Bipolar disorder: symptoms, types and treatment

Key points

• Bipolar disorder brings episodes of mania or hypomania, episodes of depression, and stable periods between them [4].
• In England, 1.9% of adults screened positive for possible bipolar disorder in 2023/4 [5].
• Bipolar I involves mania lasting longer than a week. Bipolar II involves hypomania and major depression, without full mania [7].
• Most people present when depressed, so bipolar disorder is frequently diagnosed as depression first [6][10].
• In the UK a psychiatrist makes the diagnosis, not a GP [7].
• NICE recommends psychological treatment designed for bipolar disorder alongside medication, with lithium first line long term [1].

What bipolar disorder is

Bipolar disorder is a mental health condition in which mood, energy and activity move between two extremes: episodes of mania or hypomania, when mood and energy are unusually high, and episodes of depression, when they are very low [4]. Between episodes, many people are stable for weeks, months or years [4].

In the Adult Psychiatric Morbidity Survey 2023/4, 1.9% of adults in England screened positive on the Mood Disorder Questionnaire, 2.1% of women and 1.7% of men [5]. Screening positive is not the same as having the disorder [5].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

Symptoms

Bipolar disorder is recognised by episodes rather than by a constant state [4].

Manic or hypomanic episodes. Feeling very happy or excited; irritability; high energy and restlessness; needing less sleep; racing thoughts and fast speech; impulsive spending or risk taking [4]. Severe mania can also bring hallucinations, delusions or paranoia [4].

Depressive episodes. Persistent sadness; loss of interest; low energy; disturbed sleep; appetite change; feelings of worthlessness; poor concentration; thoughts of suicide [4].

Mixed features. Symptoms of mania or hypomania and depression at once, such as feeling very low while also restless and agitated [7].

Depressive episodes are what most people present with, and hypomania often does not stop everyday life, so it may never be reported [8]. That is one reason it is frequently diagnosed as depression first [6][10].

Types

Subtypes are defined by whether a person has had full mania or only hypomania, and how often episodes occur. Mania and hypomania differ in length and severity:

• Mania typically lasts a week or longer, disrupts or stops daily activities, can involve psychosis, and in severe form often needs hospital treatment [4][8].
• Hypomania typically lasts a few days, brings the same symptoms at lower intensity, usually leaves daily life intact, and does not involve psychosis [8].

The recognised types are:

• Bipolar I. At least one episode of mania lasting longer than a week [7].
• Bipolar II. At least one period of major depression and at least one episode of hypomania, not mania [7].
• Cyclothymia. Milder highs and lows over a long period, at least two years, with no symptom-free stretch longer than two months. Less severe than bipolar I or II but often longer lasting [7].
• Rapid cycling. Four or more depressive, manic or hypomanic episodes in a twelve month period [7].

Causes and risk factors

No single cause has been identified [4]. The evidence points to inherited vulnerability plus life circumstances.

• Family history. Genetic factors are significant, and a close relative with bipolar disorder raises the risk [4].
• Childhood trauma and stressful life events, linked to the condition developing [4].
• Recreational drug use, named by the NHS as a possible trigger [4].
• Disturbed sleep, both a trigger for episodes and a symptom of them [9].

No blood test or brain scan identifies bipolar disorder, so assessment rests on a person’s history [4]. Calling it mood swings does not match a diagnosis that depends on episodes of a defined length [7][8].

How it is diagnosed

Bipolar disorder is a specialist diagnosis in the UK: a GP can recognise the possibility and refer, but a psychiatrist makes the diagnosis [7].

NICE tells GPs to ask adults presenting with depression about past periods of overactivity or disinhibited behaviour, and to consider referral if those lasted four days or more [1]. Referral, usually to the local community mental health team, should be urgent if mania or severe depression is suspected, or the person is a danger to themselves or others [1][7].

Assessment covers current and past mood, behaviour, physical health, medication and family history, often with an account from someone who knows the person, since past highs are easily read as a good spell [4][9].

Bipolar UK reports an average of nine and a half years between first seeing a doctor about a symptom and getting an accurate diagnosis, with half of people naming misdiagnosis as the main reason [6]. In one UK study of primary care patients on antidepressants, 7.3% had unrecognised bipolar disorder, all bipolar II [10].

A diagnosis opens access to specialist treatment and a care plan, but does not predict the course of the condition [4]. No reliable UK figure exists for waiting times.

Treatment

NICE sets out separate treatment for mania or hypomania, for depression, and for the long term, using medication and psychological treatment together [1].

Mania or hypomania. NICE recommends offering one of four antipsychotics: haloperidol, olanzapine, quetiapine or risperidone [2]. Valproate is an alternative but can harm an unborn baby, so it is not used for anyone who could become pregnant [2].

