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What is the difference between clinical and non-clinical depression, and is there a term for different severity of the bipolar disorder?

What is the difference between clinical and non-clinical depression, and is there a term for different severity of the bipolar disorder?


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I was looking for a term which describes a bipolar disorder of lesser severity.

I know from experience from someone I know well, what a very severe case of the bipolar disorder looks like, when an otherwise very intelligent and very sane person can become completely unstable in both directions, and requires medication to basically survive it. I'm searching for a term which has indeed the symptoms of the bipolar disorder, but is not as severe as to require medication to basically survive the mood swings. I'm not talking about being just sad for something or craving attention. I'm talking about the very real symptoms of mania, followed by depression, just not as severe to be fatally dangerous without medical intervention. A severity which I would describe of being able to cope with by learning about it and a good degree of self-control, exercise, and good eating habits.

I thought the term was clinical versus non-clinical depression, but a search of the Internet made me doubt it. They talked about it as if the clinical was a case where there is a "disorder of the brain" and the non-clinical was "just sad because of a sad event", so either were those forums wrong (I guess so, because of their apparent unprofessional writing style, and they never seemed to know about bipolar, they thought manic depression was just about being very very sad), or there is another term which best answers my question.


I think the main question here is:

Is there a term… which describes a bipolar disorder of lesser severity[?]

Yes. There are a couple ways to think about this, but you're clearly accustomed to differentiating the manic and depressive phases of bipolar disorder, so I'll start with that.

There is mania (excerpted from DSM 5*):

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day…

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

  • Inflated self-esteem or grandiosity.
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking.
  • Flight of ideas or subjective experience that thoughts are racing.
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in activities that have a high potential for painful consequences

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning…

And there is hypomania:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.… .

B. [This criteria is the same as for mania.]

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.

I have bolded the main differences between the two definitions. You can see that hypomania is the term for the less severe form of the manic phase of bipolar depression.

Neither mania nor hypomania is likely to occur in the absence of depressive symptoms, however. Thus, there are two basic phenotypes of bipolar disorder (summarized from DSM 5*):

Bipolar I disorder: Patient experiences mania; depressive periods may not qualify as Major Depressive Disorder.

Bipolar II disorder: Major Depressive episodes are required; manic phase may be hypomanic. (This is classically considered a less severe syndrome, but this notion has been challenged in recent years.)

And finally, one more term for you:

Cyclothymic disorder: patient experiences both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression.

(Your other question you seem to already know the answer to, but since it's in the title… Nonclinical depression refers to something on the spectrum of normal (i.e. not pathological), such as situational mood disturbance. A related concept, subclinical depression is a loose term to describe depressive symptoms that don't meet criteria for Major Depressive Disorder… )


*American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.


Nonclinical depression is a popular term for the natural reactions to the external factors, such as loss, seasonal changes, emotional stress http://www.depressionfree.com/non-clinical.html

while the major types of clinical depression are as follows: Major Depressive Disorder

Major depression is a severe mental disorder that deeply affects an individual's way of life and characterized by the inability to enjoy life fully and be satisfied.

Dysthymia

Dysthymia is a type of chronic mild depression.

Bipolar Disorder

Bipolar disorder, also known as manic depression, is characterized by constant mood changes.

Cyclothymic Disorder

Cyclothymic disorder is often described as a milder form of bipolar disorder.

Seasonal Affective Disorder Severe mood change according to the season. Aka SAD

Melancholia

Antenatal And Postnatal Depression


Difference Between Depression and Clinical Depression

Every one of us may undergo feelings of being down and sad. This is just normal. There is no one out there that is immune to such feelings, and it is usually different from person to person how they are able to cope up from such emotions. Even those people who have claimed to attain inner peace are not exempted from this feeling. But what matters most is that these people know how to handle such feelings and in the end, able to lift up their head and say that they are now alright.

You might have lost someone dear to you. You might have failed to attain what you most sought after. Or you might have caused grief to another person that you cannot bear to stomach in. These are only some of the many reasons why people become sad and depressed. Still, even though they may feel this way, it does not entirely mean that it is end of their world. It is even likened to a revolving wheel, at times you may be down, but you know that there will be a time that you will be on top and become happy.

But after all this have been said and done, there are still many people who have no idea what depression really is and how it affects their lives. Furthermore, some people may also not know that too much depression may cause something else, especially if they have no or inadequate coping measures. And thus, this topic will discuss the difference between plain depression and clinical depression.

Plain depression or simple depression is considered as a normal occurrence in everyone’s life. This means that everyone undergoes such an event. This kind of depression usually is rated accordingly, with mild depression as something that does not cause a great deal of damage to a person. Furthermore, mild depression also does not cause any alterations in daily living. Moderate to severe depression though may cause some inconveniences to a person, depending on the severity of the cause. But still, this kind of depression does not last long and individuals are able to cope up with the reason for their depression.

