different types of bipolar disorder. bipolar spectrum disorders include: bipolar i disorder, bipolar ii disorder, cyclothymic disorder and cases where subthreshold symptoms are found to cause clinically significant impairment or distress. these disorders involve major depressive episodes that alternate with manic or hypomanic episodes, or with mixed episodes that feature symptoms of both mood states. the concept of the bipolar spectrum is similar to that of emil kraepelin's original concept of manic depressive illness. bipolar ii disorder was established as a diagnosis in 1994 within dsm iv; though debate continues over whether it is a distinct entity, part of a spectrum, or exists at all. criteria and subtypes simplified graphical comparison of bipolar i, bipolar ii and cyclothymia: 267 the dsm and the icd characterize bipolar disorder as a spectrum of disorders occurring on a continuum. the dsm-5 and icd-11 lists three specific subtypes: bipolar i disorder: at least one manic episode is necessary to make the diagnosis; depressive episodes are common in the vast majority of cases with bipolar disorder i, but are unnecessary for the diagnosis. specifiers such as "mild, moderate, moderate-severe, severe" and "with psychotic features" should be added as applicable to indicate the presentation and course of the disorder. bipolar ii disorder: no manic episodes and one or more hypomanic episodes and one or more major depressive episodes. hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar ii more difficult to diagnose, since the hypomanic episodes may simply appear as periods of successful high productivity and are reported less frequently than a distressing, crippling depression. cyclothymia: a history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. when relevant, specifiers for peripartum onset and with rapid cycling should be used with any subtype. individuals who have subthreshold symptoms that cause clinically significant distress or impairment, but do not meet full criteria for one of the three subtypes may be diagnosed with other specified or unspecified bipolar disorder. other specified bipolar disorder is used when a clinician chooses to explain why the full criteria were not met (e.g., hypomania without a prior major depressive episode). if the condition is thought to have a non-psychiatric medical cause, the diagnosis of bipolar and related disorder due to another medical condition is made, while substance/medication-induced bipolar and related disorder is used if a medication is thought to have triggered the condition. rapid cycling most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months. rapid cycling, however, is a course specifier that may be applied to any bipolar subtype. it is defined as having four or more mood disturbance episodes within a one-year span. rapid cycling is usually temporary but is common amongst people with bipolar disorder and affects between 25.8 and 45.3% of them at some point in their life. these episodes are separated from each other by a remission (partial or full) for at least two months or a switch in mood polarity (i.e., from a depressive episode to a manic episode or vice versa). the definition of rapid cycling most frequently cited in the literature (including the dsm-v and icd-11) is that of dunner and fieve: at least four major depressive, manic, hypomanic or mixed episodes during a 12-month period. the literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management. people with the rapid cycling or ultradian subtypes of bipolar disorder tend to be more difficult to treat and less responsive to medications than other people with bipolar disorder. coexisting psychiatric conditions the diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions including obsessive–compulsive disorder, substance-use disorder, eating disorders, attention deficit hyperactivity disorder, social phobia, premenstrual syndrome (including premenstrual dysphoric disorder), or panic disorder. a thorough longitudinal analysis of symptoms and episodes, assisted if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist. children of parents with bipolar disorder more frequently have other mental health problems. children main article: bipolar disorder in children lithium is the only medication approved by the fda for treating mania in children. in the 1920s, kraepelin noted that manic episodes are rare before puberty. in general, bipolar disorder in children was not recognized in the first half of the twentieth century. this issue diminished with an increased following of the dsm criteria in the last part of the twentieth century. the diagnosis of childhood bipolar disorder, while formerly controversial, has gained greater acceptance among childhood and adolescent psychiatrists. american children and adolescents diagnosed with bipolar disorder in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while in outpatient clinics it doubled reaching 6%. studies using dsm criteria show that up to 1% of youth may have bipolar disorder. the dsm-5 has established a diagnosis—disruptive mood dysregulation disorder—that covers children with long-term, persistent irritability that had at times been misdiagnosed as having bipolar disorder, distinct from irritability in bipolar disorder that is restricted to discrete mood episodes. elderly bipolar disorder is uncommon in older patients, with a measured lifetime prevalence of 1% in over 60s and a 12-month prevalence of 0.1–0.5% in people over 65. despite this, it is overrepresented in psychiatric admissions, making up 4–8% of inpatient admission to aged care psychiatry units, and the incidence of mood disorders is increasing overall with the aging population. depressive episodes more commonly present with sleep disturbance, fatigue, hopelessness about the future, slowed thinking, and poor concentration and memory; the last three symptoms are seen in what is known as pseudodementia. clinical features also differ between those with late-onset bipolar disorder and those who developed it early in life; the former group present with milder manic episodes, more prominent cognitive changes and have a background of worse psychosocial functioning, while the latter present more commonly with mixed affective episodes, and have a stronger family history of illness. older people with bipolar disorder experience cognitive changes, particularly in executive functions such as abstract thinking and switching cognitive