Bipolar disorder

Bipolar symptoms usually begin in adolescence or early adulthood. 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. 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. 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. Psychotic symptoms are more common in bipolar type I than in bipolar type II, though people with bipolar type II can also experience psychosis. In some people with bipolar disorder, depressive symptoms predominate, and the episodes of mania are always the more subdued hypomania type. Manic episodes 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, To fit the definition of a manic episode, these behaviors must impair the individual's ability to socialize or work. In severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood. This occasionally results in hospitalization in an inpatient psychiatric hospital, 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. Authors of a chapter for a "clinical textbook" posit that mania is a medical emergency. Two other authors (Kane and Director) in the Journal of Medical Ethics have debated the medical decision-making capacity of people with mania. In a study of fifty inpatients with mania, 38% were found to have capacity to make their own treatment choices. The onset of a manic or depressive episode is often foreshadowed by sleep disturbance. Manic individuals often have a history of substance use disorder developed over years as a form of "self-medication". Hypomanic episodes Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania, while others are irritable or demonstrate poor judgment. 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. If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic unless the mood changes are uncontrollable or volatile. 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. Most commonly, symptoms continue for time periods from a few weeks to a few months. Depressive episodes 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. For most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes. 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. Mixed affective episodes 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. Psychosis Most people with bipolar disorder experience psychosis during their lifetime, with one half to two-thirds of people experiencing it. == Causes ==

The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear. Genetic influences are believed to account for 73–93% of the risk of developing the disorder indicating a strong hereditary component. 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. A combination of bipolar I, II, and cyclothymia similarly produced rates of 42% and 11% (identical and fraternal twins, respectively). 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. 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. linkage studies have been inconsistent. Findings point strongly to heterogeneity, with different genes implicated in different families. 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. 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. On the other hand, two polymorphisms in TPH2 were identified as being associated with bipolar disorder. 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, cardiac hypertrophy signaling, Wnt signaling, Notch signaling, 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. Bipolar disorder is associated with reduced expression of specific DNA repair enzymes and increased levels of oxidative DNA damages. 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 analysed 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. Environmental Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions. Recent life events and interpersonal relationships likely contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression. Subtypes of abuse, such as sexual and emotional abuse, also contribute to violent behaviors seen in patients with bipolar disorder. 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. Acutely, mania can be induced by sleep deprivation in around 30% of people with bipolar disorder. 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. ==Proposed mechanisms==

The precise mechanisms that cause bipolar disorder are not well understood. Bipolar disorder is thought to be associated with abnormalities in the structure and function of certain brain areas responsible for cognitive tasks and the processing of emotions. Functional MRI findings suggest that the ventricular prefrontal cortex regulates the limbic system, especially the amygdala. Consistent with this, pharmacological treatment of mania returns ventricular prefrontal cortex activity to the levels in non-manic people, suggesting that ventricular prefrontal cortex activity is an indicator of mood state. However, while pharmacological treatment of mania reduces amygdala hyperactivity, it remains more active than the amygdala of those without bipolar disorder, suggesting amygdala activity may be a marker of the disorder rather than the current mood state. Manic and depressive episodes tend to be characterized by dysfunction in different regions of the ventricular prefrontal cortex. Manic episodes appear to be associated with decreased activation of the right ventricular prefrontal cortex whereas depressive episodes are associated with decreased activation of the left ventricular prefrontal cortex. People with bipolar disorder who are in a euthymic mood state show decreased activity in the lingual gyrus compared to people without bipolar disorder. People with bipolar have increased activation of left hemisphere ventral limbic areaswhich mediate emotional experiences and generation of emotional responsesand decreased activation of right hemisphere cortical structures related to cognitionstructures associated with the regulation of emotions. However, further research is needed to consolidate neuroimaging findings, which are often heterogeneous and not consistently reported according to a common standard. Neuroscientists have proposed additional models to try to explain the cause of bipolar disorder. One proposed model for bipolar disorder suggests that hypersensitivity of reward circuits consisting of frontostriatal circuits causes mania, and decreased sensitivity of these circuits causes depression. 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. Dopamine, a neurotransmitter responsible for mood cycling, has increased transmission during the manic phase. The dopamine hypothesis states that the increase in dopamine results in secondary homeostatic downregulation of key system elements and receptors such as lower sensitivity of dopaminergic receptors. This results in decreased dopamine transmission characteristic of the depressive phase. Glutamate is significantly increased within the left dorsolateral prefrontal cortex during the manic phase of bipolar disorder, and returns to normal levels once the phase is over. Medications used to treat bipolar may exert their effect by modulating intracellular signaling, such as through depleting myo-inositol levels, inhibition of cAMP signaling, and through altering subunits of the dopamine-associated G-protein. Consistent with this, elevated levels of Gαi, Gαs, and Gαq/11 have been reported in brain and blood samples, along with increased protein kinase A (PKA) expression and sensitivity; typically, PKA activates as part of the intracellular signalling cascade downstream from the detachment of Gαs subunit from the G protein complex. Decreased levels of 5-hydroxyindoleacetic acid, a byproduct of serotonin, are present in the cerebrospinal fluid of persons with bipolar disorder during both the depressed and manic phases. Increased dopaminergic activity has been hypothesized in manic states due to the ability of dopamine agonists to stimulate mania in people with bipolar disorder. Decreased sensitivity of regulatory α2 adrenergic receptors as well as increased cell counts in the locus coeruleus indicated increased noradrenergic activity in manic people. Low plasma GABA levels on both sides of the mood spectrum have been found. One review found no difference in monoamine levels, but found abnormal norepinephrine turnover in people with bipolar disorder. Tyrosine depletion was found to reduce the effects of methamphetamine in people with bipolar disorder as well as symptoms of mania, implicating dopamine in mania. VMAT2 binding was found to be increased in one study of people with bipolar mania. == Diagnosis ==

