Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively we will endeavour to conduct our own review to fill this gap in the Library.

November 2021

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Differences observed in the age at onset of bipolar disorder may be influenced by genetic and/or environmental factors. Understanding these factors could lead to better understanding of the disorder, early identification, and improved intervention strategies for patients.

What is the evidence for age at onset of bipolar disorder?

Moderate quality evidence suggests the median age at onset of bipolar disorder is around 33 years old. Moderate to high quality evidence finds a trimodal distribution, with 45% of people with bipolar disorder showing an early-onset age (~17 years), 35% showing a mid-onset age (~26 years), and 20% showing a late-onset age (~42 years).

High quality evidence shows younger age at onset is associated with increased severity of depression. Moderate to high quality evidence finds younger age at onset is associated with having a personality disorder or longer delays to treatment. Moderate quality evidence finds younger age at onset is associated with suicide attempts, anxiety disorders, and substance use disorders. There were no associations between younger age at onset and severity of mania symptoms, first polarity being mania, psychotic symptoms, rapid cycling, or mixed bipolar episodes.

March 2022

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Satisfaction with medication is positively related to better treatment adherence, which in turn is associated with symptom reduction. Patient attitudes towards medications are influenced by the duration of bipolar disorder, insight into the disorder, and past treatment experiences. Identifying factors that encourage or discourage the use of medications may help inform personalised therapy.

What is the evidence for attitudes to medication?

Moderate quality evidence suggests patient attitudes towards antipsychotic medications are generally positive, with longer duration of stable illness, and psychoeducation and adherence treatments being associated with more positive attitudes. Clinician perceptions of efficacy and tolerability impact on prescribing.

November 2021

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A link between creativity and psychiatric disorders has long been postulated. This hypothetical connection has been the subject of many theoretical approaches. However, on the whole, theory and research results in this field are scattered and disparate.

What is the evidence for creativity in people with bipolar disorder?

Moderate to low quality evidence suggests increased levels of creativity in people with bipolar disorder. Creativity was measured differently across studies, and encompassed professional roles, such as artists, writers and musicians.

November 2021

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Criminal offending covers a wide range of behaviours from destructive acts, stealing, sexual assaults, to physical assaults causing injury or death. The majority of patients with a mental illness will never commit a crime, however, the few who do may help perpetuate a negative public stereotype that mental illness is associated with violent behaviour.

It is difficult to determine whether the violent acts of an individual with bipolar disorder are a consequence of the illness, or are traits of that particular individual. This ambiguity is confounded by the fact that people with mental illness may be at particularly high risk for exposure to the social factors that contribute to violent or homicidal tendencies in the general population, including social disadvantage and substance abuse. Furthermore, any increase in violent behaviour seen in an individual with bipolar disorder could be the result of a co-morbid psychiatric disorder such as antisocial personality disorder.

What is the evidence for criminal offending, aggression and violence?

Moderate to low quality evidence finds the overall arrest rate for any crime by people with schizophrenia or bipolar disorder is around 40%, which is similar to the arrest rate found in people with other mental disorders.

Moderate quality evidence finds no difference in the rate of violent criminal behaviour in people with bipolar disorder compared to general population rates. The rate of violent criminal behaviour was higher in people with bipolar disorder than in people with major depression or anxiety disorders, and was lower than in people with a psychotic disorder.

Moderate to high quality evidence finds the overall prevalence of any psychiatric inpatient violence and aggression is around 17%. There is a strong association between increased inpatient violence and having a history of violence, although having a diagnosis of bipolar disorder was not necessarily associated with increased risk of inpatient violence.

Moderate quality evidence finds a large increased risk of inpatient aggression in people with previous psychiatric admissions, small to medium-sized increased risk of inpatient aggression in people with a history of illicit substance abuse or involuntary admissions, and small effects of increased risk of inpatient aggression in males, in people with a history of self-destructive behaviour, and in people who were not married. Moderate to low quality evidence finds a small increased risk of inpatient aggression in younger patients.

November 2021

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Criminal victimisation refers to a person being the victim of a violent crime (rape or sexual assault, robbery, aggravated or simple assault) or a property crime (burglary and theft). People with a severe mental illness may be at higher risk of criminal victimisation. This may be a result of possible cognitive impairment (e.g. poor reality testing, judgment, social skills, planning, and problem solving), and sometimes compromised social situations (e.g. poverty, unemployment, homelessness, and social isolation).

What is the evidence for criminal victimisation?

