar P | title = Genetics of bipolar disorder | journal = Lancet | volume = 381 | issue = 9878 | pages = 1654‑1662 | date = May 2013 | pmid = 23663951 | doi = 10.1016/S0140-6736(13)60855-7 }}</ref> The largest and most recent genome-wide association study failed to find any locus that exerts a large effect, reinforcing the idea that no single gene is responsible for bipolar disorder in most cases.<ref name="Craddock2013" /> Polymorphisms in ''BDNF'', ''DRD4'', ''DAO'', and ''TPH1'' have been frequently associated with bipolar disorder and were initially associated in a meta-analysis, but this association disappeared after correction for multiple testing.<ref>{{cite journal | vauthors = Seifuddin F, Mahon PB, Judy J, Pirooznia M, Jancic D, Taylor J, Goes FS, Potash JB, Zandi PP | title = Meta-analysis of genetic association studies on bipolar disorder | journal = American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics | volume = 159B | issue = 5 | pages = 508–518 | date = July 2012 | pmid = 22573399 | pmc = 3582382 | doi = 10.1002/ajmg.b.32057 }}</ref> On the other hand, two polymorphisms in ''TPH2'' were identified as being associated with bipolar disorder.<ref>{{cite journal | vauthors = Gao J, Jia M, Qiao D, Qiu H, Sokolove J, Zhang J, Pan Z | title = TPH2 gene polymorphisms and bipolar disorder: A meta-analysis | journal = American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics | volume = 171B | issue = 2 | pages = 145–152 | date = March 2016 | pmid = 26365518 | doi = 10.1002/ajmg.b.32381 | doi-access = free }}</ref>
Due to the inconsistent findings in a genome-wide association study, multiple studies have undertaken the approach of analyzing SNPs in biological pathways. Signaling pathways traditionally associated with bipolar disorder that have been supported by these studies include corticotropin-releasing hormone signaling, cardiac β-adrenergic signaling, phospholipase C signaling, glutamate receptor signaling,<ref>{{cite journal | vauthors = Torkamani A, Topol EJ, Schork NJ | title = Pathway analysis of seven common diseases assessed by genome-wide association | journal = Genomics | volume = 92 | issue = 5 | pages = 265–272 | date = November 2008 | pmid = 18722519 | pmc = 2602835 | doi = 10.1016/j.ygeno.2008.07.011 }}</ref> cardiac hypertrophy signaling, Wnt signaling, Notch signaling,<ref>{{cite journal | vauthors = Pedroso I, Lourdusamy A, Rietschel M, Nöthen MM, Cichon S, McGuffin P, Al-Chalabi A, Barnes MR, Breen G | title = Common genetic variants and gene-expression changes associated with bipolar disorder are over-represented in brain signaling pathway genes | journal = Biological Psychiatry | volume = 72 | issue = 4 | pages = 311–317 | date = August 2012 | pmid = 22502986 | doi = 10.1016/j.biopsych.2011.12.031 }}</ref> and endothelin 1 signaling. Of the 16 genes identified in these pathways, three were found to be dysregulated in the dorsolateral prefrontal cortex portion of the brain in post-mortem studies: ''CACNA1C'', ''GNG2'', and ''ITPR2''.<ref>{{cite journal | vauthors = Nurnberger JI, Koller DL, Jung J, Edenberg HJ, Foroud T, Guella I, Vawter MP, Kelsoe JR | title = Identification of pathways for bipolar disorder: a meta-analysis | journal = JAMA Psychiatry | volume = 71 | issue = 6 | pages = 657–664 | date = June 2014 | pmid = 24718920 | pmc = 4523227 | doi = 10.1001/jamapsychiatry.2014.176 }}</ref>
Bipolar disorder is associated with reduced expression of specific DNA repair enzymes and increased levels of oxidative DNA damages.<ref name="pmid27126805">{{cite journal |vauthors=Raza MU, Tufan T, Wang Y, Hill C, Zhu MY |title=DNA Damage in Major Psychiatric Diseases |journal=Neurotox Res |volume=30 |issue=2 |pages=251–267 |date=August 2016 |pmid=27126805 |pmc=4947450 |doi=10.1007/s12640-016-9621-9 }}</ref> The AKAP11 gene was discovered in 2022 as the first gene linked to bipolar disorder. The exomes of around 14,000 individuals with bipolar disorder were analyzed and compared to those without the condition. The findings were combined with data from another study in the Schizophrenia Exome Sequencing Meta-Analysis (SCHEMA), examining the genome sequences of 24,000 people alongside the original 14,000 bipolar disorder cases. This study identified genetic variants, including the AKAP11 gene, associated with an increased risk of bipolar disorder. The AKAP11 gene's interaction with the GSK3B protein, a molecular target of lithium, points to a possible mechanism behind the medication's therapeutic effects.<ref>{{Cite web |first=Leah |last=Eisenstadt |date=April 6, 2022 |title=Researchers find first strong genetic risk factor for bipolar disorder |url=https://www.broadinstitute.org/news/researchers-find-first-strong-genetic-risk-factor-bipolar-disorder |access-date=March 6, 2025 |website=Broad Institute |language=en}}</ref>
=== Environmental === Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions.<ref name="Serretti">{{cite journal |vauthors=Serretti A, Mandelli L | title = The genetics of bipolar disorder: Genome 'hot regions,' genes, new potential candidates and future directions | journal = Molecular Psychiatry | volume = 13 | issue = 8 | pages = 742–71 | year = 2008 | pmid = 18332878 | doi = 10.1038/mp.2008.29 | doi-access = }}</ref><ref>{{Cite journal |last1=Robinson |first1=Natassia |last2=Bergen |first2=Sarah E. |date=June 28, 2021 |title=Environmental Risk Factors for Schizophrenia and Bipolar Disorder and Their Relationship to Genetic Risk: Current Knowledge and Future Directions |journal=Frontiers in Genetics |volume=12 |article-number=686666 |doi=10.3389/fgene.2021.686666 |doi-access=free |pmid=34262598 |pmc=8273311 }}</ref> Recent life events and interpersonal relationships likely contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression.<ref name="Geddestreatment" /> In surveys, 30–50% of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated with earlier onset, a higher rate of suicide attempts, and more co-occurring disorders such as post-traumatic stress disorder.<ref name="Brietzke2012">{{cite journal | vauthors = Brietzke E, Kauer Sant'anna M, Jackowski A, Grassi-Oliveira R, Bucker J, Zugman A, Mansur RB, Bressan RA | title = Impact of childhood stress on psychopathology | journal = Rev Bras Psiquiatr | volume = 34 | issue = 4 | pages = 480–488 | date = December 2012 | pmid = 23429820 | doi = 10.1016/j.rbp.2012.04.009 | doi-access = free | hdl = 10923/9355 | hdl-access = free }}</ref> Subtypes of abuse, such as sexual and emotional abuse, also contribute to violent behaviors seen in patients with bipolar disorder.<ref>{{cite journal | vauthors = Bal NB, Özalp E, Teksin MG, Kotan Z, Karslıoğlu EH, Çayköylü A | title = Childhood Trauma as an Environmental Determinant of Risk of Violence in Bipolar Disorder | journal = Noro Psikiyatri Arsivi | volume = 60 | issue = 4 | pages = 344–349 | year = 2023 | pmid = 38077849 | pmc = 10709710 | doi = 10.29399/npa.28340 }}</ref> The number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder than in those without, particularly events stemming from a harsh environment rather than from the child's own behavior.<ref>{{cite journal |vauthors=Miklowitz DJ, Chang KD | title = Prevention of bipolar disorder in at-risk children: Theoretical assumptions and empirical foundations | journal = Development and Psychopathology | volume = 20 | issue = 3 | pages = 881–497 | year = 2008 | pmid = 18606036 | pmc = 2504732 | doi = 10.1017/S0954579408000424 }}</ref> Acutely, mania can be induced by sleep deprivation in around 30% of people with bipolar disorder.<ref>{{cite journal | vauthors = Young JW, Dulcis D | title = Investigating the mechanism(s) underlying switching between states in bipolar disorder | journal = European Journal of Pharmacology | volume = 759 | pages = 151–162 | date = July 2015 | pmid = 25814263 | pmc = 4437855 | doi = 10.1016/j.ejphar.2015.03.019 }}</ref>
=== Gene-environment interaction === According to the "kindling" hypothesis, when people who are genetically predisposed toward bipolar disorder experience stressful events, the stress threshold at which mood changes occur becomes progressively lower, until the episodes eventually start (and recur) spontaneously. There is evidence supporting an association between early-life stress (such as childhood trauma) and dysfunction of the hypothalamic-pituitary-adrenal axis leading to its overactivation, which may play a role in the pathogenesis of bipolar disorder.<ref name="Bender2011" /><ref name="Lee2013" /><ref name=":10" />
=== Neurological === Less commonly, bipolar disorder or a bipolar-like disorder may occur as a result of or in association with a neurological condition or injury including stroke, traumatic brain injury, HIV infection, multiple sclerosis, porphyria, and rarely temporal lobe epilepsy.<ref>Murray ED, Buttner N, Price BH. (2012) "Depression and Psychosis in Neurological Practice". In: ''Neurology in Clinical Practice'', 6th Edition. Bradley WG, Daroff RB, Fenichel GM, Jankovic J (eds.) Butterworth Heinemann. {{ISBN|978-1-4377-0434-1}}</ref>
==Proposed psychosocial and biological mechanisms== {{further|Biology of bipolar disorder}} === Psychosocial hypotheses ===
==== Trauma, especially in childhood ==== According to Quide and others (2020), childhood trauma is associated with "earlier onset and greater severity of bipolar disorder (BD) in adulthood."<ref>{{Cite journal |last1=Quidé |first1=Yann |last2=Tozzi |first2=Leonardo |last3=Corcoran |first3=Mark |last4=Cannon |first4=Dara M. |last5=Dauvermann |first5=Maria R. |date=14 December 2020 |title=The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress |journal=Neuropsychiatric Disease and Treatment |volume=16 |pages=3095–3115 |doi=10.2147/NDT.S285540 |doi-access=free |issn=1176-6328 |pmc=7751794 |pmid=33364762}}</ref> A systematic review and meta-analysis by Murri and others (2016) found that cortisol levels are "associated with the manic phase of BD" and that "HPA axis dysregulation is not an endophenotype of BD, but seems related to environmental risk factors, such as childhood trauma."<ref name=":10" />
==== Stigmatization ==== According to Latifian and others (2023),
{{Blockquote|text=Stigma has considerable consequences for people living with bipolar disorders and their families and causes them to suffer from severe psychological distress in addition to the pain and agony inflicted by the disease.}}
From Table 5 of the same systematic review, examples of 'severe psychological distress' include lower self-esteem, 'social deprivation', and lower quality of life.<ref>{{Cite journal |last1=Latifian |first1=Maryam |last2=Abdi |first2=Kianoush |last3=Raheb |first3=Ghoncheh |last4=Islam |first4=Sheikh Mohammed Shariful |last5=Alikhani |first5=Rosa |date=20 February 2023 |title=Stigma in people living with bipolar disorder and their families: a systematic review |journal=International Journal of Bipolar Disorders |language=en |volume=11 |issue=1 |pages=9 |doi=10.1186/s40345-023-00290-y |doi-access=free |issn=2194-7511 |pmc=9941403 |pmid=36805368}}</ref>
=== Biological hypotheses ===
==== Vigilance regulation ==== Hegerl and Hensch (2014) proposed a "common pathophysiology" between ADHD and bipolar disorder composed of a three-part cycle:<ref>{{Cite journal |last1=Hegerl |first1=Ulrich |last2=Hensch |first2=Tilman |date=July 2014 |title=The vigilance regulation model of affective disorders and ADHD |journal=Neuroscience and Biobehavioral Reviews |volume=44 |pages=45–57 |doi=10.1016/j.neubiorev.2012.10.008 |issn=1873-7528 |pmid=23092655}}</ref>
# "Unstable vigilance regulation", as measured by electroencephalography (EEG). # Efforts at "Vigilance stabilization", such as "hyperactivity, sensation seeking". # "Sleep deficits", which have already been found to be associated with mania.
A randomized controlled trial by Hegerl and others (January 2018) failed to support the vigilance regulation hypothesis, but demonstrated that "methylphenidate was well tolerated and safe" in a sample of manic inpatients.<ref>{{Cite journal |last1=Hegerl |first1=Ulrich |last2=Mergl |first2=Roland |last3=Sander |first3=Christian |last4=Dietzel |first4=Jens |last5=Bitter |first5=Istvan |last6=Demyttenaere |first6=Koen |last7=Gusmão |first7=Ricardo |last8=González-Pinto |first8=Ana |last9=Zorrilla |first9=Iñaki |last10=Alocén |first10=Adriana García |last11=Sola |first11=Victor Perez |last12=Vieta |first12=Eduard |last13=Juckel |first13=Georg |last14=Zimmermann |first14=Ulrich S. |last15=Bauer |first15=Michael |date=January 2018 |title=A multi-centre, randomised, double-blind, placebo-controlled clinical trial of methylphenidate in the initial treatment of acute mania (MEMAP study) |url=https://www.sciencedirect.com/science/article/pii/S0924977X17319946 |journal=European Neuropsychopharmacology |volume=28 |issue=1 |pages=185–194 |doi=10.1016/j.euroneuro.2017.11.003 |pmid=29174864 |issn=0924-977X|hdl=2445/131382 |hdl-access=free }}</ref> Further development of this hypothesis was undertaken by Strauß and others, including Hegerl (March 2018).<ref>{{Cite journal |last1=Strauß |first1=Maria |last2=Ulke |first2=Christine |last3=Paucke |first3=Madlen |last4=Huang |first4=Jue |last5=Mauche |first5=Nicole |last6=Sander |first6=Christian |last7=Stark |first7=Tetyana |last8=Hegerl |first8=Ulrich |date=March 2018 |title=Brain arousal regulation in adults with attention-deficit/hyperactivity disorder (ADHD) |journal=Psychiatry Research |volume=261 |pages=102–108 |doi=10.1016/j.psychres.2017.12.043 |issn=1872-7123 |pmid=29291475}}</ref>
==== Dopamine ==== A review by Ashok and others (2017) proposed that mania is caused by "elevations in D2/3 receptor availability and a hyperactive reward processing network", though they conceded that their model "[relies] on pharmacological evidence".<ref>{{Cite journal |last1=Ashok |first1=A. H. |last2=Marques |first2=T. R. |last3=Jauhar |first3=S. |last4=Nour |first4=M. M. |last5=Goodwin |first5=G. M. |last6=Young |first6=A. H. |last7=Howes |first7=O. D. |date=14 March 2017 |title=The dopamine hypothesis of bipolar affective disorder: the state of the art and implications for treatment |journal=Molecular Psychiatry |language=en |volume=22 |issue=5 |pages=666–679 |doi=10.1038/mp.2017.16 |issn=1476-5578 |pmc=5401767 |pmid=28289283}}</ref>
Wu and others (2024) proposed that 'sleep loss' underlies changes in dopaminergic activity and subsequent mood change.<ref>{{Cite journal |last1=Wu |first1=Mingzheng |last2=Zhang |first2=Xin |last3=Feng |first3=Sihan |last4=Freda |first4=Sara N. |last5=Kumari |first5=Pushpa |last6=Dumrongprechachan |first6=Vasin |last7=Kozorovitskiy |first7=Yevgenia |date=3 January 2024 |title=Dopamine pathways mediating affective state transitions after sleep loss |journal=Neuron |language=English |volume=112 |issue=1 |pages=141–154.e8 |doi=10.1016/j.neuron.2023.10.002 |issn=0896-6273 |pmid=37922904 |pmc=10841919 }}</ref> Alloy and others (2015) proposed a similar model.<ref>{{Cite journal |last=Alloy |first=Lauren B. |last2=Nusslock |first2=Robin |last3=Boland |first3=Elaine M. |date=2015 |title=The development and course of bipolar spectrum disorders: an integrated reward and circadian rhythm dysregulation model |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC4380533/ |journal=Annual Review of Clinical Psychology |volume=11 |pages=213–250 |doi=10.1146/annurev-clinpsy-032814-112902 |issn=1548-5951 |pmc=4380533 |pmid=25581235}}</ref>
==== Neuroimmunology ==== Barbosa and others (2014) note the elevated rate of autoimmune diseases and other immunological aberrations in bipolar disorder. They propose that pro-inflammatory cytokines alter "neural processes" such as neurogenesis and memory, causing neurodegeneration.<ref>{{Cite journal |last1=Barbosa |first1=Izabela Guimarães |last2=Machado-Vieira |first2=Rodrigo |last3=Soares |first3=Jair C. |last4=Teixeira |first4=Antonio L. |date=14 February 2014 |title=The immunology of bipolar disorder |journal=Neuroimmunomodulation |volume=21 |issue=2–3 |pages=117–122 |doi=10.1159/000356539 |issn=1423-0216 |pmc=4041530 |pmid=24557044}}</ref>
Rosenblat and McIntyre (2017) propose a "bidirectional relationship between BD and immune dysfunction," with a variety of possible mechanisms connecting cytokine levels to mood changes. They conjecture that immune dysfunction is relevant to some but not all bipolar disorder patients.<ref>{{Cite journal |last1=Rosenblat |first1=Joshua D. |last2=McIntyre |first2=Roger S. |date=30 October 2017 |title=Bipolar Disorder and Immune Dysfunction: Epidemiological Findings, Proposed Pathophysiology and Clinical Implications |journal=Brain Sciences |volume=7 |issue=11 |pages=144 |doi=10.3390/brainsci7110144 |doi-access=free |issn=2076-3425 |pmc=5704151 |pmid=29084144}}</ref>
