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Bipolar disorder in adults: Clinical features

Trisha Suppes, MD
Section Editor
Paul Keck, MD
Deputy Editor
David Solomon, MD


Bipolar disorder frequently disrupts mood, energy, activity, sleep, cognition, and behavior [1], and patients thus struggle to maintain employment and interpersonal relationships [2-4]. Pharmacotherapy within the context of a positive therapeutic alliance is central to minimizing morbidity and the risk of suicide.

This topic reviews the clinical features of bipolar disorder in adults. The assessment, diagnosis, and treatment of bipolar disorder in adults are discussed separately, as are the clinical features and diagnosis of bipolar disorder in children and adolescents, geriatric patients, and patients with rapid cycling (ie, four or more mood episodes in a 12-month period):

(See "Bipolar disorder in adults: Assessment and diagnosis".)

(See "Bipolar disorder in adults: Pharmacotherapy for acute depression".)

(See "Bipolar disorder in adults: Choosing pharmacotherapy for acute mania and hypomania".)

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Literature review current through: Nov 2017. | This topic last updated: Sep 15, 2017.
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  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Goldberg JF, Harrow M, Grossman LS. Recurrent affective syndromes in bipolar and unipolar mood disorders at follow-up. Br J Psychiatry 1995; 166:382.
  3. Goldberg JF, Harrow M, Grossman LS. Course and outcome in bipolar affective disorder: a longitudinal follow-up study. Am J Psychiatry 1995; 152:379.
  4. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003; 64:161.
  5. Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd edition, Oxford University Press, New York 2007.
  6. Sylvia LG, Dupuy JM, Ostacher MJ, et al. Sleep disturbance in euthymic bipolar patients. J Psychopharmacol 2012; 26:1108.
  7. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
  8. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
  9. Perlis RH, Ostacher MJ, Goldberg JF, et al. Transition to mania during treatment of bipolar depression. Neuropsychopharmacology 2010; 35:2545.
  10. Baldessarini RJ, Tondo L, Visioli C. First-episode types in bipolar disorder: predictive associations with later illness. Acta Psychiatr Scand 2014; 129:383.
  11. Kupfer DJ, Frank E, Grochocinski VJ, et al. Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry 2002; 63:120.
  12. Skjelstad DV, Malt UF, Holte A. Symptoms and signs of the initial prodrome of bipolar disorder: a systematic review. J Affect Disord 2010; 126:1.
  13. Howes OD, Lim S, Theologos G, et al. A comprehensive review and model of putative prodromal features of bipolar affective disorder. Psychol Med 2011; 41:1567.
  14. Bauer M, Juckel G, Correll CU, et al. Diagnosis and treatment in the early illness phase of bipolar disorders. Eur Arch Psychiatry Clin Neurosci 2008; 258 Suppl 5:50.
  15. Mitchell PB, Loo CK, Gould BM. Diagnosis and monitoring of bipolar disorder in general practice. Med J Aust 2010; 193:S10.
  16. Mathias de Almeida K, Nery FG, Moreno RA, et al. A sib-pair analysis of impulsivity in bipolar disorder type I. Compr Psychiatry 2013; 54:1148.
  17. Agrawal A, Nurnberger JI Jr, Lynskey MT. Item response modeling of DSM-IV mania symptoms in two representative US epidemiological samples. Psychol Med 2010; 40:1549.
  18. Carragher N, Weinstock LM, Strong D. Psychometric evaluation of the DSM-IV criterion B mania symptoms in an Australian national sample. Psychol Med 2013; 43:433.
  19. King MJ, MacDougall AG, Ferris S, et al. Impaired episodic memory for events encoded during mania in patients with bipolar disorder. Psychiatry Res 2013; 205:213.
  20. Peele PB, Xu Y, Kupfer DJ. Insurance expenditures on bipolar disorder: clinical and parity implications. Am J Psychiatry 2003; 160:1286.
  21. Ghaemi SN, Stoll AL, Pope HG Jr. Lack of insight in bipolar disorder. The acute manic episode. J Nerv Ment Dis 1995; 183:464.
  22. Dell'Osso L, Pini S, Cassano GB, et al. Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disord 2002; 4:315.
  23. Pini S, Cassano GB, Dell'Osso L, Amador XF. Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features. Am J Psychiatry 2001; 158:122.
