Bipolar Disorder

Bipolar disorder is a recurrent, episodic disorder characterized by the occurrence of at least 1 manic or hypomanic episode. Depressive episodes also occur in bipolar disorder and often precede the first manic or hypomanic episode but are not essential to the diagnosis.

Bipolar disorder affects over 1% of the world population, usually begins in adolescence, and is associated with significant morbidity and mortality.

The diagnosis and treatment of pediatric bipolar has been complicated by controversy in the field that has spilled into public awareness over the past 25 years. While much of the controversy has settled among pediatric bipolar disorder researchers, misunderstandings about pediatric bipolar disorder persist.

DSM-5 Criteria

Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a sig­nificant degree and represent a noticeable change from usual behavior:

  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  7. Excessive involvement in activities that have a high potential for painful conse­quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or oth­ers, or there are psychotic features.

The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medi­cation, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Bipolar I Disorder

Criteria have been met for at least one manic episode.

The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional dis­order, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

What pediatric bipolar disorder is not

  • Chronic irritability
  • Quick temper; sudden angry responses to small triggers
  • A different disorder than bipolar disorder in adults

Risk Factors and Prodromal Symptoms

  • Genetics: bipolar disorder is highly heritable
  • Mood lability: exaggerated, unpredictable, and developmentally inappropriate changes in mood – but mood lability is present in other disorders
  • Anxiety and rejection sensitivity – also present in other disorders

A typical sequence may appear as episodic depression, often beginning before or near puberty, followed by episodes of decreased sleep and increased talkativeness in early adolescence, with classic manic symptoms including grandiosity emerging in late adolescence.

The Role of the Pediatrician

The main challenge for the pediatric clinician is to distinguish children and adolescents with Major Depression from those with bipolar disorder.

Depression is more common than is bipolar disorder.

When asking about a history of manic symptoms, teens will often endorse having experienced many of the symptoms, but rarely simultaneously in an episode that impaired functioning or resulted in dangerous outcomes. When asked about in a clinical interview, manic symptoms can sound very similar to those of falling in love or having an especially happy experience. Getting input from parents as well as teens is valuable. It is possible to hide symptoms of depression but very difficult to hide symptoms of mania.

Starting a patient with depressive symptoms on SSRI does not cause bipolar disorder. If a manic episode develops in a patient on an SSRI, it is appropriate to stop the SSRI and seek psychiatry consultation.

If a child or adolescent with major depression has a parental history of bipolar disorder but no personal history of manic symptoms, one can treat with an SSRI and proceed with caution, monitoring for emergence of mania.


Goldstein, B. I., Birmaher, B., Carlson, G. A., DelBello, M. P., Findling, R. L., Fristad, M., Kowatch, R. A., Miklowitz, D. J., Nery, F. G., Perezā€Algorta, G., Van Meter, A., Zeni, C. P., Correll, C. U., Kim, H., Wozniak, J., Chang, K. D., Hillegers, M., & Youngstrom, E. A. (2017). The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disorders, 19(7), 524–543.

Hunt, J., Schwarz, C. M., Nye, P., & Frazier, E. (2016). Is There a Bipolar Prodrome Among Children and Adolescents? In Curr Psychiatry Rep (Vol. 18, Issue 4, p. 35).

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., Birmaher, B., Tohen, M., & Suppes, T. (2018). Early Intervention in Bipolar Disorder. In Am J Psychiatry (Vol. 175, Issue 5, pp. 411–426).