== Diagnosis == Bipolar disorder is commonly diagnosed during adolescence or early adulthood, but onset can occur throughout life.<ref name="DSM5" /><ref name="Price2012">{{cite journal | vauthors = Price AL, Marzani-Nissen GR | title = Bipolar disorders: a review | journal = American Family Physician | volume = 85 | issue = 5 | pages = 483–493 | date = March 2012 | pmid = 22534227 | url = http://www.aafp.org/afp/2012/0301/p483.html | archive-url = https://web.archive.org/web/20140324014832/http://www.aafp.org/afp/2012/0301/p483.html | url-status=live | archive-date = March 24, 2014 }}</ref> Its diagnosis is based on the self-reported experiences of the individual, abnormal behavior reported by family members, friends or co-workers, observable signs of illness as assessed by a clinician, and ideally a medical work-up to rule out other causes. Caregiver-scored rating scales, specifically from the mother, have shown to be more accurate than teacher and youth-scored reports in identifying youths with bipolar disorder.<ref name="Youngstrom2015">{{cite journal| vauthors = Youngstrom EA, Genzlinger JE, Egerton GA, Van Meter AR |title=Multivariate Meta-Analysis of the Discriminative Validity of Caregiver, Youth, and Teacher Rating Scales for Pediatric Bipolar Disorder: Mother Knows Best About Mania|journal=Archives of Scientific Psychology|volume=3|issue=1|pages=112–137|doi=10.1037/arc0000024|year=2015|doi-access=free}}</ref> Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others.{{citation needed|date=January 2026}}
The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's (APA) ''Diagnostic and Statistical Manual of Mental Disorders'', Fifth Edition (DSM-5) and the World Health Organization's (WHO) ''International Statistical Classification of Diseases and Related Health Problems'', 10th Edition (ICD-10). The ICD-10 criteria are used more often in clinical settings outside of the U.S. while the DSM criteria are used within the U.S. and are the prevailing criteria used internationally in research studies. The DSM-5, published in 2013, includes further and more accurate specifiers compared to its predecessor, the DSM-IV-TR.<ref>{{cite book | vauthors = Perugi G, Ghaemi SN, Akiskal H | title = Bipolar Psychopharmacotherapy: Caring for the Patient | pages = 193–234 | year = 2006 | doi = 10.1002/0470017953.ch11 | chapter = Diagnostic and Clinical Management Approaches to Bipolar Depression, Bipolar II and Their Comorbidities | isbn = 978-0-470-01795-1 }}</ref> This work has influenced the eleventh revision of the ICD (ICD-11), which includes the various diagnoses within the bipolar spectrum of the DSM-5.<ref name="WHO_2019">{{cite web|url=https://icd.who.int/browse11/l-m/en|title=ICD-11 for Mortality and Morbidity Statistics|date=April 2019|website=World Health Organization|page=6A60, 6A61, 6A62|access-date=March 7, 2020|archive-date=October 15, 2023|archive-url=https://web.archive.org/web/20231015122454/https://icd.who.int/browse11/l-m/en}}</ref>
Several rating scales for the screening and evaluation of bipolar disorder exist,<ref name="Carvalho2015" /> including the Bipolar Spectrum Diagnostic Scale, Mood Disorder Questionnaire, the General Behavior Inventory and the Hypomania Checklist.<ref name="pmid19122534">{{cite journal | vauthors = Picardi A | title = Rating scales in bipolar disorder | journal = Current Opinion in Psychiatry | volume = 22 | issue = 1 | pages = 42–49 | date = January 2009 | pmid = 19122534 | doi = 10.1097/YCO.0b013e328315a4d2 }}</ref> The use of evaluation scales cannot substitute for a full clinical interview, but they serve to systematize the recollection of symptoms.<ref name="pmid19122534" /> On the other hand, instruments for screening bipolar disorder tend to have lower sensitivity.<ref name="Carvalho2015">{{cite journal | vauthors = Carvalho AF, Takwoingi Y, Sales PM, Soczynska JK, Köhler CA, Freitas TH, Quevedo J, Hyphantis TN, McIntyre RS, Vieta E | title = Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies | journal = Journal of Affective Disorders | volume = 172 | pages = 337–346 | date = February 2015 | pmid = 25451435 | doi = 10.1016/j.jad.2014.10.024 | url = https://research.birmingham.ac.uk/en/publications/4445551e-a2e4-4f99-ba90-2899c7cb6119 }}</ref>
=== Differential diagnosis === Mental disorders that can mimic bipolar disorder include schizophrenia, major depressive disorder,<ref name="Baldessarini2013" /> attention deficit hyperactivity disorder (ADHD), and certain personality disorders, such as borderline personality disorder.<ref name="Sood2005">{{cite journal |vauthors=Sood AB, Razdan A, Weller EB, Weller RA | title = How to differentiate bipolar disorder from attention deficit hyperactivity disorder and other common psychiatric disorders: A guide for clinicians | journal = Current Psychiatry Reports | volume = 7 | issue = 2 | pages = 98–103 | year = 2005 | pmid = 15802085 | doi=10.1007/s11920-005-0005-8 }}</ref><ref name="Magill2004">{{cite journal | author = Magill CA | title = The boundary between borderline personality disorder and bipolar disorder: Current concepts and challenges | journal = Canadian Journal of Psychiatry| volume = 49 | issue = 8 | pages = 551–556 | year = 2004 | pmid = 15453104 | doi = 10.1177/070674370404900806 | doi-access = }}</ref><ref name="Bassett2012">{{cite journal | author = Bassett D | title = Borderline personality disorder and bipolar affective disorder. Spectra or spectre? A review | journal = Australian and New Zealand Journal of Psychiatry | volume = 46 | issue = 4 | pages = 327–339 | year = 2012 | pmid = 22508593 | doi = 10.1177/0004867411435289 }}</ref> A key difference between bipolar disorder and borderline personality disorder is the nature of the mood swings; in contrast to the sustained changes to mood over days to weeks or longer seen in bipolar disorder, those experienced in borderline personality disorder (more accurately called emotional dysregulation) are sudden and often short-lived, and secondary to social stressors.<ref>{{cite book |vauthors=Paris J |title=Bipolar II Disorder: Modelling, Measuring and Managing |date=2012 |publisher=Cambridge University Press |location=Cambridge, UK |isbn=978-1-107-60089-8 |pages=81–84 |url=https://books.google.com/books?id=eNcqJpOQ6aIC&pg=PA81 | editor=Parker G}}</ref>
Although there are no biological tests that are diagnostic of bipolar disorder,<ref name="Craddock2013" /> blood tests and/or imaging are carried out to investigate whether medical illnesses with clinical presentations similar to that of bipolar disorder are present before making a definitive diagnosis. Neurologic diseases such as multiple sclerosis, complex partial seizures, strokes, brain tumors, Wilson's disease, traumatic brain injury, Huntington's disease, and complex migraines can mimic features of bipolar disorder.<ref name="Price2012" /> An EEG may be used to exclude neurological disorders such as epilepsy, and a CT scan or MRI of the head may be used to exclude brain lesions.<ref name="Price2012" /> Additionally, disorders of the endocrine system such as hypothyroidism, hyperthyroidism, and Cushing's disease are in the differential as is the connective tissue disease systemic lupus erythematosus. Infectious causes of mania that may appear similar to bipolar mania include herpes encephalitis, HIV, influenza, or neurosyphilis.<ref name="Price2012" /> Certain vitamin deficiencies such as pellagra (niacin deficiency), vitamin B<sub>12</sub> deficiency, folate deficiency, and Wernicke–Korsakoff syndrome (thiamine deficiency) can also lead to mania.<ref name="Price2012" /> Common medications that can cause manic symptoms include antidepressants, prednisone, Parkinson's disease medications, thyroid hormone, stimulants (including cocaine and methamphetamine), and certain antibiotics.<ref>{{cite journal | vauthors = Peet M, Peters S | title = Drug-induced mania | journal = Drug Safety | volume = 12 | issue = 2 | pages = 146–153 | date = February 1995 | pmid = 7766338 | doi = 10.2165/00002018-199512020-00007 }}</ref>
=== Bipolar spectrum === alt=Kraepelin looking to the side|thumb|right|Since Emil Kraepelin's distinction between bipolar disorder and schizophrenia in the 19th century, researchers have defined a spectrum of different types of bipolar disorder. Bipolar spectrum disorders include bipolar I disorder, bipolar II disorder, cyclothymic disorder, and cases where subthreshold symptoms are found to cause clinically significant impairment or distress.<ref name="DSM5" /><ref name="Price2012" /><ref name="WHO_2019" /> These disorders involve major depressive episodes that alternate with manic or hypomanic episodes, or with mixed episodes that feature symptoms of both mood states.<ref name="DSM5" /> The concept of the bipolar spectrum is similar to that of Emil Kraepelin's original concept of manic depressive illness.<ref>{{cite web | author = Korn ML | title = Across the Bipolar Spectrum: From Practice to Research | url = http://www.medscape.com/viewarticle/441617 | publisher = Medscape | url-status=live | archive-url = https://web.archive.org/web/20031214022212/http://www.medscape.com/viewarticle/441617 | archive-date = December 14, 2003 }}{{vs|date=May 2026}}</ref> Bipolar II disorder was established as a diagnosis in 1994 within DSM IV; though debate continues over whether it is a distinct entity, part of a spectrum, or is the very same condition as bipolar I disorder.<ref name="gitlin20">{{cite journal |vauthors=Gitlin M, Malhi G |title=The existential crisis of bipolar II disorder |journal=International Journal of Bipolar Disorders |year=2020 |volume=8 |issue=5 |article-number=5 |doi=10.1186/s40345-019-0175-7 |pmid=31993793 |pmc=6987267 |doi-access=free }}</ref><ref>{{cite journal |last1=Malhi |first1=G. S |last2=Irwin |first2=L. |last3=Outhred |first3=T. |title=Counting the days from bipolar II to bipolar true! |journal=Acta Psychiatrica Scandinavica |date=March 2019 |volume=139 |issue=3 |pages=211–213 |doi=10.1111/acps.12999 |pmid=30811580 }}</ref>
=== Criteria and subtypes === [[File:Bipolar_disorder_subtypes_comparison_between_Bipolar_I,_II_disorder_and_Cyclothymia.svg|thumb|Simplified graphical comparison of bipolar I, bipolar II and cyclothymia<ref>{{cite web|url=https://www.health.harvard.edu/newsletter_article/Bipolar_disorder|title=Bipolar disorder |work = Harvard Health Publishing |date=November 2007 |access-date=April 11, 2019}}</ref><ref>{{cite book | title = Essentials of abnormal psychology. | vauthors = Durand VM | date = 2015 | publisher = Cengage Learning | isbn = 978-1-305-63368-1 | location = [Place of publication not identified] | oclc = 884617637 | page = 267}}</ref>{{Rp|267}}]] thumb|More detailed graphical comparison of bipolar I, bipolar II, unipolar depression and cyclothymia The DSM and the ICD characterize bipolar disorder as a spectrum of disorders occurring on a continuum. The DSM-5 and ICD-11 lists three specific subtypes:<ref name="DSM5" /><ref name="WHO_2019" /> * Bipolar I disorder: At least one manic episode is necessary to make the diagnosis;<ref name="Renk2014">{{cite journal|vauthors=Renk K, White R, Lauer BA, McSwiggan M, Puff J, Lowell A |title=Bipolar Disorder in Children|journal=Psychiatry J|volume=2014 |article-number=928685|date=February 2014|pmid=24800202|pmc=3994906|doi=10.1155/2014/928685|doi-access=free}}</ref> depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis.<ref name="Barnett2009" /> Specifiers such as "mild, moderate, moderate-severe, severe" and "with psychotic features" should be added as applicable to indicate the presentation and course of the disorder.<ref name="DSM5" /> * Bipolar II disorder: No manic episodes and one or more hypomanic episodes and one or more major depressive episodes.<ref name="Renk2014" /> Hypomanic episodes do not go to the full extremes of mania (''i.e.'', do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as periods of successful high productivity and are reported less frequently than a distressing, crippling depression.{{citation needed|date=January 2026}} * Cyclothymia: A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes.<ref name="Van Meter 2012">{{cite journal|vauthors=Van Meter AR, Youngstrom EA, Findling RL |title=Cyclothymic disorder: a critical review|journal=Clinical Psychology Review|volume=32|issue=4|pages=229–243|date=June 2012|pmid=22459786|doi=10.1016/j.cpr.2012.02.001}}</ref> In cyclothymia, hypomanic and depressive episodes alternate for at least two years in adults and at least one year in children and adolescents.<ref>{{Cite web |title=What Is Bipolar Disorder? Symptoms, Diagnosis, Causes, Treatment, and Prevention |url=https://www.everydayhealth.com/bipolar-disorder/guide/ |access-date=October 26, 2025 |website=everydayHealth.com |language=en}}</ref>
When relevant, specifiers for ''peripartum onset'' and ''with rapid cycling'' should be used with any subtype.<ref>{{Cite journal |date=April 2, 2014 |title=The DSM-5 peripartum specifier: prospects and pitfalls |journal=Archives of Women's Mental Health |volume=17 |issue=2 |pages=171–173 |doi=10.1007/s00737-013-0406-3 |pmid=24414301| vauthors = Sharma V, Mazmanian D }}</ref> Individuals who have subthreshold symptoms that cause clinically significant distress or impairment, but do not meet full criteria for one of the three subtypes may be diagnosed with other specified or unspecified bipolar disorder. Other specified bipolar disorder is used when a clinician chooses to explain why the full criteria were not met (e.g., hypomania without a prior major depressive episode).<ref name="DSM5" /> If the condition is thought to have a non-psychiatric medical cause, the diagnosis of ''bipolar and related disorder due to another medical condition'' is made, while ''substance/medication-induced bipolar and related disorder'' is used if a medication is thought to have triggered the condition.<ref>{{cite journal | vauthors = Angst J | title = Bipolar disorders in DSM-5: strengths, problems and perspectives | journal = International Journal of Bipolar Disorders | volume = 1 | issue = 12 | article-number = 12 |year = 2013 | pmid = 25505679 | doi = 10.1186/2194-7511-1-12 | pmc = 4230689 | doi-access = free }}</ref>
While hyperthymic temperament is not considered a pathological disorder, it is genetically associated with bipolar I and may predispose affected individuals to a manic-depressive episode.<ref name=":0">{{cite journal |title=Current research on affective temperaments |journal=Current Opinion in Psychiatry |date=2010 |volume=23 |issue=1 |pages=12–18 |doi=10.1097/YCO.0b013e32833299d4 |pmid=19809321 | vauthors = Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS }}</ref><ref>{{Cite journal |last1=Karam |first1=Elie G. |last2=Salamoun |first2=Mariana M. |last3=Yeretzian |first3=Joumana S. |last4=Mneimneh |first4=Zeina N. |last5=Karam |first5=Aimee N. |last6=Fayyad |first6=John |last7=Hantouche |first7=Elie |last8=Akiskal |first8=Kareen |last9=Akiskal |first9=Hagop S. |date=June 2010 |title=The role of anxious and hyperthymic temperaments in mental disorders: a national epidemiologic study |journal=World Psychiatry |volume=9 |issue=2 |pages=103–110 |doi=10.1002/j.2051-5545.2010.tb00287.x |pmc=2911090 |pmid=20671899}}</ref> Hyperthymic temperament has been described as subsyndromal manifestation within the broader bipolar spectrum.<ref name=":0" />
==== Rapid cycling ==== Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months.<ref>{{cite journal | vauthors = Angst J, Sellaro R | title = Historical perspectives and natural history of bipolar disorder | journal = Biological Psychiatry | volume = 48 | issue = 6 | pages = 445–457 | date = September 2000 | pmid = 11018218 | doi = 10.1016/s0006-3223(00)00909-4 | type = Review }}</ref> ''Rapid cycling'', however, is a course specifier that may be applied to any bipolar subtype. It is defined as having four or more mood disturbance episodes within a one-year span. Rapid cycling is usually temporary but is common amongst people with bipolar disorder and affects 25.8–45.3% of them at some point in their life.<ref name="Muneer2013">{{cite journal | vauthors = Muneer A | title = Treatment of the depressive phase of bipolar affective disorder: a review | journal = The Journal of the Pakistan Medical Association | volume = 63 | issue = 6 | pages = 763–769 | date = June 2013 | pmid = 23901682 | type = Review }}</ref><ref name="Buoli2017">{{cite journal | vauthors = Buoli M, Serati M, Altamura AC | title = Biological aspects and candidate biomarkers for rapid-cycling in bipolar disorder: A systematic review | journal = Psychiatry Research | volume = 258 | pages = 565–575 | date = December 2017 | pmid = 28864122 | doi = 10.1016/j.psychres.2017.08.059 | type = Review }}</ref> These episodes are separated from each other by a remission (partial or full) for at least two months or a switch in mood polarity (i.e., from a depressive episode to a manic episode or vice versa).<ref name="Barnett2009" /> The definition of rapid cycling most frequently cited in the literature (including the DSM-5 and ICD-11) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes during a 12-month period.<ref name="Bauer2008">{{cite journal | vauthors = Bauer M, Beaulieu S, Dunner DL, Lafer B, Kupka R | title = Rapid cycling bipolar disorder—diagnostic concepts | journal = Bipolar Disorders | volume = 10 | issue = 1 Pt 2 | pages = 153–162 | date = February 2008 | pmid = 18199234 | doi = 10.1111/j.1399-5618.2007.00560.x }}</ref>