But on the other hand, when depression already lasts more than 6 months, severely affects the livelihood of the individual, and there is a significant effect to the health, then it can now be considered as a clinical depression. Psychiatrists or professionals assess such individuals in order to prevent complications later on. Clinical depression is usually reached when individuals do not have the right coping mechanisms to handle the cause of their depression.

You can read further about this topic since only basic details are provided here.

Everyone undergoes changes in emotions and being depressed is one of them.
2.

Depression usually lasts for a short time only, can be mild, moderate, or severe in form.
3.

Clinical depression lasts for more than 6 months, causes damage to livelihood and health, and cannot show correct coping measures.


Causes of Depression

It is difficult to identify a main cause of depression that applies to all people. Research shows that genetics , brain anatomy and environmental factors likely play significant roles in whether someone will develop depression. These factors also affect the scope and severity of associated symptoms.

While major depressive disorder is often linked to genetics and brain structure , short-term depression can occur due to a specific event. Known as situational depression , this type is often related to a traumatic experience or difficult life changes. If persistent situational depression is unmanaged, however, it may develop into clinical depression.


Six common depression types

Depression is not only hard to endure, it is also a risk factor for heart disease and dementia. "Depressive symptoms can occur in adults for many reasons. If you are experiencing mood or cognitive changes that last for more than a few weeks, it's a good idea to bring this up with your doctor or consult a mental health specialist to help sort out possible causes," says Dr. Nancy Donovan, an instructor in psychiatry at Harvard Medical School. The four most common types of depression are major depression, persistent depressive disorder
(formerly known as dysthymia), bipolar disorder, and seasonal affective disorder.

Major depression. The classic depression type, major depression is a state where a dark mood is all-consuming and one loses interest in activities, even ones that are usually pleasurable. Symptoms of this type of depression include trouble sleeping, changes in appetite or weight, loss of energy, and feeling worthless. Thoughts of death or suicide may occur. It is usually treated with psychotherapy and medication. For some people with severe depression that isn't alleviated with psychotherapy or antidepressant medications, electroconvulsive therapy may be effective.

Persistent depressive disorder. Formerly called "dysthymia," this type of depression refers to low mood that has lasted for at least two years but may not reach the intensity of major depression. Many people with this type of depression type are able to function day to day, but feel low or joyless much of the time. Other depressive symptoms may include appetite and sleep changes, low energy, low self-esteem, or hopelessness.

Bipolar disorder. People with bipolar disorder—once known as manic-depressive disease—have episodes of depression. But they also go through periods of unusually high energy or activity. Manic symptoms look like the opposite of depression symptoms: grandiose ideas, unrealistically high self-esteem, decreased need for sleep, thoughts and activity at higher speed, and ramped-up pursuit of pleasure including sex sprees, overspending, and risk taking. Being manic can feel great, but it doesn't last long, can lead to self-destructive behavior, and is usually followed by a period of depression. Medications for bipolar disorder are different from those given for other depression types, but can be very effective at stabilizing a person's mood.

Seasonal affective disorder (SAD). This type of depression emerges as days get shorter in the fall and winter. The mood change may result from alterations in the body's natural daily rhythms, in the eyes' sensitivity to light, or in how chemical messengers like serotonin and melatonin function. The leading treatment is light therapy, which involves daily sessions sitting close to an especially intense light source. The usual treatments for depression, such as psychotherapy and medication, may also be effective.

Depression types unique to women

Although women are at higher risk for general depression, they are also at risk for two different depression types that are influenced by reproductive hormones—perinatal depression and premenstrual dysphoric disorder (PMDD).

  1. Perinatal depression. This type of depression includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery (also known as postpartum depression). Perinatal depression affects up to one in seven women who give birth and can have devastating effects on the women, their infants, and their families. Treatment includes counseling and medication.
  2. PMDD. This type of depression is a severe form of premenstrual syndrome, or PMS. Symptoms of PMDD usually begin shortly after ovulation and end once menstruation starts. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), may reduce symptoms.

For more information on mental and physical health, check out our Special Health Report A Guide to Women's Health: Fifty and Forward.

By Beverly Merz
Executive Editor, Harvard Women's Health Watch


Can A Major Depressive Disorder Be Minor?

The reality is that minor depression is still depression. The intensity of the symptoms of a major depressive disorder can be mild, moderate, severe, or profound. That&rsquos what people are referring to when they say &ldquomild depression&rdquo &ndash mild symptoms of major depressive disorder. The intensity of the symptoms of major depression is rated based on how disabling they are and to what degree they interfere with someone&rsquos daily functioning to work and manage their households.