Antidepressants and switching. If someone develops mania or hypomania while taking an antidepressant on its own, NICE says to consider stopping the antidepressant and to offer an antipsychotic [1]. NICE’s medicine options for bipolar depression pair an antidepressant with olanzapine rather than using one alone [1][3].

Depression. NICE recommends a psychological intervention designed for bipolar disorder, or a therapy for depression such as cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy [3]. Named medicine options are fluoxetine with olanzapine, quetiapine alone, olanzapine alone, or lamotrigine [3].

Long term. NICE recommends lithium as the first-line long-term medicine, with valproate, olanzapine or quetiapine as alternatives [1]. It also recommends structured psychological treatment designed for bipolar disorder, to prevent relapse or address symptoms between episodes [1].

Living with bipolar disorder

Track your mood. A mood diary shows patterns memory does not, including what came before an episode. Bipolar UK provides free mood tracking tools [9]. Self-monitoring of mood, thoughts and behaviour forms part of the psychological treatment NICE recommends [1].

Protect your sleep. Disturbed sleep can be both a trigger and a symptom, and getting enough sleep can help keep mood stable or shorten an episode [9]. Regular routines, diet, exercise and stress management help, according to the NHS [4]. If sleep is a persistent problem, see our entry on insomnia.

Learn your early warning signs. These are small changes that come before an episode, such as sleeping less, talking faster or spending more [9]. NICE says plans should name personal triggers and early warning signs of relapse [1]. A staying-well plan written while you are stable makes it easier to act early [9].

Use UK support. Bipolar UK runs peer support groups and an eCommunity, Mind runs Side by Side, and Rethink offers local groups [4][9]. If work or study is affected, Mind suggests telling an employer what support would help [9].

When to speak to a professional

Make a GP appointment if low mood, loss of interest or low energy has lasted weeks. Mention any days of unusually high energy, far less need for sleep, or behaviour out of character, since NICE asks GPs about periods of overactivity lasting four days or more [1].

Ask for an urgent appointment if mania seems to be developing, if depression is severe, or if anyone is at risk [1]. If you have a care team, contact them when early warning signs appear rather than waiting for the next review [1].

In a crisis, call Samaritans on 116 123, or text Shout on 85258. Call NHS 111 and choose the mental health option. Call 999 if anyone is in immediate danger.

Common questions

What is the difference between bipolar 1 and bipolar 2?

Bipolar I involves at least one episode of mania lasting longer than a week [7]. Bipolar II involves major depression plus hypomania, which does not reach full mania [7]. It is not milder overall, since its depressive episodes can be long and severe.

Can a GP diagnose bipolar disorder?

No. A GP can recognise the possibility and refer for specialist assessment, but the diagnosis is made by a psychiatrist [7].

Why is bipolar disorder often diagnosed as depression first?

People usually seek help when depressed, and hypomania can pass as a good spell rather than something to report [8]. Bipolar UK reports an average delay of nine and a half years to diagnosis [6].

Does bipolar disorder go away?

It is treated as a long-term condition rather than one that clears up [4]. Treatment aims to reduce how often and how severely episodes happen [1].

Clinical review pending

References

1. National Institute for Health and Care Excellence. Bipolar disorder: assessment and management. NICE clinical guideline CG185. https://www.nice.org.uk/guidance/cg185/resources/bipolar-disorder-assessment-and-management-35109814379461
2. National Institute for Health and Care Excellence. Treatment for mania or hypomania. Information for the public, bipolar disorder: assessment and management, CG185. https://www.nice.org.uk/guidance/cg185/ifp/chapter/treatment-for-mania-or-hypomania
3. National Institute for Health and Care Excellence. Treatment for depression. Information for the public, bipolar disorder: assessment and management, CG185. https://www.nice.org.uk/guidance/cg185/ifp/chapter/treatment-for-depression
4. NHS. Bipolar disorder. nhs.uk, page last reviewed 28 October 2024. https://www.nhs.uk/mental-health/conditions/bipolar-disorder/
5. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter 11: Bipolar disorder, published 27 November 2025. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/bipolar-disorder
6. Bipolar UK. Understanding the bipolar diagnosis delay. https://www.bipolaruk.org/about-bipolar/diagnosing-bipolar/understanding-diagnosis-delay/
7. Rethink Mental Illness. Bipolar disorder. https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/bipolar-disorder/
8. Mind. What are hypomania and mania? https://www.mind.org.uk/information-support/types-of-mental-health-problems/hypomania-and-mania/about-hypomania-and-mania/
9. Mind. Self-management for bipolar disorder. https://www.mind.org.uk/information-support/types-of-mental-health-problems/bipolar-disorder/self-managing-bipolar/
10. Hughes T, Cardno A, West R, et al. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study. British Journal of General Practice, 2016, volume 66, issue 643, pages e71 to e77. https://bjgp.org/content/66/643/e71