Key Takeaways
- Bipolar disorder does not go away on its own; without treatment, episodes tend to keep coming back.
- The risks with the strongest evidence are suicide, substance use, smoking-related and other physical illness, and lost years of life.
- Many people go years without a correct diagnosis, often treated only for depression.
- Mania or hypomania appearing for the first time later in life needs a medical workup before it is called bipolar disorder.
Untreated bipolar disorder tends to persist. NIMH says it usually needs lifelong treatment and does not go away on its own, and the research on outcomes without care is sobering: higher rates of suicide, substance use and physical illness, and a shorter life expectancy on average. The same research shows why treatment matters, because many of those risks are lower with steady care. This page sets out what the evidence says, what "untreated" often looks like in real life, and what to do if bipolar symptoms first show up later in adulthood.
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If you or someone else is in danger
What "untreated" usually looks like
Few people choose to leave bipolar disorder untreated. More often it is unrecognized. NIMH notes that some people live with it for years before diagnosis, and that people with bipolar II may seek help only for depression, so hypomania goes unnoticed. A meta-analysis of 27 studies (Dagani et al., 2017) found an average of 5.8 years between onset and treatment; the VA/DoD guideline cites delays of up to 14.5 years. In one older survey of people with bipolar disorder, 69% said they had first been misdiagnosed, most often with depression.
Untreated can also mean treated for the wrong thing (for example, an antidepressant alone), or stopped treatment after feeling well. If you think depression treatment has missed something, depression or bipolar disorder? explains the clues.
Episodes tend to come back
Bipolar disorder can be episodic or chronic, but in either form it is recurrent: after one episode, more are likely without prevention. That is the reason guidelines from CANMAT/ISBD, NICE and the VA/DoD all organize care around maintenance treatment, not just treating the current episode.
People often ask whether bipolar disorder gets worse with age. There is no reliable way to predict one person's course. Some researchers have proposed that repeated episodes change the course of illness over time, but that idea is still being studied and is not established fact. What is clear is that preventing episodes protects relationships, work, finances and health, whatever the long-term biology turns out to be.
The risks, with the evidence
| Risk | What research shows | Source |
|---|---|---|
| Suicide | A pooled rate of 164 suicides per 100,000 person-years in bipolar disorder; 23–26% of people attempt suicide in population studies. One review estimates the rate at roughly 20–30 times that of the general population. | ISBD task force (Schaffer et al., 2015); Miller & Black, 2020 |
| Substance use | In clinical samples, about 42% had an alcohol use disorder and 20% a cannabis use disorder. Co-occurring substance use is linked to earlier onset and more hospitalizations. | Hunt et al., 2016 |
| Smoking | About 49% of people with bipolar disorder smoke. | VA/DoD 2023 guideline |
| Shorter life | Bipolar disorder is associated with roughly 10 years of potential life lost. | VA/DoD 2023 guideline |
| Daily functioning | Among U.S. adults with bipolar disorder in the past year, 82.9% had serious impairment (national survey data from 2001–2003). | NIMH |
Suicide risk is highest during depressive and mixed states. Warning signs to take seriously include talking about wanting to die, feeling hopeless or like a burden, giving things away and withdrawing. If you notice them, use the crisis contacts above. NICE also recommends an annual physical health check for everyone with bipolar disorder (weight, blood pressure, glucose and lipids), reflecting higher cardiometabolic risk.
Late-onset bipolar disorder and medical rule-outs
Bipolar disorder usually begins in the teens or twenties. The VA/DoD guideline notes that only about 20% of bipolar I cases start after age 40, and NIMH survey data show past-year prevalence falling to 0.7% in adults 60 and older. So when mania or hypomania appears for the first time in mid- or later life, clinicians look hard for another cause before settling on bipolar disorder.
Things that can produce manic or bipolar-like symptoms, and that an evaluation should check:
- Thyroid disease, especially an overactive thyroid (NIMH, Merck, NICE).
- Medicines such as corticosteroids and dopamine agonists (used for Parkinson's disease and restless legs), and stimulants (Merck).
- Alcohol and drugs, including withdrawal (NICE lists drug and alcohol misuse among the differential diagnoses).
- Other medical and neurological illness, which is why a new mood change in later life deserves a physical exam and labs ordered as needed.
Our page on medical conditions that mimic mental illness covers these look-alikes in more detail.
What treatment changes
The outcomes above are not fixed. Some of the best-studied effects of treatment:
- Suicide risk. Strong evidence suggests lithium is associated with lower suicide risk: a 2013 meta-analysis of 48 trials found fewer suicides with lithium than placebo. A 2021 network meta-analysis did not confirm the effect in short trials, so it is described as likely rather than proven. See lithium for bipolar disorder.