The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management.<ref name="Fountoulakis2013">{{cite journal | vauthors = Fountoulakis KN, Kontis D, Gonda X, Yatham LN | title = A systematic review of the evidence on the treatment of rapid cycling bipolar disorder | journal = Bipolar Disorders | volume = 15 | issue = 2 | pages = 115–137 | date = March 2013 | pmid = 23437958 | doi = 10.1111/bdi.12045 | type = Systematic Review | url = http://repo.lib.semmelweis.hu//handle/123456789/514 }}</ref> "Ultra rapid" and "ultradian" have been applied to faster-cycling types of bipolar disorder.<ref>{{cite journal | vauthors = Tillman R, Geller B | title = Definitions of rapid, ultrarapid, and ultradian cycling and of episode duration in pediatric and adult bipolar disorders: a proposal to distinguish episodes from cycles | journal = Journal of Child and Adolescent Psychopharmacology | volume = 13 | issue = 3 | pages = 267–271 | date = 2003 | pmid = 14642014 | doi = 10.1089/104454603322572598 }}</ref> People with the rapid cycling or faster-cycling subtypes of bipolar disorder tend to be more difficult to treat and less responsive to medications than other people with bipolar disorder.<ref name="Post2016">{{cite journal | vauthors = Post RM | title = Treatment of Bipolar Depression: Evolving Recommendations | journal = The Psychiatric Clinics of North America | volume = 39 | issue = 1 | pages = 11–33 | date = March 2016 | pmid = 26876316 | doi = 10.1016/j.psc.2015.09.001 | type = Review }}</ref> There is evidence that rapid cycling may be iatrogenic and caused by antidepressant use.<ref>{{cite journal |last1=Ghaemi |first1=S. Nassir |title=Treatment of Rapid-Cycling Bipolar Disorder: Are Antidepressants Mood Destabilizers? |journal=American Journal of Psychiatry |date=March 2008 |volume=165 |issue=3 |pages=300–302 |doi=10.1176/appi.ajp.2007.07121931 |pmid=18316425 }}</ref><ref>{{cite journal |last1=El-Mallakh |first1=Rif S. |last2=Vöhringer |first2=Paul A. |last3=Ostacher |first3=Michael M. |last4=Baldassano |first4=Claudia F. |last5=Holtzman |first5=Niki S. |last6=Whitham |first6=Elizabeth A. |last7=Thommi |first7=Sairah B. |last8=Goodwin |first8=Frederick K. |last9=Ghaemi |first9=S. Nassir |title=Antidepressants worsen rapid-cycling course in bipolar depression: A STEP-BD randomized clinical trial |journal=Journal of Affective Disorders |date=September 2015 |volume=184 |pages=318–321 |doi=10.1016/j.jad.2015.04.054 |pmid=26142612 |pmc=4519402 }}</ref> In contrast, atypical antipsychotics and mood stabilizers do not worsen rapid cycling.<ref>{{Cite book|title=Clinical Psychopharmacology: Principles and Practice|last=Ghaemi|first=S. Nassir|date=2019|publisher=Oxford University Press|isbn=978-0-19-999548-6|edition=1st|location=New York, NY|pages=268–269}}</ref><ref>{{Cite book|title=The Maudsley Prescribing Guidelines in Psychiatry|last1=Taylor|first1=David M.|date=2025|publisher=Wiley-Blackwell|isbn=978-1-394-23876-7|edition=15th|location=Hoboken, NJ|pages=316–317|last2=Barnes|first2=Thomas R. E.|last3=Young|first3=Allan H.}}</ref>
=== Coexisting psychiatric conditions === The diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions including obsessive–compulsive disorder, substance-use disorder, eating disorders, attention deficit hyperactivity disorder, social phobia, premenstrual syndrome (including premenstrual dysphoric disorder), or panic disorder.<ref name="Post2013" /><ref name="Muneer2013" /><ref name="Kerner2014" /><ref name="Cirillo2012">{{cite journal | vauthors = Cirillo PC, Passos RB, Bevilaqua MC, López JR, Nardi AE | title = Bipolar disorder and Premenstrual Syndrome or Premenstrual Dysphoric Disorder comorbidity: a systematic review | journal = Revista Brasileira de Psiquiatria | volume = 34 | issue = 4 | pages = 467–479 | date = December 2012 | pmid = 23429819 | doi = 10.1016/j.rbp.2012.04.010 | doi-access = free }}</ref> A thorough longitudinal analysis of symptoms and episodes, assisted if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist.<ref>{{cite journal |last1=Sagman |first1=Doron |last2=Tohen |first2=Mauricio |title=Comorbidity in bipolar disorder: the complexity of diagnosis and treatment |journal=Psychiatric Times |date=June 2012 |volume=29 |issue=6 |pages=30–33 |id={{Gale|A293667505}} |url=https://www.psychiatrictimes.com/view/comorbidity-bipolar-disorder }}</ref> Children of parents with bipolar disorder more frequently have other mental health problems.{{update after|2020|8|13}}<ref>{{update after|2020|8|13}}{{cite journal | vauthors = DelBello MP, Geller B | title = Review of studies of child and adolescent offspring of bipolar parents | journal = Bipolar Disorders | volume = 3 | issue = 6 | pages = 325–334 | date = December 2001 | pmid = 11843782 | doi = 10.1034/j.1399-5618.2001.30607.x | doi-access = free }}</ref><ref>{{Cite journal |last=Hafeman |first=Danella M. |date=September 2, 2024 |title=Editorial: Following Offspring of Parents With Bipolar Disorder Into Middle Adulthood: Risk Windows Relevant to Child Psychiatrists |journal=Journal of the American Academy of Child and Adolescent Psychiatry |volume=64 |issue=5 |pages=S0890–8567(24)01358–3 |doi=10.1016/j.jaac.2024.08.009 |pmid=39233137}}</ref>
== Prevention == Attempts at prevention of bipolar disorder have focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more severe course of illness.<ref>{{cite journal | vauthors = Miklowitz DJ, Chang KD | title = Prevention of bipolar disorder in at-risk children: theoretical assumptions and empirical foundations | journal = Development and Psychopathology | volume = 20 | issue = 3 | pages = 881–897 | date =Summer 2008 | pmid = 18606036 | pmc = 2504732 | doi = 10.1017/s0954579408000424 }}</ref> Longitudinal studies have indicated that full-blown manic stages are often preceded by a variety of prodromal clinical features, providing support for the occurrence of an at-risk state of the disorder when an early intervention might prevent its further development and/or improve its outcome.<ref>{{cite journal | vauthors = Vieta E, Salagre E, Grande I, Carvalho AF, Fernandes BS, Berk M, Birmaher B, Tohen M, Suppes T | title = Early Intervention in Bipolar Disorder | journal = The American Journal of Psychiatry | volume = 175 | issue = 5 | pages = 411–426 | date = May 2018 | pmid = 29361850 | doi = 10.1176/appi.ajp.2017.17090972 | doi-access = free | hdl = 10536/DRO/DU:30106379 | hdl-access = free }}</ref><ref>{{cite journal | vauthors = Faedda GL, Baldessarini RJ, Marangoni C, Bechdolf A, Berk M, Birmaher B, Conus P, DelBello MP, Duffy AC, Hillegers MH, Pfennig A, Post RM, Preisig M, Ratheesh A, Salvatore P, Tohen M, Vázquez GH, Vieta E, Yatham LN, Youngstrom EA, Van Meter A, Correll CU | title = An International Society of Bipolar Disorders task force report: Precursors and prodromes of bipolar disorder | journal = Bipolar Disorders | volume = 21 | issue = 8 | pages = 720–740 | date = December 2019 | pmid = 31479581 | doi = 10.1111/bdi.12831 | hdl = 11343/286430 | hdl-access = free | url = https://pure.eur.nl/en/publications/9b045de5-4384-4b69-809f-f3a9bf01d6d6 }}</ref> Circadian rhythm disruptions such as traveling across many time zones (jet lag) can destabilize bipolar disorder and lead to manic or psychotic episodes.<ref>{{cite journal |last1=Katz |first1=G. |last2=Knobler |first2=H.Y. |last3=Laibel |first3=Z. |last4=Strauss |first4=Z. |last5=Durst |first5=R. |title=Time zone change and major psychiatric morbidity: The results of a 6-year study in Jerusalem |journal=Comprehensive Psychiatry |date=January 2002 |volume=43 |issue=1 |pages=37–40 |doi=10.1053/comp.2002.29849 |pmid=11788917 }}</ref>
== Management == {{Main|Treatment of bipolar disorder}}
The aim of management is to treat acute episodes safely with medication and work with the patient in long-term maintenance to prevent further episodes and optimise function using a combination of pharmacological and psychotherapeutic techniques.<ref name="Lancet2016" /> Involuntary hospitalization and institutionalization were once acceptable practice,<ref name="BeckerKilian2006">{{cite journal |vauthors=Becker T, Kilian R | title = Psychiatric services for people with severe mental illness across western Europe: What can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? | journal = Acta Psychiatrica Scandinavica | volume = 113 | issue = 429 | pages = 9–16 | year = 2006 | pmid = 16445476 | doi = 10.1111/j.1600-0447.2005.00711.x }}</ref> but new recommendations to advance human rights instead call for the abolition of institutionalization and forced treatment.<ref name=":14" /> In lieu of a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or an Assertive Community Treatment team, supported employment, patient-led support groups, and intensive outpatient programs. These are sometimes referred to as partial-inpatient programs.<ref>{{cite journal |vauthors=McGurk SR, Mueser KT, Feldman K, Wolfe R, Pascaris A | title = Cognitive Training for Supported Employment: 2–3 Year Outcomes of a Randomized Controlled Trial | journal = American Journal of Psychiatry | volume = 164 | issue = 3 | pages = 437–441 | year = 2007 | pmid = 17329468 | doi = 10.1176/appi.ajp.164.3.437 }}</ref> Compared to the general population, people with bipolar disorder are less likely to frequently engage in physical exercise. Exercise may have physical and mental benefits for people with bipolar disorder, but there is a lack of research.<ref>{{cite journal | vauthors = Sá Filho AS, Cheniaux E, de Paula CC, Murillo-Rodriguez E, Teixeira D, Monteiro D, Cid L, Yamamoto T, Telles-Correia D, Imperatori C, Budde H, Machado S | title = Exercise is medicine: a new perspective for health promotion in bipolar disorder | journal = Expert Review of Neurotherapeutics | volume = 20 | issue = 11 | pages = 1099–1107 | date = November 2020 | pmid = 32762382 | doi = 10.1080/14737175.2020.1807329 | hdl-access = free | hdl = 10400.15/3006 }}</ref><ref>{{cite journal | vauthors = Goldstein BI, Baune BT, Bond DJ, Chen PH, Eyler L, Fagiolini A, Gomes F, Hajek T, Hatch J, McElroy SL, McIntyre RS, Prieto M, Sylvia LG, Tsai SY, Kcomt A, Fiedorowicz JG | title = Call to action regarding the vascular-bipolar link: A report from the Vascular Task Force of the International Society for Bipolar Disorders | journal = Bipolar Disorders | volume = 22 | issue = 5 | pages = 440–460 | date = August 2020 | pmid = 32356562 | pmc = 7522687 | doi = 10.1111/bdi.12921 | hdl-access = free | doi-access = free | hdl = 11343/251495 }}</ref><ref>{{cite book |title=Exercise on Brain Health |chapter=Exercise on bipolar disorder in humans |series=International Review of Neurobiology |date=2019 |volume=147 |pages=189–198 |doi=10.1016/bs.irn.2019.07.001 |pmid=31607354 |isbn=978-0-12-816967-4 | vauthors = Lin K, Liu T }}</ref>
=== Psychosocial === Psychotherapy aims to assist a person with bipolar disorder in accepting and understanding their diagnosis, coping with various types of stress, improving their interpersonal relationships, and recognizing prodromal symptoms before full-blown recurrence.<ref name="Bobo2017" /> Cognitive behavioral therapy (CBT), family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge.<ref>{{cite journal |vauthors=Zaretsky AE, Rizvi S, Parikh SV | title = How well do psychosocial interventions work in bipolar disorder? | journal = Canadian Journal of Psychiatry| volume = 52 | issue = 1 | pages = 14–21 | year = 2007 | pmid = 17444074 | doi = 10.1177/070674370705200104 | doi-access = }}</ref> Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.<ref>{{cite journal |vauthors=Havens LL, Ghaemi SN | title = Existential despair and bipolar disorder: The therapeutic alliance as a mood stabilizer | journal = American Journal of Psychotherapy | volume = 59 | issue = 2 | pages = 137–147 | year = 2005 | pmid = 16170918 | doi = 10.1176/appi.psychotherapy.2005.59.2.137 | doi-access = free }}</ref>
=== Medication === thumb|Lithium is often used to treat bipolar disorder and has the best evidence for reducing suicide.<ref name="pmid23814104" />
Medications are often prescribed to help improve symptoms of bipolar disorder. Medications approved for treating bipolar disorder including mood stabilizers and atypical antipsychotics. Sometimes a combination of medications may also be suggested.<ref name="Lancet2016" /> The choice of medications may differ depending on the bipolar disorder episode type or if the person is experiencing unipolar or bipolar depression.<ref name="Lancet2016" /><ref name="Dean_2021" /> Other factors to consider when deciding on an appropriate treatment approach includes if the person has any comorbidities, their response to previous therapies, adverse effects, and the desire of the person to be treated.<ref name="Lancet2016" />
====Mood stabilizers==== Lithium and the anticonvulsants carbamazepine, lamotrigine, and valproic acid are classed as mood stabilizers due to their effect on the mood states in bipolar disorder.<ref name="Post2016" /> * Lithium has the best overall evidence and is considered an effective treatment for acute manic episodes, preventing relapses, and bipolar depression.<ref name="Brown2013">{{cite journal|vauthors=Brown KM, Tracy DK|date=June 2013|title=Lithium: the pharmacodynamic actions of the amazing ion|journal=Therapeutic Advances in Psychopharmacology|volume=3|issue=3|pages=163–176|doi=10.1177/2045125312471963|pmc=3805456|pmid=24167688}}</ref><ref>{{cite journal|vauthors=McKnight RF, de La Motte de Broöns de Vauvert SJ, Chesney E, etal|date=June 2019|title=Lithium for acute mania|journal=Cochrane Database Syst Rev|volume=2019|issue=6 |article-number=CD004048|doi=10.1002/14651858.CD004048.pub4|pmc=6544558|pmid=31152444|doi-access=free}}</ref> Lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder.<ref name="pmid23814104">{{cite journal |last1=Cipriani |first1=A. |last2=Hawton |first2=K. |last3=Stockton |first3=S. |last4=Geddes |first4=J. R. |title=Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis |journal=BMJ |date=June 27, 2013 |volume=346 |issue=jun27 4 |article-number=f3646 |doi=10.1136/bmj.f3646 |pmid=23814104 |doi-access=free |url=https://zenodo.org/record/47052 }}</ref> Lithium is preferred for long-term mood stabilization.<ref name="Geddestreatment">{{cite journal |vauthors=Geddes JR, Miklowitz DJ | title = Treatment of bipolar disorder | journal = Lancet | volume = 381 | issue = 9878 | pages = 1672–1682 | date = May 11, 2013 | pmid = 23663953 | doi = 10.1016/S0140-6736(13)60857-0 | pmc=3876031}}</ref> Lithium treatment is also associated with adverse effects and it has been shown to erode kidney and thyroid function over extended periods.<ref name="Lancet2016" /> * Valproate has become a commonly prescribed treatment and effectively treats manic episodes.<ref name="Macr02">{{cite journal | vauthors = Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G | issue = 1 | article-number = CD004052 | year = 2003 | pmid = 12535506 | doi = 10.1002/14651858.CD004052 |title = Valproate for acute mood episodes in bipolar disorder | veditors = Reid K | journal = Cochrane Database of Systematic Reviews }}</ref> * Carbamazepine is less effective in preventing relapse than lithium or valproate.<ref>{{cite journal |vauthors=Post RM, Ketter TA, Uhde T, Ballenger JC | title = Thirty years of clinical experience with carbamazepine in the treatment of bipolar illness: Principles and practice | journal = CNS Drugs | volume = 21 | issue = 1 | pages = 47–71 | year = 2007 | pmid = 17190529 | doi=10.2165/00023210-200721010-00005 }}</ref><ref name="Rapoport2009">{{cite journal|vauthors=Rapoport SI, Basselin M, Kim HW, Rao JS |title=Bipolar disorder and mechanisms of action of mood stabilizers|journal=Brain Res Rev|volume=61|issue=2|pages=185–209|date=October 2009|pmid=19555719|pmc=2757443|doi=10.1016/j.brainresrev.2009.06.003}}</ref> Carbamazepine effectively treats manic episodes, with some evidence it has greater benefit in rapid-cycling bipolar disorder, or those with more psychotic symptoms or more symptoms similar to that of schizoaffective disorder.{{citation needed|date=January 2026}} * Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression.<ref>{{cite journal |vauthors=Geddes JR, Calabrese JR, Goodwin GM | title = Lamotrigine for treatment of bipolar depression: Independent meta-analysis and meta-regression of individual patient data from five randomised trials | journal = The British Journal of Psychiatry | volume = 194 | issue = 1 | pages = 4–9 | year = 2008 | pmid = 19118318 | doi = 10.1192/bjp.bp.107.048504 | doi-access = free }}</ref> Lamotrigine may have a similar effectiveness to lithium for treating bipolar disorder, however, there is evidence to suggest that lamotrigine is less effective at preventing recurrent mania episodes.<ref>{{cite journal | vauthors = Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S | title = Lamotrigine in the maintenance treatment of bipolar disorder | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 9 | article-number = CD013575 | date = September 2021 | pmid = 34523118 | pmc = 8440301 | doi = 10.1002/14651858.CD013575.pub2 }}</ref> Lamotrigine treatment has been shown to be safer compared to lithium treatment, with less adverse effects.{{citation needed|date=January 2026}}
