Bipolar I disorder

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Bipolar disorder
Specialty Psychiatry   OOjs UI icon edit-ltr-progressive.svg
Symptoms mood instability, psychosis in some cases.
Complications suicide
Usual onset25 years of age
CausesComplex
Differential diagnosis Other bipolar disorders, borderline personality disorder, antisocial personality disorder
TreatmentTherapy, mood stabilizing medication such as lithium
Medication Lithium, anticonvulsants, antipsychotics
Deaths6% die by suicide

Bipolar I disorder (BD-I; pronounced "type one bipolar disorder") is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. [1] Most people also, at other times, have one or more depressive episodes. [2]

Contents

It is a type of bipolar disorder and conforms to the classic concept of manic-depressive illness, which can include psychosis during mood episodes. [3]

Diagnosis

The essential feature of bipolar I disorder is a clinical course characterized by the occurrence of one or more manic episodes or mixed episodes. [4] Often, individuals have had one or more major depressive episodes. [5] One episode of mania is sufficient to make the diagnosis of bipolar disorder; the person may or may not have a history of major depressive disorder. [5] Episodes of substance-induced mood disorder due to the direct effects of a medication, or other somatic treatments for depression, substance use disorder, or toxin exposure, or of mood disorder due to a general medical condition need to be excluded before a diagnosis of bipolar I disorder can be made. Bipolar I disorder requires confirmation of only 1 full manic episode for diagnosis, but may be associated with hypomanic and depressive episodes as well. [6] Diagnosis for bipolar II disorder does not include a full manic episode; instead, it requires the occurrence of both a hypomanic episode and a major depressive episode. [6] Serious aggression has been reported to occur in one out of every ten major, first-episode, BD-I patients with psychotic features, the prevalence in this group being particularly high in association with a recent suicide attempt, alcohol use disorder, learning disability, or manic polarity in the first episode. [7]

Bipolar I disorder often coexists with other disorders including PTSD, substance use disorders, and a variety of mood disorders. [8] [9] Studies suggest that psychiatric comorbidities correlate with further impairment of day-to-day life. [10] Up to 40% of people with bipolar disorder also present with PTSD, with higher rates occurring in women and individuals with bipolar I disorder. [8] A diagnosis of bipolar 1 disorder is only given if bipolar episodes are not better accounted for by schizoaffective disorder or superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified. [11]

Medical assessment

Regular medical assessments are performed to rule-out secondary causes of mania and depression. [12] These tests include complete blood count, glucose, serum chemistry/electrolyte panel, thyroid function test, liver function test, renal function test, urinalysis, vitamin B12 and folate levels, HIV screening, syphilis screening, and pregnancy test, and when clinically indicated, an electrocardiogram (ECG), an electroencephalogram (EEG), a computed tomography (CT scan), and/or a magnetic resonance imagining (MRI) may be ordered. [12] Drug screening includes recreational drugs, particularly synthetic cannabinoids, and exposure to toxins.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR)

Dx Code #DisorderDescription
296.0xBipolar I disorderSingle manic episode
296.40Bipolar I disorderMost recent episode hypomanic
296.4xBipolar I disorderMost recent episode manic
296.5xBipolar I disorderMost recent episode depressed
296.6xBipolar I disorderMost recent episode mixed
296.7Bipolar I disorderMost recent episode unspecified

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

In May 2013, American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There are several proposed revisions to occur in the diagnostic criteria of Bipolar I Disorder and its subtypes. For Bipolar I Disorder 296.40 (most recent episode hypomanic) and 296.4x (most recent episode manic), the proposed revision includes the following specifiers: with psychotic features, with mixed features, with catatonic features, with rapid cycling, with anxiety (mild to severe), with suicide risk severity, with seasonal pattern, and with postpartum onset. [13] Bipolar I Disorder 296.5x (most recent episode depressed) will include all of the above specifiers plus the following: with melancholic features and with atypical features. [13] The categories for specifiers will be removed in DSM-5 and criterion A will add or there are at least 3 symptoms of major depression of which one of the symptoms is depressed mood or anhedonia. [13] For Bipolar I Disorder 296.7 (most recent episode unspecified), the listed specifiers will be removed. [13]

The criteria for manic and hypomanic episodes in criteria A & B will be edited. Criterion A will include "and present most of the day, nearly every day", and criterion B will include "and represent a noticeable change from usual behavior". These criteria as defined in the DSM-IV-TR have created confusion for clinicians and need to be more clearly defined. [14] [15]

There have also been proposed revisions to criterion B of the diagnostic criteria for a Hypomanic Episode, which is used to diagnose For Bipolar I Disorder 296.40, Most Recent Episode Hypomanic. Criterion B lists "inflated self-esteem, flight of ideas, distractibility, and decreased need for sleep" as symptoms of a Hypomanic Episode. This has been confusing in the field of child psychiatry because these symptoms closely overlap with symptoms of attention deficit hyperactivity disorder (ADHD). [14]

