Cognitive deficits have been reported in people with bipolar disorder that are present early in the course of the disorder and may be stable over time. Relatives of people with bipolar disorder may show attenuated signs of cognitive deficits. If cognitive deficits found in people with bipolar disorder are also found in their relatives, this may be suggestive of an underlying genetic basis.

What is the evidence on cognition in relatives of people with bipolar disorder?

High quality evidence shows small to medium-sized effects of poorer processing speed, verbal fluency, executive functioning (on speed tasks) and social cognition in first-degree relatives of any age compared to controls without a first-degree relative with the disorder. There were no differences in executive functioning (accuracy), IQ, verbal memory, visual memory, working memory or sustained attention. In young first-degree relatives (10 to 25 years), there were small effects of poorer performance on IQ, verbal memory, visual memory, processing speed, sustained attention, and executive functioning, with no differences in working memory.

Moderate to high quality evidence suggests small to medium-sized effects of better IQ, verbal memory, working memory, processing speed, verbal fluency and accuracy of executive functioning in first-degree relatives of people with bipolar disorder compared to first-degree relatives of people with schizophrenia. There were no differences in executive functioning (on speed tasks), visual memory or sustained attention.

September 2021

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Familial coaggregation is the rate of related disorders found in a family. Many studies have suggested a fundamental association between schizophrenia and bipolar disorder. Many family studies have investigated the possibility of this association by assessing whether schizophrenia and bipolar disorder diagnoses may cluster within the same extended family.

What is the evidence for familial coaggregation?

Moderate to low quality evidence suggests high familial coaggregation of schizophrenia and bipolar disorders, with first-degree relatives of people with schizophrenia or bipolar showing an increased risk of developing either disorder.

October 2021

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A diagnosis of bipolar disorder can have considerable impact not only on the affected individual, but also on the people closest to them. Sometimes families experience different types of burden, particularly during acute phases of the illness. Burden is considered in terms of objective effects, such as illness severity or financial strain, but also in terms of subjective effects, such as the emotional impact of the illness on family members.

What is the evidence regarding impact on families?

Moderate to low quality evidence found lower parent-reported cohesion in families with a parent with bipolar disorder compared to families with no parental psychiatric disorder. There were no differences in family environment between parents with bipolar disorder and parents with other psychiatric disorders. Families with a child with bipolar disorder had higher conflict than families without a child with bipolar disorder.

Caregiver burden is apparent during their relative’s depressive and manic episodes. Patient behaviours of most concern to caregivers include impulsive spending, over activity, lack of sleep, over talkativeness, lack of insight, and odd, aggressive or unpredictable behaviours. Around half of all caregivers report depression symptoms, and around a third report contact with mental health services for their own symptoms. Caregiver knowledge is increased, and short-term burden is decreased, following education about bipolar disorder.

October 2021

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Relatives of people with bipolar disorder may show attenuated signs of the illness, such as physical features commonly identified with the disorder. These may include structural and/or functional anomalies as well as sleep disturbances.

What is the evidence for physical anomalies in relatives?

Moderate quality evidence suggests relatives of people with bipolar disorder show increased grey matter volume in the right inferior frontal gyrus, the left supramarginal gyrus, and the left superior temporal gyrus compared to controls. Decreased grey matter volume was found in relatives in the right lingual gyrus, the right cerebellum, and the right superior frontal gyrus. There were decreases in white matter integrity in relatives compared to controls in the right corpus callosum body, left corpus callosum splenium, and the left corticospinal tract.

Across all functioning tasks, relatives showed increased brain activation in the ventral anterior cingulate, right amygdala, and parahippocampal gyrus, and decreased activation in the right inferior parietal gyrus, left postcentral gyrus, and left superior parietal gyrus. During cognitive tasks, relatives showed increased activation in the frontal lobe, right caudate, right inferior frontal gyrus, dorsal anterior cingulate, and left middle temporal gyrus/superior temporal gyrus and decreased activation in the parietal lobe. During emotion processing, relatives showed increased activation in the right amygdala, right parahippocampal gyrus, and right middle occipital gyrus. During reward processing, relatives showed increased activation in the anterior and medio-orbital parts of the prefrontal cortex.

Relatives showed a large increase in the P50 ratio compared to controls. The P50 ratio is measured with EEG and increases are indicative of reduced cortical inhibition. There was also higher relative amplitude of the sleep-wake cycle in relatives compared to people with bipolar disorder.

March 2022

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Due to the significant genetic loading of bipolar disorder, first-degree relatives of people with bipolar disorder may also show signs of psychopathology.

What is the evidence for psychopathology in families of people with bipolar disorder?

Moderate to high quality evidence finds a large increased risk of bipolar disorder, a medium-sized increased risk of ADHD, and a small increased risk of a substance use disorder in relatives. Moderate quality evidence finds medium-sized increased risk of other mood or anxiety disorders in relatives, particularly generalized anxiety and obsessive-compulsive disorders, and increased risk of disruptive behavioural disorder, oppositional defiant disorder, and conduct disorder in offspring.

October 2021

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