Bipolar disorder (BD), previously known asmanic depression, is amental disorder characterized by periods ofdepression and of abnormally elevatedmood that each last from days to weeks, and in some cases months.[4][5] If the elevated mood is severe or associated withpsychosis, it is calledmania; if it does not significantly affect functioning, it is calledhypomania.[4] During mania, an individual behaves or feels abnormally energetic, happy, or irritable,[4] and often makes impulsive decisions with little regard for the consequences.[5] There is usuallysleep disturbance during manic phases.[7][5][8][9] During periods of depression, the individual may experience crying, have a negative outlook, and demonstrate poor eye contact.[4] Over a period of 20 years, 6% of those with BD died bysuicide,[4] with about one-thirdattempting suicide in their lifetime.[5] Among those with BD, 40–50% overall and 78% of adolescents engaged inself-harm.[10][11]
While the causes of thismood disorder are not clearly understood,genetic andenvironmental factors are thought to play a role.[4]Genetic factors may account for up to 70–90% of the risk of developing BD.[12][13] Environmental risks include a history ofchild abuse and long-termstress.[4] The condition is classified asbipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and asbipolar II disorder if there has been at least one hypomanic episode (but no full manic episodes) and one major depressive episode.[5] It is classified ascyclothymia if there are hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes.[14]If these symptoms are due to drugs or medical problems, they are not diagnosed as BD.[5]
Mood stabilizers, particularlylithium, andanticonvulsants, such aslamotrigine andvalproate, as well as atypical antipsychotics are the mainstay of long-term pharmacologic relapse prevention.[15]Antipsychotics are used for acute manic episodes or when mood stabilizers are ineffective or not tolerated, with long-acting injectables available for patients with adherence issues.[15] There is evidence thatpsychotherapy improves the course of BD.[16] Use ofantidepressants in depressive episodes is controversial: they can be effective, but certain classes of antidepressants increase the risk of mania.[17][18] The treatment of depressive episodes, therefore, is often difficult.[15]Electroconvulsive therapy (ECT) is effective in acute manic and depressive episodes, especially with psychosis orcatatonia.[a][15] Admission to apsychiatric hospital may be required if someone is a risk to themselves or others;involuntary treatment is sometimes necessary if someone refuses treatment.[4]
BD occurs in approximately 2% of the population.[20] Symptoms most commonly begin between 20-25 years old; an earlier onset is associated with a worse prognosis.[21] Around 30% of people with BD have financial, social or work-related problems due to the condition.[4] BD is among the top 20 causes of disability and leads to substantial societal costs.[22] Due to lifestyle consequences and medication side effects, risk of death from natural causes, such ascoronary artery disease, in people with BD is twice the average.[4]
Signs and symptoms
Late adolescence and early adulthood are peak years for the onset of bipolar disorder.[23][24] The condition is characterized by intermittent episodes ofmania, commonly (but not in every patient) alternating with bouts of depression, with an absence of symptoms in between.[25][26] During these episodes, people with bipolar disorder exhibit disruptions in normalmood, psychomotor activity (the level of physical activity that is influenced by mood)—e.g. constant fidgeting during mania or slowed movements during depression—circadian rhythm and cognition. Mania can present with varying levels of mood disturbance, ranging fromeuphoria, which is associated with "classic mania", todysphoria andirritability.[27] Psychotic symptoms such asdelusions orhallucinations may occur in both manic and depressive episodes; their content and nature are consistent with the person's prevailing mood.[4] In some people with bipolar disorder, depressive symptoms predominate, and the episodes of mania are always the more subduedhypomania type.[26]
According to theDSM-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.[15] The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood.[28]
Manic episodes
An 1892 color lithograph depicting a woman diagnosed withhilarious mania
Also known as a manic episode, mania is a distinct period of at least one week of elevated or irritable mood, which can range from euphoria todelirium. The core symptom of mania involves anincrease in energy of psychomotor activity. Mania can also present with increased self-esteem orgrandiosity,racing thoughts,pressured speech that is difficult to interrupt, decreased need for sleep, disinhibited social behavior,[27] increasedgoal-oriented activities and impaired judgement, which can lead to exhibition of behaviors characterized as impulsive or high-risk, such ashypersexuality orexcessive spending.[29][30][31] To fit the definition of a manic episode, these behaviors must impair the individual's ability to socialize or work.[29][31] If untreated, a manic episode usually lasts three to six months.[32]
In severe manic episodes, a person can experiencepsychotic symptoms, where thought content is affected along with mood.[31] 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.[33][34] This may lead to violent behavior and, sometimes, hospitalization in an inpatientpsychiatric hospital.[30][31] The severity of manic symptoms can be measured by rating scales such as theYoung Mania Rating Scale, though questions remain about the reliability of these scales.[35]
The onset of a manic or depressive episode is often foreshadowed bysleep disturbance.[36] Manic individuals often have a history ofsubstance use disorder developed over years as a form of "self-medication".[37]
Hypomanic episodes