ICD-10

Treatment

Medication

Mood stabilizers are often used as part of the treatment process. [16]

  1. Lithium is the mainstay in the management of bipolar disorder but it has a narrow therapeutic range and typically requires monitoring [17]
  2. Anticonvulsants, such as valproate, [18] carbamazepine, or lamotrigine
  3. Atypical antipsychotics, such as quetiapine, [19] [20] risperidone, olanzapine, or aripiprazole
  4. Electroconvulsive therapy, a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect

Antidepressant-induced mania occurs in 20–40% of people with bipolar disorder. Mood stabilizers, especially lithium, may protect against this effect, but some research contradicts this. [21]

A frequent problem in these individuals is non-adherence to pharmacological treatment; long-acting injectable antipsychotics may contribute to solving this issue in some patients. [22]

A review of validated treatment guidelines for bipolar disorder by international bodies was published in 2020. [23]

Prognosis

Bipolar I usually has a poor prognosis, which is associated with substance abuse, psychotic features, depressive symptoms, and inter-episode depression. [24] A manic episode can be so severe that it requires hospitalization. An estimated 63% of all BP-I related mania results in hospitalization. [25] The natural course of BP-I, if left untreated, leads to episodes becoming more frequent or severe over time. [26] But with proper treatment, individuals with BP-I can lead a healthy lifestyle. [27]

Education

Psychosocial interventions can be used for managing acute depressive episodes and for maintenance treatment to aid in relapse prevention. [28] This includes psychoeducation, cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT), and peer support. [28]

Information on the condition, importance of regular sleep patterns, routines and eating habits and the importance of compliance with medication as prescribed. Behavior modification through counseling can have positive influence to help reduce the effects of risky behavior during the manic phase. Additionally, the lifetime prevalence for bipolar I disorder is estimated to be 1%. [29]

See also

Related Research Articles

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Mania, also known as manic syndrome, is a mental and behavioral disorder defined as a state of abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation with enhanced affective expression together with lability of affect." During a manic episode, an individual will experience rapidly changing emotions and moods, highly influenced by surrounding stimuli. Although mania is often conceived as a "mirror image" to depression, the heightened mood can be either euphoric or dysphoric. As the mania intensifies, irritability can be more pronounced and result in anxiety or anger.

<span class="mw-page-title-main">Mood disorder</span> Mental disorder affecting the mood of an individual, over a long period of time

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.many people with schizoaffective disorder have other mental disorder such as anxiety disorder

<span class="mw-page-title-main">Mixed affective state</span> Medical condition

A mixed affective state, formerly known as a mixed-manic or mixed episode, has been defined as a state wherein features and symptoms unique to both depression and (hypo)mania, including episodes of anguish, despair, self doubt, rage, excessive impulsivity and suicidal ideation, sensory overload, racing thoughts, heightened irritability, decreased "need" for sleep and other symptoms of depressive and manic states occur either simultaneously or in very short succession.

The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

Cyclical variations in moods and energy levels have been recorded at least as far back as several thousand years. The words "melancholia" and "mania" have their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας, meaning "black", and chole/χολη, meaning "bile" or "gall", indicative of the term's origins in pre-Hippocratic humoral theories. A man known as Aretaeus of Cappadocia has the first records of analyzing the symptoms of depression and mania in the 1st century of Greece. There is documentation that explains how bath salts were used to calm those with manic symptoms and also help those who are dealing with depression. Even today, lithium is used as a treatment to bipolar disorder which is significant because lithium could have been an ingredient in the Greek bath salt. Centuries passed and very little was studied or discovered. It wasn't until the mid-19th century that a French psychiatrist by the name of Jean-Pierre Falret wrote an article describing "circular insanity" and this is believed to be the first recorded diagnosis of bipolar disorder. Years later, in the early 1900s, Emil Kraepelin, a German psychiatrist, analyzed the influence of biology on mental disorders, including bipolar disorder. His studies are still used as the basis of classification of mental disorders today.

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

The associated features of bipolar disorder are clinical phenomena that often accompany bipolar disorder (BD) but are not part of the diagnostic criteria for the disorder. There are several childhood precursors in children who later receive a diagnosis of bipolar disorder. They may show subtle early traits such as mood abnormalities, full major depressive episodes, and attention-deficit hyperactivity disorder. BD is also accompanied by changes in cognition processes and abilities. This includes reduced attentional and executive capabilities and impaired memory. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Some studies have found a significant association between bipolar disorder and creativity.

<span class="mw-page-title-main">Melancholic depression</span> Medical condition

Melancholic depression, or depression with melancholic features, is a DSM-IV and DSM-5 specifier of depressive disorders. The specifier is used to distinguish clinically relevant subsets of causes and symptoms that have the potential to influence treatment.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder. It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5–10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old. The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.

