Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4

Bipolar disorder is an often long-term condition, characterised by recurrent periods of depression, mania, hypomania and mixed episodes.

As in 2014, APMS 2023/4 used the 15-item Mood Disorder Questionnaire to screen for bipolar disorder. Screening positive for bipolar disorder required occurrence over the life course of at least 7 manic/hypomanic symptoms, as well as several co-occurring symptoms, together with functional impairment. A positive screen did not indicate presence of bipolar disorder, rather that fuller assessment would be warranted.

• Prevalence of screening positive for bipolar disorder using the 15-item Mood Disorder Questionnaire has remained stable. The proportion of adults screening positive was similar in 2014 (2.0%) and 2023/4 (1.9%), and consistent with studies using a more comprehensive assessment.
• Among both men and women about one in fifty screened positive. Prevalence of screening positive for bipolar disorder was similar for men and women, and generally higher in younger age groups (especially those aged 25 to 44) than older.
• People screening positive for bipolar disorder often face socioeconomic adversity. Screening positive was more likely among those seriously behind with debt repayments (6.4%), those living in a more deprived local area (3.6%) and - among people of working age - those who were unemployed (9.0%) or economically inactive (4.9%).
• People in poor health were more likely to screen positive for bipolar disorder. Those with a limiting physical health condition were twice as likely to screen positive for bipolar disorder (3.0%) as those without such a condition (1.5%).

Bipolar disorder is a long-term mental health condition. It is generally characterised by recurring episodes of depression (feelings of low mood and lethargy) and of mania (feelings of elation and overactivity) or hypomania (a milder form of mania) (Royal College of Psychiatrists 2020). Several bipolar disorder subtypes can be identified, diagnoses of which are based on the extent and time over which the symptoms are sustained.

The global prevalence of bipolar disorder is estimated to be between around 1 in 150 adults (GBD 2019 Mental Disorders Collaborators 2022) and 2.4% of the global population (Merikangas et al. 2011). Figures varied depending on the part of the bipolar spectrum researchers assess and whether a screening tool or diagnostic tool was used. Prevalence rates have been found to be comparable in men and women, with younger people more likely to screen positive than older people (Merikangas et al. 2011; Pini et al. 2005; GBD 2019 Mental Disorders Collaborators 2022). Prior to APMS 2014, there was a lack of epidemiological data on the prevalence of bipolar disorder in the UK (Gupta and Guest 2002).

Bipolar disorder is one of the leading causes of disability in the world (World Health Organization 2024). It leads to significant psychosocial impairment, such as fewer employment prospects and lower annual income (Coryell et al. 1993; Judd et al. 2005; Marwaha et al. 2013), as well as placing a great burden on health care services (Pini et al. 2005). The annual economic costs for bipolar disorder in England were estimated, in 2018-19, to be £6.43 billion, with 68% of the total costs attributed to lost productivity and informal care, and 31% to health care costs (Simon et al. 2021). 

Bipolar disorder is often comorbid with poor physical health, substance misuse, personality disorders, attention-deficit/hyperactivity disorder (ADHD) (National Institute for Health and Care Excellence (NICE) 2014) and anxiety disorders including posttraumatic stress disorder (Freeman et al. 2002). Furthermore, the risk of suicide among those with bipolar disorder is approximately 10–30 times greater than that in the general population (Dome et al. 2019). The peak incidence (for approximately 50% of people with bipolar disorder) is around the age of 25 years, with a younger peak incidence of 17 years for another 28% (Bellivier et al. 2003). There is often considerable delay between onset and identification and treatment, with those seeking help not receiving a correct diagnosis for six years from the onset of symptoms and very often longer (NICE 2014). Diagnosis of bipolar disorder is challenging in that it cannot be confidently differentiated from unipolar depression until an episode of mania and/or hypomania is identified.

Treatment options, as based on NICE guidelines, vary depending on whether the individual is experiencing a depressive or manic (or a hypomanic) episode. For manic or hypomanic episodes, treatment will usually involve some form of mood stabilising medication. For depressive episodes, NICE currently recommends psychological therapies such as cognitive behavioural therapy (CBT), and/or medication. Long term treatment with mood stabilising medication such as lithium is also recommended as maintenance treatment to reduce the risk of relapse (NICE 2014). Analysis using APMS 2014 data found that 40% of adults who screened positive for bipolar disorder had not received health care for a mental health reason in the past year and 14.5% were in receipt of bipolar disorder specific medication (Humpston et al. 2021; McManus et al. 2016).