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,[31] but which does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features such asdelusions orhallucinations, and does not require psychiatric hospitalization.[29] Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some.[38] Hypomanic episodes rarely progress to full-blown manic episodes.[38] Some people who experience hypomania show increased creativity,[31][39] while others are irritable or demonstrate poor judgment.[13]
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.[31] People with bipolar disorder who experience hypomania tend to forget the effects of their actions on those around them. Even when family and friends recognizemood swings, the individual will often deny that anything is wrong.[40] If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic unless the mood changes are uncontrollable or volatile.[38] 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.[41] Most commonly, symptoms continue for time periods from a few weeks to a few months.[42]
Symptoms of thedepressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger,loss of interest in previously enjoyed activities, excessive or inappropriateguilt,hopelessness,sleeping too much ornot enough, changes in appetite or weight,fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide.[43] 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.[15]
The earlier the age of onset, the more likely the first few episodes are to be depressive.[44] For most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes.[21] Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initiallymisdiagnosed as havingmajor depression and treated with prescribed antidepressants.[45]
In bipolar disorder, amixed state is an episode during which symptoms of both mania and depression occur simultaneously.[46] 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.[46] They are considered to have a higher risk for suicidal behavior as depressive emotions such as hopelessness are often paired withmood swings ordifficulties with impulse control.[46]Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania.[46] Substance (includingalcohol) use also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance use.[46]
Comorbid conditions
People with bipolar disorder often have other co-existing psychiatric conditions such asanxiety (present in about 71% of people with bipolar disorder), substance abuse (56%),personality disorders (36%) andattention deficit hyperactivity disorder (10–20%) which can add to the burden of illness and worsen the prognosis.[21] Certain medical conditions are also more common in people with bipolar disorder as compared to the general population. This includes increased rates ofmetabolic syndrome (present in 37% of people with bipolar disorder),migraine headaches (35%),obesity (21%) andtype 2 diabetes (14%).[21] This contributes to a risk of death that is two times higher in those with bipolar disorder as compared to the general population.[21]Hypothyroidism is also common regardless of drug choice.[47]
The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear.[51] Genetic influences are believed to account for 73–93% of the risk of developing the disorder indicating a strong hereditary component.[13] The overallheritability of thebipolar spectrum has been estimated at 0.71.[52]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 whichidentical twins (same genes) will both have bipolar I disorder (concordance) is around 40%, compared to about 5% infraternal twins.[29][53] A combination of bipolar I, II, andcyclothymia similarly produced rates of 42% and 11% (identical and fraternal twins, respectively).[52] The rates of bipolar II combinations without bipolar I are lower—bipolar II at 23 and 17%, and bipolar II combining with cyclothymia at 33 and 14%—which may reflect relatively higher geneticheterogeneity.[52]
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.[54] 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.[52]
Genetic
Behavioral genetic studies have suggested that manychromosomal regions andcandidate genes are related to bipolar disorder susceptibility witheach gene exerting a mild to moderate effect.[55] The risk of bipolar disorder is nearly ten-fold higher infirst-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.[29]
Although the firstgenetic linkage finding for mania was in 1969,[56] linkage studies have been inconsistent.[29] Findings point strongly to heterogeneity, with different genes implicated in different families.[57] Robust and replicable genome-wide significant associations showed several commonsingle-nucleotide polymorphisms (SNPs) are associated with bipolar disorder, including variants within the genesCACNA1C,ODZ4, andNCAN.[55][58] The largest and most recentgenome-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.[58] Polymorphisms inBDNF,DRD4,DAO, andTPH1 have been frequently associated with bipolar disorder and were initially associated in ameta-analysis, but this association disappeared after correction formultiple testing.[59] On the other hand, two polymorphisms inTPH2 were identified as being associated with bipolar disorder.[60]
Bipolar disorder is associated with reduced expression of specificDNA repair enzymes and increased levels of oxidativeDNA damages.[64] 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.[65]
Environmental
Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions.[66][67] Recent life events and interpersonal relationships likely contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression.[68] 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 aspost-traumatic stress disorder.[69] Subtypes of abuse, such as sexual and emotional abuse, also contribute to violent behaviors seen in patients with bipolar disorder.[70] 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.[71] Acutely, mania can be induced bysleep deprivation in around 30% of people with bipolar disorder.[72]
Brain imaging studies have revealed differences in the volume of various brain regions between patients with bipolar disorder and healthy control subjects.
