Early determinants of four‐year clinical outcomes in bipolar disorder with psychosis

Abstract

Objectives Bipolar disorder with psychosis is common in inpatient settings and is associated with diverse outcomes after hospital discharge, which can range from a return to premorbid functioning with no recurrence to a chronic or recurring illness. Less is known, however, about factors that can predict a better or worse clinical outcome. The present report sought to assess four-year clinical outcomes and their predictors in patients hospitalized for bipolar I disorder with psychosis. Methods Participants from the Suffolk County Mental Health Project (SCMHP) with a baseline diagnosis of bipolar I disorder with psychotic features (N = 126) were reassessed using face-to-face interviews at six months, two years, and four years following their first hospitalization. At each time point, clinical status, role functioning, and treatment were assessed by highly trained interviewers using standardized instruments. Results The majority of participants (73.2%) returned to their premorbid level of role functioning by the four-year follow-up and the median percent time ill during the interval was less than 20%. Nevertheless, almost half the sample (46.9%) was rehospitalized at least once. Psychotic symptoms at baseline (particularly Schneiderian symptoms), depressive phenomenology, childhood psychopathology, and younger age at first hospitalization predicted worse outcome; whereas mood incongruent psychotic features and age of mood disorder onset did not. Conclusions The four-year outcomes of a first-admission cohort with bipolar I disorder with psychosis were generally favorable. Poorer premorbid functioning, Schneiderian delusions, greater depressive symptoms, and a younger age of first hospitalization portend a worse course.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

“…While the prognosis for patients experiencing mood‐congruent psychotic features may not differ from those with an absence of psychotic symptoms, limited evidence does suggest that those with mood‐incongruent features have a more severe illness with poorer long‐term prognosis 207, 208, 209, 210, 211, 212. There is no evidence of superiority of any first‐line monotherapy treatment in comparison to other monotherapy options in treating patients with psychotic features.…”

“…Risk factors for recurrence include younger age of onset,332 psychotic features,212 rapid cycling,331 more (and more frequent) previous episodes,333 comorbid anxiety,334 and comorbid SUDs 335. Persistent subthreshold symptoms also increase risk for subsequent mood episodes,334, 336, 337 and the presence of residual symptoms should therefore be an indicator of a need for further treatment optimization.…”

The Neural Effects of Psychotropic Medications in Children and Adolescents

“…1 An early onset of many psychiatric disorders in youth has been linked with a more severe course of illness, morbidities such as suicide attempts and substance abuse, as well as the presence of comorbidities and complications such as poor academic and job performance, interpersonal conflicts, or legal problems. 2–5 Despite vigorous efforts to find effective treatments for psychiatric conditions in youth, treatment challenges are frequent and illness carries high rates of complications, including mortality. 6 …”

Comorbidity

“…Comorbid ADHD is associated with earlier age at illness onset (Sachs et al 2000 ;Nierenberg et al 2005 ;Tamam et al 2006 ), more frequent mixed episodes vs. pure manic (Perugi et al 2013 ), more frequent early onset of substance abuse (in up to 90 % of patients) (Wilens et al 1997 ), a higher number of psychiatric comorbidities (Wilens et al 2009 ; ), decreased quality of life ) and worse course of bipolar disorder and greater burden of other psychiatric comorbid conditions (Klassen et al 2010 ;Perugi et al 2013 ;Pataki and Carlson 2013 ;Nierenberg et al 2005 ;Bernardi et al 2010 ;Ruggero et al 2010 ;Carlson et al 2012 ;Ryden et al 2009 ). Two confl icting reports on the type of BD exist.…”