While it seems like a contradiction, minor depression can and does often meet the DSM criteria for major depression. As explained above, the difference is that their symptoms are at the milder end of the scale of severity of symptoms. Some people mistakenly believe that mild depression isn&rsquot a serious condition that requires treatment, and in most cases, that&rsquos not fair or accurate.

Various Types Of Depression

Harvard Medical School identifies the following types of depression:

  • Persistent depressive disorder
  • Major depression (which includes minor depression)
  • Seasonal affective disorder
  • Perinatal and postpartum depression
  • Premenstrual dysphoric disorder
  • Bipolar disorder

Minor Depression And Persistent Depressive Disorder

When learning more about minor or major depression, you may encounter the term persistent depressive disorder, which is also called dysthymia or PDD. The persistent depressive disorder differs from minor depression because of the length of time that it lasts, as opposed to the severity of the symptoms. A persistent depressive disorder is continuous and chronic, meaning the symptoms last for a long time (typically, over two years). The symptoms of persistent depressive disorder are much the same as for major depression. It&rsquos just that they can last for years and can significantly interfere with your relationships and other areas of your life. A persistent depressive disorder isn&rsquot usually as severe as major depression, although symptoms commonly fall into the mild, moderate, or severe range. The intensity of the symptoms can change over time. Generally, someone with persistent depressive disorder won&rsquot have a lack of symptoms for up to two months. To complicate things further, a person can have episodes of major depression before or during the time they have a persistent depressive disorder, which may be referred to as a double depression.

People that have the persistent depressive disorder can generally tolerate their symptoms and go on with daily activities, but they don&rsquot get much enjoyment from them.


Join a Study

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

    : Information about participating in clinical trials : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country : List of studies currently recruiting adults with depression being conducted on the NIH Campus in Bethesda, MD : List of studies currently recruiting children with depression being conducted on the NIH Campus in Bethesda, MD : List of studies on perimenopause-related mood disorders being conducted on the NIH Campus in Bethesda, MD : List of studies on postpartum depression being conducted on the NIH Campus in Bethesda, MD

How Long Does Depression Last?

If you’re living with depression, you might wonder how long your symptoms will last and if they will go away on their own.

Because every person’s experience with the condition is different, there is no average duration for depression symptoms.

In other words, how long depression lasts depends on a combination of factors.

From a clinical perspective, symptoms of depression must be present for at least two weeks for a mental health professional to reach a diagnosis.

Sometimes, depression symptoms will last for only a few weeks. For many people though, untreated depression could last months and even years.

Regardless of how long you’ve experienced depression, the condition is treatable. In fact, seeking the support of a professional often helps symptoms resolve much sooner.

Depression affects everyone differently.

Even though there are a few established symptoms of the condition, not everyone experiences them in the same way.

For some people, depression symptoms are persistent over the years. For others, symptoms will come and go at times.

Some research suggests that the symptoms of clinical depression can last an average of 10 months if no other mental health conditions are present.

But this is not always the case. Because there are different types of depression, symptom duration varies greatly.

For example, a depressive episode caused by mourning might last a few days or weeks and often resolves on its own.

In most cases, however, depression requires the support of a health professional.

There are many types of depression, and the type you’re experiencing may impact how long or intense your symptoms are.

Major depressive disorder (MDD)

Also known as clinical depression, major depressive disorder (MDD) is what most people refer to when talking about depression.

Symptoms of clinical depression include low mood, loss of interest in daily activities, lack of energy, and feelings of low self-worth.

Some people experience clinical depression only once in their life, while others have recurring episodes.

MDD episodes can last between 6 and 18 months or longer.

If you start treatment soon after you experience the first symptoms, you might be more likely to recover and prevent future episodes.

Persistent depressive disorder (PDD)

When your depression symptoms last for 2 years or longer, you are likely to receive a diagnosis of persistent depressive disorder.

Sometimes called dysthymia, PDD is a chronic condition that generally involves less severe — but longer-lasting — symptoms than clinical depression.

When you live with PDD, you may have low energy levels or feel unmotivated and disengaged from life at times. You may also deal with pessimism and a poor self-image.

Some people with PDD have experienced a major loss, while others experience the condition due to being under chronic stress.

Because symptoms are often not as severe as those of other types of depression, they can sometimes go undetected.

This has led some people to call this condition “high-functioning depression,” which is actually not a formal diagnosis.

In some cases, PDD lasts so long that you may believe its symptoms are just part of who you are.

Health professionals often use a combination of psychotherapy and antidepressants to treat PDD. This combination approach may be more successful at reducing the severity of your symptoms than using either treatment independently.

Perinatal/postpartum depression (PPD)

Perinatal depression occurs during pregnancy or after giving birth.

