Bipolar spectrum disorders in divers: risks, recognition, and recommendations.
Clinical Snapshot
PICO Framework
| P — Population | Adults with bipolar spectrum disorders (bipolar I, bipolar II, cyclothymia) who are current or prospective scuba divers, including recreational, occupational, and military divers |
| I — Intervention | Participation in scuba diving activities, including assessment of fitness-to-dive in the context of bipolar disorder, its pharmacological management, and associated functional impairments |
| C — Comparator | Individuals without bipolar disorder undertaking diving; parallel evidence from aviation, occupational, and other safety-critical domains used as analogical comparators |
| O — Outcomes | Safety-relevant functional outcomes (cognitive impairment, decision-making, emotional regulation, insight), medication effects in the hyperbaric environment, relapse risk, fitness-to-dive determination criteria, and clinical recommendations for diving medical examiners |
Bottom Line
This systematic review provides the first structured synthesis of evidence relevant to fitness-to-dive assessment in individuals with bipolar spectrum disorders. Drawing on psychiatric, occupational, aviation, and diving medicine literature, it identifies persistent cognitive impairments — particularly in attention, executive function, and decision-making — as safety-relevant concerns even during euthymia. Pharmacological management, especially lithium use in the context of diving-associated dehydration and exertion, polypharmacy, and antidepressant therapy, introduces additional risk dimensions. Comorbidity, sleep disruption, circadian dysregulation, and impaired insight during early relapse further complicate risk stratification. Critically, the review argues against blanket exclusion, instead advocating for individualised fitness-to-dive assessments that prioritise sustained functional stability, treatment adherence, and illness insight over symptom absence alone. The evidence base is predominantly extrapolated from adjacent safety-critical domains, and no primary diving-outcome data exist — a fundamental limitation. For Australian diving medical examiners, this review offers a practical conceptual framework for an underserved clinical scenario, supporting collaborative assessment between mental health clinicians and diving medicine specialists. Recommendations should be interpreted as informed expert consensus rather than high-certainty evidence, and prospective research on diving outcomes in this population is urgently needed.
Key Findings
P Value: Not applicable — narrative systematic review without statistical analysis
Effect Size: No quantitative effect size reported; qualitative synthesis indicates that even euthymic individuals with bipolar disorder demonstrate subtle but clinically meaningful deficits in safety-critical cognitive domains
Primary Outcome: Fitness-to-dive assessment framework for individuals with bipolar spectrum disorders, identifying key safety-relevant factors: persistent cognitive impairment during euthymia (attention, executive function, decision-making), pharmacological risks (lithium toxicity risk, polypharmacy interactions, antidepressant-associated mood destabilisation), comorbidity burden, circadian disruption, sleep deprivation, and reduced insight during early relapse
Nnt Or Sensitivity: Not calculable from available data; the review recommends prioritising sustained functional stability, reliable treatment adherence, and illness insight over symptom absence alone as the primary criteria for fitness-to-dive determination
Confidence Interval: Not applicable — no meta-analytic pooling performed
Clinical Application
The recommended individualised, collaborative assessment approach is feasible in specialist diving medicine settings. Implementation requires coordination between psychiatrists or treating mental health clinicians and accredited diving medical examiners. Standardised cognitive assessment tools (e.g., neuropsychological testing of executive function and attention) and structured relapse-prevention planning are recommended adjuncts. Barriers include limited availability of diving medicine specialists with psychiatric expertise and absence of validated bipolar-specific fitness-to-dive assessment instruments. In Australia, fitness-to-dive assessments for recreational divers are guided by the Australian and New Zealand College of Anaesthetists (ANZCA) and Diving and Hyperbaric Medicine Society of Australia and New Zealand (SPUMS) frameworks. Occupational divers are subject to AS/NZS 2299.1 standards. Bipolar disorder is not explicitly addressed in current SPUMS guidelines, making this review directly relevant to Australian diving medical examiners. Pharmacologically, lithium carbonate is PBS-listed (Schedule 4) for bipolar disorder maintenance, and its narrow therapeutic index, combined with dehydration risk during diving, represents a specific safety concern in the Australian context. Atypical antipsychotics used as mood stabilisers (e.g., quetiapine, olanzapine, aripiprazole) are PBS-listed under the bipolar disorder authority prescription pathway. TGA-approved medications for bipolar disorder do not carry specific hyperbaric contraindications in product information, highlighting a regulatory gap. RACGP mental health guidelines emphasise shared care models, consistent with the review's recommendation for psychiatrist–diving examiner collaboration. The review's cautious, individualised approach aligns with medico-legal expectations under Australian occupational health and safety legislation for safety-critical work. Adults with bipolar I disorder, bipolar II disorder, or cyclothymia who present for fitness-to-dive assessment, including recreational divers, occupational divers, and military/public safety divers. Particularly relevant for individuals seeking return-to-diving clearance following a mood episode or medication change.
Abstract
Bipolar disorder is a recurrent psychiatric condition characterised by episodic mood disturbances, residual functional impairment, and high rates of psychiatric and medical comorbidity. While many individuals achieve symptomatic remission, persistent deficits in cognition, emotional regulation, and insight may remain, raising concerns for participation in safety-critical activities such as scuba diving. This systematic review synthesised evidence from psychiatric, occupational, aviation, and diving medicine literature to examine the clinical course of bipolar disorder, treatment considerations, functional outcomes, and safety-relevant factors pertinent to fitness-to-dive assessments. Bipolar disorder exhibits marked heterogeneity in syndromal and functional outcomes. Even during euthymia, subtle impairments in attention, executive functioning, and decision-making may persist. Pharmacological stability is essential for diving, but treatment regimens, particularly lithium use, polypharmacy, and antidepressant therapy, introduce additional considerations. Comorbidity, circadian disruption, sleep deprivation, and reduced insight during early relapse further complicate risk assessment. Empirical data on diving outcomes in individuals with bipolar disorder are scarce, necessitating reliance on expert opinion and extrapolation from related safety-critical domains. Fitness-to-dive assessments in bipolar disorder should prioritise sustained functional stability, reliable treatment adherence, and illness insight over symptom absence alone. A cautious, individualised approach is warranted, incorporating medication effects, comorbidity, operational context, and relapse-prevention planning, supported by collaboration between mental health professionals and diving medical examiners.
References
- 1.Querido, A. L., & Wingelaar, T. T. (2026). Bipolar spectrum disorders in divers: risks, recognition, and recommendations. Diving and Hyperbaric Medicine, 56(2), 170–176. https://doi.org/10.28920/dhm56.2.170-176
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