Not necessarily. Studies have shown that approximately 10% of patients have a single episode only. However, the majority of patients have more than one. The number of episodes within a patient’s lifetime varies. Some individuals may have only two or three within their lifetime while others may have the two or three within a single year. Frequency of episodes depends on many factors including the natural course of the condition and appropriate treatment. Not taking medication or taking it incorrectly are frequent causes of episode recurrence.

Although it is possible that during the natural course of the illness individual patients may get well without any medication, the challenge is that it is impossible to identify or determine beforehand who those fortunate patients are. Even though patient’s response to available treatments may vary from person to person, for the vast majority of patients the benefits of medications outweigh the risks.

The term “mixed episode” was changed to “mixed features” in the last edition of the Diagnostic and Statistical Manual (DSM-5-TR) published by the American Psychiatric Association in 2022. Even though patients with bipolar disorder typically alternate between periods of mania and periods of depression, some can have both types of symptoms at the same time (either episodes of mania combined with some symptoms of depression or episodes of depression combined with some symptoms of mania). When that happens, we say that the patient is experiencing a mood episode with mixed features. Symptoms of mania include elated or irritable mood, decreased need to sleep or racing thoughts. Symptoms of depression can include depressed mood, impaired sleep and feelings of hopelessness or worthlessness.

Outcomes are always better when there is a strong family support network. Think of bipolar disorder as any other severe medical condition. However, also note that in many severe psychiatric conditions, patients may not be aware that they are ill. They may minimize the severity of their condition. The result of these factors may be that patients will not follow through on their treatment. In very severe cases, there may be instances of a lack of behavioral control where family members may not be able to look after their loved ones. In those cases, assistance from providers or crisis services (call the national 988 Suicide and Crisis Lifeline) may be necessary.

Patients with bipolar disorder can have what is called hypomania, or hypomanic episodes. Those are states when the person experiences symptoms very similar to mania but in a smaller scale. Patients with hypomania often feel like they are doing “really well,” more energetic, more productive, and happier or more irritable than usual. They can at times make out-of-character decisions. By definition, hypomanic episodes are not associated with important functional impairment and do not have psychotic symptoms (delusions or hallucinations).

Also, if a patient in a hypomanic episode needs to be hospitalized because of their symptoms, the episode should automatically be considered mania and not hypomania, based on the current diagnostic criteria. Hypomania can be difficult to pinpoint by someone who does not know the patient well and even by the patient itself, although family members and close friends are usually able to notice the differences in the patient’s behavior and mental state.