Bipolar disorder is a recurrent mood illness defined by discrete episodes of mania or hypomania alternating with episodes of major depression, separated by intervals of relative wellness. About 2.8% of US adults meet criteria in a given year and roughly 4.4% over a lifetime, with a global prevalence near 1% for bipolar I and another 1-2% for bipolar II.
Bipolar disorder (ICD-10: F31; DSM-5-TR 296.xx) is a chronic episodic mood disorder characterized by at least one lifetime episode of mania (bipolar I) or hypomania plus a major depressive episode (bipolar II). A manic episode requires a distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased energy lasting at least 7 days or any duration requiring hospitalization, plus three or more of seven DSM-5-TR symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity or psychomotor agitation, and excessive involvement in high-risk pleasurable activities. Hypomania requires the same symptom cluster for at least 4 consecutive days but without psychotic features and without marked functional impairment. Bipolar depressive episodes meet the same criteria as unipolar major depression but more often feature hypersomnia, hyperphagia, leaden paralysis, and psychomotor retardation.
The key symptoms of Bipolar Disorder are: Distinct manic episodes of elevated, expansive, or irritable mood with increased energy lasting at least 7 days, often beginning abruptly and noticed first by family rather than the patient., Decreased need for sleep during mania — feeling rested after only 2-3 hours, sometimes going days without sleep while remaining energetic and goal-driven., Pressured rapid speech that is difficult to interrupt, flight of ideas with racing thoughts, and easy distractibility by irrelevant stimuli., Inflated self-esteem or grandiosity, which can reach delusional intensity (special powers, special mission, special identity) in severe mania with psychotic features., Excessive involvement in high-risk pleasurable activities during manic or hypomanic episodes — uncontrolled spending, sexual indiscretions, unwise investments, reckless driving, substance binges., Hypomanic episodes lasting 4 or more days that look like productive bursts of energy and creativity but are still abnormal for the patient and noticed by others; the patient often denies illness during hypomania., Major depressive episodes with hypersomnia, hyperphagia, leaden paralysis, anhedonia, slowed thinking, and intense fatigue — bipolar depression typically tilts toward retarded rather than agitated features..
Bipolar disorder is a clinical diagnosis built on a careful longitudinal mood history, collateral information from family or partners, and validated screening tools. The single most important diagnostic question is whether the patient has ever had a manic or hypomanic episode, because the average gap between first depressive episode and correct bipolar diagnosis is still 6-10 years. The Mood Disorder Questionnaire (MDQ, Hirschfeld 2000) is a 13-item self-report that screens for past hypomania or mania with 73% sensitivity and 90% specificity for bipolar I; the Hypomania Checklist (HCL-32) is more sensitive for bipolar II. The Composite International Diagnostic Interview and the Structured Clinical Interview for DSM-5 (SCID-5) are gold-standard structured interviews used in research and complex cases. DSM-5-TR requires that mania last at least 7 days (or any duration if hospitalization is required), and hypomania at least 4 days, with the symptom cluster representing a distinct change from baseline that is observable to others. Every patient presenting with depression should be specifically asked about past hypomania, family psychiatric history, postpartum episodes, antidepressant-induced switches, and substance-induced mood changes — these features substantially raise the prior probability of bipolarity. Medical mimics must be excluded: TSH for hyperthyroidism, complete metabolic panel, vitamin B12, urine toxicology, and HIV testing where appropriate. Brain imaging is not routinely required but is indicated for atypical presentations, late-onset cases, or neurological signs. Suicide-risk assessment using the Columbia Scale (C-SSRS) is mandatory at every visit. Once diagnosed, severity is rated with the Young Mania Rating Scale (YMRS) for mania and the Montgomery-Åsberg Depression Rating Scale (MADRS) or PHQ-9 for depression to track response to treatment.
With consistent maintenance treatment, most patients experience longer well intervals, fewer hospitalizations, and improved functional outcomes. Lithium reduces overall relapse by roughly 40% and suicide death by approximately 60% in long-term users (Cipriani 2013 BMJ meta-analysis). STEP-BD showed that 58% of patients reached recovery within 2 years, with adjunctive psychotherapy adding 25-40% relapse reduction over medication alone. Despite treatment advances, bipolar disorder remains a chronic relapsing illness — average lifetime episode count is 8-10 untreated, with shortening cycles. Lifetime suicide risk is 10-15% and lifetime attempt rate is 30-40%, the highest of any psychiatric illness. Predictors of better outcome include lithium response, early treatment initiation, stable sleep, social support, absence of substance use, and engagement with psychosocial treatment. Predictors of worse outcome include rapid cycling, mixed features, comorbid substance use, childhood adversity, and antidepressant-induced switching. Functional recovery often lags symptomatic recovery; cognitive remediation, supported employment, and family-focused therapy substantially improve real-world outcomes.
Bipolar disorder should be managed by a psychiatrist. Referral is essential for any suspected manic or hypomanic episode, any depressed patient who screens positive on the MDQ, postpartum patients with mood-disorder history, treatment-resistant depression, recurrent depression with atypical features, antidepressant-induced switching, suicidal ideation with bipolar features, and active substance use complicating mood. Primary care has an important continuity role for metabolic monitoring, lithium and valproate levels, and physical-health comorbidities, but treatment selection and adjustment is psychiatry-led.
Find specialists →Acute mania typically responds within 1-3 weeks once an effective agent reaches therapeutic level — lithium effects begin at week 1-2 and peak by week 4; antipsychotic effects begin within days. Acute bipolar depression usually responds over 4-8 weeks with quetiapine, lurasidone, or cariprazine. Functional recovery typically lags symptom remission by 3-6 months and may take longer when cognitive symptoms persist. Maintenance treatment is recommended indefinitely after a single severe manic episode and after two or more episodes of any polarity. Lithium discontinuation, even after years of stability, is associated with relapse in roughly 50% within 6 months and a rebound elevation in suicide risk; any discontinuation should be gradual and supervised.
Aim for 30-45 minutes of moderate-intensity aerobic exercise 3-5 days per week, plus resistance training twice weekly. Exercise supports mood, sleep, and cardiometabolic health, which is particularly important on antipsychotics. During acute mania, exercise should be limited and supervised because patients may push to dangerous extremes; during severe depression, even short walks help. Group-based or routine-anchored exercise reinforces social-rhythm stability.
Look for board certification by the American Board of Psychiatry and Neurology (ABPN), explicit experience with bipolar disorder rather than only depression, comfort with lithium dosing and monitoring, and familiarity with antipsychotic metabolic monitoring. Integrated behavioral-health programs with psychiatry plus therapy plus care management improve adherence and outcomes. For severe or refractory illness, academic-medical-center programs with ECT, ketamine, and clinical-trial access offer the full spectrum. Continuity over years matters more than prestige; the patient-clinician alliance is the strongest predictor of long-term outcome.
Medically reviewed by AIHealz Medical Editorial Board · May 12, 2026
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