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Bipolar disorder affects approximately 3 million persons in the United States. It is characterized by unpredictable swings in mood from mania (or hypomania) to depression. Some patients suffer only from recurrent attacks of mania, which in its pure form is associated with increased psychomotor activity, excessive social extroversion, decreased need for sleep, impulsivity and impairment in judgment, and expansive, grandiose, and sometimes irritable mood. In severe mania, patients may experience delusions and paranoid thinking indistinguishable from that associated with schizophrenia. About half of all patients with bipolar disorder present with a mixture of psychomotor agitation and activation with dysphoria, anxiety, and irritability. It may be difficult to distinguish mixed mania from agitated depression. In some bipolar patients (bipolar II disorder), the full criteria for mania are lacking, and recurrent depressions are separated by periods of mild activation and increased energy (hypomania). In cyclothymic disorder, there are numerous hypomanic periods, usually of relatively short duration, alternating with clusters of depressive symptoms that fail to meet the criteria of major depression, either in severity or duration. The mood fluctuations are chronic and should be present for at least 2 years before the diagnosis is made.
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Manic episodes typically emerge over a period of days to weeks, but onset within hours is possible, usually in the early morning hours. An untreated episode of either depression or mania can last as short as several weeks or as long as 8 to 12 months, and rare patients have an unremitting chronic course. The term “rapid cycling” is used for patients who have four or more episodes of either depression or mania in a given year. This pattern occurs in 15 percent of all patients, almost all of whom are women. In some cases, rapid cycling is linked to an underlying thyroid dysfunction and, in others, iatrogenically triggered by prolonged antidepressant treatment.

Although bipolar illness is associated with frequent episodic recurrence, it was once thought to have a favorable prognosis and outcome. More recent data, however, show that approximately half of patients with the disorder have sustained difficulties in work performance and psychosocial functioning. The most frequent age of onset for bipolar disorder is between 20 and 30 years of age, but many individuals report premorbid symptoms in late childhood or early adolescence. The prevalence is similar for men and women, but there are gender differences in course, with women likely to have more depressive and men more manic episodes over a lifetime.