Bipolar disorder is commonly diagnosed during adolescence or early adulthood, but onset can occur throughout life. 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. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. 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. 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. Several rating scales for the screening and evaluation of bipolar disorder exist, The use of evaluation scales cannot substitute for a full clinical interview, but they serve to systematize the recollection of symptoms. Differential diagnosis Mental disorders that can mimic bipolar disorder include schizophrenia, major depressive disorder, 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. Although there are no biological tests that are diagnostic of bipolar disorder, Bipolar spectrum 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. 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. Criteria and subtypes 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: depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis. In cyclothymia, hypomanic and depressive episodes alternate for at least two years in adults and at least one year in children and adolescents. When relevant, specifiers for peripartum onset and with rapid cycling should be used with any subtype. 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). 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. Hyperthymic temperament has been described as subsyndromal manifestation within the broader bipolar spectrum. 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. 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). The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management. "Ultra rapid" and "ultradian" have been applied to faster-cycling types of bipolar disorder. 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. There is evidence that rapid cycling may be iatrogenic and caused by antidepressant use. In contrast, atypical antipsychotics and mood stabilizers do not worsen rapid cycling. 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. 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. Children of parents with bipolar disorder more frequently have other mental health problems. == 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. 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. Circadian rhythm disruptions such as traveling across many time zones (jet lag) can destabilize bipolar disorder and lead to manic or psychotic episodes. == Management ==

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. but new recommendations to advance human rights instead call for the abolition of institutionalization and forced treatment. 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. 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. Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery. Medication . • Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression. 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. Lamotrigine treatment has been shown to be safer compared to lithium treatment, with less adverse effects. 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. The effectiveness of topiramate is unknown. 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. 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. Antidepressants Antidepressant monotherapy is not recommended in the treatment of bipolar disorder and does not provide any benefit over mood stabilizers. 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. 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. 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. 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. Other drugs Short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective. 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. Gabapentin and pregabalin are not proven to be effective for treating bipolar disorder. Children Treating bipolar disorder in children involves medication and psychotherapy. 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. Mood stabilizers and atypical antipsychotics are commonly prescribed. Psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy. Guidelines to the definition of treatment-resistant bipolar disorder and evidence-based options for its management were reviewed in 2020. 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. 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. Some people with bipolar disorder who have obesity may also be eligible for bariatric surgery. The effectiveness of these various approaches to improving or managing obesity in people with bipolar disorder is not clear. == Prognosis ==

A lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse, bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality. 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. 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. as well as subtypes that are nonresponsive to lithium. 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. These include reduced attentional and executive capabilities and impaired memory. 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. 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%. Maintenance treatment with lithium reduces rates of dementia to that of the general population. When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development. 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. 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. 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. 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". 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. Symptoms preceding a relapse (prodromal), especially those related to mania, can be reliably identified by people with bipolar disorder. There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results. 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. One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed. 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. 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. 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. In addition to reducing suicide, lithium also decreases all-cause mortality in people with bipolar disorder. == Epidemiology ==

s per 100,000 inhabitants in 2004 Bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime prevalence of about 1 to 3% in the general population. 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. 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. Estimates vary about how many children and young adults have bipolar disorder. The incidence of bipolar disorder is similar in men and women as well as across different cultures and ethnic groups. 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. Within the United States, Asian Americans have significantly lower rates than their African American and European American counterparts. 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. 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. Substance use disorder is a common comorbidity in bipolar disorder; the subject has been widely reviewed. == 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". 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". 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). Likewise, a continuing education article by the American Psychological Association emphasizes, 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. Earlier reviews also found elevated rates as high as 6–9%, but estimates vary depending on diagnostic criteria and design. 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. Risk factors 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. Homelessness was also highly associated with prior incarceration and co-occurring substance use, which highlights the cyclical relationship between social instability and mental illness. Disruptions in care contribute to poor participation in treatment plans, higher rates of psychiatric hospitalization, and worsened long-term outcomes. 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. 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. 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. == History ==

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. The basis of the current conceptualization of bipolar illness can be traced back to the 1850s. In 1850, Jean-Pierre Falret described "circular insanity" (', ); the lecture was summarized in 1851 in the ' ("Hospital Gazette"). 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 (, "madness in double form"). Baillarger's original paper, "", appeared in the medical journal Annales médico-psychologiques (Medico-psychological annals) in 1854. The term "manic–depressive reaction" appeared in the first version of the DSM in 1952, influenced by the legacy of Adolf Meyer. 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. 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. == Society and culture ==

's public revelation of bipolar disorder made her an early celebrity spokesperson for mental illness. 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. One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007. In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide. 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. The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs. Advocacy There are widespread issues with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder. In 2000, actress Carrie Fisher went public with her bipolar disorder diagnosis. 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. 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. 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. 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. • The International Bipolar Foundation (IBPF) provides education and resources for those living with bipolar disorder. • CREST.BD is a Canadian network focused on bipolar disorder. The CREST.BD network includes researchers, mental health professionals and people with bipolar disorder. • Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes treatment guidelines for bipolar disorder together with the International Society for Bipolar Disorders (ISBD). 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. It is sponsored by the International Society for Bipolar Disorders, the International Bipolar Foundation, and the Asian Network of Bipolar Disorder (ANBD). 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. Attendance at a DBSA support group has been associated with increased functioning and well-being among participants. 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. 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). It is likely that Grigory Potemkin, Russian statesman and alleged husband of Catherine the Great, suffered from some kind of bipolar disorder. 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, Jane Pauley, Demi Lovato, and Russell Brand. 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.” 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. 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. 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. Psychiatrists have suggested that Willy Loman, the main character in Arthur Miller's classic play Death of a Salesman, has bipolar disorder. The 2009 drama 90210 featured a character, Silver, who was diagnosed with bipolar disorder. 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. The Channel 4 soap Brookside had earlier featured a story about bipolar disorder when the character Jimmy Corkhill was diagnosed with the condition. 2011 Showtime's political thriller drama Homeland protagonist Carrie Mathison has bipolar disorder, which she has kept secret since her school days. The 2014 ABC medical drama, Black Box, featured a world-renowned neuroscientist with bipolar disorder. 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. 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. Creativity 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. 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. == Special populations ==

Children 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. The diagnosis of childhood bipolar disorder, while formerly controversial, distinct from irritability in bipolar disorder that is restricted to discrete mood episodes. 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. Elderly Bipolar disorder is uncommon in older patients, with a measured lifetime prevalence of 1% in over 60s and a 12-month prevalence of 0.10.5% in people over 65. Despite this, it is overrepresented in psychiatric admissions, making up 48% 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, and have a stronger family history of illness. 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. == Further reading ==

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