Moderate to high quality evidence suggests large increased odds of physical partner violence in both men and women with bipolar disorder compared to the general population.

There were no other reviews that met inclusion criteria on other forms of criminal victimisation.

November 2021

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Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively we will endeavour to conduct our own review to fill this gap in the Library.

November 2021

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People with mental disorders may be at increased risk of nutritional deficiencies due to poor diet. Poor diet is a major and modifiable cause of comorbid conditions, including metabolic syndrome and obesity. During pregnancy, it also contributes to the risk of developmental problems in the foetus.

What is the evidence for diet in people with bipolar disorder?

Moderate quality evidence finds people with bipolar disorder have higher energy intake than people without bipolar disorder.

Moderate to low quality evidence finds caffeine consumption could be related to switching to mania or mixed states. Review authors suggest that acute increases in caffeine consumption may precede the occurrence of manic symptoms, potentially through a direct stimulant effect, affecting sleep patterns, and/or the metabolism of lithium or other medications.

No reviews meeting inclusion criteria were identified that assessed other dietary factors.

November 2021

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Substance use is a concern for people with a mental illness due to the association with poor clinical and social outcomes. Substance use places additional burden on patients, families, psychiatric services, and government resources due to high rates of treatment non-adherence and relapse.

Substance abuse leads to risk-taking behaviour, illegal activity, interpersonal problems and a loss of interest in usual activities. Abuse jeopardises physical health and neglect of important commitments at home, school or work.

Substance dependence involves having a strong physical or psychological need for the substance. Not taking it leads to withdrawal symptoms within a few hours of stopping, such as nausea, vomiting, tremors, chills, sweating, low blood pressure, irritability, depression, anxiety or confused thinking.

What is the evidence for substance use in people with bipolar disorder?

Moderate to low quality evidence finds a medium to large increased risk of any substance use disorder in people with bipolar disorder compared to people without a mood disorder. Moderate to high quality evidence shows people with a comorbid substance use disorder have more manic episodes, and are more likely to have a diagnosis of bipolar I rather than bipolar II disorder. They are also more likely to be male, have a history of suicidal behaviour, and have an early age of onset of bipolar disorder (<18 years). Having a substance use disorder was also associated with a greater risk of hospitalisation, high levels of alcohol intake, increased the risk of a mood recurrence and rapid-cycling.

For cannabis use in particular, moderate quality evidence found around one-quarter of people with bipolar disorder reported using cannabis. Cannabis use was associated with more depression, anxiety, and mania symptom severity, more mood episodes, more suicide attempts, and more insomnia or hypersomnia. Cannabis use was also associated with younger age, male gender, single marital status, having fewer years of education, an earlier onset of affective symptoms, psychotic symptoms, and use of other substances.

In children and youth with bipolar disorder, moderate to low quality evidence finds the risk of having a substance use disorder is around 31%. Rates were significantly higher in youth than in children, and in youth with comorbid PTSD or disruptive behaviour disorder.

November 2021

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Employment status is often indicative of the extent of functional ability in people with bipolar disorder. Low rates of employment places burden on social support and disability services, and on an individual’s quality of life. Employment outcomes involve rates of employment and factors that predict success in obtaining and retaining employment.

What is the evidence regarding employment?

Moderate to low quality evidence suggests around 40% to 60% of people with bipolar disorder are employed and have effective work functioning. However, around 40% to 50% report workplace under performance and see a decline in their occupational status over time.

Large associations were found between favourable employment outcomes and having better interpersonal functioning and not having a comorbid personality disorder. Medium-sized associations were found between favourable employment outcomes and having good cognitive functioning; in particular having good verbal learning, visual memory, verbal memory, concentration, insight about psychotic symptoms (if apparent), and executive functioning. Also having fewer psychiatric hospitalisations, less severe psychotic symptoms, less severe depression, high income, more years of education, shorter duration of illness, and being married predicted favourable employment outcomes. Small associations were found between favourable employment outcomes and being young, taking fewer psychotropic medications, having less severe symptoms in general, fewer electroconvulsive treatments, less rapid cycling, being Caucasian, being older at illness onset, being in a relationship (living together), and having independent housing. No significant associations were found between favourable employment outcomes and the severity of mania or negative symptoms, or for maternal education levels.

Moderate to low quality evidence finds a medium-sized, increased odds of being competitively employed following individual placement and support interventions compared to treatment as usual. However, there were no differences in the number of hours or weeks worked.

November 2021

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