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.[25] A neurologic model for bipolar disorder proposes that the emotional circuitry of the brain can be divided into two main parts.[25] The ventral system (regulates emotional perception) includes brain structures such as theamygdala,insula, ventralstriatum, ventralanterior cingulate cortex, and theprefrontal cortex.[25] The dorsal system (responsible for emotional regulation) includes thehippocampus, dorsal anterior cingulate cortex, and other parts of the prefrontal cortex.[25] The model hypothesizes that bipolar disorder may occur when the ventral system is overactivated and the dorsal system is underactivated.[25] Other models suggest the ability to regulate emotions is disrupted in people with bipolar disorder and that dysfunction of the ventricular prefrontal cortex is crucial to this disruption.[25]
Functional MRI findings suggest that the ventricular prefrontal cortex regulates thelimbic system, especially the amygdala.[78] In people with bipolar disorder, decreased ventricular prefrontal cortex activity allows for the dysregulated activity of the amygdala, which likely contributes to labile mood and poor emotional regulation.[78] 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.[79] 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.[78] These disruptions often occur during development linked withsynaptic pruning dysfunction.[80]
People with bipolar disorder who are in aeuthymic mood state show decreased activity in thelingual gyrus compared to people without bipolar disorder.[25] In contrast, they demonstrate decreased activity in the inferiorfrontal cortex during manic episodes compared to people without the disorder.[25] Similar studies examining the differences in brain activity between people with bipolar disorder and those without did not find a consistent area in the brain that was more or less active when comparing these two groups.[25] People with bipolar have increased activation of left hemisphere ventral limbic areas—which mediate emotional experiences and generation of emotional responses—and decreased activation of right hemisphere cortical structures related to cognition—structures associated with the regulation of emotions.[81] However, further research is needed to consolidate neuroimaging findings, which are often heterogeneous and not consistently reported according to a common standard.[82]
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 offrontostriatal circuits causes mania, and decreased sensitivity of these circuits causes depression.[83] 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 and dysfunction of thehypothalamic-pituitary-adrenal axis leading to its overactivation, which may play a role in the pathogenesis of bipolar disorder.[84][85] Other brain components that have been proposed to play a role in bipolar disorder are themitochondria[51] and a sodiumATPasepump.[86]Circadian rhythms and regulation of the hormonemelatonin also seem to be altered.[87]
Dopamine, aneurotransmitter responsible for mood cycling, has increased transmission during the manic phase.[28][88] The dopamine hypothesis states that the increase in dopamine results in secondaryhomeostaticdownregulation of key system elements and receptors such as lower sensitivity of dopaminergic receptors. This results in decreased dopamine transmission characteristic of the depressive phase.[28] The depressive phase ends with homeostatic upregulation potentially restarting the cycle over again.[89]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.[90]
Medications used to treat bipolar may exert their effect by modulating intracellular signaling, such as through depleting myo-inositol levels, inhibition ofcAMP signaling, and through altering subunits of the dopamine-associated G-protein.[91] Consistent with this, elevated levels ofGαi,Gαs, andGαq/11 have been reported in brain and blood samples, along with increasedprotein kinase A (PKA) expression and sensitivity;[92] typically, PKA activates as part of the intracellular signalling cascade downstream from the detachment of Gαs subunit from the G protein complex.
