Can Bipolar Disorder Worsen with Age?
Bipolar disorder does not inherently worsen with age in terms of symptom severity, but the illness remains highly recurrent throughout life, with patients spending approximately 20% of their lifetime in episodes, and the prognosis remains poor despite modern treatments. 1
Natural Course Across the Lifespan
The longitudinal trajectory of bipolar disorder shows specific patterns:
Episode frequency stabilizes rather than accelerates: After the first few episodes, which tend to have shortening intervals between them, episodes later return at an irregular rhythm of approximately 0.4 episodes per year with high individual variability. 1
Chronic recurrence is the rule: Full recovery without further episodes is rare, recurrence with incomplete remission is typical, and development of chronicity remains frequent even into old age. 1
Polarity shifts toward depression: In older adults, there is a shift in the polarity of episodes toward depression rather than mania, though the disorder remains active. 2
Age-Related Considerations
Prevalence and Presentation in Older Adults
Prevalence slightly decreases: Point prevalence of bipolar disorder in older adults (>60 years) appears slightly lower (0.1-0.4%) than in working-age adults, though it still accounts for 8-10% of late-life psychiatric admissions. 3, 4
The disorder remains active: Bipolar disorder becomes less common with advancing age but does not necessarily become more severe; rather, it persists as a heterogeneous lifelong illness. 4
Treatment Challenges in Older Age
Medical comorbidity complicates management: Older adults with bipolar disorder frequently have substantial medical comorbidity and age-related variations in treatment response, creating different treatment needs compared to younger patients. 3
Higher rates of metabolic complications: Prevalence rates of metabolic syndrome (37%), obesity (21%), cigarette smoking (45%), and type 2 diabetes (14%) are elevated among people with bipolar disorder, contributing to reduced life expectancy by 12-14 years. 5
Critical Prognostic Factors
Mortality and Morbidity
Cardiovascular mortality increases: There is a 1.6- to 2-fold increase in cardiovascular mortality occurring a mean of 17 years earlier compared to the general population. 5
Suicide risk remains elevated: The annual suicide rate is approximately 0.9% among individuals with bipolar disorder (compared to 0.014% in the general population), with 15-20% of people with bipolar disorder dying by suicide across the lifespan. 5
Episode Duration and Recovery
Episodes are lengthy: Fifty percent of bipolar episodes last between 2 and 7 months (median 3 months), requiring sustained treatment throughout the natural episode duration. 1
Poor long-term outcomes persist: Despite modern antidepressant and mood-stabilizing treatments, naturalistic follow-up studies show outcomes into old age remain poor, with findings closely compatible to pre-treatment era studies. 1
Common Pitfalls to Avoid
Do not assume older age means milder disease: While prevalence decreases, the disorder remains active and recurrent in those who continue to have it. 4
Do not undertreat based on age: The evidence shows that intensive antidepressant, antimanic, and mood-stabilizing treatments are required in most cases throughout the lifespan, with treatment needing to continue as long as the natural episode lasts. 1
Monitor for treatment non-adherence: More than 50% of patients with bipolar disorder are not adherent to treatment, which significantly impacts outcomes regardless of age. 5