Bipolar disorder

An 1892 color lithograph depicting a woman diagnosed with hilarious mania

Also known as a manic episode, mania is a distinct period of at least one week of elevated or irritable mood, which can range from euphoria 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,[22] increased goal-oriented activities and impaired judgment—exhibition of behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending.[24][25][26] To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work.[24][26] If untreated, a manic episode usually lasts three to six months.[27]

In severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood.[26] 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.[28] This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital.[25][26] 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.[29]

The onset of a manic or depressive episode is often foreshadowed by sleep disturbance.[30] Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops. Manic individuals often have a history of substance abuse developed over years as a form of "self-medication".[31]

An 1858 lithograph captioned 'Melancholy passing into mania'

Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania,[26] 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.[24] Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some.[32] Hypomanic episodes rarely progress to full-blown manic episodes.[32] Some people who experience hypomania show increased creativity[26][33] 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.[26] 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.[34] If not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic, unless the mood changes are uncontrollable, or volatile.[32] Most commonly, symptoms continue for a few weeks to a few months.[35]

'Melancholy' by William Bagg, after a photograph by Hugh Welch Diamond

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.[36] 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.[37] 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.[38]

In bipolar disorder, a mixed state is an episode during which symptoms of both mania and depression occur simultaneously.[39] 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.[39] 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.[39] Anxiety disorders occur more frequently a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania.[39] Substance abuse (including alcohol) also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance abuse.[39]

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.[31][36][40][41] 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.[42] Children of parents with bipolar disorder more frequently have other mental health problems.[43]

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]

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.[40] 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.[24]

Although the first genetic linkage finding for mania was in 1969,[48] linkage studies have been inconsistent.[24] Findings point strongly to heterogeneity, with different genes implicated in different families.[49] 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.[40][50] 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.[50] 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.[51] On the other hand, two polymorphisms in TPH2 were identified as being associated with bipolar disorder.[52]

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,[53] cardiac hypertrophy signaling, Wnt signaling, Notch signaling,[54] 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.[55]

Bipolar disorder is associated with reduced expression of specific DNA repair enzymes and increased levels of oxidative DNA damages.[56]

Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions.[57] Recent life events and interpersonal relationships likely contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression.[58] 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.[59] 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.[60] Acutely, mania can be induced by sleep deprivation in around 30% of people with bipolar disorder.[61]

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.[62]

Mental disorders that can have symptoms similar to those seen in bipolar disorder include schizophrenia, major depressive disorder,[89] attention deficit hyperactivity disorder (ADHD), and certain personality disorders, such as borderline personality disorder.[90][91][92] 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.[93]

Although there are no biological tests that are diagnostic of bipolar disorder,[50] 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.[83] 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.[83] 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.[83] Certain vitamin deficiencies such as pellagra (niacin deficiency), Vitamin B12 deficiency, folate deficiency, and Wernicke Korsakoff syndrome (thiamine deficiency) can also lead to mania.[83] Common medications that can cause manic symptoms include antidepressants, prednisone, Parkinson's disease medications, thyroid hormone, stimulants (including cocaine and methamphetamine), and certain antibiotics.[94]

Since Emil Kraepelin's distinction between bipolar disorder and schizophrenia in the 19th century, researchers have defined a spectrum of different types of bipolar disorder.

Bipolar spectrum disorders include: bipolar I disorder, bipolar II disorder, cyclothymic disorder and cases where subthreshold symptoms are found to cause clinically significant impairment or distress.[5][83][86] 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.[95] 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.[96]

Simplified graphical comparison of bipolar I, bipolar II and cyclothymia[97][98]^:267

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][86]

• Bipolar I disorder: At least one manic episode is necessary to make the diagnosis;[99] depressive episodes are common in the vast majority of cases with bipolar disorder I, but are unnecessary for the diagnosis.[24] Specifiers such as "mild, moderate, moderate-severe, severe" and "with psychotic features" should be added as applicable to indicate the presentation and course of the disorder.[5]
• Bipolar II disorder: No manic episodes and one or more hypomanic episodes and one or more major depressive episode.[99] Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as periods of successful high productivity and are reported less frequently than a distressing, crippling depression.
• Cyclothymia: A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes.[100]

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 provide an explanation for 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.[101]

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.[102] 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.[36][103] 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).[24] 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.[104] The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management.[105] 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.[106]

Lithium is the only medication approved by the FDA for treating mania in children.