Decreased levels of5-hydroxyindoleacetic acid, a byproduct ofserotonin, are present in thecerebrospinal 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 ofdopamine agonists to stimulate mania in people with bipolar disorder. Decreased sensitivity of regulatory α2adrenergic receptors as well as increased cell counts in thelocus coeruleus indicated increased noradrenergic activity in manic people. Low plasma GABA levels on both sides of the mood spectrum have been found.[93] One review found no difference in monoamine levels, but found abnormal norepinephrine turnover in people with bipolar disorder.[94]Tyrosine depletion was found to reduce the effects ofmethamphetamine 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.[95]
Diagnosis
Bipolar disorder is commonly diagnosed during adolescence or early adulthood, but onset can occur throughout life.[5][96] 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.[97] Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others.
Mental disorders that can mimic bipolar disorder includeschizophrenia, major depressive disorder,[102] attention deficit hyperactivity disorder (ADHD), and certain personality disorders, such asborderline personality disorder.[103][104][105] 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 calledemotional dysregulation) are sudden and often short-lived, and secondary tosocial stressors.[106]
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.[5][96][99] These disorders involve major depressive episodes that alternate with manic or hypomanic episodes, or with mixed episodes that feature symptoms of both mood states.[5] The concept of the bipolarspectrum is similar to that ofEmil Kraepelin's original concept of manic depressive illness.[108] 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 exists at all.[109]
Criteria and subtypes
Simplified graphical comparison of bipolar I, bipolar II and cyclothymia[110][111]: 267 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:[5][99]
Bipolar I disorder: At least one manic episode is necessary to make the diagnosis;[112] depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis.[29] 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.[5]
Bipolar II disorder: No manic episodes and one or more hypomanic episodes and one or more major depressive episodes.[112] 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.
Cyclothymia: A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes.[14] In cyclothymia, hypomanic and depressive episodes alternate for at least two years in adults and at least one year in children and adolescents.[113]
When relevant, specifiers forperipartum onset andwith rapid cycling should be used with any subtype.[114] 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 orunspecified 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).[5] If the condition is thought to have a non-psychiatric medical cause, the diagnosis ofbipolar and related disorder due to another medical condition is made, whilesubstance/medication-induced bipolar and related disorder is used if a medication is thought to have triggered the condition.[115]
Whilehyperthymic temperament is not considered a pathological disorder, it is genetically associated with bipolar I and may predispose affected individuals to a manic-depressive episode.[116][117] Hyperthymic temperament has been described as subsyndromal manifestation within the broader bipolar spectrum.[116]
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.[118]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.[43][119] 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).[29] The definition of rapid cycling most frequently cited in the literature (including the DSM-V and ICD-11) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes during a 12-month period.[120] The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management.[121] "Ultra rapid" and "ultradian" have been applied to faster-cycling types of bipolar disorder.[122] 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.[123]
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.[128] 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.[128][129] The diagnosis of childhood bipolar disorder, while formerly controversial,[130] has gained greater acceptance among childhood and adolescent psychiatrists.[131] American children and adolescents diagnosed with bipolar disorder incommunity hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while inoutpatient clinics it doubled reaching 6%.[130] Studies using DSM criteria show that up to 1% of youth may have bipolar disorder.[128] 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,[132] distinct from irritability in bipolar disorder that is restricted to discrete mood episodes.[131]
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).[133] 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.[134]
Elderly
Bipolar disorder is uncommon in older patients, with a measured lifetime prevalence of 1% in over 60s and a 12-month prevalence of 0.1–0.5% in people over 65. Despite this, it is overrepresented in psychiatric admissions, making up 4–8% 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 aspseudodementia. 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,[135] and have a stronger family history of illness.[136] 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.[135]
Prevention
Attempts atprevention of bipolar disorder have focused on stress (such aschildhood 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.[137] Longitudinal studies have indicated that full-blown manic stages are often preceded by a variety ofprodromal 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.[138][139]
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 ofpharmacological andpsychotherapeutic techniques.[15] Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (local legislation permitting)involuntary. Long-term inpatient stays are now less common due todeinstitutionalization, although these can still occur.[140] Following (or in lieu of) a hospital admission, support services available can includedrop-in centers, visits from members of acommunity mental health team or anAssertive Community Treatment team,supported employment,patient-led support groups, andintensive outpatient programs. These are sometimes referred to as partial-inpatient programs.[141] 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.[142][143][144]
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 recognizingprodromal symptoms before full-blown recurrence.[13]Cognitive behavioral therapy (CBT),family-focused therapy, andpsychoeducation have the most evidence for efficacy in regard to relapse prevention, whileinterpersonal 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.[145] Some clinicians emphasize the need to talk with individuals experiencing mania, to develop atherapeutic alliance in support ofrecovery.[146]
Medication
Lithium is often used to treat bipolar disorder and has the best evidence for reducing suicide.