Valproate and carbamazepine are teratogenic and should be avoided as a treatment in women of childbearing age, but discontinuation of these medications during pregnancy is associated with a high risk of relapse.<ref name="Carvalho" /> Lithium is also teratogenic in the first trimester, though it can be acceptable during this period after careful weighing of benefits and risks.<ref>{{cite web |title=Lithium in pregnancy and breastfeeding |url=https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/lithium-in-pregnancy-and-breastfeeding |work=Royal College of Psychiatrists }}</ref><ref>{{cite journal | vauthors = Poels EM, Bijma HH, Galbally M, Bergink V | title = Lithium during pregnancy and after delivery: a review | journal = International Journal of Bipolar Disorders | volume = 6 | issue = 1 | article-number = 26 | date = December 2018 | pmid = 30506447 | pmc = 6274637 | doi = 10.1186/s40345-018-0135-7 | doi-access = free }}</ref>
The effectiveness of topiramate is unknown.<ref name="pmid16437453">{{cite journal | vauthors = Vasudev K, Macritchie K, Geddes J, Watson S, Young A | journal = Cochrane Database of Systematic Reviews | issue = 1 | article-number = CD003384 | year = 2006 | pmid = 16437453 | doi = 10.1002/14651858.CD003384.pub2 | title= Topiramate for acute affective episodes in bipolar disorder | veditors = Young AH }}</ref> Mood stabilizers are used for long-term maintenance but have not demonstrated the ability to quickly treat acute bipolar depression. However, several atypical antipsychotics are FDA approved to treat bipolar depression.<ref name="Post2016" />
====Antipsychotics==== Antipsychotic medications are effective for short-term treatment of bipolar manic episodes and appear to be superior to lithium and anticonvulsants for this purpose.<ref name="Geddestreatment" /> Multiple atypical antipsychotics are FDA approved to treat bipolar depression: lurasidone, quetiapine, olanzapine-fluoxetine combination, cariprazine, and lumateperone are all FDA approved for depression in bipolar disorder. Atypical antipsychotics such as lurasidone and clozapine are also indicated for bipolar depression refractory to treatment with mood stabilizers.<ref name="Post2016" /> Olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium.<ref>{{cite journal | vauthors = Cipriani A, Rendell JM, Geddes J | title = Olanzapine in long-term treatment for bipolar disorder | journal = The Cochrane Database of Systematic Reviews | issue = 1 | article-number = CD004367 | date = January 2009 | pmid = 19160237 | doi = 10.1002/14651858.CD004367.pub2 | veditors = Cipriani A }}</ref> A 2006 review found that haloperidol was an effective treatment for acute mania, limited data supported no difference in overall efficacy between haloperidol, olanzapine or risperidone, and that it could be less effective than aripiprazole.<ref>{{cite journal | vauthors = Cipriani A, Rendell JM, Geddes JR | title = Haloperidol alone or in combination for acute mania | journal = The Cochrane Database of Systematic Reviews | issue = 3 | article-number = CD004362 | date = July 2006 | volume = 2010 | pmid = 16856043 | doi = 10.1002/14651858.CD004362.pub2 | pmc = 13092891 }}</ref>
====Antidepressants==== {{See also|SSRI#Bipolar switch}}Antidepressant monotherapy is not recommended in the treatment of bipolar disorder and does not provide any benefit over mood stabilizers.<ref name="Lancet2016" /><ref name="PostGrad10">{{cite journal |vauthors=El-Mallakh RS, Elmaadawi AZ, Loganathan M, Lohano K, Gao Y | title = Bipolar disorder: an update | journal = Postgraduate Medicine | volume = 122 | issue = 4 | pages = 24–31 | date = July 2010 | pmid = 20675968 | doi = 10.3810/pgm.2010.07.2172 }}</ref> Atypical antipsychotic medications are preferred over antidepressants to augment the effects of mood stabilizers due to the lack of efficacy of antidepressants in bipolar disorder. The FDA has approved 5 atypical antipsychotic medications to specifically treat bipolar depression. Treatment of bipolar disorder using antidepressants may carry a risk of affective switches where a person switches from depression to manic or hypomanic phases or mixed states.<ref name="Carvalho" />
There may also be a risk of accelerating cycling between phases when antidepressants are used in bipolar disorder, known as rapid cycling.<ref name=":4">{{Cite journal |last1=Pacchiarotti |first1=Isabella |last2=Bond |first2=David J. |last3=Baldessarini |first3=Ross J. |last4=Nolen |first4=Willem A. |last5=Grunze |first5=Heinz |last6=Licht |first6=Rasmus W. |last7=Post |first7=Robert M. |last8=Berk |first8=Michael |last9=Goodwin |first9=Guy M. |last10=Sachs |first10=Gary S. |last11=Tondo |first11=Leonardo |last12=Findling |first12=Robert L. |last13=Youngstrom |first13=Eric A. |last14=Tohen |first14=Mauricio |last15=Undurraga |first15=Juan |date=November 2013 |title=The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders |journal=American Journal of Psychiatry |volume=170 |issue=11 |pages=1249–1262 |doi=10.1176/appi.ajp.2013.13020185 |pmc=4091043 |pmid=24030475}}</ref> The risk of affective switches is higher in bipolar I depression; antidepressants are generally avoided in bipolar I disorder or only used with mood stabilizers when they are deemed necessary.<ref>{{cite journal |last1=Aiken |first1=Chris |title=Antidepressants in Bipolar II Disorder |journal=Psychiatric Times |date=May 14, 2019 |volume=36 |issue=5 |url=https://www.psychiatrictimes.com/view/antidepressants-bipolar-ii-disorder }}</ref><ref name="Carvalho" />{{rp|63}} Whether modern antidepressants cause mania or rapid cycling in bipolar disorder is highly controversial, as is whether antidepressants provide any benefit over mood stabilizers alone.<ref name="Carvalho" />{{rp|63}}<ref>{{cite journal | vauthors = Gitlin MJ | title = Antidepressants in bipolar depression: an enduring controversy | journal = International Journal of Bipolar Disorders | volume = 6 | issue = 1 | article-number = 25 | date = December 2018 | pmid = 30506151 | pmc = 6269438 | doi = 10.1186/s40345-018-0133-9 | doi-access = free }}</ref><ref>{{cite journal |last1=Ghaemi |first1=S Nassir |last2=Hsu |first2=Douglas J |last3=Soldani |first3=Federico |last4=Goodwin |first4=Frederick K |title=Antidepressants in bipolar disorder: the case for caution |journal=Bipolar Disorders |date=December 2003 |volume=5 |issue=6 |pages=421–433 |doi=10.1046/j.1399-5618.2003.00074.x |pmid=14636365 }}</ref> Selective serotonin reuptake inhibitors and bupropion still have a risk of rapid cycling and manic switch, but it is lower than other types of antidepressants.<ref name=":4" /><ref>{{Cite book |last=Ghaemi |first=S. Nassir |title=Clinical Psychopharmacology: Principles and Practice |date=2019 |publisher=Oxford University Press |isbn=978-0-19-999548-6 |edition=1st |location=New York, NY |pages=250–256}}</ref> Serotonin-norepinephrine reuptake inhibitors, such as venlafaxine and duloxetine, tetracyclic antidepressants such as mirtazapine, and tricyclic antidepressants have higher rates of manic switch and rapid cycling.<ref name=":4" />
==== Combined treatment approaches ==== Atypical antipsychotics and mood stabilizers used together are quicker and more effective at treating mania than either class of drug used alone. According to the International Society for Bipolar Disorders (ISBD) and Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines, a first-line combination treatment for bipolar depression is the atypical antipsychotic lurasidone plus the mood stabilizers lithium or valproate.<ref>{{Cite journal |last1=Keramatian |first1=Kamyar |last2=Chithra |first2=Nellai K. |last3=Yatham |first3=Lakshmi N. |date=October 2023 |title=The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence |journal=Focus |volume=21 |issue=4 |pages=344–353 |doi=10.1176/appi.focus.20230009 |pmc=11058959 |pmid=38695002}}</ref>
====Other drugs==== Short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective.<ref>{{cite web|title=Benzodiazepines for Bipolar Disorder|url=http://www.webmd.com/bipolar-disorder/bipolar-benzodiazepines|publisher=WebMD.com|access-date=February 13, 2013|url-status=live|archive-url=https://web.archive.org/web/20130225080713/http://www.webmd.com/bipolar-disorder/bipolar-benzodiazepines|archive-date=February 25, 2013}}</ref> Electroconvulsive therapy (ECT) is an effective form of treatment for acute mood disturbances in those with bipolar disorder, especially when psychotic or catatonic features are displayed. ECT is also recommended for use in pregnant women with bipolar disorder.<ref name="Lancet2016" /> A single intravenous dose of ketamine may produce a rapid but transient antidepressant effect in bipolar depression, although the evidence is of low to very low certainty, and evidence for other glutamate receptor modulators or for sustained remission and safety remains inconclusive.<ref name="Dean_2021">{{cite journal | vauthors = Dean RL, Marquardt T, Hurducas C, Spyridi S, Barnes A, Smith R, Cowen PJ, McShane R, Hawton K, Malhi GS, Geddes J, Cipriani A | title = Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 10 | article-number = CD011611 | date = October 2021 | pmid = 34623633 | pmc = 8499740 | doi = 10.1002/14651858.CD011611.pub3 }}</ref> Gabapentin and pregabalin are not proven to be effective for treating bipolar disorder.<ref>{{cite report |title=Review finds little evidence to support gabapentinoid use in bipolar disorder or insomnia |date=2022 |doi=10.3310/nihrevidence_54173 }}</ref><ref name="Hong_2022">{{cite journal | vauthors = Hong JS, Atkinson LZ, Al-Juffali N, Awad A, Geddes JR, Tunbridge EM, Harrison PJ, Cipriani A | title = Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale | journal = Molecular Psychiatry | volume = 27 | issue = 3 | pages = 1339–1349 | date = March 2022 | pmid = 34819636 | pmc = 9095464 | doi = 10.1038/s41380-021-01386-6 }}</ref><ref>{{cite journal | vauthors = Ng QX, Han MX, Teoh SE, Yaow CY, Lim YL, Chee KT | title = A Systematic Review of the Clinical Use of Gabapentin and Pregabalin in Bipolar Disorder | journal = Pharmaceuticals | volume = 14 | issue = 9 | page = 834 | date = August 2021 | pmid = 34577534 | pmc = 8469561 | doi = 10.3390/ph14090834 | doi-access = free }}</ref>
===Children=== Treating bipolar disorder in children involves medication and psychotherapy.<ref name="Lei2008">{{cite journal |vauthors=Leibenluft E, Rich BA | title = Pediatric Bipolar Disorder | journal = Annual Review of Clinical Psychology | volume = 4 | pages = 163–187 | year = 2008 | pmid = 17716034 | doi = 10.1146/annurev.clinpsy.4.022007.141216 | url = https://zenodo.org/record/1234949 }}</ref> The literature and research on the effects of psychosocial therapy on bipolar spectrum disorders are scarce, making it difficult to determine the efficacy of various therapies.<ref name="Fristad">{{cite journal | vauthors = Fristad MA, MacPherson HA | title = Evidence-based psychosocial treatments for child and adolescent bipolar spectrum disorders | journal = Journal of Clinical Child and Adolescent Psychology | volume = 43 | issue = 3 | pages = 339–355 |year = 2014 | pmid = 23927375 | pmc = 3844106 | doi = 10.1080/15374416.2013.822309 }}</ref> Mood stabilizers and atypical antipsychotics are commonly prescribed.<ref name="Lei2008" /> Among the former, lithium is the only compound approved by the FDA for children.<ref name="pmid17195735">{{cite journal | vauthors = McClellan J, Kowatch R, Findling RL | title = Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder | journal = Journal of the American Academy of Child & Adolescent Psychiatry | volume = 46 | issue = 1 | pages = 107–125 | year = 2007 | pmid = 17195735 | doi = 10.1097/01.chi.0000242240.69678.c4 | others = Work Group on Quality Issues | doi-access = free }}</ref> Psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy.<ref name="Lei2008" /> Long-term medication is often needed.<ref name="Lei2008" />
=== Resistance to treatment === The poor response from some bipolar patients to treatment has given evidence to the concept of treatment-resistant bipolar disorder.<ref>{{cite journal | vauthors = Gitlin M | title = Treatment-resistant bipolar disorder | journal = Molecular Psychiatry | volume = 11 | issue = 3 | pages = 227–240 | date = March 2006 | pmid = 16432528 | doi = 10.1038/sj.mp.4001793 | doi-access = }}</ref><ref>{{cite journal | vauthors = Hui Poon S, Sim K, Baldessarini RJ | title = Pharmacological Approaches for Treatment-resistant Bipolar Disorder | journal = Current Neuropharmacology | volume = 13 | issue = 5 | pages = 592–604 |year = 2015 | pmid = 26467409 | pmc = 4761631 | doi = 10.2174/1570159x13666150630171954 }}</ref> Guidelines to the definition of treatment-resistant bipolar disorder and evidence-based options for its management were reviewed in 2020.<ref>{{cite journal | vauthors = Fountoulakis KN, Yatham LN, Grunze H, Vieta E, Young AH, Blier P, Tohen M, Kasper S, Moeller HJ | title = The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder | journal = The International Journal of Neuropsychopharmacology | volume = 23 | issue = 4 | pages = 230–256 | date = April 2020 | pmid = 31802122 | pmc = 7177170 | doi = 10.1093/ijnp/pyz064 }}</ref>
=== Management of obesity === A large proportion (approximately 68%) of people who seek treatment for bipolar disorder are obese or overweight and managing obesity is important for reducing the risk of other health conditions that are associated with obesity.<ref name="Tully_2020">{{cite journal | vauthors = Tully A, Smyth S, Conway Y, Geddes J, Devane D, Kelly JP, Jordan F | title = Interventions for the management of obesity in people with bipolar disorder | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 7 | article-number = CD013006 | date = July 2020 | pmid = 32687629 | pmc = 7386454 | doi = 10.1002/14651858.CD013006.pub2 }}</ref> Management approaches include non-pharmacological, pharmacological, and surgical. Examples of non-pharmacological include dietary interventions, exercise, behavioral therapies, or combined approaches. Pharmacological approaches include weight-loss medications or changing medications already being prescribed.<ref>{{cite journal | vauthors = | title = Corrigendum | journal = The Journal of Clinical Endocrinology and Metabolism | volume = 100 | issue = 5 | pages = 2135–2136 | date = May 2015 | pmid = 25955325 | doi = 10.1210/jc.2015-1782 | doi-access = free }}</ref> Some people with bipolar disorder who have obesity may also be eligible for bariatric surgery.<ref name="Tully_2020" /> The effectiveness of these various approaches to improving or managing obesity in people with bipolar disorder is not clear.<ref name="Tully_2020" />
== Prognosis == A lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse,<ref name="Muneer2013" /><ref name="pmid18425912">{{cite journal | vauthors = Montgomery P, Richardson AJ | title = Omega-3 fatty acids for bipolar disorder | journal = Cochrane Database Syst Rev | issue = 2 | article-number = CD005169 | date = April 2008 | pmid = 18425912 | doi = 10.1002/14651858.CD005169.pub2 }}</ref> bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality.<ref name="pmid18425912" /> It is also associated with co-occurring psychiatric and medical problems, higher rates of death from natural causes (e.g., cardiovascular disease), and high rates of initial under- or misdiagnosis, causing a delay in appropriate treatment and contributing to poorer prognoses.<ref name="BMJ2012" /><ref name="Bowden" /> When compared to the general population, people with bipolar disorder also have higher rates of other serious medical comorbidities including diabetes mellitus, respiratory diseases, HIV, and hepatitis C virus infection.<ref name="Cloutier2018" /> After a diagnosis is made, it remains difficult to achieve complete remission of all symptoms with the currently available psychiatric medications and symptoms often become progressively more severe over time.<ref name="Carvalho2015" /><ref name="Muneer2016">{{cite journal | vauthors = Muneer A | title = Staging Models in Bipolar Disorder: A Systematic Review of the Literature | journal = Clinical Psychopharmacology and Neuroscience | volume = 14 | issue = 2 | pages = 117–130 | date = May 2016 | pmid = 27121423 | pmc = 4857867 | doi = 10.9758/cpn.2016.14.2.117 }}</ref>