Hypomania is a mental and behavioral disorder, characterised essentially by an apparently non-contextual elevation of mood (euphoria) that contributes to persistently disinhibited behaviour.

The General Behavior Inventory (GBI) is a 73-question psychological self-report assessment tool designed by Richard Depue and colleagues to identify the presence and severity of manic and depressive moods in adults, as well as to assess for cyclothymia. It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder and the fluctuation of symptoms over time. The GBI is intended to be administered for adult populations; however, it has been adapted into versions that allow for juvenile populations, as well as a short version that allows for it to be used as a screening test.

Sleep is known to play an important role in the etiology and maintenance of bipolar disorder. Patients with bipolar disorder often have a less stable and more variable circadian activity. Circadian activity disruption can be apparent even if the person concerned is not currently ill.

Borderline personality disorder (BPD) is a psychological disorder characterized by chronic instability of relationships, self-image, moods, and affect, which is frequently misdiagnosed. This misdiagnosis can come in the form of providing a BPD diagnosis to a person who does not actually meet criteria or providing an incorrect alternative diagnosis in the place of a BPD diagnosis.

Unipolar mania is a form of bipolar disorder whereby individuals only experience manic episodes without depression. Depression is often characterised by a persistent low mood, decreased energy and thoughts of suicide. What is seen as its counterpart, mania, can be characterized by racing thoughts, less need for sleep and psychomotor agitation.