Medications are often prescribed to help improve symptoms of bipolar disorder. Medications approved for treating bipolar disorder including mood stabilizers, antipsychotics, and certain antidepressants. Sometimes a combination of medications may also be suggested.[15] The choice of medications may differ depending on the bipolar disorder episode type or if the person is experiencing unipolar or bipolar depression.[15][147] 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.[15]
Lithium has the best overall evidence and is considered an effective treatment for acute manic episodes, preventing relapses, and bipolar depression.[148][149] Lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder.[150] Lithium is preferred for long-term mood stabilization.[68] Lithium treatment is also associated with adverse effects and it has been shown to erode kidney and thyroid function over extended periods.[15]
Valproate has become a commonly prescribed treatment and effectively treats manic episodes.[151]
Carbamazepine is less effective in preventing relapse than lithium or valproate.[152][153] 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 ofschizoaffective disorder.
Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression.[154] 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.[155] Lamotrigine treatment has been shown to be safer compared to lithium treatment, with less adverse effects.
Valproate andcarbamazepine 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.[21] Lithium is also teratogenic in the first trimester, though it can be acceptable during this period after careful weighing of benefits and risks.[156][157]
Mood stabilizers are used for long-term maintenance but have not demonstrated the ability to quickly treat acute bipolar depression.[123]
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.[68] Atypical antipsychotics such aslurasidone andclozapine are also indicated for bipolar depression refractory to treatment with mood stabilizers.[123]Olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium.[159] A 2006 review found thathaloperidol was an effective treatment for acute mania, limited data supported no difference in overall efficacy between haloperidol,olanzapine orrisperidone, and that it could be less effective thanaripiprazole.[160]
Antidepressants
Antidepressant monotherapy is not recommended in the treatment of bipolar disorder and does not provide any benefit over mood stabilizers.[15][161] Atypicalantipsychotic medications (e.g.,aripiprazole) are preferred over antidepressants to augment the effects of mood stabilizers due to the lack of efficacy of antidepressants in bipolar disorder. 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.[21] There may also be a risk of accelerating cycling between phases when antidepressants are used in bipolar disorder. 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.[162][21]: 63
Whether modern antidepressants cause mania or cycle acceleration in bipolar disorder is highly controversial, as is whether antidepressants provide any benefit over mood stabilizers alone.[21]: 63 [163]
Antipsychotics and mood stabilizers used together are quicker and more effective at treating mania than either class of drug used alone. Some analyses indicate antipsychotics alone are also more effective at treating acute mania.[15] A first-line treatment for depression in bipolar disorder is a combination of olanzapine and fluoxetine.[147]
Other drugs
Short courses ofbenzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective.[164]Electroconvulsive therapy (ECT) is an effective form of treatment for acute mood disturbances in those with bipolar disorder, especially when psychotic orcatatonic features are displayed. ECT is also recommended for use in pregnant women with bipolar disorder.[15] A singleintravenous dose ofketamine 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.[147]Gabapentin andpregabalin are not proven to be effective for treating bipolar disorder.[165][166][167]
Children
Treating bipolar disorder in children involves medication and psychotherapy.[130] 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.[168]Mood stabilizers andatypical antipsychotics are commonly prescribed.[130] Among the former,lithium is the only compound approved by theFDA for children.[128] Psychological treatment combines normallyeducation on the disease,group therapy, andcognitive behavioral therapy.[130] Long-term medication is often needed.[130]
Resistance to treatment
The poor response from some bipolar patients to treatment has given evidence to the concept of treatment-resistant bipolar disorder.[169][170] Guidelines to the definition of treatment-resistant bipolar disorder and evidence-based options for its management were reviewed in 2020.[171]
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.[172] 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.[173] Some people with bipolar disorder who have obesity may also be eligible for bariatric surgery.[172] The effectiveness of these various approaches to improving or managing obesity in people with bipolar disorder is not clear.[172]
Prognosis
A lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse,[43][174] bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality.[174] 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.[4][44] When compared to the general population, people with bipolar disorder also have higher rates of other serious medical comorbidities includingdiabetes mellitus, respiratory diseases, HIV, andhepatitis C virus infection.[175] 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.[100][176]
