Background Few studies have reported real-life data on socio-economic functioning in patients with bipolar disorder and their unaffected first-degree relatives. Methods We used Danish nation-wide population-based longitudinal register linkage to investigate socio-economic functioning in 19 955 patients with bipolar disorder, their 13 923 siblings and 20 sex, age and calendar-matched control individuals from the general population. Follow-up was from 1995 to 2017. Results Patients with a diagnosis of bipolar disorder had lower odds of having achieved the highest educational level [OR 0.75 (95% confidence interval (CI) 0.73–0.77)], being employed [OR 0.16 (95% CI 0.159–0.168)], having achieved the 80% highest quartile of income [OR 0.33 (95% CI 0.32–0.35)], cohabitating [OR 0.44 (95% CI 0.43–0.46)] and being married [OR 0.54 (95% CI 0.52–0.55)] at first contact to hospital psychiatry as inpatient or outpatient compared with control individuals from the general population. Similarly, siblings to patients with bipolar disorder had a lower functioning within all five socio-economic areas than control individuals. Furthermore, patients and partly siblings showed substantially decreased ability to enhance their socio-economic functioning during the 23 years follow-up compared to controls. Conclusions Socio-economic functioning is substantially decreased in patients with bipolar disorder and their siblings and does not improve during long-term follow-up after the initial hospital contact, highlighting a severe and overlooked treatment gap.

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Bipolar disorder is a potentially disabling mental illness with a prevalence of 1%-2% and a high risk of recurrence of mood episodes, 1 and a substantial heritability of 60%-80%. 2 First-degree relatives of patients with bipolar disorder are at increased risk of developing bipolar disorder and other psychiatric disorders and targeted primary prevention in high-risk individuals has emerged as a new focus area. 3,4 Nevertheless, high-risk studies show a substantial variation in the rate ratios of bipolar disorder ranging from 2.6 to 39.0 and any psychiatric disorder ranging from 1.5 to 11.4 among first-degree relatives to patients with bipolar disorder

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