What Is the Leading Cause of Death in Bipolar People?

People with bipolar disorder face a significantly higher risk of premature death compared to the general population. While mental health symptoms are a primary concern, physical health complications and lifestyle factors also contribute to this increased mortality rate. Understanding these risks can help improve prevention efforts and treatment strategies.

Cardiovascular Health Concerns

Individuals with bipolar disorder are at a significantly higher risk of cardiovascular disease (CVD), a leading cause of premature mortality in this population. Research shows they develop cardiovascular conditions at a younger age, sometimes up to a decade earlier than the general population. A meta-analysis in The Lancet Psychiatry found that people with bipolar disorder are nearly twice as likely to develop heart disease.

One major contributor is autonomic nervous system dysregulation, which affects heart rate variability and blood pressure control. Studies indicate that individuals with bipolar disorder often exhibit increased sympathetic nervous system activity, leading to hypertension. Chronic stress and mood instability further exacerbate these issues, promoting arterial stiffness and endothelial dysfunction—precursors to atherosclerosis and other cardiovascular conditions.

Inflammation also plays a significant role. Elevated levels of pro-inflammatory cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), contribute to vascular damage and increase the risk of coronary artery disease. A JAMA Psychiatry study highlighted that systemic inflammation in bipolar disorder persists beyond mood episodes and may accelerate cardiovascular aging.

Medication use further complicates cardiovascular health. Many mood stabilizers and second-generation antipsychotics, such as olanzapine and quetiapine, are linked to weight gain, dyslipidemia, and insulin resistance—factors that elevate the risk of hypertension and type 2 diabetes. While these medications are essential for mood stabilization, their long-term effects on heart health require careful monitoring and, when possible, the selection of options with a lower metabolic burden.

Elevated Suicide Risk

Suicide is a leading cause of death among individuals with bipolar disorder, with the lifetime risk estimated to be 10 to 20 times higher than in the general population. A meta-analysis in The American Journal of Psychiatry found that nearly 15% of individuals with bipolar disorder die by suicide, and up to 50% attempt it at least once. The extreme mood fluctuations characteristic of the disorder create a volatile emotional landscape, increasing the likelihood of suicidal behavior.

Depressive episodes often bring profound hopelessness, anhedonia, and feelings of worthlessness, significantly heightening suicide risk. Bipolar depression can be particularly severe, with abrupt mood shifts amplifying distress. Research in JAMA Psychiatry suggests that mixed episodes—where depressive and manic symptoms co-occur—pose an even greater risk due to the combination of despair and heightened energy, which can facilitate suicidal actions.

Manic and hypomanic episodes also contribute to suicide risk. While mania is often associated with euphoria, it can also manifest as agitation, recklessness, and impaired judgment. Individuals in a manic state may engage in impulsive suicide attempts driven by momentary distress rather than prolonged ideation. A study in Bipolar Disorders found that those with bipolar I disorder, who experience full manic episodes, are at greater risk of lethal suicide attempts than those with bipolar II, where hypomania is less severe. The presence of psychotic features, such as delusions of persecution or nihilism, further increases danger, as individuals may act on distorted beliefs.

Rapid cycling, defined as four or more mood episodes within a year, is another significant risk factor. Research in Molecular Psychiatry indicates that individuals with rapid cycling bipolar disorder are twice as likely to attempt suicide. The relentless emotional shifts can create exhaustion and instability, diminishing resilience. Early onset of bipolar disorder, particularly in adolescence or young adulthood, further compounds risk, as early mood instability disrupts critical developmental milestones and social integration.

Substance Use Patterns

Substance use disorders (SUDs) are significantly more common in individuals with bipolar disorder, with up to 60% struggling with alcohol or drug misuse. The cyclical nature of bipolar disorder creates a complex relationship with substance use, as individuals may turn to drugs or alcohol to manage mood fluctuations. Stimulants like cocaine may be used to counteract depressive lethargy, while sedatives such as benzodiazepines or opioids may be used to temper manic agitation. This pattern of self-medication worsens mood instability and increases the risk of addiction.

Neurobiological factors further compound the issue. Both bipolar disorder and substance use involve dysregulation of the brain’s reward system, particularly within the dopaminergic pathways that govern motivation and pleasure. Functional MRI studies show heightened sensitivity in the nucleus accumbens in individuals with bipolar disorder, predisposing them to seek substances that provide immediate gratification. Genetic studies have also identified shared heritability between bipolar disorder and SUDs, with genome-wide association studies (GWAS) linking variations in the CACNA1C and ANK3 genes to increased susceptibility for both conditions.

Substance use worsens clinical outcomes, leading to more frequent mood episodes, greater treatment resistance, and higher hospitalization rates. Alcohol has been linked to more severe depressive episodes, while cannabis use increases the likelihood of manic episodes and rapid cycling. A longitudinal study in Psychological Medicine found that individuals with bipolar disorder who regularly used cannabis had twice the likelihood of experiencing rapid cycling, further destabilizing their condition.

Metabolic Factors

Metabolic syndrome—a cluster of conditions including central obesity, insulin resistance, dyslipidemia, and hypertension—affects nearly 40% of people with bipolar disorder, a rate significantly higher than in the general population. This elevated burden is influenced by genetic predisposition, altered neuroendocrine regulation, and medication-induced metabolic changes.

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis plays a major role in metabolic disturbances. Chronic exposure to elevated cortisol levels, a hallmark of HPA axis dysfunction, promotes visceral fat accumulation and reduces insulin sensitivity, increasing the risk of type 2 diabetes. Studies show that individuals with bipolar disorder exhibit prolonged cortisol responses to stress, which not only exacerbates mood instability but also accelerates metabolic decline. Hormonal imbalances in leptin and ghrelin further disrupt appetite regulation, contributing to weight gain.

Physical Activity Patterns

Mood fluctuations influence motivation, energy levels, and engagement in physical activity. While regular exercise improves mood stability and cardiovascular health, individuals with bipolar disorder often struggle with maintaining consistent routines. Depressive episodes can cause profound fatigue, making even basic movement overwhelming. Conversely, during manic or hypomanic states, some individuals may engage in excessive physical activity, sometimes to the point of exhaustion or injury. These drastic shifts contribute to irregular activity patterns, further impacting overall health.

Reduced physical activity is linked to metabolic dysfunction and cardiovascular disease. Sedentary behavior, more common during depressive phases, contributes to obesity, insulin resistance, and hypertension. A study in Psychosomatic Medicine found that individuals with bipolar disorder engage in significantly less moderate-to-vigorous physical activity than those without the condition, exacerbating their already elevated risk for metabolic syndrome. Medication side effects—particularly those that cause sedation or weight gain—can also make regular exercise more difficult. Structured interventions, such as supervised exercise programs tailored to accommodate mood fluctuations, have shown promise in improving adherence and reducing the negative health impact of inactivity.