Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

ARTICLE HIGHLIGHTS

Research background

Psychotic symptoms are very common in bipolar disorder (BD) and have the potential to adversely affect its course, outcome, and treatment. However, despite the considerable amount of research and several reviews on the subject, the impact of psychotic symptoms on the course and outcome of BD remains unclear. Moreover, there are very few systematic reviews on the impact of psychosis in BD.

Research motivation

The lack of information about the impact of psychotic symptoms in BD in existing literature prompted the current systematic review. Moreover, it was prompted by the possibility that the presence of such symptoms in BD and their impact on the illness may have significant etiological, nosological, and clinical implications.

Research objectives

The current systematic review was specifically intended to address the gaps in the literature regarding psychotic symptoms in BD. Therefore, it aimed to examine psychotic symptoms in BD and their impact on several domains of BD. This review focused on four groups of studies and four types of psychotic symptoms. The impact of psychotic symptoms was determined by exploring demographic correlates of psychotic symptoms, their clinical correlates, and the influence of psychotic symptoms on different parameters of course and outcome of BD.

Research methods

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. It undertook an electronic search supplemented by a manual one. Articles were selected in two phases: Screening of abstracts and review of full texts. The methodological quality of the studies and the risk of bias were ascertained by standard tools.

Research results

This systematic review included 339 studies of BD. The results endorsed the high rates of all types of psychotic symptoms found in BD. More than a half to two-thirds of the patients experienced psychosis during their lifetimes. Current psychosis was found in a little less than half of these patients. Delusions were more common than hallucinations. About a third of the patients had first-rank symptoms or mood-incongruent psychotic symptoms. Psychotic symptoms were more frequent in bipolar type I disorder, and in mania or mixed episodes. However, psychosis was associated with an adverse impact only in a few domains of the illness including the severity of BD, lack of insight, more frequent occurrence of agitation, anxiety, and hostility, the rate of and the duration of hospitalizations, switch to BD among patients with depression, and poorer outcomes with mood-incongruent symptoms. No consistent associations were found in other areas, suggesting that psychosis is not always associated with a negative impact on BD. This finding conformed to the current consensus in the literature on psychotic BD.

Research conclusions

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Research perspectives

The ongoing debate about the impact of psychosis in BD is yet to be resolved. Studies with more improved methodology are needed to ascertain the true impact of psychotic symptoms in several domains of BD.