Bipolar disorder

Several subtypes of bipolar disorder are recognised in the US-based Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with the major groupings being bipolar I, bipolar II and cyclothymia (APA 2013). In the World Health Organization’s (WHO) International Classification of Diseases version 10 (ICD-10) (WHO 1993), no distinction was made between type I and II, although in ICD-11 bipolar disorders are now subdivided into bipolar I and bipolar II disorder (Severus and Bauer 2020):

• People with bipolar type I disorder experience one or more manic episodes (periods of elevated mood and increased energy including such symptoms as increased talkativeness, inflated self-esteem, feelings of grandiosity, and a decreased need for sleep, which last at least one week and causes significant impairment in social or occupational functioning) interspaced with episodes of depression.
• People with bipolar type II disorder have had one or more hypomanic episodes (which are less intense than manic episodes) and at least one depressive episode, but no history of manic episodes and less impairment in social or occupational functioning.

Mood Disorder Questionnaire (MDQ)

The term ‘screening’ is used throughout this report to refer to identifying people with a higher likelihood of having a disorder. A definitive diagnosis of bipolar disorder would require a comprehensive clinical assessment which was not carried out in this survey. Instead, on both the APMS 2014 and 2023/4, bipolar disorder was screened for as part of the self-completion section of the interview using the Mood Disorder Questionnaire (MDQ). The MDQ is a 15-item scale based on DSM-IV criteria. The DSM-IV was designed to screen for bipolar spectrum disorders across the lifespan, i.e. bipolar I, bipolar II, and bipolar NOS although it does not differentiate between the bipolar disorder subtypes (APA 1994).

The MDQ assesses lifetime experience of manic or hypomanic symptoms by way of 13 yes/no items. The DSM-IV, like other diagnostic systems, do not require a depressive episode to screen positive for bipolar disorder, and so this is not part of the MDQ. Two further items establish whether several of the symptoms have been experienced at the same time, and whether they have caused moderate to serious problems (Hirschfeld et al. 2000). A positive screen for bipolar disorder requires reporting at least seven lifetime manic/hypomanic symptoms, as well as several co-occurring symptoms, and moderate or serious associated impairment in life.

Widely used in epidemiological studies, the MDQ has been found to have a low sensitivity of 0.28 (indicating false negatives may be likely) and a high specificity of 0.97 (which suggests that false positives are unlikely) (Hirschfeld et al. 2003). All APMS participants were asked the first 13 items on the MDQ. Those who answered yes to at least seven items were asked whether they had experienced several symptoms at the same time, and if so, how much of a problem this caused in terms of being unable to work; having family, money or legal troubles; or getting into arguments or fights.

Screening positive for bipolar disorder, by age and gender

Overall, 1.9% of participants in 2023/4 screened positive for bipolar disorder, with the proportion in the wider population likely to be between 1.5% and 2.4% (referred to as the 95% confidence interval (CI)). This equates to an estimated 890 thousand adults living in private households in England.

The proportion screening positive for bipolar disorder was similar for men (1.7%, CI 1.2, 2.5) and women (2.1%, 95% CI 1.5, 2.8), but varied by age. Positive screens were most common among those aged 25 to 34 (3.5%, CI 2.2, 5.4) and 35 to 44 (3.1%, CI 2.0, 4.7), and least common in those 65 to 74 (0.5%, CI 0.2, 1.0) and 75 and over (0.9%, CI 0.3, 2.8).

For more information: Table 11.1 and Table A1 for confidence intervals

Screening positive for bipolar disorder in 2014 and 2023/4

The proportion of adults screening positive for bipolar disorder was similar in 2014 (2.0%, CI 1.6, 2.4) and 2023/4 (1.9%, CI 1.5, 2.4). See How to interpret the findings for information on how changes over time were assessed.

For more information: Table 11.2 and Table B1 for confidence intervals

Variation in screening positive for bipolar disorder by other characteristics

Ethnic group

Age-standardised prevalence of screening positive for bipolar disorder varied by ethnic group. Screening positive for bipolar disorder was lower among those in the White other (0.3%, 95% CI 0.1, 1.2), Black/Black British (0.7%, CI 0.2, 2.1) and Asian/Asian British (0.7%, CI 0.2, 2.3) groups, and higher among those in the Mixed/multiple/other group (5.1%, CI 1.1, 20.7). 2.4% of those in the White British group screened positive (CI 1.8, 3.0). It should be noted that the confidence intervals for some estimates were wide and overlapping, so apparent differences between ethnic groups should be treated with caution.