- Recovery from depression. In the STEP-BD trial, people who received intensive psychotherapy (family-focused therapy, interpersonal and social rhythm therapy, or CBT) alongside medication had higher year-end recovery than those who got a brief intervention (64.4% vs 51.5%).
There is no cure, but bipolar disorder is very treatable and many people stay well for long stretches with ongoing treatment.
Signs bipolar disorder may be going unrecognized
Because the illness so often hides behind a depression diagnosis, these patterns are worth raising with a clinician, especially if you are already in treatment and it is not working:
- Depression that keeps returning, started young, or has never responded well to antidepressants.
- Feeling agitated, wired or unable to sleep after starting an antidepressant.
- Past stretches of several days with much less need for sleep, unusual confidence, fast speech or out-of-character spending or risk-taking.
- A parent, sibling or child with bipolar disorder.
- Mood episodes after childbirth.
- Alcohol or drug use that seems to track with mood swings.
None of these proves bipolar disorder, and no single sign is decisive. Together, they are the kind of history an evaluation is designed to sort out. If you are a family member noticing them, living with bipolar disorder has a section on how to help.
Coming back to treatment after a gap
If you were diagnosed years ago and stopped treatment, you are not starting from zero. Bring what you remember: past medications and how they worked, side effects, hospital stays and the pattern of past episodes. Do not restart old prescriptions on your own; doses and safety checks may need to be different now. How bipolar disorder is diagnosed explains what an evaluation looks at.
At Willow & Stone
If you are worried that bipolar disorder has gone untreated, a 90-minute evaluation is a reasonable first step. Bipolar disorder treatment at Willow & Stone explains what care looks like, and the complete guide to bipolar disorder covers symptoms, types and treatment.
Common Questions
What happens if bipolar disorder goes untreated?
It usually persists, and episodes tend to recur. Research links untreated or under-treated bipolar disorder with higher rates of suicide, substance use, smoking and physical illness, and with about 10 years of potential life lost on average. Many of these risks are lower with steady treatment.
Can bipolar disorder go away on its own?
No. NIMH says bipolar disorder usually needs lifelong treatment and does not go away on its own. People can have long symptom-free stretches, which can make it seem gone, but the risk of new episodes remains, which is why maintenance treatment matters.
Does bipolar disorder get worse with age?
Not necessarily. No one can predict a single person's course. Some researchers think repeated episodes may change the illness over time, but this is unproven. Preventing episodes with ongoing treatment is the most reliable way to protect long-term health and functioning.
Can bipolar disorder develop later in life?
It can, but it is less common: only about 20% of bipolar I cases start after age 40. When mania appears for the first time in mid- or later life, clinicians first check for thyroid disease, medications such as corticosteroids, substances and other medical or neurological causes.
Can untreated bipolar disorder cause brain damage?
That has not been established. NIMH notes that brain structure and function may differ in groups of people with bipolar disorder, but research has not settled whether such differences come from episodes, treatment or the condition itself, and no test can show it in an individual. Preventing episodes is still worthwhile for many other reasons.
What is the suicide risk with bipolar disorder?
It is many times higher than in the general population; one review estimates roughly 20–30 times. Risk is highest during depressive and mixed episodes. If you are having suicidal thoughts, call or text 988, or chat at 988lifeline.org; in an emergency call 911.
Part of our bipolar disorder guide
Sources & Further Reading
- NIMH: Bipolar Disorder (NIH Pub. No. 25-MH-8088, revised 2025)
- VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder (2023)
- Schaffer A et al. ISBD Task Force: suicide and bipolar disorder. Aust N Z J Psychiatry 2015
- Miller JN, Black DW. Bipolar disorder and suicide: a review. Curr Psychiatry Rep 2020
- Hunt GE et al. Prevalence of comorbid substance use in bipolar disorder: meta-analysis. J Affect Disord 2016
- Dagani J et al. Meta-analysis of the interval between onset and management of bipolar disorder. Can J Psychiatry 2017
- Merck Manual Professional: Bipolar Disorders (Coryell, reviewed Jan 2026)
- NICE CG185: Bipolar disorder assessment and management (last updated 2 Sept 2025)
This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.
If you need help right now
Willow & Stone is an outpatient practice and is not an emergency service. If you or someone you care about is in immediate danger, call 911.
For urgent mental health support at any hour, call or text 988 to reach the Suicide & Crisis Lifeline, or text HOME to 741741 for the Crisis Text Line. Both are free, confidential, and available 24/7 nationwide.
Dr. Stacey Forbes, DNP, APRN, PMHNP-BC
Board-certified Psychiatric-Mental Health Nurse Practitioner and founder of Willow & Stone Integrative Mental Health. Nearly two decades of clinical experience; integrative, root-cause psychiatry in person in Arlington and by telehealth. Licensed in Texas, New Mexico, Florida, Alaska, Arizona, Colorado & Washington.
About Dr. Forbes →