People with perinatal depression may experience feelings of anxiety, sadness, and fatigue that make it hard for them to care for themselves or others.

Postpartum depression may occur right after the birth of a child or up to a year later.

Postpartum depression can last a few weeks or may develop into a major depressive disorder. This depends on many factors, but not getting treatment for symptoms is one of the most important ones.

A 2014 literature review indicated that postpartum depression symptoms may improve over time, with some cases resolving 3 to 6 months after onset.

The same review suggests that some people may still experience these symptoms beyond the 6-month mark and could live with lingering symptoms for over a year.

In addition to treatment, having support from family and friends can shorten the duration of perinatal depressions.

Seasonal affective disorder

If you’ve noticed changes in your mood and energy levels when the seasons change, you might have had seasonal affective disorder.

In fact, symptoms of this type of mood disorder may come and go with the seasons.

Consequently, seasonal affective disorder typically lasts between 4 and 5 months.

For most people, this disorder involves symptoms that start in the late fall and end in the spring.

However, some people experience seasonal affective disorder during the summer months too.

Bipolar disorder

Bipolar disorder is a mental health condition that may cause changes in mood that range from extreme highs (mania) to lows (depression).

Bipolar depression is a term used for someone who experiences low mood episodes related to bipolar disorder.

The duration of a mood episode in bipolar disorder varies widely, with some studies suggesting an episode may last between 8 and 12 months.

In fact, depressive episodes tend to last longer than manic episodes in people with bipolar disorder.

Bipolar disorder is a lifelong condition, but you can manage the condition and live a healthy life with ongoing treatment and support. This includes managing your symptoms so episodes of depression don’t last as long.


Contents

Late adolescence and early adulthood are peak years for the onset of bipolar disorder. [20] [21] The condition is characterized by intermittent episodes of mania or depression, with an absence of symptoms in between. [22] During these episodes, people with bipolar disorder exhibit disruptions in normal mood, psychomotor activity-the level of physical activity that is influenced by mood-(e.g., constant fidgeting with mania or slowed movements with depression), circadian rhythm, and cognition. Mania can present with varying levels of mood disturbance, ranging from euphoria that is associated with "classic mania" to dysphoria and irritability. [23] Psychotic symptoms such as delusions or hallucinations may occur in both manic and depressive episodes, their content and nature is consistent with the person's prevailing mood. [4]

According to the DSM-5 criteria, mania is distinguished from hypomania by length, as hypomania is present if elevated mood symptoms are present for at least four consecutive days, and mania is present if such symptoms are present for more than a week. Unlike mania, hypomania is not always associated with impaired functioning. [12] The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood. [24]

Manic episodes

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 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, [23] increased goal-oriented activities and impaired judgment—exhibition of behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending. [25] [26] [27] To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work. [25] [27] If untreated, a manic episode usually lasts three to six months. [28]

In severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood. [27] They may feel unstoppable, or as if they have a special relationship with God, a great mission to accomplish, or other grandiose or delusional ideas. [29] This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital. [26] [27] 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. [30]

The onset of a manic or depressive episode is often foreshadowed by sleep disturbance. [31] Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops. [ medical citation needed ] Manic individuals often have a history of substance abuse developed over years as a form of "self-medication". [32]

Hypomanic episodes

Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania, [27] but which does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features such as delusions or hallucinations, and does not require psychiatric hospitalization. [25] Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some. [33] Hypomanic episodes rarely progress to full-blown manic episodes. [33] Some people who experience hypomania show increased creativity [27] [34] while others are irritable or demonstrate poor judgment. [10]

Hypomania may feel good to some persons who experience it, though most people who experience hypomania state that the stress of the experience is very painful. [27] Bipolar people who experience hypomania tend to forget the effects of their actions on those around them. Even when family and friends recognize mood swings, the individual will often deny that anything is wrong. [35] If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic, unless the mood changes are uncontrollable, or volatile. [33] Most commonly, symptoms continue for a few weeks to a few months. [36]

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 and/or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide. [37] 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. [12]

The earlier the age of onset, the more likely the first few episodes are to be depressive. [38] For most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes. [17] Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and incorrectly treated with prescribed antidepressants. [39]

Mixed affective episodes

In bipolar disorder, a mixed state is an episode during which symptoms of both mania and depression occur simultaneously. [40] 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. [40] 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. [40] Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania. [40] Substance abuse (including alcohol) also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance abuse. [40]

Comorbid 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. [32] [37] [41] [42] 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. [43] Children of parents with bipolar disorder more frequently have other mental health problems. [ needs update ] [44]