In the 1920s, Kraepelin noted that manic episodes are rare before puberty.[107] 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.[107][108] The diagnosis of childhood bipolar disorder, while formerly controversial,[109] has gained greater acceptance among childhood and adolescent psychiatrists.[110] 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%.[109] Studies using DSM criteria show that up to 1% of youth may have bipolar disorder.[107] 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,[111] distinct from irritability in bipolar disorder that is restricted to discrete mood episodes.[110]

Bipolar disorder is uncommon in older patients, with measured lifetime prevalence of 1% in over 60s and 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,[112] and have a stronger family history of illness.[113] 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.[112]

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.[117] Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.[118]

Lithium is often used to treat bipolar disorder and has the best evidence for reducing suicide.

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.[119][120] Lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder.[121] 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.[106] It is unclear if ketamine (a common general dissociative anesthetic used in surgery) is useful in bipolar disorder.[122]

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.[106] Lithium is preferred for long-term mood stabilization,[58] although it erodes kidney and thyroid function over extended periods.[12] Valproate has become a commonly prescribed treatment and effectively treats manic episodes.[123] Carbamazepine is less effective in preventing relapse than lithium or valproate.[124][125] Lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression.[126] 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.[127] 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.[128]

Antipsychotic medications are effective for short-term treatment of bipolar manic episodes and appear to be superior to lithium and anticonvulsants for this purpose.[58] Atypical antipsychotics are also indicated for bipolar depression refractory to treatment with mood stabilizers.[106] Olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium.[129] 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.[130] 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 are not recommended for use alone in the treatment of bipolar disorder and have not been found to be of any benefit over mood stabilizers.[12][131] 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.[106] 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]

Short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective.[132] 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]

Treating bipolar disorder in children involves medication and psychotherapy.[109] 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.[133] Mood stabilizers and atypical antipsychotics are commonly prescribed.[109] Among the former, lithium is the only compound approved by the FDA for children.[107] Psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy.[109] Long-term medication is often needed.[109]

Changes in cognitive processes and abilities are seen in mood disorders, with those of bipolar disorder being greater than those in major depressive disorder.[142] These include reduced attentional and executive capabilities and impaired memory.[143] 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.[138] When bipolar disorder occurs in children, it severely and adversely affects their psychosocial development.[110] 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.[110] 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.[144] 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.[136]

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.[145] 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][146] However, the course of illness (duration, age of onset, number of hospitalizations, and 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.[146]

A naturalistic study from 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.[147]

Symptoms preceding a relapse (prodromal), specially those related to mania, can be reliably identified by people with bipolar disorder.[148] There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results.[149]

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.[89] One out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed.[40] The annual average suicide rate is 0.4%, which is 10–20 times that of the general population.[150] 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.[151] The lifetime risk of suicide has been estimated to be as high as 20% in those with bipolar disorder.[24]

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]

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.[135] One analysis estimated that the United Kingdom spent approximately £5.2 billion on the disorder in 2007.[172][173] In addition to the economic costs, bipolar disorder is a leading cause of disability and lost productivity worldwide.[18] 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.[174] The decrease in the productivity seen in those who care for people with bipolar disorder also significantly contributes to these costs.[175]

There are widespread issues with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder.[176] 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.[177] 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.[177] 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.[178][179] 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.[180][181]

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).[182] 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,[177] and Selena Gomez.[183]

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.[184] 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.[185] Psychiatrists have suggested that Willy Loman, the main character in Arthur Miller's classic play Death of a Salesman, has bipolar disorder.[186]

The 2009 drama 90210 featured a character, Silver, who was diagnosed with bipolar disorder.[187] 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.[188] The Channel 4 soap Brookside had earlier featured a story about bipolar disorder when the character Jimmy Corkhill was diagnosed with the condition.[189] 2011 Showtime's political thriller drama Homeland protagonist Carrie Mathison has bipolar disorder, which she has kept secret since her school days.[190] The 2014 ABC medical drama, Black Box, featured a world-renowned neuroscientist with bipolar disorder.[191] 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.[192]

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.[193]