  24. Solomon DA, Leon AC, Coryell WH, et al. Longitudinal course of bipolar I disorder: duration of mood episodes. Arch Gen Psychiatry 2010; 67:339.
  25. Benazzi F. Bipolar disorder--focus on bipolar II disorder and mixed depression. Lancet 2007; 369:935.
  26. Casper RC, Redmond DE Jr, Katz MM, et al. Somatic symptoms in primary affective disorder. Presence and relationship to the classification of depression. Arch Gen Psychiatry 1985; 42:1098.
  27. Post RM, Leverich GS, Nolen WA, et al. A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation Bipolar Network. Bipolar Disord 2003; 5:396.
  28. De Dios C, Ezquiaga E, Garcia A, et al. Time spent with symptoms in a cohort of bipolar disorder outpatients in Spain: a prospective, 18-month follow-up study. J Affect Disord 2010; 125:74.
  29. Perlis RH, Ostacher MJ, Uher R, et al. Stability of symptoms across major depressive episodes in bipolar disorder. Bipolar Disord 2009; 11:867.
  30. Azorin JM, Baraille L, Gérard S, et al. Mixed states with predominant manic or depressive symptoms: baseline characteristics and 24-month outcomes of the EMBLEM cohort. J Affect Disord 2013; 146:369.
  31. Swann AC, Lafer B, Perugi G, et al. Bipolar mixed states: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. Am J Psychiatry 2013; 170:31.
  32. Goldberg JF, Perlis RH, Bowden CL, et al. Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 2009; 166:173.
  33. Suppes T, Mintz J, McElroy SL, et al. Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Network: a sex-specific phenomenon. Arch Gen Psychiatry 2005; 62:1089.
  34. Judd LL, Schettler PJ, Akiskal H, et al. Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord 2012; 138:440.
  35. Angst J, Cui L, Swendsen J, et al. Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Am J Psychiatry 2010; 167:1194.
  36. McIntyre RS, Soczynska JK, Cha DS, et al. The prevalence and illness characteristics of DSM-5-defined "mixed feature specifier" in adults with major depressive disorder and bipolar disorder: Results from the International Mood Disorders Collaborative Project. J Affect Disord 2015; 172:259.
  37. McElroy SL, Keck PE Jr, Pope HG Jr, et al. Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry 1992; 149:1633.
  38. Swann AC, Bowden CL, Morris D, et al. Depression during mania. Treatment response to lithium or divalproex. Arch Gen Psychiatry 1997; 54:37.
  39. Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. JAMA 1994; 271:918.
  40. Keck PE Jr, McElroy SL, Havens JR, et al. Psychosis in bipolar disorder: phenomenology and impact on morbidity and course of illness. Compr Psychiatry 2003; 44:263.
  41. Dell'Osso L, Pini S, Tundo A, et al. Clinical characteristics of mania, mixed mania, and bipolar depression with psychotic features. Compr Psychiatry 2000; 41:242.
  42. Black DW, Nasrallah A. Hallucinations and delusions in 1,715 patients with unipolar and bipolar affective disorders. Psychopathology 1989; 22:28.
  43. Ostergaard SD, Bertelsen A, Nielsen J, et al. The association between psychotic mania, psychotic depression and mixed affective episodes among 14,529 patients with bipolar disorder. J Affect Disord 2013; 147:44.
  44. Tohen M, Waternaux CM, Tsuang MT. Outcome in Mania. A 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry 1990; 47:1106.
  45. Coryell W, Leon AC, Turvey C, et al. The significance of psychotic features in manic episodes: a report from the NIMH collaborative study. J Affect Disord 2001; 67:79.
  46. Harrow M, Goldberg JF, Grossman LS, Meltzer HY. Outcome in manic disorders. A naturalistic follow-up study. Arch Gen Psychiatry 1990; 47:665.
  47. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007; 64:543.
  48. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
  49. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 2011; 68:241.
  50. Subramaniam M, Abdin E, Vaingankar JA, Chong SA. Prevalence, correlates, comorbidity and severity of bipolar disorder: results from the Singapore Mental Health Study. J Affect Disord 2013; 146:189.