People with bipolar disorder often have other co-existing psychiatric conditions such as anxiety (present in about 71% of people with bipolar disorder), substance use (56%), personality disorders (36%) and attention deficit hyperactivity disorder (10–20%) which can add to the burden of illness and worsen the prognosis. [17] Certain medical conditions are also more common in people with bipolar disorder as compared to the general population. This includes increased rates of metabolic syndrome (present in 37% of people with bipolar disorder), migraine headaches (35%), obesity (21%) and type 2 diabetes (14%). [17] This contributes to a risk of death that is two times higher in those with bipolar disorder as compared to the general population. [17]

Substance abuse is a common comorbidity in bipolar disorder, the subject has been widely reviewed. [45] [46]

The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear. [47] Genetic influences are believed to account for 73–93% of the risk of developing the disorder indicating a strong hereditary component. [10] The overall heritability of the bipolar spectrum has been estimated at 0.71. [48] 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. [25] [49] A combination of bipolar I, II, and cyclothymia similarly produced rates of 42% and 11% (identical and fraternal twins, respectively). [48] 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 genetic heterogeneity. [48]

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. [50] 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. [48]

Genetic

Behavioral genetic studies have suggested that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility with each gene exerting a mild to moderate effect. [41] 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. [25]

Although the first genetic linkage finding for mania was in 1969, [51] linkage studies have been inconsistent. [25] Findings point strongly to heterogeneity, with different genes implicated in different families. [52] 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. [41] [53] 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. [53] Polymorphisms in BDNF, DRD4, DAO, and TPH1 have been frequently associated with bipolar disorder and were initially associated in a meta-analysis, but this association disappeared after correction for multiple testing. [54] On the other hand, two polymorphisms in TPH2 were identified as being associated with bipolar disorder. [55]

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, [56] cardiac hypertrophy signaling, Wnt signaling, Notch signaling, [57] 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. [58]

Bipolar disorder is associated with reduced expression of specific DNA repair enzymes and increased levels of oxidative DNA damages. [59]

Environmental

Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions. [60] Recent life events and interpersonal relationships likely contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression. [61] In surveys, 30–50% of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated with earlier onset, a higher rate of suicide attempts, and more co-occurring disorders such as post-traumatic stress disorder. [62] 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. [63] Acutely, mania can be induced by sleep deprivation in around 30% of people with bipolar disorder. [64]

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. [65]

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. [22] A neurologic model for bipolar disorder proposes that the emotional circuitry of the brain can be divided into two main parts. [22] The ventral system (regulates emotional perception) includes brain structures such as the amygdala, insula, ventral striatum, ventral anterior cingulate cortex, and the prefrontal cortex. [22] The dorsal system (responsible for emotional regulation) includes the hippocampus, dorsal anterior cingulate cortex, and other parts of the prefrontal cortex. [22] The model hypothesizes that bipolar disorder may occur when the ventral system is overactivated and the dorsal system is underactivated. [22] Other models suggest the ability to regulate emotions is disrupted in people with bipolar disorder and that dysfunction of the ventricular prefrontal cortex (vPFC) is crucial to this disruption. [22]

Meta-analyses of structural MRI studies have shown that certain brain regions (e.g., the left rostral anterior cingulate cortex, fronto-insular cortex, ventral prefrontal cortex, and claustrum) are smaller in people with bipolar disorder, whereas other are larger (lateral ventricles, globus pallidus, subgenual anterior cingulate, and the amygdala). Additionally, these meta-analyses found that people with bipolar disorder have higher rates of deep white matter hyperintensities. [66] [67] [68] [69]

Functional MRI findings suggest that the vPFC regulates the limbic system, especially the amygdala. [70] In people with bipolar disorder, decreased vPFC activity allows for the dysregulated activity of the amygdala, which likely contributes to labile mood and poor emotional regulation. [70] Consistent with this, pharmacological treatment of mania returns vPFC activity to the levels in non-manic people, suggesting that vPFC 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. [71] Manic and depressive episodes tend to be characterized by dysfunction in different regions of the vPFC. Manic episodes appear to be associated with decreased activation of the right vPFC whereas depressive episodes are associated with decreased activation of the left vPFC. [70]

People with bipolar disorder who are in a euthymic mood state show decreased activity in the lingual gyrus compared to people without bipolar disorder. [22] In contrast, they demonstrate decreased activity in the inferior frontal cortex during manic episodes compared to people without the disorder. [22] 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. [22] 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. [72]

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. [73] 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 the hypothalamic-pituitary-adrenal axis leading to its overactivation, which may play a role in the pathogenesis of bipolar disorder. [74] [75] Other brain components that have been proposed to play a role in bipolar disorder are the mitochondria [47] and a sodium ATPase pump. [76] Circadian rhythms and regulation of the hormone melatonin also seem to be altered. [77]