sets, as well as concentrating for long periods and decision-making. prevention attempts at prevention of bipolar disorder have focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more severe course of illness. longitudinal studies have indicated that full-blown manic stages are often preceded by a variety of prodromal clinical features, providing support for the occurrence of an at-risk state of the disorder when an early intervention might prevent its further development and/or improve its outcome. management main article: treatment of bipolar disorder the aim of management is to treat acute episodes safely with medication and work with the patient in long-term maintenance to prevent further episodes and optimise function using a combination of pharmacological and psychotherapeutic techniques. hospitalization may be required especially with the manic episodes present in bipolar i. this can be voluntary or (local legislation permitting) involuntary. long-term inpatient stays are now less common due to deinstitutionalization, although these can still occur. following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or an assertive community treatment team, supported employment, patient-led support groups, and intensive outpatient programs. these are sometimes referred to as partial-inpatient programs. psychosocial psychotherapy aims to assist a person with bipolar disorder in accepting and understanding their diagnosis, coping with various types of stress, improving their interpersonal relationships, and recognizing prodromal symptoms before full-blown recurrence. cognitive behavioral therapy (cbt), family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. most studies have been based only on bipolar i, however, and treatment during the acute phase can be a particular challenge. some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery. medication lithium is often used to treat bipolar disorder and has the best evidence for reducing suicide. medications are often prescribed to help improve symptoms of bipolar disorder. medications approved for treating bipolar disorder including mood stabilizers, antipsychotics, and antidepressants. sometimes a combination of medications may also be suggested. the choice of medications may differ depending on the bipolar disorder episode type or if the person is experiencing unipolar or bipolar depression. other factors to consider when deciding on an appropriate treatment approach includes if the person has any comorbidities, their response to previous therapies, adverse effects, and the desire of the person to be treated. mood stabilizers lithium and the anticonvulsants carbamazepine, lamotrigine, and valproic acid are classed as mood stabilizers due to their effect on the mood states in bipolar disorder. lithium has the best overall evidence and is considered an effective treatment for acute manic episodes, preventing relapses, and bipolar depression. lithium reduces the risk of suicide, self-harm, and death in people with bipolar disorder. lithium is preferred for long-term mood stabilization. lithium treatment is also associated with adverse effects and it has been shown to erode kidney and thyroid function over extended periods. valproate has become a commonly prescribed treatment and effectively treats manic episodes. carbamazepine is less effective in preventing relapse than lithium or valproate. lamotrigine has some efficacy in treating depression, and this benefit is greatest in more severe depression. lamotrigine may have a similar effectiveness to lithium for treating bipolar disorder, however, there is evidence to suggest that lamotrigine is less effective at preventing recurrent mania episodes. lamotrigine treatment has been shown to be safer compared to lithium treatment, with less adverse effects. valproate and carbamazepine are teratogenic and should be avoided as a treatment in women of childbearing age, but discontinuation of these medications during pregnancy is associated with a high risk of relapse. the effectiveness of topiramate is unknown. carbamazepine effectively treats manic episodes, with some evidence it has greater benefit in rapid-cycling bipolar disorder, or those with more psychotic symptoms or more symptoms similar to that of schizoaffective disorder. mood stabilizers are used for long-term maintenance but have not demonstrated the ability to quickly treat acute bipolar depression. antipsychotics antipsychotic medications are effective for short-term treatment of bipolar manic episodes and appear to be superior to lithium and anticonvulsants for this purpose. atypical antipsychotics are also indicated for bipolar depression refractory to treatment with mood stabilizers. olanzapine is effective in preventing relapses, although the supporting evidence is weaker than the evidence for lithium. a 2006 review found that haloperidol was an effective treatment for acute mania, limited data supported no difference in overall efficacy between haloperidol, olanzapine or risperidone, and that it could be less effective than aripiprazole. antidepressants antidepressants are not recommended for use alone in the treatment of bipolar disorder and do not provide any benefit over mood stabilizers. atypical antipsychotic medications (e.g., aripiprazole) are preferred over antidepressants to augment the effects of mood stabilizers due to the lack of efficacy of antidepressants in bipolar disorder. treatment of bipolar disorder using antidepressants carries a risk of affective switches; where a person switches from depression to manic or hypomanic phases. the risk of affective switches is higher in bipolar i depression; antidepressants are generally avoided in bipolar i disorder or only used with mood stabilizers when they are deemed necessary. there is also a risk of accelerating cycling between phases when antidepressants are used in bipolar disorder. combined treatment approaches antipsychotics and mood stabilizers used together are quicker and more effective at treating mania than either class of drug used alone. some analyses indicate antipsychotics alone are also more effective at treating acute mania. a first-line treatment for depression in bipolar disorder is a combination of olanzapine and fluoxetine. other drugs short courses of benzodiazepines are used in addition to other medications for calming effect until mood stabilizing become effective. electroconvulsive therapy (ect) is an effective form of treatment