  51. McIntyre RS, Soczynska JK, Bottas A, et al. Anxiety disorders and bipolar disorder: a review. Bipolar Disord 2006; 8:665.
  52. Simon NM, Otto MW, Wisniewski SR, et al. Anxiety disorder comorbidity in bipolar disorder patients: data from the first 500 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry 2004; 161:2222.
  53. Goes FS, McCusker MG, Bienvenu OJ, et al. Co-morbid anxiety disorders in bipolar disorder and major depression: familial aggregation and clinical characteristics of co-morbid panic disorder, social phobia, specific phobia and obsessive-compulsive disorder. Psychol Med 2012; 42:1449.
  54. Otto MW, Simon NM, Wisniewski SR, et al. Prospective 12-month course of bipolar disorder in out-patients with and without comorbid anxiety disorders. Br J Psychiatry 2006; 189:20.
  55. Sala R, Goldstein BI, Morcillo C, et al. Course of comorbid anxiety disorders among adults with bipolar disorder in the U.S. population. J Psychiatr Res 2012; 46:865.
  56. Quarantini LC, Miranda-Scippa A, Nery-Fernandes F, et al. The impact of comorbid posttraumatic stress disorder on bipolar disorder patients. J Affect Disord 2010; 123:71.
  57. Simon NM. Generalized anxiety disorder and psychiatric comorbidities such as depression, bipolar disorder, and substance abuse. J Clin Psychiatry 2009; 70 Suppl 2:10.
  58. Bellani M, Hatch JP, Nicoletti MA, et al. Does anxiety increase impulsivity in patients with bipolar disorder or major depressive disorder? J Psychiatr Res 2012; 46:616.
  59. Hawton K, Sutton L, Haw C, et al. Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J Clin Psychiatry 2005; 66:693.
  60. Neves FS, Malloy-Diniz LF, Corrêa H. Suicidal behavior in bipolar disorder: what is the influence of psychiatric comorbidities? J Clin Psychiatry 2009; 70:13.
  61. Simon GE, Hunkeler E, Fireman B, et al. Risk of suicide attempt and suicide death in patients treated for bipolar disorder. Bipolar Disord 2007; 9:526.
  62. Nierenberg AA, Miyahara S, Spencer T, et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry 2005; 57:1467.
  63. Klassen LJ, Katzman MA, Chokka P. Adult ADHD and its comorbidities, with a focus on bipolar disorder. J Affect Disord 2010; 124:1.
  64. McIntyre RS, Kennedy SH, Soczynska JK, et al. Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project. Prim Care Companion J Clin Psychiatry 2010; 12.
  65. Rydén E, Thase ME, Stråht D, et al. A history of childhood attention-deficit hyperactivity disorder (ADHD) impacts clinical outcome in adult bipolar patients regardless of current ADHD. Acta Psychiatr Scand 2009; 120:239.
  66. McElroy SL, Frye MA, Hellemann G, et al. Prevalence and correlates of eating disorders in 875 patients with bipolar disorder. J Affect Disord 2011; 128:191.
  67. McElroy SL, Crow S, Biernacka JM, et al. Clinical phenotype of bipolar disorder with comorbid binge eating disorder. J Affect Disord 2013; 150:981.
  68. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348.
  69. Brietzke E, Moreira CL, Toniolo RA, Lafer B. Clinical correlates of eating disorder comorbidity in women with bipolar disorder type I. J Affect Disord 2011; 130:162.
  70. Wildes JE, Marcus MD, Fagiolini A. Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder. Psychiatry Res 2008; 161:51.
  71. Amerio A, Stubbs B, Odone A, et al. The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review and meta-analysis. J Affect Disord 2015; 186:99.
  72. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 62:553.
  73. Fan AH, Hassell J. Bipolar disorder and comorbid personality psychopathology: a review of the literature. J Clin Psychiatry 2008; 69:1794.
  74. Friborg O, Martinsen EW, Martinussen M, et al. Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010. J Affect Disord 2014; 152-154:1.
  75. Swartz HA, Pilkonis PA, Frank E, et al. Acute treatment outcomes in patients with bipolar I disorder and co-morbid borderline personality disorder receiving medication and psychotherapy. Bipolar Disord 2005; 7:192.