For more information: Table 11.3 and Table A2 for confidence intervals

Employment status

Age-standardised proportions of screening positive for bipolar disorder varied by employment status for those of working age (16 to 64 years). 9.0% of adults who were unemployed and 4.9% of adults who were economically inactive screened positive for bipolar disorder, compared with 1.6% among those who were employed.

For more information: Table 11.4

Problem debt

In age-standardised analyses, being seriously behind on at least one debt repayment or having utilities cut off was associated with greater likelihood of screening positive for bipolar disorder. 6.4% of those with problem debt screened positive for bipolar disorder compared with 1.5% of the rest of the population. See the APMS 2023/4 Methods documentation for more information on how problem debt was derived.

For more information: Table 11.5

Area-level deprivation

Screening positive for bipolar disorder was associated with area-level deprivation. 3.6% of those living in areas in the most deprived quintile screened positive for bipolar disorder, compared with between 1.2% and 1.7% of those living in other IMD quintiles.

For more information: Table 11.6

Region

The proportion of adults screening positive for bipolar disorder did not vary significantly by region.

For more information: Table 11.7

Comorbidity

Physical health conditions

Age-standardised prevalence of screening positive for bipolar disorder varied by the presence of a limiting physical health condition. 3.0% of those with a limiting physical health condition screened positive for bipolar disorder, compared with 1.5% of those without.

Common mental health conditions

Presence of a CMHC was associated in age-standardised analyses with screening positive for bipolar disorder. 6.2% of adults with a common mental health condition screened positive for bipolar disorder, compared with 0.7% of those without.

For more information: Table 11.8

Self-diagnosis and professional diagnosis of bipolar disorder

Participants were asked whether they themselves thought they had ever experienced bipolar disorder. If they did, they were asked whether this had been diagnosed by a professional, and whether they thought that the disorder had been present in the past 12 months.

80 people (1.4%) in the 2023/4 APMS sample reported thinking that they had had ‘bipolar disorder or manic depression’ at some point. About half of these participants (44, 0.7%) had had this diagnosis confirmed by a professional.

One in four (26.5%) of those screening positive for bipolar disorder on the MDQ reported thinking they had had bipolar disorder or manic depression at some point in their life, compared with 0.8% of those who screened negative on the MDQ. One in six (17.8%) adults screening positive for bipolar disorder reported that they had been diagnosed with bipolar disorder by a professional.

For more information: Table 11.9

Treatment

Treatment and service use

Participants were asked about different types of mental health treatment and service use. These included current medication or psychological therapy for a mental or emotional problem, not necessarily specifically for bipolar disorder, together with the use of a range of health, community and day care services over the past year. These are detailed in the APMS 2023/4 Methods documentation.

Of those who screened positive for bipolar disorder, 50.0% were currently receiving treatment for a mental or emotional problem, compared with 14.9% of those who screened negative. People screening positive for bipolar were more likely to be in receipt of psychotropic medication (40.9%) than psychological therapy (22.2%). 13.6% were in receipt of both.

Among those screening positive for bipolar disorder, 54.9% used health services for a mental health related reason in the past year, 30.8% used community care services, and 14.1% used a day care service.

For more information: Table 11.10

Psychotropic medication

Participants were asked which psychotropic (mental health related) medications that they take. These were not necessarily taken in relation to bipolar disorder. Overall, 12.5% of all adults were taking some form of psychotropic medication, with the most common medication types those primarily used to treat depression (11.7%) and anxiety (10.7%). See Chapter 2 Mental health treatment and service use for more details. 

About two-thirds (40.9%) of those screening positive for bipolar disorder were in receipt of psychotropic medication. The most common among those screening positive for bipolar disorder were medications used to treat depression (37.7%) or anxiety (35.6%). 5.1% of those who screened positive for bipolar disorder reported taking medication for bipolar disorder. 

For more information: Table 11.11

Prevalence remained stable, with one adult in fifty screening positive for bipolar disorder. The prevalence of possible bipolar disorder in the APMS 2023/4 was 1.9%, consistent with findings from epidemiological studies in other countries (GBD 2019 Mental Disorders Collaborator 2022; Merikangas et al. 2011). For example, the World Mental Health Survey Initiative found the lifetime aggregate prevalence from 11 countries (not UK) to be 2.4% for bipolar disorders (BP-I, BP-II, and subthreshold BP) (Merikangas et al. 2011). The proportion screening positive was also similar in APMS 2014, indicating stability in the population prevalence in England over time (McManus et al. 2016).

