Bipolar disorder
| Bipolar disorder | |
|---|---|
| Other names | Bipolar affective disorder (BPAD), bipolar illness, manic depression, manic depressive disorder, manic–depressive illness (historical), manic–depressive psychosis |
 | |
| Bipolar disorder is characterized by episodes of mania or hypomania and depression. | |
| Specialty | Psychiatry, clinical psychology |
| Symptoms | Periods of depression and elevated mood |
| Complications | Suicide, self harm, social, legal and financial problems, higher risk of diabetes mellitus, heart disease and STIs, cognitive impairment |
| Usual onset | 20s or 40s |
| Types | Bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise specified, others |
| Causes | Environmental and genetic |
| Risk factors | Family history, child abuse, long-term stress |
| Differential diagnosis | Attention deficit hyperactivity disorder, autism, personality disorders, schizophrenia, substance use disorder, post-traumatic stress disorder |
| Treatment | Psychotherapy, medications |
| Medication | Lithium, antipsychotics, anticonvulsants |
| Frequency | 1% per 6–12 months; 1–3% lifetime |
| Deaths | 11.7 times higher risk of death by suicide |
Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of depression and abnormally elevated mood, lasting days to weeks, and in some cases months. If the elevated mood is severe or associated with psychosis, it is called mania; if it does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy, or irritable, and often makes impulsive and reckless decisions. There is usually sleep disturbance during manic phases. During periods of depression, the individual may experience crying, have a negative outlook, and demonstrate poor eye contact. People with BD are at 11.7 times greater risk of dying by suicide than the general population. Approximately 34% attempt suicide during their lifetime. Among adolescents with BD, 78% engaged in self-harm.
The mechanisms of this mood disorder are not clearly understood, although some studies suggest areas for future clinical research. Structural and functional MRI studies have shown differences in brain regions in BD, such as regions involved in perceiving risk-reward and regulating emotions. A systematic review and meta-analysis by Murri and others found that cortisol levels are "associated with the manic phase" of BD. Likewise, various other studies support an important role for hypothalamic-pituitary-adrenal axis (HPA axis).
Risk for BD is thought to be influenced by genetics, environment, and ADHD. In one respect (heritability), genetic factors may account for up to 70–90% of the risk of developing BD. In another respect (concordance rate), identical twins both have bipolar disorder (or both do not) at a rate of ~40%, in contrast to dizygotic twins' ~5%. Environmental risks include a history of child abuse and long-term stress. A meta-analysis and a separate critical literature review have found worse prognosis and earlier onset of BD in people with childhood maltreatment and "early emotional trauma" respectively. Likewise, traumatic bonding increases risk of BD. ADHD increases the risk of developing bipolar disorder. More research is needed to understand the nature of this association.
The condition is classified as bipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and as bipolar II disorder if there has been at least one hypomanic episode (but no full manic episodes) and one major depressive episode. It is classified as cyclothymia if there are hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes. If these symptoms are due to drugs or medical problems, they are not diagnosed as BD.
Mood stabilizers, particularly lithium, and anticonvulsants, such as lamotrigine and valproate, as well as atypical antipsychotics are used for treatment. Atypical antipsychotics are used for acute manic episodes or when mood stabilizers are ineffective or not tolerated, with long-acting injectables available for patients who struggle to maintain a medication regimen. There is evidence that psychotherapy improves the course of BD. Use of antidepressants in depressive episodes is controversial: they can be effective, but certain classes of antidepressants increase the risk of mania. The treatment of depressive episodes, therefore, is often difficult. Past studies have found that electroconvulsive therapy (ECT) is effective in acute manic and depressive episodes, particularly with psychosis or catatonia; likewise, past guidelines have recommended admission to a psychiatric hospital if someone is a risk to themselves or others, or involuntary treatment if someone refuses treatment. However, the Committee on Rights of Persons with Disabilities (CRPD) of the United Nations has recommended the abolition of institutionalization and forced treatments "such as sedatives, mood stabilizers, electro-convulsive treatment, and conversion therapy".
The 6–12 month prevalence of bipolar disorder is 1%, while the lifetime prevalence is between 1 and 3%. The prevalence of pediatric bipolar disorder is 3.9%, although study estimates are higher with "broad bipolar criteria" and "older minimum age". The most frequent ages of onset are 24 or 46; the distribution of onset age is bimodal. An earlier onset is associated with worse depression and more frequent co-diagnosis of anxiety and substance use. Around 40–60% of people with BD are employed and over 80% "may take time off work for psychiatric reasons in a five year period." Occupational therapies appear cost-effective at returning people with BD to work. Social cognition is moderately impaired in people with BD, regardless of mood state. 16% of people with BD are high functioning. As of 2021, people with BD accounted for 183 Years Lived with Disability (YLDs) per 100,000 people in the Americas (ranking 20th out of all conditions). Risk of death due to unnatural and natural causes is 7.3 and 1.9 times higher respectively. On average, life expectancy is 12.9 years shorter.