  76. George EL, Miklowitz DJ, Richards JA, et al. The comorbidity of bipolar disorder and axis II personality disorders: prevalence and clinical correlates. Bipolar Disord 2003; 5:115.
  77. Greenwood TA, Badner JA, Byerley W, et al. Heritability and linkage analysis of personality in bipolar disorder. J Affect Disord 2013; 151:748.
  78. McDermid J, Sareen J, El-Gabalawy R, et al. Co-morbidity of bipolar disorder and borderline personality disorder: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Compr Psychiatry 2015; 58:18.
  79. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264:2511.
  80. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA 2000; 284:2606.
  81. Frye MA, Salloum IM. Bipolar disorder and comorbid alcoholism: prevalence rate and treatment considerations. Bipolar Disord 2006; 8:677.
  82. Kawa I, Carter JD, Joyce PR, et al. Gender differences in bipolar disorder: age of onset, course, comorbidity, and symptom presentation. Bipolar Disord 2005; 7:119.
  83. Ostacher MJ, Perlis RH, Nierenberg AA, et al. Impact of substance use disorders on recovery from episodes of depression in bipolar disorder patients: prospective data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry 2010; 167:289.
  84. Swann AC. The strong relationship between bipolar and substance-use disorder. Ann N Y Acad Sci 2010; 1187:276.
  85. Gaudiano BA, Uebelacker LA, Miller IW. Impact of remitted substance use disorders on the future course of bipolar I disorder: findings from a clinical trial. Psychiatry Res 2008; 160:63.
  86. Hoblyn JC, Balt SL, Woodard SA, Brooks JO 3rd. Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatr Serv 2009; 60:50.
  87. Goldstein BI, Levitt AJ. A gender-focused perspective on health service utilization in comorbid bipolar I disorder and alcohol use disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2006; 67:925.
  88. Weiss RD, Ostacher MJ, Otto MW, et al. Does recovery from substance use disorder matter in patients with bipolar disorder? J Clin Psychiatry 2005; 66:730.
  89. Goldstein BI, Levitt AJ. The specific burden of comorbid anxiety disorders and of substance use disorders in bipolar I disorder. Bipolar Disord 2008; 10:67.
  90. Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring cannabis use disorders on the course of bipolar disorder after a first hospitalization for mania. Arch Gen Psychiatry 2007; 64:57.
  91. van Gorp WG, Altshuler L, Theberge DC, et al. Cognitive impairment in euthymic bipolar patients with and without prior alcohol dependence. A preliminary study. Arch Gen Psychiatry 1998; 55:41.
  92. Mazza M, Mandelli L, Di Nicola M, et al. Clinical features, response to treatment and functional outcome of bipolar disorder patients with and without co-occurring substance use disorder: 1-year follow-up. J Affect Disord 2009; 115:27.
  93. Kilbourne AM, Perron BE, Mezuk B, et al. Co-occurring conditions and health-related quality of life in patients with bipolar disorder. Psychosom Med 2009; 71:894.
  94. Singh J, Mattoo SK, Sharan P, Basu D. Quality of life and its correlates in patients with dual diagnosis of bipolar affective disorder and substance dependence. Bipolar Disord 2005; 7:187.
  95. Grunebaum MF, Galfalvy HC, Nichols CM, et al. Aggression and substance abuse in bipolar disorder. Bipolar Disord 2006; 8:496.
  96. McDermott BE, Quanbeck CD, Frye MA. Comorbid substance use disorder in women with bipolar disorder associated with criminal arrest. Bipolar Disord 2007; 9:536.
  97. Vornik LA, Brown ES. Management of comorbid bipolar disorder and substance abuse. J Clin Psychiatry 2006; 67 Suppl 7:24.
  98. Brown ES. Bipolar disorder and substance abuse. Psychiatr Clin North Am 2005; 28:415.
  99. McIntyre RS, Konarski JZ, Soczynska JK, et al. Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization. Psychiatr Serv 2006; 57:1140.
  100. Perron BE, Howard MO, Nienhuis JK, et al. Prevalence and burden of general medical conditions among adults with bipolar I disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2009; 70:1407.