Compliance with medications is one of the most significant factors that can decrease the rate and severity of relapse and have a positive impact on overall prognosis.<ref name="Jann" /> However, the types of medications used in treating BD commonly cause side effects<ref name="Tsitsipa" /> and more than 75% of individuals with BD inconsistently take their medications for various reasons.<ref name="Jann">{{cite journal | vauthors = Jann MW | title = Diagnosis and treatment of bipolar disorders in adults: a review of the evidence on pharmacologic treatments | journal = American Health & Drug Benefits | volume = 7 | issue = 9 | pages = 489–499 | date = December 2014 | pmid = 25610528 | pmc = 4296286 }}</ref> Of the various types of the disorder, rapid cycling (four or more episodes in one year) is associated with the worst prognosis due to higher rates of self-harm and suicide.<ref name="Muneer2013" /> Individuals diagnosed with bipolar who have a family history of bipolar disorder are at a greater risk for more frequent manic/hypomanic episodes.<ref name="Maciukiewicz" /> Early onset and psychotic features are also associated with worse outcomes,<ref>{{cite journal | vauthors = Kennedy KP, Cullen KR, DeYoung CG, Klimes-Dougan B | title = The genetics of early-onset bipolar disorder: A systematic review | journal = Journal of Affective Disorders | volume = 184 | pages = 1–12 | date = September 2015 | pmid = 26057335 | pmc = 5552237 | doi = 10.1016/j.jad.2015.05.017 }}</ref><ref>{{cite journal | vauthors = Serafini G, Pompili M, Borgwardt S, Houenou J, Geoffroy PA, Jardri R, Girardi P, Amore M | title = Brain changes in early-onset bipolar and unipolar depressive disorders: a systematic review in children and adolescents | journal = European Child & Adolescent Psychiatry | volume = 23 | issue = 11 | pages = 1023–1041 | date = November 2014 | pmid = 25212880 | doi = 10.1007/s00787-014-0614-z }}</ref> as well as subtypes that are nonresponsive to lithium.<ref name="Muneer2016" />
Early recognition and intervention also improve prognosis as the symptoms in earlier stages are less severe and more responsive to treatment.<ref name="Muneer2016" /> Onset after adolescence is connected to better prognoses for both genders, and being male is a protective factor against higher levels of depression. For women, better social functioning before developing bipolar disorder and being a parent are protective towards suicide attempts.<ref name="Maciukiewicz">{{cite journal |vauthors=Maciukiewicz M, Pawlak J, Kapelski P, Łabędzka M, Skibinska M, Zaremba D, Leszczynska-Rodziewicz A, Dmitrzak-Weglarz M, Hauser J |title=Can Psychological, Social and Demographical Factors Predict Clinical Characteristics Symptomatology of Bipolar Affective Disorder and Schizophrenia? |journal=Psychiatr Q |volume=87 |issue=3 |pages=501–513 |year=2016 |pmid=26646576 |pmc=4945684 |doi=10.1007/s11126-015-9405-z }}</ref>
=== Functioning === Changes in cognitive processes and abilities are seen in mood disorders, with those of bipolar disorder being greater than those in major depressive disorder.<ref name="MacQueen2017">{{cite journal | vauthors = MacQueen GM, Memedovich KA | title = Cognitive dysfunction in major depression and bipolar disorder: Assessment and treatment options | journal = Psychiatry and Clinical Neurosciences | volume = 71 | issue = 1 | pages = 18–27 | date = January 2017 | pmid = 27685435 | doi = 10.1111/pcn.12463 | type = Review | doi-access = free }}</ref> These include reduced attentional and executive capabilities and impaired memory.<ref name="Cipriani2017">{{cite journal | vauthors = Cipriani G, Danti S, Carlesi C, Cammisuli DM, Di Fiorino M | title = Bipolar Disorder and Cognitive Dysfunction: A Complex Link | journal = The Journal of Nervous and Mental Disease | volume = 205 | issue = 10 | pages = 743–756 | date = October 2017 | pmid = 28961594 | doi = 10.1097/NMD.0000000000000720 | type = Review }}</ref> People with bipolar disorder often experience a decline in cognitive functioning during (or possibly before) their first episode, after which a certain degree of cognitive dysfunction typically becomes permanent, with more severe impairment during acute phases and moderate impairment during periods of remission. As a result, two-thirds of people with BD continue to experience impaired psychosocial functioning in between episodes even when their mood symptoms are in full remission. A similar pattern is seen in both BD-I and BD-II, but people with BD-II experience a lesser degree of impairment.<ref name="Tsitsipa">{{cite journal | vauthors = Tsitsipa E, Fountoulakis KN | title = The neurocognitive functioning in bipolar disorder: a systematic review of data | journal = Annals of General Psychiatry | volume = 14 | article-number = 42 | date = December 1, 2015 | pmid = 26628905 | pmc = 4666163 | doi = 10.1186/s12991-015-0081-z | doi-access = free }}</ref> People with bipolar disorder have higher relative odds for dementia (by a factor of 2.96) and lithium reduces the relative odds of dementia by 49%.<ref>{{Cite journal |last1=Velosa |first1=J. |last2=Delgado |first2=A. |last3=Finger |first3=E. |last4=Berk |first4=M. |last5=Kapczinski |first5=F. |last6=de Azevedo Cardoso |first6=T. |date=2020 |title=Risk of dementia in bipolar disorder and the interplay of lithium: a systematic review and meta-analyses |journal=Acta Psychiatrica Scandinavica |language=en |volume=141 |issue=6 |pages=510–521 |doi=10.1111/acps.13153 |pmid=31954065 |hdl=11343/275396 |hdl-access=free }}</ref> Maintenance treatment with lithium reduces rates of dementia to that of the general population.<ref>{{cite journal |last1=Kessing |first1=Lars Vedel |last2=Søndergård |first2=Lars |last3=Forman |first3=Julie Lyng |last4=Andersen |first4=Per Kragh |title=Lithium Treatment and Risk of Dementia |journal=Archives of General Psychiatry |date=November 3, 2008 |volume=65 |issue=11 |pages=1331–1335 |doi=10.1001/archpsyc.65.11.1331 |pmid=18981345 }}</ref>
When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development.<ref name="Diler2019">{{cite book |url=https://iacapap.org/content/uploads/E.2-Bipolar-2019.pdf |title=JM Rey's IACAPAP e-Textbook of Child and Adolescent Mental Health. |vauthors=Diler RS, Birmaher B |date=2019 |publisher=International Association for Child and Adolescent Psychiatry and Allied Professions |location=Geneva |pages=1–37 |chapter=Chapter E2 Bipolar Disorders in Children and Adolescents |access-date=March 18, 2020 |archive-url=https://ghostarchive.org/archive/20221009/https://iacapap.org/content/uploads/E.2-Bipolar-2019.pdf |archive-date=October 9, 2022 |url-status=live}}</ref> Children and adolescents with bipolar disorder have higher rates of significant difficulties with substance use disorders, psychosis, academic difficulties, behavioral problems, social difficulties, and legal problems.<ref name="Diler2019" /> Cognitive deficits typically increase over the course of the illness. Higher degrees of impairment correlate with the number of previous manic episodes and hospitalizations, and with the presence of psychotic symptoms.<ref name="Bortolato">{{cite journal | vauthors = Bortolato B, Miskowiak KW, Köhler CA, Vieta E, Carvalho AF | title = Cognitive dysfunction in bipolar disorder and schizophrenia: a systematic review of meta-analyses | journal = Neuropsychiatric Disease and Treatment | volume = 11 | pages = 3111–3125 | year = 2015 | pmid = 26719696 | pmc = 4689290 | doi = 10.2147/NDT.S76700 | doi-access = free }}</ref> Early intervention can slow the progression of cognitive impairment, while treatment at later stages can help reduce distress and negative consequences related to cognitive dysfunction.<ref name="Muneer2016" />
Despite the overly ambitious goals that are frequently part of manic episodes, symptoms of mania undermine the ability to achieve these goals and often interfere with an individual's social and occupational functioning. One-third of people with BD remain unemployed for one year following a hospitalization for mania.<ref>{{cite journal | vauthors = Johnson SL | title = Mania and dysregulation in goal pursuit: a review | journal = Clinical Psychology Review | volume = 25 | issue = 2 | pages = 241–262 | date = February 2005 | pmid = 15642648 | pmc = 2847498 | doi = 10.1016/j.cpr.2004.11.002 }}</ref> Depressive symptoms during and between episodes, which occur much more frequently for most people than hypomanic or manic symptoms over the course of illness, are associated with lower functional recovery in between episodes, including unemployment or underemployment for both BD-I and BD-II.<ref name="DSM5" /><ref name="Tse" /> However, the course of illness (duration, age of onset, number of hospitalizations, and the presence or not of rapid cycling) and cognitive performance are the best predictors of employment outcomes in individuals with bipolar disorder, followed by symptoms of depression and years of education.<ref name="Tse">{{cite journal | vauthors = Tse S, Chan S, Ng KL, Yatham LN | title = Meta-analysis of predictors of favorable employment outcomes among individuals with bipolar disorder | journal = Bipolar Disorders | volume = 16 | issue = 3 | pages = 217–229 | date = May 2014 | pmid = 24219657 | doi = 10.1111/bdi.12148 }}</ref>
Stigmatization by others is "associated with greater functional impairment, anxiety and poorer work-related outcomes"; vice versa, self-stigmatization is associated with "lower levels of functioning across a range of domains and greater depressive and anxiety symptoms".<ref>{{Cite journal |last1=Perich |first1=Tania |last2=Mitchell |first2=Philip B. |last3=Vilus |first3=Bojana |date=February 16, 2022 |title=Stigma in bipolar disorder: A current review of the literature |journal=The Australian and New Zealand Journal of Psychiatry |volume=56 |issue=9 |pages=1060–1064 |doi=10.1177/00048674221080708 |pmid=35172630 }}</ref>
=== Recovery and recurrence === A naturalistic study in 2003 by Tohen and coworkers from the first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. Within two years, 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.<ref>{{cite journal |vauthors=Tohen M, Zarate CA, Hennen J, Khalsa HM, Strakowski SM, Gebre-Medhin P, Salvatore P, Baldessarini RJ | title = The McLean-Harvard First-Episode Mania Study: Prediction of recovery and first recurrence | journal = The American Journal of Psychiatry | volume = 160 | issue = 12 | pages = 2099–2107 | year = 2003 | pmid = 14638578 | doi = 10.1176/appi.ajp.160.12.2099 | hdl = 11381/1461461 }}</ref>
Symptoms preceding a relapse (prodromal), especially those related to mania, can be reliably identified by people with bipolar disorder.<ref name="pmid12738039">{{cite journal |vauthors=Jackson A, Cavanagh J, Scott J | title = A systematic review of manic and depressive prodromes | journal = Journal of Affective Disorders | volume = 74 | issue = 3 | pages = 209–217 | year = 2003 | pmid = 12738039 | doi=10.1016/s0165-0327(02)00266-5}}</ref> There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results.<ref name="pmid16125292">{{cite journal |vauthors=Lam D, Wong G | title = Prodromes, coping strategies and psychological interventions in bipolar disorders | journal = Clinical Psychology Review | volume = 25 | issue = 8 | pages = 1028–1042 | year = 2005 | pmid = 16125292 | doi = 10.1016/j.cpr.2005.06.005 }}</ref>
=== Suicide === {{See also|Lithium (medication)#Prevention of suicide}}
Bipolar disorder can cause suicidal ideation that leads to suicide attempts. Individuals whose bipolar disorder begins with a depressive or mixed affective episode seem to have a poorer prognosis and an increased risk of suicide.<ref name="Baldessarini2013">{{cite journal |vauthors=Baldessarini RJ, Faedda GL, Offidani E, Vázquez GH, Marangoni C, Serra G, Tondo L | title = Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: a review | journal = J Affect Disord | volume = 148 | issue = 1 | pages = 129–135 | date = May 2013 | pmid = 23219059 | doi = 10.1016/j.jad.2012.10.033 }}</ref> One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed.<ref name="Kerner2014" /> The annual average suicide rate is 0.4–1.4%, which is 30 to 60 times greater than that of the general population.<ref name="Nierenberg 2023">{{cite journal | vauthors = Nierenberg AA, Agustini B, Köhler-Forsberg O, Cusin C, Katz D, Sylvia LG, Peters A, Berk M | title = Diagnosis and Treatment of Bipolar Disorder: A Review | journal = JAMA | volume = 330 | issue = 14 | pages = 1370–1380 | date = October 2023 | pmid = 37815563 | doi = 10.1001/jama.2023.18588 }}</ref> The number of deaths from suicide in bipolar disorder is between 18 and 25 times higher than would be expected in similarly aged people without bipolar disorder.<ref name="MortBio_2006">{{cite journal |last1=McIntyre |first1=Roger S. |last2=Soczynska |first2=Joanna K. |last3=Konarski |first3=Jakub |title=Bipolar Disorder: Defining Remission and Selecting Treatment |journal=Psychiatric Times |date=October 2006 |volume=23 |issue=11 |page=46 |id={{Gale|A153644880}} |url=https://www.psychiatrictimes.com/view/bipolar-disorder-defining-remission-and-selecting-treatment }}</ref> The lifetime risk of suicide is much higher in those with bipolar disorder, with an estimated 34% of people attempting suicide and 15–20% dying by suicide.<ref name="Nierenberg 2023" />
Risk factors for suicide attempts and death from suicide in people with bipolar disorder include older age, prior suicide attempts, a depressive or mixed index episode (first episode), a manic index episode with psychotic symptoms, hopelessness or psychomotor agitation present during the episodes, co-existing anxiety disorder, a first degree relative with a mood disorder or suicide, interpersonal conflicts, occupational problems, bereavement or social isolation.<ref name="Carvalho" />
Lithium has been shown to reduce the risk of suicide in people with bipolar disorder or major depression to close to the same level as that of the general population.<ref name=":5">{{cite journal |last1=Cipriani |first1=Andrea |last2=Hawton |first2=Keith |last3=Stockton |first3=Sarah |last4=Geddes |first4=John R. |title=Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis |journal=BMJ |date=June 27, 2013 |volume=346 |article-number=f3646 |doi=10.1136/bmj.f3646 |pmid=23814104 |url=https://zenodo.org/record/47052 }}</ref><ref>{{cite journal |last1=Baldessarini |first1=Ross J |last2=Tondo |first2=Leonardo |last3=Davis |first3=Paula |last4=Pompili |first4=Maurizio |last5=Goodwin |first5=Frederick K |last6=Hennen |first6=John |title=Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review |journal=Bipolar Disorders |date=October 2006 |volume=8 |issue=5p2 |pages=625–639 |doi=10.1111/j.1399-5618.2006.00344.x |pmid=17042835 |url=http://nrs.harvard.edu/urn-3:HUL.InstRepos:37960817 }}</ref> Randomized controlled trials and other studies for over 40 years have shown that lithium is highly effective in reducing suicide among people with bipolar disorder.<ref name=":5" /><ref>{{cite journal |last1=Smith |first1=Katharine A |last2=Cipriani |first2=Andrea |title=Lithium and suicide in mood disorders: Updated meta-review of the scientific literature |journal=Bipolar Disorders |date=November 2017 |volume=19 |issue=7 |pages=575–586 |doi=10.1111/bdi.12543 |pmid=28895269 }}</ref> In addition to reducing suicide, lithium also decreases all-cause mortality in people with bipolar disorder.<ref name=":5" /><ref>{{cite journal |last1=Tondo |first1=Leonardo |last2=Baldessarini |first2=Ross J. |title=History of Suicide Prevention with Lithium Treatment |journal=Pharmaceuticals |date=February 14, 2025 |volume=18 |issue=2 |page=258 |doi=10.3390/ph18020258 |pmid=40006071 |pmc=11858927 |doi-access=free }}</ref>
== Epidemiology ==
[[File:Bipolar disorder world map - DALY - WHO2004.svg|thumb|Burden of bipolar disorder around the world: disability-adjusted life years per 100,000 inhabitants in 2004 {{Div col|small=yes|colwidth=7em}} {{legend|#ffff65|<180}} {{legend|#fff200|180–185}} {{legend|#ffdc00|185–190}} {{legend|#ffc600|190–195}} {{legend|#ffb000|195–200}} {{legend|#ff9a00|200–205}} {{legend|#ff8400|205–210}} {{legend|#ff6e00|210–215}} {{legend|#ff5800|215–220}} {{legend|#ff4200|220–225}} {{legend|#ff2c00|225–230}} {{legend|#cb0000|>230}} {{div col end}} ]]
Bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime prevalence of about 1 to 3% in the general population.<ref name="Boland2013">{{cite journal | vauthors = Boland EM, Alloy LB | title = Sleep disturbance and cognitive deficits in bipolar disorder: toward an integrated examination of disorder maintenance and functional impairment | journal = Clinical Psychology Review | volume = 33 | issue = 1 | pages = 33–44 | date = February 2013 | pmid = 23123569 | pmc = 3534911 | doi = 10.1016/j.cpr.2012.10.001 }}</ref><ref name="Schmitt2014">{{cite journal |vauthors=Schmitt A, Malchow B, Hasan A, Falkai P |date=February 2014 |title=The impact of environmental factors in severe psychiatric disorders |journal=Frontiers in Neuroscience |volume=8 |issue=19 |page=19 |doi=10.3389/fnins.2014.00019 |pmc=3920481 |pmid=24574956 |doi-access=free}}</ref><ref name=":3">{{cite journal |vauthors=Moreira AL, Van Meter A, Genzlinger J, Youngstrom EA |title=Review and Meta-Analysis of Epidemiologic Studies of Adult Bipolar Disorder |journal=The Journal of Clinical Psychiatry |volume=78 |issue=9 |pages=e1259–e1269 |year=2017 |pmid=29188905 |doi=10.4088/JCP.16r11165}}</ref> However, a reanalysis of data from the National Epidemiological Catchment Area survey in the United States suggested that 0.8% of the population experience a manic episode at least once (the diagnostic threshold for bipolar I) and a further 0.5% have a hypomanic episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1% of the population, adding up to a total of 6.4%, were classified as having a bipolar spectrum disorder.<ref name="Judd_and_Akiskal_2003">{{cite journal | vauthors = Judd LL, Akiskal HS | title = The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases | journal = Journal of Affective Disorders | volume = 73 | issue = 1–2 | pages = 123–131 | date = January 2003 | pmid = 12507745 | doi = 10.1016/s0165-0327(02)00332-4 }}</ref> A more recent analysis of data from a second US National Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar I, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.<ref>{{cite journal | vauthors = Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, Kessler RC | title = Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication | journal = Archives of General Psychiatry | volume = 64 | issue = 5 | pages = 543–552 | date = May 2007 | pmid = 17485606 | pmc = 1931566 | doi = 10.1001/archpsyc.64.5.543 }}</ref> Estimates vary about how many children and young adults have bipolar disorder.<ref name="Diler2019" /> These estimates range from 0.6 to 15% depending on differing settings, methods, and referral settings, raising suspicions of overdiagnosis.<ref name="Diler2019" /> One meta-analysis of bipolar disorder in young people worldwide estimated that about 1.8% of people between the ages of seven and 21 have bipolar disorder.<ref name="Diler2019" /> Similar to adults, bipolar disorder in children and adolescents is thought to occur at a similar frequency in boys and girls.<ref name="Diler2019" />
There are conceptual and methodological limitations and variations in the findings. Prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may have limited validity. In addition, diagnoses (and therefore estimates of prevalence) vary depending on whether a categorical or spectrum approach is used. This consideration has led to concerns about the potential for both underdiagnosis and overdiagnosis.<ref>{{cite journal |last1=Phelps |first1=James |title=Bipolar Disorder: Particle or Wave? DSM Categories or Spectrum Dimensions? |journal=Psychiatric Times |date=July 2006 |volume=23 |issue=8 |page=76 |id={{Gale|A147759624}} |url=https://www.psychiatrictimes.com/view/bipolar-disorder-particle-or-wave-dsm-categories-or-spectrum-dimensions }}</ref>
The incidence of bipolar disorder is similar in men and women<ref name="Farren2012">{{cite journal | vauthors = Farren CK, Hill KP, Weiss RD | title = Bipolar disorder and alcohol use disorder: a review | journal = Current Psychiatry Reports | volume = 14 | issue = 6 | pages = 659–666 | date = December 2012 | pmid = 22983943 | pmc = 3730445 | doi = 10.1007/s11920-012-0320-9 }}</ref> as well as across different cultures and ethnic groups.<ref name="A systematic review of the global d">{{cite journal |vauthors=Ferrari AJ, Baxter AJ, Whiteford HA |date=November 2011 |title=A systematic review of the global distribution and availability of prevalence data for bipolar disorder |journal=Journal of Affective Disorders |volume=134 |issue=1–3 |pages=1–13 |doi=10.1016/j.jad.2010.11.007 |pmid=21131055}}</ref> A 2000 study by the World Health Organization found that prevalence and incidence of bipolar disorder are very similar across the world. Age-standardized prevalence per 100,000 ranged from 421.0 in South Asia to 481.7 in Africa and Europe for men and from 450.3 in Africa and Europe to 491.6 in Oceania for women. However, severity may differ widely across the globe. Disability-adjusted life year rates, for example, appear to be higher in developing countries, where medical coverage may be poorer and medication less available.<ref>{{cite web|title=Global burden of bipolar disorder in the year 2000|url=https://www.who.int/healthinfo/statistics/bod_bipolar.pdf|publisher=World Health Organization| vauthors = Ayuso-Mateos JL |access-date=December 9, 2012|url-status=live|archive-url=https://web.archive.org/web/20130119132547/http://www.who.int/healthinfo/statistics/bod_bipolar.pdf |archive-date=January 19, 2013}}</ref> Within the United States, Asian Americans have significantly lower rates than their African American and European American counterparts.<ref name="kurasaki">{{cite book |editor-first1=Karen S. |editor-first2=Sumie |editor-first3=Stanley |editor-last1=Kurasaki |editor-last2=Okazaki |editor-last3=Sue |title=Asian American Mental Health |date=2002 |doi=10.1007/978-1-4615-0735-2 |isbn=978-1-4613-5216-7 }}{{page needed|date=February 2026}}</ref> In 2017, the Global Burden of Disease Study estimated there were 4.5 million new cases and a total of 45.5 million cases globally.<ref name="GBD2018">{{cite journal |vauthors=James SL, Abate D |title=Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017 |journal=The Lancet |date=November 2018 |volume=392 |issue=10159 |pages=1789–1858 |doi=10.1016/S0140-6736(18)32279-7|pmid=30496104 |pmc=6227754 |bibcode=2018Lanc..392.1789J }}</ref>
=== Comorbid conditions === People with bipolar disorder often have other co-existing psychiatric conditions such as anxiety (present in about 71% of people with bipolar disorder), substance abuse (56%), personality disorders (36%) and attention deficit hyperactivity disorder (10–20%) which can add to the burden of illness and worsen the prognosis.<ref name="Carvalho" /> Certain medical conditions are also more common in people with bipolar disorder as compared to the general population. This includes metabolic syndrome (present in 37% of people with bipolar disorder), migraine headaches (35%), obesity (21%) and type 2 diabetes (14%).<ref name="Carvalho" /> This contributes to a risk of death that is two times higher in those with bipolar disorder as compared to the general population.<ref name="Carvalho" /> Hypothyroidism is also common regardless of drug choice.<ref>{{cite journal |vauthors=Lambert CG, Mazurie AJ, Lauve NR, Hurwitz NG, Young SS, Obenchain RL, Hengartner NW, Perkins DJ, Tohen M, Kerner B |date=May 2016 |title=Hypothyroidism risk compared among nine common bipolar disorder therapies in a large US cohort |journal=Bipolar Disorders |volume=18 |issue=3 |pages=247–260 |doi=10.1111/bdi.12391 |pmc=5089566 |pmid=27226264}}</ref>
Substance use disorder is a common comorbidity in bipolar disorder; the subject has been widely reviewed.<ref>{{cite journal |vauthors=Cassidy F, Ahearn EP, Carroll BJ |date=August 2001 |title=Substance abuse in bipolar disorder |journal=Bipolar Disorders |volume=3 |issue=4 |pages=181–188 |doi=10.1034/j.1399-5618.2001.30403.x |pmid=11552957}}</ref>{{update inline|date=August 2022}}<ref>{{cite journal |vauthors=Preuss UW, Schaefer M, Born C, Grunze H |date=2021 |title=Bipolar Disorder and Comorbid Use of Illicit Substances |journal=Medicina |volume=57 |issue=11 |page=1256 |doi=10.3390/medicina57111256 |pmc=8623998 |pmid=34833474 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Messer T, Lammers G, Müller-Siecheneder F, Schmidt RF, Latifi S |date=July 2017 |title=Substance abuse in patients with bipolar disorder: A systematic review and meta-analysis |journal=Psychiatry Research |volume=253 |pages=338–350 |doi=10.1016/j.psychres.2017.02.067 |pmid=28419959}}</ref>
== Socioeconomic challenges ==
=== Victimization by criminals === According to Teplin and others (2005), people with severe mental illness experience four times more incidences of violent crime compared to the "general population".<ref>{{Cite journal |last1=Teplin |first1=Linda A. |last2=McClelland |first2=Gary M. |last3=Abram |first3=Karen M. |last4=Weiner |first4=Dana A. |date=August 2005 |title=Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey |journal=Archives of General Psychiatry |volume=62 |issue=8 |pages=911–921 |doi=10.1001/archpsyc.62.8.911 |pmc=1389236 |pmid=16061769 }}</ref> According to a systematic review and meta-analysis by Kaul and others (2024), people accessing psychiatric services are at greater risk of "sexual violence victimization" than "the general population".<ref>{{cite journal |last1=Kaul |first1=Anjuli |last2=Connell-Jones |first2=Laura |last3=Paphitis |first3=Sharli Anne |last4=Oram |first4=Sian |title=Prevalence and risk of sexual violence victimization among mental health service users: a systematic review and meta-analyses |journal=Social Psychiatry and Psychiatric Epidemiology |date=August 2024 |volume=59 |issue=8 |pages=1285–1297 |doi=10.1007/s00127-024-02656-8 |pmc=11291586 |pmid=38570379 }}</ref> For context, interpersonal violence accounted for 1180 Disability Adjusted Life Years (DALYs) per 100,000 people in the Americas in 2021 (ranking 5th compared to all conditions).<ref name=":12" />
Vice versa, a corrected meta-analysis by Verdolini and others (2020) found that rates of violent criminal behavior were not statistically significantly different between people with bipolar disorder and people with substance use disorders.<ref>{{cite journal |last1=Verdolini |first1=Norma |last2=Pacchiarotti |first2=Isabella |last3=Köhler |first3=Cristiano A. |last4=Reinares |first4=Maria |last5=Samalin |first5=Ludovic |last6=Colom |first6=Francesc |last7=Tortorella |first7=Alfonso |last8=Stubbs |first8=Brendon |last9=Carvalho |first9=André F. |last10=Vieta |first10=Eduard |last11=Murru |first11=Andrea |title=Corrigendum to 'Violent criminal behavior in the context of bipolar disorder: Systematic review and meta-analysis' [Journal of Affective Disorders (2018) 239:161–170] |journal=Journal of Affective Disorders |date=February 2020 |volume=263 |pages=735–738 |doi=10.1016/j.jad.2019.10.022 |pmid=31668994 }}</ref> Likewise, a continuing education article by the American Psychological Association<ref>{{Cite web |last=DeAngelis |first=Tori |date=July 11, 2022 |title=Mental illness and violence: Debunking myths, addressing realities |url=https://www.apa.org/monitor/2021/04/ce-mental-illness |access-date=April 19, 2026 |website=American Psychological Association}}</ref> emphasizes,
{{Blockquote|text=[...] the strong role that contextual factors such as poverty, neighborhood, and substance use play in violence perpetration by people with serious mental illness, as well as those without mental illness.}}
=== Homelessness and housing instability ===
==== Prevalence of bipolar disorder ==== Studies have shown that bipolar disorder occurs at significantly higher rates among people experiencing homelessness compared with the general population. A 2024 meta-analysis and systematic review estimates that there is a global prevalence of approximately 8% of bipolar disorder amongst homeless individuals, which is several times higher than the population averages.<ref name=":02">{{cite journal |title=Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness |journal=JAMA Psychiatry |date=2024 |volume=81 |issue=7 |doi=10.1001/jamapsychiatry.2024.0426 | vauthors = Barry R, Anderson J, Tran L, Bahji A, Dimitropoulos G, Ghosh SM, Kirkham J, Messier G, Patten SB, Rittenbach K, Seitz D |pages=691–699 |pmid=38630486 |pmc=11024772 }}</ref> Earlier reviews also found elevated rates as high as 6–9%, but estimates vary depending on diagnostic criteria and design.<ref name=":1">{{Cite journal |last1=Ayano |first1=Getinet |last2=Shumet |first2=Shegaye |last3=Tesfaw |first3=Getachew |last4=Tsegay |first4=Light |date=June 9, 2020 |title=A systematic review and meta-analysis of the prevalence of bipolar disorder among homeless people |journal=BMC Public Health |volume=20 |issue=1 |page=731 |doi=10.1186/s12889-020-08819-x |doi-access=free |pmc=7282102 |pmid=32513264}}</ref> Researchers state that methodological differences, such as inconsistent definitions of homelessness and small sample sizes, may contribute to the wide range of reported prevalence rates.{{citation needed|date=January 2026}}
==== Risk factors ==== thumb|Sign made by homeless veteran. Bipolar disorder is associated with several risk factors for homelessness, including incarceration, substance use, and socioeconomic instability. In the United States, it was reported that in veterans with bipolar disorder, 55% reported being homeless at some point in their lives, and 12% had been homeless within the last four weeks.<ref name=":2">{{Cite journal |last1=Copeland |first1=Laurel A. |last2=Miller |first2=Alexander L. |last3=Welsh |first3=Deborah E. |last4=McCarthy |first4=John F. |last5=Zeber |first5=John E. |last6=Kilbourne |first6=Amy M. |date=May 2009 |title=Clinical and Demographic Factors Associated With Homelessness and Incarceration Among VA Patients With Bipolar Disorder |journal=American Journal of Public Health |volume=99 |issue=5 |pages=871–877 |doi=10.2105/AJPH.2008.149989 |pmid=19299667 |pmc=2667856 }}</ref> Homelessness was also highly associated with prior incarceration and co-occurring substance use, which highlights the cyclical relationship between social instability and mental illness.<ref name=":2" />
Additionally, individuals with bipolar disorder who are experiencing homelessness often have an early onset of illness, more frequent manic or depressive episodes, and poor adherence to medication. This can increase the likelihood of relapse and the loss of housing.<ref name=":02" /><ref name=":2" /> Veterans and individuals who have been to correctional or psychiatric settings are especially at risk. This highlights that the lack of post-discharge support contributes to the chronic cycles of instability.{{citation needed|date=January 2026}}
Social determinants like poverty, unemployment, and stigma also increase vulnerability to both bipolar disorder and homelessness.<ref name=":1" /> Once you are homeless, factors like stress, sleep deprivation, and exposure to unsafe environments are very prevalent and can worsen mood symptoms, making lasting recovery and reintegration even more difficult.<ref name=":02" />
==== Access to care ==== People who are experiencing homelessness face significant barriers to consistent and quality mental health treatment. A study of over 10,000 patients with serious mental illness in the public health system found that homeless patients were less likely to have insurance, the ability to maintain continuous care, and more likely to rely on emergency services in comparison to housed individuals.<ref>{{cite journal |title=Prevalence and Risk Factors for Homelessness and Utilization of Mental Health Services Among 10,340 Patients with Serious Mental Illness in a Large Public Mental Health System |journal=American Journal of Psychiatry |date=2005 |volume=162 |issue=2 |pages=370–376 |doi=10.1176/appi.ajp.162.2.370 | vauthors = Folsom DP, Hawthorne W, Lindamer L, Gilmer T, Bailey A, Golshan S, Garcia P, Unützer J, Hough R, Jeste DV |pmid=15677603 }}</ref> Disruptions in care contribute to poor participation in treatment plans, higher rates of psychiatric hospitalization, and worsened long-term outcomes.<ref name=":2" /> Individuals with bipolar disorder require consistent medication management and therapeutic monitoring, but unstable living conditions make meeting these needs quite difficult. Unable to refill medications, attend appointments, or engage in therapy.<ref name=":2" />
==== Limitations ==== The research on the prevalence of bipolar disorder in the homeless population is limited by the varying definitions of homelessness and challenges in keeping up with individuals on the move. and the variations in diagnostic methods across studies.<ref name=":1" /> As a result of this, current estimates of the prevalence of bipolar disorder in the homeless population may be underestimated. Expanding integrated models of care that combine psychiatric treatment with housing and social services has been suggested as a potential approach to improving long-term stability and reducing emergency service use.<ref name=":1" />
== History == {{Main|History of bipolar disorder}}