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.[177] However, the types of medications used in treating BD commonly cause side effects[178] and more than 75% of individuals with BD inconsistently take their medications for various reasons.[177] 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 ofself-harm and suicide.[43] Individuals diagnosed with bipolar who have a family history of bipolar disorder are at a greater risk for more frequent manic/hypomanic episodes.[179] Early onset and psychotic features are also associated with worse outcomes,[180][181] as well as subtypes that are nonresponsive to lithium.[176]
Early recognition and intervention also improve prognosis as the symptoms in earlier stages are less severe and more responsive to treatment.[176] 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.[179]
Functioning
Changes incognitive processes and abilities are seen in mood disorders, with those of bipolar disorder being greater than those in major depressive disorder.[182] These include reducedattentional andexecutive capabilities and impairedmemory.[183] 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 duringacute phases and moderate impairment during periods of remission. As a result, two-thirds of people with BD continue to experience impairedpsychosocial 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.[178]
When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development.[131] 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.[131] 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.[184] 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.[176]
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.[185] 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.[5][186] 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.[186]
Recovery and recurrence
A naturalistic study in 2003 byTohen 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.[187]
Symptoms preceding a relapse (prodromal), especially those related to mania, can be reliably identified by people with bipolar disorder.[188] There have been intents to teach patientscoping strategies when noticing such symptoms with encouraging results.[189]
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.[102] One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed.[55] The annual average suicide rate is 0.4–1.4%, which is 30 to 60 times greater than that of the general population.[20] The number of deaths from suicide in bipolar disorder is between 18 and 25 times higherthan would be expected in similarly aged people without bipolar disorder.[190] 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.[20]
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.[21]
Bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime prevalence of about 1 to 3% in the general population.[6][191][192] However, a reanalysis of data from the National Epidemiological Catchment Area survey in the United States suggested that 0.8% of the population experience amanic episode at least once (the diagnostic threshold forbipolar I) and a further 0.5% have ahypomanic 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.[193] A more recent analysis of data from a second USNational Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar I, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.[194] Estimates vary about how many children and young adults have bipolar disorder.[131] These estimates range from 0.6 to 15% depending on differing settings, methods, and referral settings, raising suspicions of overdiagnosis.[131] 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.[131] Similar to adults, bipolar disorder in children and adolescents is thought to occur at a similar frequency in boys and girls.[131]
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 orspectrum approach is used. This consideration has led to concerns about the potential for both underdiagnosis and overdiagnosis.[195]
The incidence of bipolar disorder is similar in men and women[196] as well as across different cultures and ethnic groups.[197] A 2000 study by theWorld 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.[198] Within the United States, Asian Americans have significantly lower rates than their African American andEuropean American counterparts.[199] In 2017, theGlobal Burden of Disease Study estimated there were 4.5 million new cases and a total of 45.5 million cases globally.[200]
Homelessness and housing instability
Prevalence
Studies have shown that bipolar disorder occurs at significantly higher rates among people experiencinghomelessness 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.[201] Earlier reviews also found elevated rates as high as 6%-9%, but estimates vary depending on diagnostic criteria and design.[202] 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
Sign made by homeless veteran.
Bipolar disorder is associated with several risk factors for homelessness, includingincarceration, 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.[203] Homelessness was also highly associated with prior incarceration and co-occurring substance use, which highlights the cyclical relationship between social instability andmental illness.[203]
Additionally, individuals with bipolar disorder who are experiencing homelessness often have an early onset of illness, more frequent manic ordepressive episodes, and poor adherence to medication. This can increase the likelihood ofrelapse and the loss of housing.[201][203]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.