Dopamine, a neurotransmitter responsible for mood cycling, has increased transmission during the manic phase. [24] [78] 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. [24] The depressive phase ends with homeostatic upregulation potentially restarting the cycle over again. [79] 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. [80]

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. [81] 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 [82] 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. [83] One review found no difference in monoamine levels, but found abnormal norepinephrine turnover in people with bipolar disorder. [84] 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. [85]

Bipolar disorder is commonly diagnosed during adolescence or early adulthood, but onset can occur throughout life. [5] [86] 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. [87] 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. [88] This work has influenced the upcoming eleventh revision of the ICD, which includes the various diagnoses within the bipolar spectrum of the DSM-V. [89]

Several rating scales for the screening and evaluation of bipolar disorder exist, [90] including the Bipolar spectrum diagnostic scale, Mood Disorder Questionnaire, the General Behavior Inventory and the Hypomania Checklist. [91] The use of evaluation scales cannot substitute a full clinical interview but they serve to systematize the recollection of symptoms. [91] On the other hand, instruments for screening bipolar disorder tend to have lower sensitivity. [90]

Differential diagnosis

Mental disorders that can have symptoms similar to those seen in bipolar disorder include schizophrenia, major depressive disorder, [92] attention deficit hyperactivity disorder (ADHD), and certain personality disorders, such as borderline personality disorder. [93] [94] [95] 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, those of the latter condition (more accurately called emotional dysregulation) are sudden and often short-lived, and secondary to social stressors. [96]

Although there are no biological tests that are diagnostic of bipolar disorder, [53] blood tests and/or imaging are carried out to investigate whether medical illnesses with clinical presentations similar to that of bipolar disorder are present before making a definitive diagnosis. Neurologic diseases such as multiple sclerosis, complex partial seizures, strokes, brain tumors, Wilson's disease, traumatic brain injury, Huntington's disease, and complex migraines can mimic features of bipolar disorder. [86] An EEG may be used to exclude neurological disorders such as epilepsy, and a CT scan or MRI of the head may be used to exclude brain lesions. [86] Additionally, disorders of the endocrine system such as hypothyroidism, hyperthyroidism, and Cushing's disease are in the differential as is the connective tissue disease systemic lupus erythematosus. Infectious causes of mania that may appear similar to bipolar mania include herpes encephalitis, HIV, influenza, or neurosyphilis. [86] Certain vitamin deficiencies such as pellagra (niacin deficiency), Vitamin B12 deficiency, folate deficiency, and Wernicke Korsakoff syndrome (thiamine deficiency) can also lead to mania. [86] Common medications that can cause manic symptoms include antidepressants, prednisone, Parkinson's disease medications, thyroid hormone, stimulants (including cocaine and methamphetamine), and certain antibiotics. [97]

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. [5] [86] [89] 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 bipolar spectrum is similar to that of Emil Kraepelin's original concept of manic depressive illness. [98] 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. [99]

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: [5] [89]

    : At least one manic episode is necessary to make the diagnosis [102] depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis. [25] 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] : No manic episodes and one or more hypomanic episodes and one or more major depressive episodes. [102] 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. : A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. [103]

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). [5] If the condition is thought to have a non-psychiatric medical cause, the diagnosis of bipolar and related disorder due to another medical condition is made, while substance/medication-induced bipolar and related disorder is used if a medication is thought to have triggered the condition. [104]

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. [105] 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 between 25.8%–45.3% of them at some point in their life. [37] [106] 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). [25] 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. [107] The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management. [108] People with the rapid cycling or ultradian subtypes of bipolar disorder tend to be more difficult to treat and less responsive to medications than other people with bipolar disorder. [109]

Children

In the 1920s, Kraepelin noted that manic episodes are rare before puberty. [110] 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. [110] [111] The diagnosis of childhood bipolar disorder, while formerly controversial, [112] has gained greater acceptance among childhood and adolescent psychiatrists. [113] American children and adolescents diagnosed with bipolar disorder in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while in outpatient clinics it doubled reaching 6%. [112] Studies using DSM criteria show that up to 1% of youth may have bipolar disorder. [110] 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, [114] distinct from irritability in bipolar disorder that is restricted to discrete mood episodes. [113]

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 to 0.5% in people over 65. Despite this, it is overrepresented in psychiatric admissions, making up 4 to 8% of inpatient admission to aged care psychiatry units, and the incidence of mood disorders is increasing overall with the aging population. Depressive episodes more commonly present with sleep disturbance, fatigue, hopelessness about the future, slowed thinking, and poor concentration and memory the last three symptoms are seen in what is known as pseudodementia. Clinical features also differ between those with late-onset bipolar disorder and those who developed it early in life the former group present with milder manic episodes, more prominent cognitive changes and have a background of worse psychosocial functioning, while the latter present more commonly with mixed affective episodes, [115] and have a stronger family history of illness. [116] Older people with bipolar disorder suffer cognitive changes, particularly in executive functions such as abstract thinking and switching cognitive sets, as well as concentrating for long periods and decision-making. [115]

