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Bipolar Disorder

General Information


  • bipolar disorder is a mood disorder characterized by recurrent episodes of abnormally and persistently elevated, expansive, or irritable mood and alternating or intertwining episodes of major depression1, 2, 4
    • mood episodes are accompanied by changes in activity or energy and associated with cognitive, physical, and behavioral symptoms
    • bipolar I disorder characterized by ≥ 1 episode of mania, with or without psychosis and/or major depression
    • bipolar II disorder characterized by ≥ 1 episode of major depression and at least 1 hypomanic episode, without episodes of mania

Also called

  • manic disorder
  • manic affective disorder
  • manic-depressive disorder
  • affective disorder (manic type)


  • Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) delineates specifiers that describe certain additional clinical features of bipolar disorder, including
    • rapid cycling1, 2, 3, 4
      • characterized by ≥ 4 episodes in 12 months that meet criteria for manic, hypomanic, or major depressive disorder
      • episodes are interspersed with periods of partial or full remission for ≥ 2 months or a switch to episode of opposite polarity
      • appears associated with a more severe prognosis, frequent and prolonged episodes, increased deaths by suicide, and additional comorbidity
    • mixed features4
      • requires ≥ 3 symptoms from opposite pole that occur during depressive, hypomanic, or manic episodes
        • for example, during hypomanic or manic episode: depressed mood, anhedonia, fatigue, feeling of worthlessness, recurrent thoughts of death, or psychomotor retardation occurring nearly every day
        • for example, during depressive episode: elevated mood, inflated self-esteem or grandiosity, more talkative than usual, racing thoughts, increased goal-oriented activities, or decreased need for sleep
    • anxious distress4
      • applied to patients with anxiety symptoms not otherwise part of bipolar diagnostic criteria
      • requires ≥ 2 symptoms that occur during depressive, hypomanic, or manic episodes
      • includes symptoms, such as, feeling tense, feeling restless, difficulty concentrating due to worry, fear that something bad may happen, or feeling that the individual might lose control of himself or herself
    • psychotic features4, 6
      • delusions more common than hallucinations
      • delusions or hallucinations can be mood congruent (consistent with episode polarity) or mood incongruent (inconsistent with episode polarity)
      • may be used per DSM-5 to distinguish mania and bipolar I disorder from hypomania and bipolar II disorder
    • melancholic features4
      • characterized by loss of pleasure in all, or almost all, activities or lack of reactivity to normally pleasurable stimuli in most severe period of current episode
      • requires presence of ≥ 3 symptoms in most severe period of current episode
        • anorexia or significant weight loss
        • depressed mood with profound despair and/or moroseness
        • early morning awakening (≥ 2 hours before usual awakening)
        • excessive or inappropriate guilt
        • significant psychomotor agitation or retardation
        • worsened morning depression
    • atypical features4
      • characterized by predominating features during current or most recent depressive episode
        • mood reactivity
        • requires ≥ 2 symptoms that include
          • hypersomnia
          • leaden paralysis
          • significant social or occupational impairment due to pattern of sensitivity to interpersonal rejection
          • significant weight gain or increase in appetite
    • seasonal pattern4
      • characterized by regular seasonal patterning of at least 1 type of episode (mania, hypomania, or depressive episode) in last 2 years, with no nonseasonal episodes of that polarity
      • seasonal patterns involve regular temporal relationships between episode onset and time of year
      • lifetime number of seasonal episodes of that polarity significantly greater than nonseasonal episodes
    • catatonia - episode of mania or depression with catatonic features present during a majority of the episode4
  • mixed state2
    • term used previously in DSM-IV-TR to describe concurrent depressed mood plus increased energy, restlessness, and racing thoughts
    • required full symptomatic criteria for a major depressive and a manic episode for ≥ 1 week, as opposed to the specifier in DSM-5, mixed features, which requires only 3 or more symptoms from opposite pole during the majority of days during the current episode
    • Reference - World J Biol Psychiatry 2018 Feb;19(1):2


  • bipolar spectrum disorders categorized in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) include1, 4
    • bipolar I disorder, characterized by at least 1 episode of mania or mixed episode with or without psychosis and/or major depression
    • bipolar II disorder, characterized by at least 1 episode of major depression and 1 hypomanic episode (not mania or mixed episode)
    • cyclothymic disorder, characterized by periods with hypomanic and depressive symptoms that do not meet criteria for hypomanic episode or major depression for at least 2 years
    • other specified bipolar and related disorder, characterized by bipolar-like disorders that do not meet criteria for bipolar I disorder, bipolar II disorder, or cyclothymia because of insufficient duration or severity
    • unspecified bipolar and related disorder, characterized by symptoms of bipolar and related disorders that do not meet full criteria for any category previously mentioned
    • substance/medication-induced bipolar and related disorder, in which mood disorder developed after substance intoxication or withdrawal, or after exposure to a medication capable of producing symptoms
    • bipolar and related disorder due to another medical condition, in which mood disorder developed as a direct pathophysiological consequence of another medical condition based on evidence from the history, physical examination, or laboratory findings


General references used

  1. Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72, commentary can be found in Lancet 2016 Aug 27;388(10047):868 and Lancet 2016 Aug 27;388(10047):869
  2. Price AL, Marzani-Nissen GR. Bipolar disorders: a review. Am Fam Physician. 2012 Mar 1;85(5):483-93full-text
  3. Saunders KE, Geddes JR. The management of bipolar disorder. Br J Hosp Med (Lond). 2016 Mar;77(3):175-9
  4. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018 Mar;20(2):97-170full-text
  5. National Institute for Health and Clinical Excellence (NICE). Bipolar disorder: assessment and management. NICE 2014 Sep:CG185PDF
  6. Mohammad O, Osser DN. The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania. Harv Rev Psychiatry. 2014 Sep-Oct;22(5):274-94
  7. Ansari A, Osser DN. The psychopharmacology algorithm project at the Harvard South Shore Program: an update on bipolar depression. Harv Rev Psychiatry. 2010 Jan-Feb;18(1):36-55

Recommendation grading systems used

  • American Psychiatric Association (APA) categories of recommendation
    • Category I - recommended with substantial clinical confidence
    • Category II - recommended with moderate clinical confidence
    • Category III - may be recommended on the basis of individual circumstances
    • Reference - APA 2010 practice guideline on treatment of patients with major depressive disorder, third edition (APA 2010 Nov PDF)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
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  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
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Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114738, Bipolar Disorder; [updated 2018 Dec 05, cited place cited date here]. Available from Registration and login required.


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