[[File:Emil Kraepelin 1926.jpg|alt=|thumb|right|German psychiatrist Emil Kraepelin first distinguished between manic–depressive illness and "dementia praecox" (now known as schizophrenia) in the late 19th century.]] In the early 1800s, French psychiatrist Jean-Étienne Dominique Esquirol's lypemania, one of his affective monomanias, was the first elaboration on what was to become modern depression.<ref>{{cite journal | author = Borch-Jacobsen M | title = Which came first, the condition or the drug? | journal = London Review of Books | volume = 32 | issue = 19 | pages = 31–33 | date = October 2010 | url = http://www.lrb.co.uk/v32/n19/mikkel-borch-jacobsen/which-came-first-the-condition-or-the-drug | quote = at the beginning of the 19th century with Esquirol's 'affective monomanias' (notably 'lypemania', the first elaboration of what was to become our modern depression) | url-status=live | archive-url = https://web.archive.org/web/20150313201452/http://www.lrb.co.uk/v32/n19/mikkel-borch-jacobsen/which-came-first-the-condition-or-the-drug | archive-date = March 13, 2015 }}</ref> The basis of the current conceptualization of bipolar illness can be traced back to the 1850s. In 1850, Jean-Pierre Falret described "circular insanity" (''{{Lang|fr|la folie circulaire}}'', {{IPA|fr|la fɔli siʁ.ky.lɛʁ}}); the lecture was summarized in 1851 in the ''{{Lang|fr|Gazette des hôpitaux}}'' ("Hospital Gazette").<ref name="Shorter2005">{{cite book|author=Edward Shorter|title=A Historical Dictionary of Psychiatry|url=https://books.google.com/books?id=M49pEDoEpl0C&pg=PA165|year=2005|place=New York|publisher=Oxford University Press|isbn=978-0-19-517668-1|pages=165–166}}</ref> Three years later, in 1854, Jules-Gabriel-François Baillarger (1809–1890) described to the French Imperial Académie Nationale de Médecine a biphasic mental illness causing recurrent oscillations between mania and melancholia, which he termed {{Lang|fr|la folie à double forme}} ({{IPA|fr|la fɔli a dubl fɔʀm}}, "madness in double form").<ref name="Shorter2005" /><ref>{{cite journal |author=Pichot P. |title=150e anniversaire de la Folie Circulaire |trans-title=Circular insanity, 150 years on |journal = Bulletin de l'Académie Nationale de Médecine |volume=188 |issue=2 |pages=275–284 |year=2004 |pmid = 15506718 |language=fr|doi=10.1016/S0001-4079(19)33801-4 |doi-access= }}</ref> Baillarger's original paper, "{{Lang|fr|De la folie à double forme|italic=no}}", appeared in the medical journal ''Annales médico-psychologiques'' (''Medico-psychological annals'') in 1854.<ref name="Shorter2005" />
These concepts were developed by the German psychiatrist Emil Kraepelin (1856–1926), who, using Kahlbaum's concept of cyclothymia,{{sfn|Millon|1996|p=290}} categorized and studied the natural course of untreated bipolar patients. He coined the term ''manic depressive psychosis'', after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.<ref>{{cite book |last1=Kraepelin |first1=Emil |title=Manic-depressive insanity and paranoia |date=1921 |publisher=Livingstone |oclc=697991177 }}{{page needed|date=January 2026}}</ref>
The term "manic–depressive ''reaction''" appeared in the first version of the DSM in 1952, influenced by the legacy of Adolf Meyer.{{sfn|Goodwin|Jamison|2007| loc=Chapter 1}} Subtyping into "unipolar" depressive disorders and bipolar disorders has its origin in Karl Kleist's concept – since 1911 – of unipolar and bipolar affective disorders, which was used by Karl Leonhard in 1957 to differentiate between unipolar and bipolar disorder in depression.<ref name="Angst-2001">{{cite journal | vauthors = Angst J, Marneros A | title = Bipolarity from ancient to modern times: conception, birth and rebirth | journal = J Affect Disord | volume = 67 | issue = 1–3 | pages = 3–19 | date = December 2001 | pmid = 11869749 | doi = 10.1016/s0165-0327(01)00429-3 }}</ref> These subtypes have been regarded as separate conditions since publication of the DSM-III. The subtypes bipolar II and rapid cycling have been included since the DSM-IV, based on work from the 1970s by David Dunner, Elliot Gershon, Frederick Goodwin, Ronald Fieve, and Joseph Fleiss.<ref>{{cite book |editor1-first=Carlos A. |editor1-last=Zarate Jr |editor2-first=Husseini K. |editor2-last=Manji |title=Bipolar Depression: Molecular Neurobiology, Clinical Diagnosis, and Pharmacotherapy |series=Milestones in Drug Therapy |date=2016 |doi=10.1007/978-3-319-31689-5 |isbn=978-3-319-31687-1 }}{{page needed|date=February 2026}}</ref><ref>{{cite journal | doi = 10.1192/apt.bp.107.004903 | volume=16 | title=The course of bipolar disorder | year=2010 | journal=Advances in Psychiatric Treatment | pages=318–328 | author=Saunders KE| issue=5 | doi-access=free }}</ref><ref name="Ban">[http://d.plnk.co/ACNP/50th/Transcripts/David%20Dunner%20by%20Thomas%20A.%20Ban.doc David L. Dunner interviewed by Thomas A. Ban] {{webarchive|url=https://web.archive.org/web/20130521160737/http://d.plnk.co/ACNP/50th/Transcripts/David%20Dunner%20by%20Thomas%20A.%20Ban.doc |date=May 21, 2013 }} for the ANCP, Waikoloa, Hawaii, December 13, 2001</ref> {{Clear left}}
== Society and culture == {{See also|List of people with bipolar disorder|Category:Books about bipolar disorder|Category:Films about bipolar disorder}} [[File:Rosemary Clooney Allan Warren.jpg|alt=|thumb|Singer Rosemary Clooney's public revelation of bipolar disorder made her an early celebrity spokesperson for mental illness.<ref>{{cite news |last1=Fenichel |first1=Marilyn |title=More Than a Girl Singer |url=https://www.cancertodaymag.org/fall2014/singer-rosemary-clooney-lung-cancer-treatment-advancements/ |work=Cancer Today |date=29 September 2014 }}</ref>]]
===Cost=== The United States spent approximately $202.1 billion on people diagnosed with bipolar I disorder (excluding other subtypes of bipolar disorder and undiagnosed people) in 2015.<ref name="Cloutier2018">{{cite journal | vauthors = Cloutier M, Greene M, Guerin A, Touya M, Wu E | title = The economic burden of bipolar I disorder in the United States in 2015 | journal = Journal of Affective Disorders | volume = 226 | pages = 45–51 | date = January 2018 | pmid = 28961441 | doi = 10.1016/j.jad.2017.09.011 | doi-access = free | type = Review }}</ref> One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007.<ref name="Abdul2014">{{cite journal | vauthors = Abdul Pari AA, Simon J, Wolstenholme J, Geddes JR, Goodwin GM | title = Economic evaluations in bipolar disorder: a systematic review and critical appraisal | journal = Bipolar Disorders | volume = 16 | issue = 6 | pages = 557–582 | date = September 2014 | pmid = 24917477 | doi = 10.1111/bdi.12213 | type = Review }}</ref><ref name="McCrone2008">{{cite book |last1=McCrone |first1=Paul |last2=Dhanasiri |first2=Sujith |last3=Patel |first3=Anita |last4=Knapp |first4=Martin |last5=Lawton-Smith |first5=Simon |title=Paying the price: the cost of mental health care in England to 2026 |date=2008 |publisher=The King's Fund |isbn=978-1-85717-571-4 |url=https://www.kingsfund.org.uk/insight-and-analysis/reports/paying-price-mental-health-cost }}{{pn|date=May 2026}}</ref> In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide.<ref name="Ferrari2016">{{cite journal |vauthors=Ferrari AJ, Stockings E, Khoo JP, Erskine HE, Degenhardt L, Vos T, Whiteford HA |date=August 2016 |title=The prevalence and burden of bipolar disorder: findings from the Global Burden of Disease Study 2013 |url=http://handle.unsw.edu.au/1959.4/unsworks_41662 |journal=Bipolar Disorders |type=Review |volume=18 |issue=5 |pages=440–450 |doi=10.1111/bdi.12423 |hdl=11343/291577 |pmid=27566286 |hdl-access=free}}</ref> People with bipolar disorder are generally more disabled, have a lower level of functioning, longer duration of illness, and increased rates of work absenteeism and decreased productivity when compared to people experiencing other mental health disorders.<ref name="Kleine2014">{{cite journal | vauthors = Kleine-Budde K, Touil E, Moock J, Bramesfeld A, Kawohl W, Rössler W | title = Cost of illness for bipolar disorder: a systematic review of the economic burden | journal = Bipolar Disorders | volume = 16 | issue = 4 | pages = 337–353 | date = June 2014 | pmid = 24372893 | doi = 10.1111/bdi.12165 | type = Review }}</ref> The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs.<ref name="Miller2014">{{cite journal | vauthors = Miller S, Dell'Osso B, Ketter TA | title = The prevalence and burden of bipolar depression | journal = Journal of Affective Disorders | volume = 169 | issue = Supplement 1 | pages = S3-11 | date = December 2014 | pmid = 25533912 | doi = 10.1016/S0165-0327(14)70003-5 | type = Review | doi-access = free | hdl = 2434/265329 | hdl-access = free }}</ref>
===Advocacy=== There are widespread issues with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder.<ref name="Elgie2007">{{cite journal | author = Elgie R. Morselli PL | title = Social functioning in bipolar patients: the perception and perspective of patients, relatives and advocacy organizations – a review | journal = Bipolar Disorders | volume = 9 | issue = 1–2 | pages = 144–157 | date = Feb–Mar 2007 | pmid = 17391357 | doi = 10.1111/j.1399-5618.2007.00339.x | doi-access = free }}</ref> In 2000, actress Carrie Fisher went public with her bipolar disorder diagnosis.<ref>{{cite web | vauthors = Stephens S |date=January 1, 2015 |title=Our Leading Lady, Carrie Fisher |url=https://www.bphope.com/our-leading-lady-carrie-fisher/ |access-date=September 27, 2023 |website=bpHope.com}}</ref><ref>{{cite web | vauthors = Howard J |date=December 27, 2016 |title=Carrie Fisher was a champion for mental health, too |url=https://www.cnn.com/2016/12/27/health/mental-health-carrie-fisher/index.html |access-date=September 27, 2023 |publisher=CNN}}</ref> She became one of the most well-recognized advocates for people with bipolar disorder in the public eye and fiercely advocated to eliminate the stigma surrounding mental illnesses, including bipolar disorder. Stephen Fried, who has written extensively on the topic, noted that Fisher helped to draw attention to the disorder's chronicity, relapsing nature, and that bipolar disorder relapses do not indicate a lack of discipline or moral shortcomings.<ref name="WilerUSAToday">{{cite news |last1=Weller |first1=Sheila |title=Carrie Fisher was a mental health hero. Her advocacy was as important as her acting. |url=https://www.usatoday.com/story/opinion/2019/07/26/carrie-fisher-champion-mental-health-awareness-column/1820161001/ |work=USA TODAY |date=July 26, 2019 }}</ref> Since being diagnosed at age 37, actor Stephen Fry has pushed to raise awareness of the condition, with his 2006 documentary ''Stephen Fry: The Secret Life of the Manic Depressive''.<ref>{{cite web |url=https://www.bbc.co.uk/health/tv_and_radio/secretlife_index.shtml |title=The Secret Life of the Manic Depressive |publisher=BBC |year=2006 |access-date=February 20, 2007 |archive-url=https://web.archive.org/web/20061118045848/http://www.bbc.co.uk/health/tv_and_radio/secretlife_index.shtml |archive-date=November 18, 2006 }}</ref><ref>{{cite news | vauthors = Barr S |title=Stephen Fry discusses mental health and battle with bipolar disorder: 'I'm not going to kid myself that it's cured' |url=https://www.independent.co.uk/life-style/health-and-families/stephen-fry-mental-health-bipolar-disorder-fearne-cotton-podcast-happy-place-a8274051.html |access-date=March 10, 2020 |work=The Independent |date=March 26, 2018}}</ref> In an effort to ease the social stigma associated with bipolar disorder, the orchestra conductor Ronald Braunstein cofounded the ME/2 Orchestra with his wife Caroline Whiddon in 2011. Braunstein was diagnosed with bipolar disorder in 1985 and his concerts with the ME/2 Orchestra were conceived in order to create a welcoming performance environment for his musical colleagues, while also raising public awareness about mental illness.<ref>{{cite news | vauthors = Gram D | date=December 27, 2013 | title=For this orchestra, playing music is therapeutic | work=The Boston Globe | url=https://www.bostonglobe.com/arts/theater-art/2013/12/27/mentally-ill-and-their-supporters-fill-vermont-orchestra/WIeh9mIp9GzPampyIXwtLM/story.html | access-date=March 7, 2019 | archive-url=https://web.archive.org/web/20190414112300/https://www.bostonglobe.com/arts/theater-art/2013/12/27/mentally-ill-and-their-supporters-fill-vermont-orchestra/WIeh9mIp9GzPampyIXwtLM/story.html | archive-date=April 14, 2019 }}</ref><ref>{{cite news | vauthors = Strasser F, Botti D | date= January 7, 2013|title=Conductor with bipolar disorder on music and mental illness | work= BBC News|url=https://www.bbc.com/news/magazine-20732070}}</ref>
==== Advocacy organizations ==== A variety of advocacy organizations exist to support people living with bipolar disorder, the people who care for them, and those researching the illness.
* The International Society for Bipolar Disorders (ISBD) is a research and educational organization focused on bipolar disorder. The ISBD offers resources for mental health professionals, patients and their families. It publishes the journal Bipolar Disorders.<ref>{{Cite web|title=ISBD - Who We Are|url=http://www.isbd.org/whoweare|website=ISBD|access-date=February 1, 2026|language=en}}</ref> * The International Bipolar Foundation (IBPF) provides education and resources for those living with bipolar disorder.<ref>{{Cite web|url=https://ibpf.org/about-international-bipolar-foundation/|title=About International Bipolar Foundation|access-date=February 1, 2026|website=IBPF |date=November 16, 2013 }}</ref> * CREST.BD is a Canadian network focused on bipolar disorder. The CREST.BD network includes researchers, mental health professionals and people with bipolar disorder.<ref>{{Cite web|title=About|url=https://www.crestbd.ca/about/|website=CREST.BD|access-date=February 1, 2026|language=en}}</ref> * Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes treatment guidelines for bipolar disorder together with the International Society for Bipolar Disorders (ISBD).<ref>{{Cite web|title=Bipolar Disorder - Resources {{!}} CANMAT|url=https://www.canmat.org/2025/04/29/bipolar-disorder/|website=www.canmat.org|access-date=February 1, 2026}}</ref><ref>{{cite journal |last1=Keramatian |first1=Kamyar |last2=Chithra |first2=Nellai K. |last3=Yatham |first3=Lakshmi N. |title=The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence |journal=Focus |date=October 2023 |volume=21 |issue=4 |pages=344–353 |doi=10.1176/appi.focus.20230009 |pmid=38695002 |pmc=11058959 }}</ref>
==== World Bipolar Day ==== World Bipolar Day is on March 30, the birthday of Vincent Van Gogh. The goal of the day is to eliminate stigma about bipolar disorder.<ref>{{Cite web |title=About WBD |url=https://www.worldbipolarday.org/about_wbd.html |access-date=February 1, 2026 |website=World Bipolar Day |language=en}}</ref> It is sponsored by the International Society for Bipolar Disorders, the International Bipolar Foundation, and the Asian Network of Bipolar Disorder (ANBD).<ref>{{Cite web|title=World Bipolar Day|url=http://www.isbd.org/world-bipolar-day|website=ISBD|access-date=February 1, 2026|language=en}}</ref>
=== Support groups === The Depression and Bipolar Support Alliance (DBSA), formerly the National Depressive and Manic Depressive Association, is patient-run support and advocacy organization with approximately 200 chapters and 700 support groups mostly in the United States.<ref>{{Cite web|title=Depression and Bipolar Support Alliance|url=https://screening.mhanational.org/content/depression-and-bipolar-support-alliance/|website=Mental Health America|access-date=February 1, 2026|language=en-US}}</ref><ref>{{Cite web|title=Support - National Institute of Mental Health (NIMH)|url=https://www.nimh.nih.gov/research/research-conducted-at-nimh/research-areas/clinics-and-labs/hgb/gbmad/support|website=www.nimh.nih.gov|access-date=February 1, 2026|language=en}}</ref> Attendance at a DBSA support group has been associated with increased functioning and well-being among participants.<ref>{{cite journal |last1=Kelly |first1=John F. |last2=Hoffman |first2=Lauren |last3=Vilsaint |first3=Corrie |last4=Weiss |first4=Roger |last5=Nierenberg |first5=Andrew |last6=Hoeppner |first6=Bettina |title=Peer support for mood disorder: Characteristics and benefits from attending the Depression and Bipolar Support Alliance mutual-help organization |journal=Journal of Affective Disorders |date=August 2019 |volume=255 |pages=127–135 |doi=10.1016/j.jad.2019.05.039 |pmid=31150942 |pmc=6591033 }}</ref>
Bipolar UK, formerly the Manic Depression Fellowship, is a patient-led mental health support and advocacy organization in the United Kingdom. It runs 85 support groups for people living with bipolar disorder in the UK.<ref>{{Cite web|title=Our story|url=https://www.bipolaruk.org/about-us/our-story/|website=www.bipolaruk.org|access-date=February 1, 2026|language=en-gb}}</ref>
===Notable cases=== Numerous authors have written about bipolar disorder and many successful people have openly discussed their experience with it. Kay Redfield Jamison, a clinical psychologist and professor of psychiatry at the Johns Hopkins University School of Medicine, profiled her own bipolar disorder in her memoir ''An Unquiet Mind'' (1995).{{sfn|Jamison|1995}} It is likely that Grigory Potemkin, Russian statesman and alleged husband of Catherine the Great, suffered from some kind of bipolar disorder.<ref>{{cite book|url=https://books.google.com/books?id=9crS6557gVgC&q=manic&pg=PA169|title = Potemkin: Catherine the Great's Imperial Partner|isbn = 978-1-4000-7717-5| vauthors = Montefiore SS |year = 2005| publisher=Vintage Books }}</ref> Several celebrities have also publicly shared that they have bipolar disorder; in addition to Carrie Fisher and Stephen Fry these include Catherine Zeta-Jones, Mariah Carey, Kanye West,<ref>{{cite news |last1=Berman |first1=Michele R. |last2=Boguski |first2=Mark S. |title=Understanding Kanye West's Bipolar Disorder |url=https://www.medpagetoday.com/popmedicine/celebritydiagnosis/87581 |work=MedPage Today |date=July 15, 2020 |url-status=live |archive-url=https://web.archive.org/web/20210607232802/https://www.medpagetoday.com/popmedicine/celebritydiagnosis/87581 |archive-date=June 7, 2021 }}</ref> Jane Pauley, Demi Lovato,<ref name="WilerUSAToday" /> Selena Gomez,<ref name="Naftulin 2020">{{cite web | vauthors = Naftulin J | title=Selena Gomez opened up about the challenges of being in lockdown after her bipolar diagnosis | website=Insider | date=August 7, 2020 | url=https://www.insider.com/selena-gomez-bipolar-disorder-diagnosis-pandemic-mental-health-2020-8 | access-date=December 6, 2020}}</ref> and Russell Brand.<ref>{{cite magazine |url=https://www.harpersbazaar.com/uk/beauty/mind-body/a33519731/bipolar-disorder-why-we-need-to-keep-talking/ |title=Bipolar disorder: why we need to keep talking about it after the headlines fade | vauthors = Newall S |date=August 5, 2020 |magazine=Harper's Bazaar |access-date=January 14, 2022}}</ref>
