Aggression in Bipolar I Disorder and Psychosis Associated With Suicidal Ideation, Alcohol Abuse

Aggression toward others is common among patients with first major episode bipolar type I (BD-I) with psychotic features, according to study data published in the International Journal of Bipolar Disorders. Features associated with increased risk for aggression among patients with psychotic BD-I included recent suicide attempt, alcohol abuse, learning disability, and mania.

Demographic and clinical data were abstracted from the medical records of 216 hospitalized patients with first-episode psychotic BD-I. Aggression was captured using the Expanded Brief Psychiatry Rating Scale, which included a 10-item “Hostility” measure. Clinical documentation of serious physical aggression, homicidal ideation, and attempted homicide during the first major BD-I episode were also used in analyses. Among 216 participants, 117 (54.2%) were men and 173 (80.1%) were Caucasian. The average age of onset for first psychotic BD-I episode was 31.2 years. Initial episode presentations among participants included BD-I mania (35.9%), BD-I mixed (33.8%), major depression with psychotic features (2.31%), and nonaffective psychosis (1.85%).

Serious aggressive acts were identified in 10.7% of participants (n=23). Patients with documented aggression specifically displayed agitation (44.0%), irritability (40.3%), anger outbursts (29.6%), homicidal ideation (8.8%), hostility (4.6%), and homicidal behaviors (3.7%). Per the Hostility subscale of the Expanded Brief Psychiatry Rating Scale, 84.3% of patients were in the mild to moderate range of aggressive behavior. Characteristics associated with increased risk for serious aggression included recent suicide attempt (odds ratio [OR], 4.86; 95% CI, 1.69-13.9; P =.003), alcohol abuse (OR, 3.63; 95% CI, 1.03-12.8; P =.044), learning disability (OR, 3.14; 95% CI, 1.01-9.78; P =.049), and initial presentation with mania (OR, 2.59; 95% CI, 1.41-4.78 P =.002). Sex, age of onset, onset type, comorbid personality disorder, and recent drug abuse were not associated with aggression.

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These data suggest that management of alcohol abuse, suicidal ideation or behavior, and manic symptoms may reduce aggression among patients with bipolar disorder with psychotic features. By proxy, targeted treatment efforts may also mitigate the risk for violent behavior, injuries, or deaths in this patient demographic.


Khalsa H-MK, Baldessarini RJ, Tohen M, Salvatore P. Aggression among 216 patients with a first‑psychotic episode of bipolar I disorder [published online August 11, 2018]. Int J Bipolar Disord. doi: 10.1186/s40345-018-0126-8