There may or may not be periods of normal mood intervening. The average age for a first manic episode is 32 years and often occurs after about three episodes of depression. When untreated, manic episodes usually last an average of three months. The time period between episodes becomes shorter as bipolar illness progresses. The cycles may be of shorter duration and increased frequency.
Irritability is often the most prominent symptom alternating with painful depression.
Often the manic phase is denied by the patients because they think they never felt better. Alcohol and other drug abuse is common as an attempt to medicate the mood swings. The suicide rate in physicians is extremely high. Often physician suicide victims have experienced recent professional, personal or family difficulties. Self prescription of psychoactive drugs is an ominous sign.