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. [117] 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. [118] [119]

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. [12] 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 to deinstitutionalization, although these can still occur. [120] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or an Assertive Community Treatment team, supported employment, patient-led support groups, and intensive outpatient programs. These are sometimes referred to as partial-inpatient programs. [121]

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. [10] Cognitive behavioral therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge. [122] Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery. [123]

Medication

Medications may differ depending on what episode is being treated. [12] The medication with the best overall evidence is lithium, which is an effective treatment for acute manic episodes, preventing relapses, and bipolar depression. [124] [125] Lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder. [126] 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. [12] Mood stabilizers are used for long-term maintenance but have not demonstrated the ability to quickly treat acute bipolar depression. [109] It is unclear if ketamine (a common general dissociative anesthetic used in surgery) is useful in bipolar disorder. [127]

Mood stabilizers

Lithium and the anticonvulsants carbamazepine, lamotrigine, and valproic acid are classed as mood stabilizers due to their effect on the mood states in bipolar disorder. [109] Lithium is preferred for long-term mood stabilization, [61] although it erodes kidney and thyroid function over extended periods. [12] Valproate has become a commonly prescribed treatment and effectively treats manic episodes. [128] Carbamazepine is less effective in preventing relapse than lithium or valproate. [129] [130] Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression. [131] It has also been shown to have some benefit in preventing bipolar disorder relapses, though there are concerns about the studies done, and is of no benefit in rapid cycling subtype of bipolar disorder. [132] 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. [17] The effectiveness of topiramate is unknown. [133]

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. [61] Atypical antipsychotics are also indicated for bipolar depression refractory to treatment with mood stabilizers. [109] Olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium. [134] 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. [135] Carbamazepine effectively treats manic episodes, with some evidence it has greater benefit in rapid-cycling bipolar disorder, or those with more psychotic symptoms or more symptoms similar to that of schizoaffective disorder.

Antidepressants

Antidepressants are not recommended for use alone in the treatment of bipolar disorder and do not provide any benefit over mood stabilizers. [12] [136] Atypical antipsychotic 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. [109] Treatment of bipolar disorder using antidepressants carries a risk of affective switches where a person switches from depression to manic or hypomanic phases. [17] 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. [17] There is also a risk of accelerating cycling between phases when antidepressants are used in bipolar disorder. [17]

Other drugs

Short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective. [137] 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. [12]

Children

Treating bipolar disorder in children involves medication and psychotherapy. [112] Unfortunately, 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. [138] Mood stabilizers and atypical antipsychotics are commonly prescribed. [112] Among the former, lithium is the only compound approved by the FDA for children. [110] Psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy. [112] Long-term medication is often needed. [112]

Resistance to treatment

The occurrence of poor response to treatment in has given support to the concept of resistance to treatment in bipolar disorder. [139] [140] Guidelines to the definition of such treatment resistance and evidence-based options for its management were reviewed in 2020. [141]

A lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse, [37] [142] bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality. [142] 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] [38] When compared to the general population, people with bipolar disorder also have higher rates of other serious medical comorbidities including diabetes mellitus, respiratory diseases, HIV, and Hepatitis C virus infection. [143] 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. [90] [144]

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. [145] However, the types of medications used in treating BD commonly cause side effects [146] and more than 75% of individuals with BD inconsistently take their medications for various reasons. [145] 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. [37] Individuals diagnosed with bipolar who have a family history of bipolar disorder are at a greater risk for more frequent manic/hypomanic episodes. [147] Early onset and psychotic features are also associated with worse outcomes, [148] [149] as well as subtypes that are nonresponsive to lithium. [144]

Early recognition and intervention also improve prognosis as the symptoms in earlier stages are less severe and more responsive to treatment. [144] 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. [147]

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. [150] These include reduced attentional and executive capabilities and impaired memory. [151] 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. [146]

When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development. [113] Children and adolescents with bipolar disorder have higher rates of significant difficulties with substance abuse, psychosis, academic difficulties, behavioral problems, social difficulties, and legal problems. [113] 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. [152] 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. [144]

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. [153] 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] [154] 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. [154]

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. [155]

Symptoms preceding a relapse (prodromal), specially those related to mania, can be reliably identified by people with bipolar disorder. [156] There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results. [157]

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. [92] One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed. [41] The annual average suicide rate is 0.4%, which is 10–20 times that of the general population. [158] 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. [159] The lifetime risk of suicide has been estimated to be as high as 20% in those with bipolar disorder. [25]

