for acute mood disturbances in those with bipolar disorder, especially when psychotic or catatonic features are displayed. ect is also recommended for use in pregnant women with bipolar disorder. it is unclear if ketamine (a common general dissociative anesthetic used in surgery) is useful in bipolar disorder. gabapentin and pregabalin are not proven to be effective for treating bipolar disorder. children treating bipolar disorder in children involves medication and psychotherapy. the literature and research on the effects of psychosocial therapy on bipolar spectrum disorders are scarce, making it difficult to determine the efficacy of various therapies. mood stabilizers and atypical antipsychotics are commonly prescribed. among the former, lithium is the only compound approved by the fda for children. psychological treatment combines normally education on the disease, group therapy, and cognitive behavioral therapy. long-term medication is often needed. resistance to treatment the occurrence of poor response to treatment in has given support to the concept of resistance to treatment in bipolar disorder. guidelines to the definition of such treatment resistance and evidence-based options for its management were reviewed in 2020. management of obesity a large proportion (approximately 68%) of people who seek treatment for bipolar disorder are obese or overweight and managing obesity is important for reducing the risk of other health conditions that are associated with obesity. management approaches include non-pharmacological, pharmacological, and surgical. examples of non-pharmacological include dietary interventions, exercise, behavioral therapies, or combined approaches. pharmacological approaches include weight-loss medications or changing medications already being prescribed. some people with bipolar disorder who have obesity may also be eligible for bariatric surgery. the effectiveness of these various approaches to improving or managing obesity in people with bipolar disorder is not clear. prognosis a lifelong condition with periods of partial or full recovery in between recurrent episodes of relapse, bipolar disorder is considered to be a major health problem worldwide because of the increased rates of disability and premature mortality. it is also associated with co-occurring psychiatric and medical problems, higher rates of death from natural causes (e.g., cardiovascular disease), and high rates of initial under- or misdiagnosis, causing a delay in appropriate treatment and contributing to poorer prognoses. when compared to the general population, people with bipolar disorder also have higher rates of other serious medical comorbidities including diabetes mellitus, respiratory diseases, hiv, and hepatitis c virus infection. after a diagnosis is made, it remains difficult to achieve complete remission of all symptoms with the currently available psychiatric medications and symptoms often become progressively more severe over time. compliance with medications is one of the most significant factors that can decrease the rate and severity of relapse and have a positive impact on overall prognosis. however, the types of medications used in treating bd commonly cause side effects and more than 75% of individuals with bd inconsistently take their medications for various reasons. of the various types of the disorder, rapid cycling (four or more episodes in one year) is associated with the worst prognosis due to higher rates of self-harm and suicide. individuals diagnosed with bipolar who have a family history of bipolar disorder are at a greater risk for more frequent manic/hypomanic episodes. early onset and psychotic features are also associated with worse outcomes, as well as subtypes that are nonresponsive to lithium. early recognition and intervention also improve prognosis as the symptoms in earlier stages are less severe and more responsive to treatment. onset after adolescence is connected to better prognoses for both genders, and being male is a protective factor against higher levels of depression. for women, better social functioning before developing bipolar disorder and being a parent are protective towards suicide attempts. functioning changes in cognitive processes and abilities are seen in mood disorders, with those of bipolar disorder being greater than those in major depressive disorder. these include reduced attentional and executive capabilities and impaired memory. people with bipolar disorder often experience a decline in cognitive functioning during (or possibly before) their first episode, after which a certain degree of cognitive dysfunction typically becomes permanent, with more severe impairment during acute phases and moderate impairment during periods of remission. as a result, two-thirds of people with bd continue to experience impaired psychosocial functioning in between episodes even when their mood symptoms are in full remission. a similar pattern is seen in both bd-i and bd-ii, but people with bd-ii experience a lesser degree of impairment. when bipolar disorder occurs in children, it severely and adversely affects their psychosocial development. children and adolescents with bipolar disorder have higher rates of significant difficulties with substance use disorders, psychosis, academic difficulties, behavioral problems, social difficulties, and legal problems. cognitive deficits typically increase over the course of the illness. higher degrees of impairment correlate with the number of previous manic episodes and hospitalizations, and with the presence of psychotic symptoms. early intervention can slow the progression of cognitive impairment, while treatment at later stages can help reduce distress and negative consequences related to cognitive dysfunction. despite the overly ambitious goals that are frequently part of manic episodes, symptoms of mania undermine the ability to achieve these goals and often interfere with an individual's social and occupational functioning. one-third of people with bd remain unemployed for one year following a hospitalization for mania. depressive symptoms during and between episodes, which occur much more frequently for most people than hypomanic or manic symptoms over the course of illness, are associated with lower functional recovery in between episodes, including unemployment or underemployment for both bd-i and bd-ii. however, the course of illness (duration, age of onset, number of hospitalizations, and the presence or not of rapid cycling) and cognitive performance are the best predictors of employment outcomes in individuals with bipolar disorder, followed by symptoms of