References

  1. ↑ "The Two Types of Bipolar Disorder". Psych Central.com. Archived from the original on 6 August 2013. Retrieved 25 November 2015.
  2. ↑ "Bipolar Disorder: Who's at Risk?" . Retrieved 22 November 2011.
  3. ↑ "What are the types of bipolar disorder?" . Retrieved 22 November 2011.
  4. ↑ Phillips, Mary L; Kupfer, David J (11 May 2013). "Bipolar disorder diagnosis: challenges and future directions". Lancet. 381 (9878): 1663–1671. doi:10.1016/S0140-6736(13)60989-7. ISSN   0140-6736. PMC   5858935 . PMID   23663952.
  5. 1 2 "Online Bipolar Tests: How Much Can You Trust Them?". DepressionD. Retrieved 7 January 2012.
  6. 1 2 Diagnostic and statistical manual of mental disorders : DSM-5. American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force. (Fifth ed.). Arlington, VA. 2013. ISBN   978-0-89042-559-6. OCLC   847226928.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: others (link)
  7. ↑ Khalsa, Hari-Mandir K.; Baldessarini, Ross J.; Tohen, Mauricio; Salvatore, Paola (11 August 2018). "Aggression among 216 patients with a first-psychotic episode of bipolar I disorder". International Journal of Bipolar Disorders. 6 (1): 18. doi: 10.1186/s40345-018-0126-8 . ISSN   2194-7511. PMC   6161985 . PMID   30097737.
  8. 1 2 Cerimele, Joseph M.; Bauer, Amy M.; Fortney, John C.; Bauer, Mark S. (May 2017). "Patients With Co-Occurring Bipolar Disorder and Posttraumatic Stress Disorder: A Rapid Review of the Literature". The Journal of Clinical Psychiatry. 78 (5): e506–e514. doi:10.4088/JCP.16r10897. ISSN   1555-2101. PMID   28570791.
  9. ↑ Hunt, Glenn E.; Malhi, Gin S.; Cleary, Michelle; Lai, Harry Man Xiong; Sitharthan, Thiagarajan (December 2016). "Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990–2015: Systematic review and meta-analysis". Journal of Affective Disorders. 206: 331–349. doi:10.1016/j.jad.2016.07.011. ISSN   1573-2517. PMID   27476137.
  10. ↑ Léda-Rêgo, Gabriela; Studart-Bottó, Paula; Sarmento, Stella; Cerqueira-Silva, Thiago; Bezerra-Filho, Severino; Miranda-Scippa, Ângela (1 February 2023). "Psychiatric comorbidity in individuals with bipolar disorder: relation with clinical outcomes and functioning". European Archives of Psychiatry and Clinical Neuroscience. 273 (5): 1175–1181. doi:10.1007/s00406-023-01562-5. ISSN   0940-1334. PMID   36725737. S2CID   256501014.
  11. ↑ "Bipolar Disorder Residential Treatment Center Los Angeles". PCH Treatment. Retrieved 25 November 2015.
  12. 1 2 Bobo, William V. (October 2017). "The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update". Mayo Clinic Proceedings. 92 (10): 1532–1551. doi: 10.1016/j.mayocp.2017.06.022 . ISSN   0025-6196. PMID   28888714.
  13. 1 2 3 4 American Psychiatric Association (22 May 2013). Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. doi:10.1176/appi.books.9780890425596. ISBN   978-0-89042-555-8.
  14. 1 2 Issues pertinent to a developmental approach to bipolar disorder in DSM-5. American Psychiatric Association. 2010.
  15. ↑ Diagnostic and Statistical Manual of Mental Disorders (4th ed. text revision). Washington, DC: American Psychiatric Association. 2000. pp. 345–392.
  16. ↑ Schwartz, Jeremy (20 July 2017). "Can People Recover From Bipolar Disorder?". U.S. News & World Report.
  17. ↑ Burgess, Sally SA; Geddes, John; Hawton, Keith KE; Taylor, Matthew J.; Townsend, Ellen; Jamison, K.; Goodwin, Guy (2001). "Lithium for maintenance treatment of mood disorders | Cochrane". Cochrane Database of Systematic Reviews. 2001 (3): CD003013. doi:10.1002/14651858.CD003013. PMC   7005360 .
  18. ↑ MacRitchie, Karine; Geddes, John; Scott, Jan; Haslam, D. R.; Silva De Lima, Mauricio; Goodwin, Guy (2003). "Valproate for acutre mood episodes in bipolar disorder | Cochrane". Cochrane Database of Systematic Reviews (1): CD004052. doi:10.1002/14651858.CD004052. PMID   12535506.
  19. ↑ Datto, Catherine (11 March 2016). "Bipolar II compared with bipolar I disorder: baseline characteristics and treatment response to quetiapine in a pooled analysis of five placebo-controlled clinical trials of acute bipolar depression". Annals of General Psychiatry. 15: 9. doi: 10.1186/s12991-016-0096-0 . PMC   4788818 . PMID   26973704.
  20. ↑ Young, Allan (February 2014). "A Randomised, Placebo-Controlled 52-Week Trial of Continued Quetiapine Treatment in Recently Depressed Patients With Bipolar I And Bipolar II Disorder". World Journal of Biological Psychiatry. 15 (2): 96–112. doi:10.3109/15622975.2012.665177. PMID   22404704. S2CID   2224996.
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  22. ↑ Tohen, Mauricio; Goldberg, Joseph F.; Hassoun, Youssef; Sureddi, Suresh (16 June 2020). "Identifying Profiles of Patients With Bipolar I Disorder Who Would Benefit From Maintenance Therapy With a Long-Acting Injectable Antipsychotic". The Journal of Clinical Psychiatry. 81 (4). doi: 10.4088/JCP.OT19046AH1 . ISSN   1555-2101. PMID   32558403. S2CID   219923839.
  23. ↑ Verdolini, Norma; Hidalgo-Mazzei, Diego; Del Matto, Laura; Muscas, Michele; Pacchiarotti, Isabella; Murru, Andrea; Samalin, Ludovic; Aedo, Alberto; Tohen, Mauricio; Grunze, Heinz; Young, Allan H. (22 December 2020). "Long-term treatment of bipolar disorder type I: A systematic and critical review of clinical guidelines with derived practice algorithms". Bipolar Disorders. 23 (4): 324–340. doi:10.1111/bdi.13040. ISSN   1399-5618. PMID   33354842. S2CID   229693238.
  24. ↑ Jain, A.; Mitra, P. (2023). "Bipolar Disorder". StatPearls. PMID   32644424.
  25. ↑ De Zelicourt, M.; Dardennes, R.; Verdoux, H.; Gandhi, G.; Khoshnood, B.; Chomette, E.; Papatheodorou, M. L.; Edgell, E. T.; Even, C.; Fagnani, F. (2003). "Frequency of hospitalisations and inpatient care costs of manic episodes: In patients with bipolar I disorder in France". Pharmacoeconomics. 21 (15): 1081–1090. doi:10.2165/00019053-200321150-00002. PMID   14596627. S2CID   41439636.
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  27. ↑ "Living Well with Bipolar Disorder". 7 May 2019.
  28. 1 2 Yatham, Lakshmi N.; Kennedy, Sidney H.; Parikh, Sagar V.; Schaffer, Ayal; Bond, David J.; Frey, Benicio N.; Sharma, Verinder; Goldstein, Benjamin I.; Rej, Soham; Beaulieu, Serge; Alda, Martin (2018). "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 Disorders. 20 (2): 97–170. doi:10.1111/bdi.12609. ISSN   1399-5618. PMC   5947163 . PMID   29536616.
  29. ↑ Merikangas, Kathleen R.; Akiskal, Hagop S.; Angst, Jules; Greenberg, Paul E.; Hirschfeld, Robert M.A.; Petukhova, Maria; Kessler, Ronald C. (1 May 2007). "Lifetime and 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication". Archives of General Psychiatry. 64 (5): 543–552. doi:10.1001/archpsyc.64.5.543. ISSN   0003-990X. PMC   1931566 . PMID   17485606.
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