  101. Leboyer M, Soreca I, Scott J, et al. Can bipolar disorder be viewed as a multi-system inflammatory disease? J Affect Disord 2012; 141:1.
  102. Kilbourne AM, Cornelius JR, Han X, et al. Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord 2004; 6:368.
  103. Carney CP, Jones LE. Medical comorbidity in women and men with bipolar disorders: a population-based controlled study. Psychosom Med 2006; 68:684.
  104. Matthews AM, Huckans MS, Blackwell AD, Hauser P. Hepatitis C testing and infection rates in bipolar patients with and without comorbid substance use disorders. Bipolar Disord 2008; 10:266.
  105. Regenold WT, Thapar RK, Marano C, et al. Increased prevalence of type 2 diabetes mellitus among psychiatric inpatients with bipolar I affective and schizoaffective disorders independent of psychotropic drug use. J Affect Disord 2002; 70:19.
  106. Goldstein BI, Liu SM, Zivkovic N, et al. The burden of obesity among adults with bipolar disorder in the United States. Bipolar Disord 2011; 13:387.
  107. McIntyre RS, Danilewitz M, Liauw SS, et al. Bipolar disorder and metabolic syndrome: an international perspective. J Affect Disord 2010; 126:366.
  108. Gurpegui M, Martínez-Ortega JM, Gutiérrez-Rojas L, et al. Overweight and obesity in patients with bipolar disorder or schizophrenia compared with a non-psychiatric sample. Prog Neuropsychopharmacol Biol Psychiatry 2012; 37:169.
  109. Goldstein BI, Fagiolini A, Houck P, Kupfer DJ. Cardiovascular disease and hypertension among adults with bipolar I disorder in the United States. Bipolar Disord 2009; 11:657.
  110. McIntyre RS, Konarski JZ, Wilkins K, et al. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache 2006; 46:973.
  111. Kemp DE, Gao K, Chan PK, et al. Medical comorbidity in bipolar disorder: relationship between illnesses of the endocrine/metabolic system and treatment outcome. Bipolar Disord 2010; 12:404.
  112. Kilbourne AM. The burden of general medical conditions in patients with bipolar disorder. Curr Psychiatry Rep 2005; 7:471.
  113. Fagiolini A, Goracci A. The effects of undertreated chronic medical illnesses in patients with severe mental disorders. J Clin Psychiatry 2009; 70 Suppl 3:22.
  114. Magalhães PV, Kapczinski F, Nierenberg AA, et al. Illness burden and medical comorbidity in the Systematic Treatment Enhancement Program for Bipolar Disorder. Acta Psychiatr Scand 2012; 125:303.
  115. Thompson WK, Kupfer DJ, Fagiolini A, et al. Prevalence and clinical correlates of medical comorbidities in patients with bipolar I disorder: analysis of acute-phase data from a randomized controlled trial. J Clin Psychiatry 2006; 67:783.
  116. Soreca I, Fagiolini A, Frank E, et al. Relationship of general medical burden, duration of illness and age in patients with bipolar I disorder. J Psychiatr Res 2008; 42:956.
  117. Fagiolini A, Frank E, Houck PR, et al. Prevalence of obesity and weight change during treatment in patients with bipolar I disorder. J Clin Psychiatry 2002; 63:528.
  118. Fagiolini A, Kupfer DJ, Houck PR, et al. Obesity as a correlate of outcome in patients with bipolar I disorder. Am J Psychiatry 2003; 160:112.
  119. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Compr Psychiatry 2012; 53:809.
  120. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disord 2010; 12:397.
  121. Fagiolini A, Frank E, Scott JA, et al. Metabolic syndrome in bipolar disorder: findings from the Bipolar Disorder Center for Pennsylvanians. Bipolar Disord 2005; 7:424.
  122. Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry 2013; 70:931.
  123. Arts B, Jabben N, Krabbendam L, van Os J. Meta-analyses of cognitive functioning in euthymic bipolar patients and their first-degree relatives. Psychol Med 2008; 38:771.
  124. Mann-Wrobel MC, Carreno JT, Dickinson D. Meta-analysis of neuropsychological functioning in euthymic bipolar disorder: an update and investigation of moderator variables. Bipolar Disord 2011; 13:334.