John Adams, president of the United States 1787-1801, probably suffered from bipolar II, although the condition had not been named at the time. Adams exhibited periods of intense activity, temper, and "mania" alternating with times of deep depression and withdrawal, such as a documented five-day period of severe, low-energy withdrawal while in the Netherlands. Benjamin Franklin noted that Adams “is always an honest man, often a wise one, but sometimes and in some things, absolutely out of his senses.”<ref>Curtis Hier, "The Adams Family: Triumphs and Groans" (International Bipolar Foundation, [https://ibpf.org/the-adams-family-triumphs-and-groans/ online])</ref><ref>Allan B. Schwartz, "Medical Mystery: What made John Adams lose his temper?" ''The Philadelphia Inquirer'' October 25, 2019, [https://www.inquirer.com/health/medical-mystery-president-john-adams-20191011.html online] </ref><ref>John E. Ferling, ''John Adams: A Life'' (University of Tennessee Press, 1992), pp.159, 236-237, 393-394.</ref>
===Media portrayals=== Several dramatic works have portrayed characters with traits suggestive of the diagnosis which have been the subject of discussion by psychiatrists and film experts alike.{{citation needed|date=January 2026}}
In ''Mr. Jones'' (1993), the titular character (Richard Gere) swings from a manic episode into a depressive phase and back again, spending time in a psychiatric hospital and displaying many of the features of the syndrome.{{sfn|Robinson|2003|pp=78–81}} In ''The Mosquito Coast'' (1986), Allie Fox (Harrison Ford) displays some features including recklessness, grandiosity, increased goal-directed activity and mood lability, as well as some paranoia.{{sfn|Robinson|2003|pp=84–85}} Psychiatrists have suggested that Willy Loman, the main character in Arthur Miller's classic play ''Death of a Salesman'', has bipolar disorder.<ref>{{cite news| vauthors = McKinley J |title=Get That Man Some Prozac; If the Dramatic Tension Is All in His Head|url=https://www.nytimes.com/1999/02/28/weekinreview/ideas-trends-get-that-man-some-prozac-if-the-dramatic-tension-is-all-in-his-head.html|access-date=March 3, 2012|newspaper=The New York Times|date=February 28, 1999|url-status=live |archive-url= https://web.archive.org/web/20120101024850/http://www.nytimes.com/1999/02/28/weekinreview/ideas-trends-get-that-man-some-prozac-if-the-dramatic-tension-is-all-in-his-head.html |archive-date=January 1, 2012}}</ref>
The 2009 drama ''90210'' featured a character, Silver, who was diagnosed with bipolar disorder.<ref>{{Cite book |last1=McMahon-Coleman |first1=Kimberley |url=https://books.google.com/books?id=wDnlDwAAQBAJ&dq=90210+%22silver%22+%22bipolar%22&pg=PA95 |title=Mental Health Disorders on Television: Representation Versus Reality |last2=Weaver |first2=Roslyn |date=May 14, 2020 |publisher=McFarland |isbn=978-1-4766-4020-4 |language=en |pages=95–101}}</ref> Characters Jean Slater and Stacey Slater from the BBC soap ''EastEnders'' have been diagnosed with the disorder. Stacey's storyline was developed as part of the BBC's Headroom campaign.<ref>{{cite web|url=https://www.bbc.co.uk/pressoffice/pressreleases/stories/2009/05_may/14/stacey.shtml|title=EastEnders' Stacey faces bipolar disorder|publisher=BBC Press Office|date=May 14, 2009|access-date=May 28, 2009|url-status=live|archive-url=https://web.archive.org/web/20090518033958/http://www.bbc.co.uk/pressoffice/pressreleases/stories/2009/05_may/14/stacey.shtml|archive-date=May 18, 2009}}</ref> The Channel 4 soap ''Brookside'' had earlier featured a story about bipolar disorder when the character Jimmy Corkhill was diagnosed with the condition.<ref name="Echo14May2003">{{cite news |title=The Brookie boys who shone at soap awards show |url=https://www.liverpoolecho.co.uk/news/liverpool-news/brookie-boys-who-shone-soap-3554398 |work=Liverpool Echo |date=May 13, 2003 }}</ref> 2011 Showtime's political thriller drama ''Homeland'' protagonist Carrie Mathison has bipolar disorder, which she has kept secret since her school days.<ref name="pilot">{{cite episode|title=Pilot|episode-link=Homeland (season 1)#ep1|series=Homeland|series-link=Homeland|network=Showtime|air-date=October 2, 2011|season=1|number=1}}</ref> The 2014 ABC medical drama, ''Black Box'', featured a world-renowned neuroscientist with bipolar disorder.<ref>{{cite web|url=http://abc.go.com/shows/black-box/cast/catherine-black|title=Catherine Black by Kelly Reilly |publisher=American Broadcasting Company|archive-url=https://web.archive.org/web/20140523174651/http://abc.go.com/shows/black-box/cast/catherine-black |archive-date=May 23, 2014|access-date=May 22, 2014}}</ref> In the TV series ''Dave'', the eponymous main character, played by Lil Dicky as a fictionalized version of himself, is an aspiring rapper. Lil Dicky's real-life hype man GaTa also plays himself. In one episode, after being off his medication and having an episode, GaTa tearfully confesses to having bipolar disorder. GaTa has bipolar disorder in real life but, like his character in the show, he is able to manage it with medication.<ref>{{cite web |title=How a white rapper's sidekick became a breakout sitcom star — and TV's unlikeliest role model |url=https://www.latimes.com/entertainment-arts/music/story/2020-04-15/gata-dave-lil-dicky |website=Los Angeles Times|date=April 15, 2020 }}</ref>
Since 2024, Nicola Coughlan, has co-starred alongside Lydia West, in the British Channel 4 dark television comedy-drama ''Big Mood. ''Coughlan portrays the leading role of Maggie who was diagnosed with bipolar disorder. In a series about two best friends navigating friendship amidst a mental health crisis.<ref>{{Cite web |last=Sarrubba |first=Stefania |date=October 16, 2023 |title=Bridgerton's Nicola Coughlan stars in first-look at new TV drama |url=https://www.digitalspy.com/tv/a45545891/bridgerton-nicola-coughlan-big-mood-first-look/ |access-date=May 12, 2025 |website=Digital Spy |language=en-GB |archive-date=November 11, 2023 |archive-url=https://web.archive.org/web/20231111140632/https://www.digitalspy.com/tv/a45545891/bridgerton-nicola-coughlan-big-mood-first-look/ |url-status=live }}</ref>
===Creativity=== {{Main|Creativity and mental illness#Bipolar disorder}}
A link between mental illness and professional success or creativity has been suggested, including in accounts by Socrates, Seneca the Younger, and Cesare Lombroso. Despite prominence in popular culture, the link between creativity and bipolar has not been rigorously studied. This area of study also is likely affected by confirmation bias. Some evidence suggests that some heritable component of bipolar disorder overlaps with heritable components of creativity. Probands of people with bipolar disorder are more likely to be professionally successful, as well as to demonstrate temperamental traits similar to bipolar disorder.<ref>{{cite journal |title=Bipolar affective disorder and high achievement: A familial association |journal=American Journal of Psychiatry |date=1989 |volume=146 |issue=8 |pages=983–988 |doi=10.1176/ajp.146.8.983 |pmid=2750997 | vauthors = Coryell W, Endicott J, Keller M, Andreasen N, Grove W, Hirschfeld RM, Scheftner W }}</ref><ref>{{Cite web |title=cyclothymia |url=https://www.theanxietycenter.com/specialities/cyclothymia |access-date=October 26, 2025 |website=The Anxiety Center |language=en}}</ref> Furthermore, while studies of the frequency of bipolar disorder in creative population samples have been conflicting, full-blown bipolar disorder in creative samples is rare.<ref>{{cite book |title=Bipolar Disorder |chapter=The Genius-Insanity Debate: Focus on Bipolarity, Temperament, Creativity and Leadership |date=2010 |pages=83–89 |doi=10.1002/9780470661277.ch9 |isbn=978-0-470-72198-8 | vauthors = Akiskal HS, Akiskal KK }}</ref>
== Special populations ==
=== Children === {{Main|Bipolar disorder in children}}
[[File:Lithium-carbonate-xtal-1979-Mercury-3D-sf.png|thumb|Lithium is the only medication approved by the FDA for treating mania in children.]] In the 1920s, Kraepelin noted that manic episodes are rare before puberty.<ref name="pmid17195735" /> In general, bipolar disorder in children was not recognized in the first half of the twentieth century. This issue diminished with an increased following of the DSM criteria in the last part of the twentieth century.<ref name="pmid17195735" /><ref>{{cite journal |vauthors=Anthony J, Scott P |year=1960 |title=Manic–depressive Psychosis in Childhood |journal=Journal of Child Psychology and Psychiatry |volume=1 |pages=53–72 |doi=10.1111/j.1469-7610.1960.tb01979.x}}</ref> The diagnosis of childhood bipolar disorder, while formerly controversial,<ref name="Lei2008" /> has gained greater acceptance among childhood and adolescent psychiatrists.<ref name="Diler2019" /> American children and adolescents diagnosed with bipolar disorder in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while in outpatient clinics it doubled reaching 6%.<ref name="Lei2008" /> Studies using DSM criteria show that up to 1% of youth may have bipolar disorder.<ref name="pmid17195735" /> The DSM-5 has established a diagnosis—disruptive mood dysregulation disorder—that covers children with long-term, persistent irritability that had at times been misdiagnosed as having bipolar disorder,<ref>{{cite journal |vauthors=Roy AK, Lopes V, Klein RG |date=September 2014 |title=Disruptive mood dysregulation disorder: a new diagnostic approach to chronic irritability in youth |journal=The American Journal of Psychiatry |volume=171 |issue=9 |pages=918–924 |doi=10.1176/appi.ajp.2014.13101301 |pmc=4390118 |pmid=25178749}}</ref> distinct from irritability in bipolar disorder that is restricted to discrete mood episodes.<ref name="Diler2019" />
=== Adults === Bipolar, on average, starts during adulthood. Bipolar 1, on average, starts at the age of 18 years old, and Bipolar 2 starts at age 22 years old on average. However, most delay seeking treatment for an average of 8 years after symptoms start. Bipolar is often misdiagnosed with other psychiatric disorders. There is no definitive association between race, ethnicity, or socioeconomic status (SES).<ref>{{cite journal |vauthors=Hilty DM, Leamon MH, Lim RF, Kelly RH, Hales RE |date=September 2006 |title=A review of bipolar disorder in adults |journal=Psychiatry |volume=3 |issue=9 |pages=43–55 |pmc=2963467 |pmid=20975827}}</ref> Adults with Bipolar report having a lower quality of life, even outside of a manic or depressive episode. Bipolar can put strain on marriage and other relationships, having a job, and everyday functioning. Bipolar is associated with higher rates of unemployment. Most have trouble keeping a job, which can lead to trouble with accessing healthcare, resulting in a further decline in their mental health due to not receiving treatment such as medicine and therapy.<ref>{{cite journal |vauthors=Sylvia LG, Montana RE, Deckersbach T, Thase ME, Tohen M, Reilly-Harrington N, McInnis MG, Kocsis JH, Bowden C, Calabrese J, Gao K, Ketter T, Shelton RC, McElroy SL, Friedman ES, Rabideau DJ, Nierenberg AA |date=December 2017 |title=Poor quality of life and functioning in bipolar disorder |journal=International Journal of Bipolar Disorders |volume=5 |issue=1 |doi=10.1186/s40345-017-0078-4 |pmc=5366290 |pmid=28188565 |doi-access=free |article-number=10}}</ref>
=== Elderly === Bipolar disorder is uncommon in older patients, with a measured lifetime prevalence of 1% in over 60s and a 12-month prevalence of 0.1{{ndash}}0.5% in people over 65. Despite this, it is overrepresented in psychiatric admissions, making up 4{{ndash}}8% of inpatient admission to aged care psychiatry units, and the incidence of mood disorders is increasing overall with the aging population. Depressive episodes more commonly present with sleep disturbance, fatigue, hopelessness about the future, slowed thinking, and poor concentration and memory; the last three symptoms are seen in what is known as pseudodementia. Clinical features also differ between those with late-onset bipolar disorder and those who developed it early in life; the former group present with milder manic episodes, more prominent cognitive changes and have a background of worse psychosocial functioning, while the latter present more commonly with mixed affective episodes,<ref name="Forlenza16">{{cite journal |vauthors=Forlenza O, Valiengo L, Stella F |year=2016 |title=Mood disorders in the elderly: Prevalence, functional impact, and management challenges |journal=Neuropsychiatric Disease and Treatment |volume=12 |pages=2105–2114 |doi=10.2147/NDT.S94643 |pmc=5003566 |pmid=27601905 |doi-access=free}}</ref><!-- cites all previous in para --> and have a stronger family history of illness.<ref name="Vasudev2010">{{cite journal |vauthors=Vasudev A, Thomas A |date=July 2010 |title='Bipolar disorder' in the elderly: what's in a name? |journal=Maturitas |volume=66 |issue=3 |pages=231–235 |doi=10.1016/j.maturitas.2010.02.013 |pmid=20307944}}</ref> Older people with bipolar disorder experience cognitive changes, particularly in executive functions such as abstract thinking and switching cognitive sets, as well as concentrating for long periods and decision-making.<ref name="Forlenza16" />
== Further reading ==
* Meyer JM, Stahl SM (2023). The Lithium Handbook. New York, NY: Cambridge University Press. p. 25. ISBN 978-1-009-22505-2.
==See also== {{Portal|Psychiatry|Psychology|Medicine}} * List of people with bipolar disorder * Outline of bipolar disorder * Depression and Bipolar Support Alliance
==Notes== {{notelist}}
==References== {{Reflist}}
==Cited texts== {{refbegin}} * {{cite book | vauthors = Brown MR, Basso MR |year=2004 |title=Focus on Bipolar Disorder Research |publisher=Nova Science Publishers |isbn=978-1-59454-059-2 }} * {{cite book | vauthors = Goodwin FK, Jamison KR |year=2007 |title=Manic–depressive illness: bipolar disorders and recurrent depression |publisher=Oxford University Press |isbn=978-0-19-513579-4 |edition=2nd.|url=https://books.google.com/books?id=rnr_OxfcqDcC |oclc=70929267 |access-date=April 2, 2016}} * {{cite book | vauthors = Jamison KR |year=1995 |title=An Unquiet Mind: A Memoir of Moods and Madness |location=New York |publisher=Knopf |isbn=978-0-330-34651-1 }} * {{cite book | vauthors = Millon T |year=1996 |title=Disorders of Personality: DSM-IV-TM and Beyond |location=New York |publisher=John Wiley and Sons |isbn=978-0-471-01186-6 }} * {{cite book | vauthors = Robinson DJ |year= 2003 |title=Reel Psychiatry: Movie Portrayals of Psychiatric Conditions |location=Port Huron, Michigan |publisher=Rapid Psychler Press |isbn=978-1-894328-07-4 }} {{refend}}
== Further reading == {{Library resources box}} {{refbegin}} * {{cite journal |vauthors=Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, Kowatch RA, Miklowitz DJ, Nery FG, Perez-Algorta G, Van Meter A, Zeni CP, Correll CU, Kim HW, Wozniak J, Chang KD, Hillegers M, Youngstrom EA |title=The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research |journal=Bipolar Disorders |volume=19 |issue=7 |pages=524–543 |date=November 2017 |pmid=28944987 |pmc=5716873 |doi=10.1111/bdi.12556}} {{refend}}
{{Sister project links|d=Q131755|species=no|v=no|voy=no|m=no|mw=no|wikt=bipolar disorder|q=no|s=no|b=Psychiatric Disorders/Mood Disorders/Bipolar Disorder|n=Category:Bipolar disorder}} {{Medical condition classification and resources | DiseasesDB = 7812 | ICD11 = {{ICD11|6A60}}, {{ICD11|6A61}} | ICD10 = {{ICD10|F31}} | ICD9 = {{ICD9|296.0}}, {{ICD9|296.1}}, {{ICD9|296.4}}, {{ICD9|296.5}}, {{ICD9|296.6}}, {{ICD9|296.7}}, {{ICD9|296.8}} | ICDO = | OMIM = 125480 | OMIM_mult = {{OMIM|309200||none}} | MedlinePlus = 000926 | eMedicineSubj = med | eMedicineTopic = 229 | MeshID = D001714 }} {{Mental and behavioral disorders|selected = mood}} {{Mood disorders}} {{Digital media use and mental health}} {{authority control}}
Category:Bipolar disorder Category:Depression (mood) Category:Mood disorders Category:Wikipedia neurology articles ready to translate Category:Wikipedia medicine articles ready to translate