Psychotic or Not, Mania Hurts: A 5-Year Cohort Study With a Spotlight on the Non-Psychotic Subtype and Mixed Features

Psychotic symptoms are frequent during acute episodes of bipolar disorder (BD), particularly in mania, and are traditionally considered a marker of greater severity and worse prognosis. However, data comparing psychotic and nonpsychotic mania remain limited and inconsistent.

This study aimed to retrospectively examine clinical, therapeutical and 3-year outcome differences between patients hospitalized for mania with and without psychotic symptoms.

We included all patients admitted for a manic episode to the acute psychiatry unit at Hospital Clínic of Barcelona between 2015 and 2019 (n = 277). Data were extracted from medical records. Patients were followed for 3 years to assess psychiatric emergency department (PED) visits and readmissions. Functional outcomes were also analyzed in the BD subgroup (n = 234). Descriptive statistics and survival analyses were used.

Psychotic symptoms were present in 73.6% of the patients and were associated with younger age (p < 0.001), earlier onset (p = 0.020), poorer insight (p < 0.001), higher cannabis use (p = 0.018) and manic predominant polarity (p = 0006). Non-psychotic patients had more previous admissions for depressive episodes (p = 0.003), more previous mixed episodes (p = 0.006) and suicide attempts (p = 0.002). No significant differences were found in PED visits or readmissions in the next 3 years. Logistic regression identified the number of previous mixed-episode-related admissions as a significant predictor of readmissions (p = 0.041), while psychotic symptoms were not associated with either outcome.

While psychotic and non-psychotic mania show clinical and therapeutical differences, psychosis may not predict short- to medium-term outcomes. Non-psychotic mania-which is associated with depressive polarity, mixed features and suicidal behaviour-may indicate a clinically relevant and therapeutically challenging but underrecognized subgroup. These findings call for a nuanced comprehension of the impact of psychosis in mania and multidimensional approaches.