  125. Robinson LJ, Thompson JM, Gallagher P, et al. A meta-analysis of cognitive deficits in euthymic patients with bipolar disorder. J Affect Disord 2006; 93:105.
  126. Kurtz MM, Gerraty RT. A meta-analytic investigation of neurocognitive deficits in bipolar illness: profile and effects of clinical state. Neuropsychology 2009; 23:551.
  127. Bora E, Yucel M, Pantelis C. Cognitive endophenotypes of bipolar disorder: a meta-analysis of neuropsychological deficits in euthymic patients and their first-degree relatives. J Affect Disord 2009; 113:1.
  128. Bourne C, Aydemir Ö, Balanzá-Martínez V, et al. Neuropsychological testing of cognitive impairment in euthymic bipolar disorder: an individual patient data meta-analysis. Acta Psychiatr Scand 2013; 128:149.
  129. Solé B, Martínez-Arán A, Torrent C, et al. Are bipolar II patients cognitively impaired? A systematic review. Psychol Med 2011; 41:1791.
  130. Bora E, Yücel M, Pantelis C, Berk M. Meta-analytic review of neurocognition in bipolar II disorder. Acta Psychiatr Scand 2011; 123:165.
  131. Hellvin T, Sundet K, Simonsen C, et al. Neurocognitive functioning in patients recently diagnosed with bipolar disorder. Bipolar Disord 2012; 14:227.
  132. Smith DJ, Muir WJ, Blackwood DH. Neurocognitive impairment in euthymic young adults with bipolar spectrum disorder and recurrent major depressive disorder. Bipolar Disord 2006; 8:40.
  133. Torres IJ, DeFreitas VG, DeFreitas CM, et al. Neurocognitive functioning in patients with bipolar I disorder recently recovered from a first manic episode. J Clin Psychiatry 2010; 71:1234.
  134. Mora E, Portella MJ, Forcada I, et al. Persistence of cognitive impairment and its negative impact on psychosocial functioning in lithium-treated, euthymic bipolar patients: a 6-year follow-up study. Psychol Med 2013; 43:1187.
  135. Samamé C, Martino DJ, Strejilevich SA. Longitudinal course of cognitive deficits in bipolar disorder: a meta-analytic study. J Affect Disord 2014; 164:130.
  136. Santos JL, Aparicio A, Bagney A, et al. A five-year follow-up study of neurocognitive functioning in bipolar disorder. Bipolar Disord 2014; 16:722.
  137. Depp CA, Mausbach BT, Harmell AL, et al. Meta-analysis of the association between cognitive abilities and everyday functioning in bipolar disorder. Bipolar Disord 2012; 14:217.
  138. Schretlen DJ, Cascella NG, Meyer SM, et al. Neuropsychological functioning in bipolar disorder and schizophrenia. Biol Psychiatry 2007; 62:179.
  139. Amann B, Gomar JJ, Ortiz-Gil J, et al. Executive dysfunction and memory impairment in schizoaffective disorder: a comparison with bipolar disorder, schizophrenia and healthy controls. Psychol Med 2012; 42:2127.
  140. Lewandowski KE, Cohen BM, Ongur D. Evolution of neuropsychological dysfunction during the course of schizophrenia and bipolar disorder. Psychol Med 2011; 41:225.
  141. Bora E, Yucel M, Pantelis C. Cognitive functioning in schizophrenia, schizoaffective disorder and affective psychoses: meta-analytic study. Br J Psychiatry 2009; 195:475.
  142. Xu G, Lin K, Rao D, et al. Neuropsychological performance in bipolar I, bipolar II and unipolar depression patients: a longitudinal, naturalistic study. J Affect Disord 2012; 136:328.
  143. Quraishi S, Frangou S. Neuropsychology of bipolar disorder: a review. J Affect Disord 2002; 72:209.
  144. Burdick KE, Russo M, Frangou S, et al. Empirical evidence for discrete neurocognitive subgroups in bipolar disorder: clinical implications. Psychol Med 2014; 44:3083.
  145. Samamé C, Martino DJ, Strejilevich SA. Social cognition in euthymic bipolar disorder: systematic review and meta-analytic approach. Acta Psychiatr Scand 2012; 125:266.