Caution is required, screening positive is not the same as having the disorder. The instrument used to screen for bipolar disorder, while designed to cover all bipolar spectrum disorders, does have limitations. The MDQ is less sensitive at identifying bipolar II disorders than the longer Hypomania Checklist, another widely used instrument (Meyer et al. 2011). There are also limitations on its use in general population studies (APA 1994). While showing excellent specificity (suggesting a positive result is useful for ruling in bipolar disorder), the instrument has been shown to have limited sensitivity (the proportion of people with the condition who have a positive result) (Swift et al. 2020). The results in this chapter may therefore be underestimates. Overall, the MDQ, appears to have performed well in the APMS 2014 and 2023/4.

The demographic profiles indicate association with ethnicity. APMS 2023/4 data show an association between screening positive for bipolar disorder and ethnicity, with prevalence highest among those in the Mixed/multiple/other ethnic group. Given these comparisons are based on small numbers and that age-standardisation had a large impact on the results, the finding should be interpreted with caution. The association is noteworthy, as it was not evident in APMS 2014 data, although elevated incidence rates for people from black and other minoritised groups have been found before in patient populations in England (Lloyd et al. 2005). Previous research has also noted how some minoritised groups with bipolar disorder are more likely to be misdiagnosed by professionals with other conditions, especially psychosis (Akinhanmi et al. 2018; Haeri et al. 2011).

Prevalence was highest among those aged 25 to 44, and lowest among those aged 65 and over. As bipolar disorder is screened for in relation to symptoms across the life course, prevalence might be expected to gradually increase with age. The survey findings may reflect problems with recall, as well as the increased mortality associated with the disorder. People with bipolar disorder or psychosis experience marked reductions in life expectancy compared with the general population: 14.5 years loss in men with schizophrenia-spectrum and bipolar disorders, and 13.2 years in women (Das-Munshi et al. 2021). Comorbidities contribute to this reduced life expectancy, consistent with the results in this chapter showing greater likelihood of both limiting physical health conditions and common mental health conditions among people who screened positive for bipolar disorder.

Results here confirm the associations with financial difficulties. The findings here are consistent with the strong associations between bipolar disorder and financial difficulties that previous research has found (Richardson et al. 2018). The likelihood of screening positive was higher for those experiencing problem debt, who were unemployed or economically inactive, or living in the most deprived neighbourhoods. Stressful circumstances, including job loss and separation, have been identified by people with the condition as potential triggers for bipolar episodes (Bipolar UK 2022).

One in six screening positive reported that they had been diagnosed with bipolar disorder. The APMS data presented here shows that around a quarter of people screening positive for bipolar disorder thought that they had the condition, and about one in six had been diagnosed by a professional. Existing research shows that some people with bipolar disorder experience substantial delays in diagnosis and treatment after presentation to mental health services, particularly those with other conditions such as alcohol and substance disorders (Patel et al. 2015). Research by Bipolar UK indicates it takes an average of nine and a half years for a diagnosis of bipolar disorder to be made after first telling a clinician about symptoms (Bipolar UK 2022; Scott et al. 2022). In part, initial diagnostic challenges can lead to delayed diagnosis as symptoms of depressive episodes can overlap with major depressive disorder, which can lead to inappropriate treatment. Stigma associated with mental health conditions and misinformation and attitudes can play a part in delayed recognition (Oliva et al. 2025).

Half of those screening positive were not receiving mental health treatment, either psychological therapy or psychotropic (mental health) medication. 40.9% of adults screening positive for bipolar disorder were currently taking some form of psychotropic medication, and 22.2% were in receipt of some form of psychological therapy. Recommendations for treatment vary, depending on whether the individual is experiencing a manic or depressive episode. Manic episodes are usually treated pharmacologically with mood stabilisers and antipsychotics, whereas depressive episodes are treated either psychologically or with medication (NICE 2014). The depressive symptoms tend to be important in explaining the functional consequences of the disorder (Gilbert and Marwaha 2013).

APMS provides unique community-level data on an under researched group. The findings discussed in this chapter are consistent with prevalence studies internationally, despite the limitations of the survey screening method. They offer much needed information on the characteristics, difficulties and health service contact of people screening positive for bipolar disorder living in the community. Future study is warranted to establish the prevalence of bipolar disorder using more detailed examination, and of bipolar subtypes. Research is also needed into why people do not obtain help and inequalities in this, and how health services might adapt to better meet their needs.

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Please cite this chapter as:

Randall, E., Clery, E., Morris, S., McManus, S., & Marwaha, S. (2025). Bipolar disorder. In Morris, S., Hill, S., Brugha, T., McManus, S. (Eds.). Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. NHS England.