depression and years of education. recovery and recurrence a naturalistic study in 2003 by tohen and coworkers from the first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. within two years, 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). however, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery. symptoms preceding a relapse (prodromal), especially those related to mania, can be reliably identified by people with bipolar disorder. there have been intents to teach patients coping strategies when noticing such symptoms with encouraging results. suicide bipolar disorder can cause suicidal ideation that leads to suicide attempts. individuals whose bipolar disorder begins with a depressive or mixed affective episode seem to have a poorer prognosis and an increased risk of suicide. one out of two people with bipolar disorder attempt suicide at least once during their lifetime and many attempts are successfully completed. the annual average suicide rate is 0.4%, which is 10–20 times that of the general population. the number of deaths from suicide in bipolar disorder is between 18 and 25 times higher than would be expected in similarly aged people without bipolar disorder. the lifetime risk of suicide has been estimated to be as high as 20% in those with bipolar disorder. risk factors for suicide attempts and death from suicide in people with bipolar disorder include older age, prior suicide attempts, a depressive or mixed index episode (first episode), a manic index episode with psychotic symptoms, hopelessness or psychomotor agitation present during the episodes, co-existing anxiety disorder, a first degree relative with a mood disorder or suicide, interpersonal conflicts, occupational problems, bereavement or social isolation. epidemiology burden of bipolar disorder around the world: disability-adjusted life years per 100,000 inhabitants in 2004. <180 180–185 185–190 190–195 195–200 200–205 205–210 210–215 215–220 220–225 225–230 >230 bipolar disorder is the sixth leading cause of disability worldwide and has a lifetime prevalence of about 1 to 3% in the general population. however, a reanalysis of data from the national epidemiological catchment area survey in the united states suggested that 0.8% of the population experience a manic episode at least once (the diagnostic threshold for bipolar i) and a further 0.5% have a hypomanic episode (the diagnostic threshold for bipolar ii or cyclothymia). including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1% of the population, adding up to a total of 6.4%, were classified as having a bipolar spectrum disorder. a more recent analysis of data from a second us national comorbidity survey found that 1% met lifetime prevalence criteria for bipolar i, 1.1% for bipolar ii, and 2.4% for subthreshold symptoms. estimates vary about how many children and young adults have bipolar disorder. these estimates range from 0.6 to 15% depending on differing settings, methods, and referral settings, raising suspicions of overdiagnosis. one meta-analysis of bipolar disorder in young people worldwide estimated that about 1.8% of people between the ages of seven and 21 have bipolar disorder. similar to adults, bipolar disorder in children and adolescents is thought to occur at a similar frequency in boys and girls. there are conceptual and methodological limitations and variations in the findings. prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may have limited validity. in addition, diagnoses (and therefore estimates of prevalence) vary depending on whether a categorical or spectrum approach is used. this consideration has led to concerns about the potential for both underdiagnosis and overdiagnosis. the incidence of bipolar disorder is similar in men and women as well as across different cultures and ethnic groups. a 2000 study by the world health organization found that prevalence and incidence of bipolar disorder are very similar across the world. age-standardized prevalence per 100,000 ranged from 421.0 in south asia to 481.7 in africa and europe for men and from 450.3 in africa and europe to 491.6 in oceania for women. however, severity may differ widely across the globe. disability-adjusted life year rates, for example, appear to be higher in developing countries, where medical coverage may be poorer and medication less available. within the united states, asian americans have significantly lower rates than their african american and european american counterparts. in 2017, the global burden of disease study estimated there were 4.5 million new cases and a total of 45.5 million cases globally. history main article: history of bipolar disorder german psychiatrist emil kraepelin first distinguished between manic–depressive illness and "dementia praecox" (now known as schizophrenia) in the late 19th century. in the early 1800s, french psychiatrist jean-étienne dominique esquirol's lypemania, one of his affective monomanias, was the first elaboration on what was to become modern depression. the basis of the current conceptualization of bipolar illness can be traced back to the 1850s. in 1850, jean-pierre falret described "circular insanity" (la folie circulaire, french pronunciation: ​); the lecture was summarized in 1851 in the "gazette des hôpitaux" ("hospital gazette"). three years later, in 1854, jules-gabriel-françois baillarger (1809–1890) described to the french imperial académie nationale de médecine a biphasic mental illness causing recurrent oscillations between mania and melancholia, which he termed folie à double forme (french pronunciation: ​, "madness in double form"). baillarger's original paper, "de la folie à double forme," appeared in the medical journal annales médico-psychologiques (medico-psychological annals) in 1854. these concepts were developed by the german psychiatrist emil kraepelin (1856–1926), who, using kahlbaum's concept of cyclothymia, categorized and studied the natural course of untreated bipolar patients. he coined the term manic depressive psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally. the term "manic–depressive reaction" appeared in the first version of the dsm in 1952, influenced by the legacy of adolf meyer. subtyping into "unipolar" depressive disorders and bipolar disorders has its origin in karl kleist's concept – since 1911 – of unipolar and bipolar affective disorders, which was used by karl leonhard in 1957 to differentiate between unipolar and bipolar disorder in depression. these subtypes have been regarded as separate conditions since publication of the dsm-iii. the subtypes bipolar ii and rapid cycling have been included since the dsm-iv,