Social determinants like poverty, unemployment, and stigma also increase vulnerability to both bipolar disorder and homelessness.[202]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.[201]
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 haveinsurance, the ability to maintain continuous care, and more likely to rely on emergency services in comparison to housed individuals.[204] Disruptions in care contribute to poor participation in treatment plans, higher rates of psychiatric hospitalization, and worsened long-term outcomes.[203] 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.[203]
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.[202] 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.[202]
German psychiatristEmil Kraepelin first distinguished between manic–depressive illness and "dementia praecox" (now known asschizophrenia) in the late 19th century.
In the early 1800s, French psychiatristJean-Étienne Dominique Esquirol's lypemania, one of his affectivemonomanias, was the first elaboration on what was to become modern depression.[205] The basis of the current conceptualization of bipolar illness can be traced back to the 1850s. In 1850,Jean-Pierre Falret described "circular insanity" (la folie circulaire,French pronunciation:[lafɔlisiʁ.ky.lɛʁ]); the lecture was summarized in 1851 in theGazette des hôpitaux ("Hospital Gazette").[2] Three years later, in 1854,Jules-Gabriel-François Baillarger (1809–1890) described to the French ImperialAcadémie Nationale de Médecine a biphasic mental illness causing recurrent oscillations between mania and melancholia, which he termedla folie à double forme (French pronunciation:[lafɔliadublfɔʀm], "madness in double form").[2][206] Baillarger's original paper, "De la folie à double forme", appeared in the medical journalAnnales médico-psychologiques (Medico-psychological annals) in 1854.[2]
These concepts were developed by the German psychiatristEmil Kraepelin (1856–1926), who, usingKahlbaum's concept of cyclothymia,[207] categorized and studied the natural course of untreated bipolar patients. He coined the termmanic 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.[208]
The term "manic–depressivereaction" appeared in the first version of theDSM in 1952, influenced by the legacy ofAdolf Meyer.[209] Subtyping into "unipolar" depressive disorders and bipolar disorders has its origin inKarl Kleist's concept – since 1911 – of unipolar and bipolar affective disorders, which was used byKarl Leonhard in 1957 to differentiate between unipolar and bipolar disorder in depression.[210] 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 byDavid Dunner,Elliot Gershon,Frederick Goodwin,Ronald Fieve, andJoseph Fleiss.[211][212][213]
SingerRosemary Clooney's public revelation of bipolar disorder made her an early celebrity spokesperson for mental illness.[214]
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.[175] One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007.[215][216] In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide.[22] 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.[217] The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs.[218]
Advocacy
There are widespread issues withsocial stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder.[219] In 2000, actressCarrie Fisher went public with her bipolar disorder diagnosis.[220][221] 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.[222] Since being diagnosed at age 37, actorStephen Fry has pushed to raise awareness of the condition, with his 2006 documentaryStephen Fry: The Secret Life of the Manic Depressive.[223][224] In an effort to ease the social stigma associated with bipolar disorder, the orchestra conductorRonald 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.[225][226]
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.
InMr. Jones (1993), (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.[232] InThe Mosquito Coast (1986), Allie Fox (Harrison Ford) displays some features including recklessness, grandiosity, increased goal-directed activity and mood lability, as well as someparanoia.[233] Psychiatrists have suggested thatWilly Loman, the main character inArthur Miller's classic playDeath of a Salesman, has bipolar disorder.[234]
The 2009 drama90210 featured a character, Silver, who was diagnosed with bipolar disorder.[235]Stacey Slater, a character from the BBC soapEastEnders, has been diagnosed with the disorder. The storyline was developed as part of the BBC's Headroom campaign.[236] TheChannel 4 soapBrookside had earlier featured a story about bipolar disorder when the characterJimmy Corkhill was diagnosed with the condition.[237] 2011Showtime'spolitical thriller dramaHomeland protagonistCarrie Mathison has bipolar disorder, which she has kept secret since her school days.[238] The 2014ABC medical drama,Black Box, featured a world-renowned neuroscientist with bipolar disorder.[239]In the TV seriesDave, the eponymous main character, played byLil Dicky as a fictionalized version of himself, is an aspiring rapper. Lil Dicky's real-life hype manGaTa 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.[240]
Since 2024,Nicola Coughlan, has co-starred alongsideLydia West, in the BritishChannel 4 dark television comedy-dramaBig 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.[241]
A link between mental illness and professional success or creativity has been suggested, including in accounts bySocrates,Seneca the Younger, andCesare 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 byconfirmation 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.[242][243] 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.[244]
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