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. [17]

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] [160] [161] 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. [162] 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. [163] Estimates vary about how many children and young adults have bipolar disorder. [113] These estimates range from 0.6 to 15% depending on differing settings, methods, and referral settings, raising suspicions of overdiagnosis. [113] 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. [113] Similar to adults, bipolar disorder in children and adolescents is thought to occur at a similar frequency in boys and girls. [113]

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 suffer limited validity. In addition, diagnoses (and therefore estimates of prevalence) vary depending on whether a categorical or spectrum approach is used. This consideration has led to concerns about the potential for both underdiagnosis and overdiagnosis. [164]

The incidence of bipolar disorder is similar in men and women [165] as well as across different cultures and ethnic groups. [166] 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. [167] Within the United States, Asian Americans have significantly lower rates than their African and European American counterparts. [168] 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. [169]

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. [170] 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: ​ [la fɔli siʁ.ky.lɛʁ] ) the lecture was summarized in 1851 in the "Gazette des hôpitaux" ("Hospital Gazette"). [2] 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 folie à double forme (French pronunciation: ​ [fɔli a dubl fɔʀm] , "madness in double form"). [2] [171] Baillarger's original paper, "De la folie à double forme," appeared in the medical journal Annales médico-psychologiques (Medico-psychological annals) in 1854. [2]

These concepts were developed by the German psychiatrist Emil Kraepelin (1856–1926), who, using Kahlbaum's concept of cyclothymia, [172] categorized and studied the natural course of untreated bipolar patients. He coined the term manic depressive psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally. [173]

The term "manic–depressive reaction" appeared in the first version of the DSM in 1952, influenced by the legacy of Adolf Meyer. [174] 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. [175] 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. [176] [177] [178]

The United States spent approximately $202.1 billion on people diagnosed with bipolar disorder I (excluding other subtypes of bipolar disorder and undiagnosed people) in 2015. [143] One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007. [180] [181] In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide. [19] 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. [182] The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs. [183]

Advocacy

There are widespread issues with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder. [184] 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. [185] 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. [185] 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. [186] [187] 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. [188] [189]

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). [190] 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, Jane Pauley, Demi Lovato, [185] and Selena Gomez. [191]

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), (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. [192] 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. [193] Psychiatrists have suggested that Willy Loman, the main character in Arthur Miller's classic play Death of a Salesman, has bipolar disorder. [194]

The 2009 drama 90210 featured a character, Silver, who was diagnosed with bipolar disorder. [195] Stacey Slater, a character from the BBC soap EastEnders, has been diagnosed with the disorder. The storyline was developed as part of the BBC's Headroom campaign. [196] The Channel 4 soap Brookside had earlier featured a story about bipolar disorder when the character Jimmy Corkhill was diagnosed with the condition. [197] 2011 Showtime's political thriller drama Homeland protagonist Carrie Mathison has bipolar disorder, which she has kept secret since her school days. [198] The 2014 ABC medical drama, Black Box, featured a world-renowned neuroscientist with bipolar disorder. [199] In the TV series Dave, the main character Dave, played by Lil Dicky who plays a fictionalized version of himself, is an aspiring rapper. Lil Dicky's real-life hype man GaTa plays himself. In an episode, after being off his medication and having an episode, GaTa tearfully confesses to having bipolar disorder and that was the reason for his episode. GaTa suffers from bipolar disorder in real life, but, as with his character in the show, is able to maintain it with medication. [200]

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. [201]

Research directions for bipolar disorder in children include optimizing treatments, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder and improving diagnostic criteria. [112] Some treatment research suggests that psychosocial interventions that involve the family, psychoeducation, and skills building (through therapies such as CBT, DBT, and IPSRT) can benefit in addition to pharmocotherapy. [138]

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  • Definitions from Wiktionary
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  • Textbooks from Wikibooks
  • Data from Wikidata

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Summary

Bipolar disorder is a recurrent chronic disorder characterised by fluctuations in mood state and energy. It affects more than 1% of the world's population irrespective of nationality, ethnic origin, or socioeconomic status. Bipolar disorder is one of the main causes of disability among young people, leading to cognitive and functional impairment and raised mortality, particularly death by suicide. A high prevalence of psychiatric and medical comorbidities is typical in affected individuals. Accurate diagnosis of bipolar disorder is difficult in clinical practice because onset is most commonly a depressive episode and looks similar to unipolar depression. Moreover, there are currently no valid biomarkers for the disorder. Therefore, the role of clinical assessment remains key. Detection of hypomanic periods and longitudinal assessment are crucial to differentiate bipolar disorder from other conditions. Current knowledge of the evolving pharmacological and psychological strategies in bipolar disorder is of utmost importance.