Published online Sep 19, 2022. doi: 10.5498/wjp.v12.i9.1204
Peer-review started: January 12, 2022
First decision: April 18, 2022
Revised: May 2, 2022
Accepted: August 26, 2022
Article in press: August 26, 2022
Published online: September 19, 2022
Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.
To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.
The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.
This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.
Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.
Core Tip: This systematic review examined the extent and impact of psychosis in 339 studies of bipolar disorder (BD). The results endorsed the high rates of all types of psychotic symptoms in BD. However, psychosis was associated with an adverse impact only in a few domains of the illness including the severity of BD, the rate/duration of hospitalizations, switches to BD, 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.