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

Introduction 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. Objectives This study aimed to retrospectively examine clinical, therapeutical and 3‐year outcome differences between patients hospitalized for mania with and without psychotic symptoms. Methods 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. Results 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. Conclusions 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.