  146. Cusi AM, Macqueen GM, McKinnon MC. Patients with bipolar disorder show impaired performance on complex tests of social cognition. Psychiatry Res 2012; 200:258.
  147. Samamé C. Social cognition throughout the three phases of bipolar disorder: a state-of-the-art overview. Psychiatry Res 2013; 210:1275.
  148. McCraw S, Parker G, Fletcher K, Friend P. Self-reported creativity in bipolar disorder: prevalence, types and associated outcomes in mania versus hypomania. J Affect Disord 2013; 151:831.
  149. Johnson SL, Murray G, Fredrickson B, et al. Creativity and bipolar disorder: touched by fire or burning with questions? Clin Psychol Rev 2012; 32:1.
  150. Jamison KR. Great wits and madness: more near allied? Br J Psychiatry 2011; 199:351.
  151. Srivastava S, Ketter TA. The link between bipolar disorders and creativity: evidence from personality and temperament studies. Curr Psychiatry Rep 2010; 12:522.
  152. Santosa CM, Strong CM, Nowakowska C, et al. Enhanced creativity in bipolar disorder patients: a controlled study. J Affect Disord 2007; 100:31.
  153. Tremblay CH, Grosskopf S, Yang K. Brainstorm: occupational choice, bipolar illness and creativity. Econ Hum Biol 2010; 8:233.
  154. Kyaga S, Lichtenstein P, Boman M, et al. Creativity and mental disorder: family study of 300,000 people with severe mental disorder. Br J Psychiatry 2011; 199:373.
  155. Power RA, Steinberg S, Bjornsdottir G, et al. Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. Nat Neurosci 2015; 18:953.
  156. Keller MC, Visscher PM. Genetic variation links creativity to psychiatric disorders. Nat Neurosci 2015; 18:928.
  157. Hawton K, van Heeringen K. Suicide. Lancet 2009; 373:1372.
  158. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 1997; 170:205.
  159. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 2001; 58:844.
  160. Angst J, Angst F, Gerber-Werder R, Gamma A. Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years' follow-up. Arch Suicide Res 2005; 9:279.
  161. Goetz I, Tohen M, Reed C, et al. Functional impairment in patients with mania: baseline results of the EMBLEM study. Bipolar Disord 2007; 9:45.
  162. Marangell LB, Bauer MS, Dennehy EB, et al. Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years. Bipolar Disord 2006; 8:566.
  163. Dennehy EB, Marangell LB, Allen MH, et al. Suicide and suicide attempts in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). J Affect Disord 2011; 133:423.
  164. Fazel S, Lichtenstein P, Grann M, et al. Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review. Arch Gen Psychiatry 2010; 67:931.
  165. Pulay AJ, Dawson DA, Hasin DS, et al. Violent behavior and DSM-IV psychiatric disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2008; 69:12.
  166. Harford TC, Yi HY, Grant BF. Other- and self-directed forms of violence and their relationships to DSM-IV substance use and other psychiatric disorders in a national survey of adults. Compr Psychiatry 2013; 54:731.
  167. Ten Have M, de Graaf R, van Weeghel J, van Dorsselaer S. The association between common mental disorders and violence: to what extent is it influenced by prior victimization, negative life events and low levels of social support? Psychol Med 2014; 44:1485.
  168. Binder RL, McNiel DE. Effects of diagnosis and context on dangerousness. Am J Psychiatry 1988; 145:728.
  169. Barlow K, Grenyer B, Ilkiw-Lavalle O. Prevalence and precipitants of aggression in psychiatric inpatient units. Aust N Z J Psychiatry 2000; 34:967.
  170. Ballester J, Goldstein B, Goldstein TR, et al. Prospective longitudinal course of aggression among adults with bipolar disorder. Bipolar Disord 2014; 16:262.
  171. Chou YH, Lin CL, Wang SJ, et al. Aggression in bipolar II disorder and its relation to the serotonin transporter. J Affect Disord 2013; 147:59.
  172. Desmarais SL, Van Dorn RA, Johnson KL, et al. Community violence perpetration and victimization among adults with mental illnesses. Am J Public Health 2014; 104:2342.
  173. McCabe PJ, Christopher PP, Pinals DA, Fisher WH. Predictors of criminal justice involvement in severe mania. J Affect Disord 2013; 149:367.