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\begin{document}

\title{A Nepalese Bipolar case amidst risk and protective factors during
COVID-19 pandemic: A Case Report}



\author[1]{Dhana Shakya}%
\author[1]{Sandesh Upadhaya}%
\affil[1]{BP Koirala Institute of Health Sciences}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Bipolar disorder is a chronic and recurring psychiatric illness.
Emphasis on enhancing key protective factors like social support systems
and promoting this to minimize risk factors like non-compliance is one
of the key strategies tied to enhance overall health for symptoms
remission and relapse prevention even during the COVID-19 Pandemic.%
\end{abstract}%



\sloppy


Running head: A Nepalese Bipolar case amidst risk and protective factors
during COVID-19

\textbf{A Nepalese Bipolar case amidst risk and protective factors
during COVID-19 pandemic: A Case Report}

Dhana Ratna Shakya\textsuperscript{1}, Sandesh Raj
Upadhaya\textsuperscript{2}

\textsuperscript{1} Professor, Department of Psychiatry, BP Koirala
Institute of Health Sciences, Dharan, Nepal

\textsuperscript{2} Junior Resident, Department of Psychiatry, BP
Koirala Institute of Health Sciences, Dharan, Nepal

*Corresponding author:

Dr. Dhana Ratna Shakya

Email:\emph{drdhanashakya@yahoo.com}, Phone : +977-025-525555,
Extension-5334

\textbf{Abstract}

Bipolar disorder is a chronic and recurring psychiatric illness.
Emphasis on enhancing key protective factors like social support systems
and promoting this to minimize risk factors like non-compliance is one
of the key strategies tied to enhance overall health for symptoms
remission and relapse prevention even during the COVID-19 Pandemic.

Keywords: Bipolar disorder, Protective factor, Risk Factor, Social
support, COVID-19 Pandemic

\textbf{Key clinical message}

The attribute of social cohesiveness and compassion is evident in this
case report. Despite disturbed family dynamics, neighbors' and societal
support plays an important protective role for a chronic and recurring
illness like bipolar mood.

\textbf{Introduction}

Bipolar disorder is a severe and chronic illness with recurrent episodes
of mania and depression.~The overall lifetime prevalence of bipolar
spectrum disorders, based on a large cross-sectional survey, was 2.4\%,
with an account of 0.6\% prevalence for bipolar type I and 0.4\% for
bipolar type II {[}1{]}. The notion of risk and protective factors is
one of the important parameters linked with predicting the outcome of
bipolar disorder. These factors, of various forms as bio-psycho-social,
have multidimensional operations starting from individual to family,
school, neighborhood, and a broader societal level. The more chance of
having the positive effects of protective factors that outweighs
negative risk factors, the better is the prognosis. Major protective
factors for a positive outcome in a bipolar patient include social
support (from at least one caring adult) which is protective about a
wide range of adversities {[}2{]}.

The Second wave of COVID-19 was recorded in Nepal by April/May 2021,
after the exponential rise of cases {[}3{]}. We report a case of 23
years old male who was rescued by the neighbors after the exacerbation
of the second episode of mania and brought to our center amid the
COVID-19 second wave. We intend here to point out the implication of the
dynamics of the protective and risk factors for bipolar mood through a
23-year patient from eastern Nepal which is largely harmonious in its
multi-ethnic, multilingual, and multicultural social composition.

\textbf{Case Presentation}

A 23-years-old unmarried Hindu male from Bishwakarma (ironsmith), a
Dalit (oppressed) ethnicity {[}4{]}, low middle socioeconomic status,
and educated up to the third standard had been brought to our institute
emergency department (E.D.) three years back for the sudden abnormal
change in behavior.

The history of substance use was present in a problematic pattern in his
father and three elder brothers. The mother passed away when the patient
was 5 years of age. Father committed suicide by hanging after 6 months
of the death of their mother under the influence of alcohol. The third
elder brother with a history of multiple substance use (cannabis,
benzodiazepine, opioids, and alcohol) was kept in prison for possession
of an illegal amount of cannabis and involvement in a fight and
robbery.~He died during his stay in prison.

At the age of 13 years, the patient took his first puff of tobacco under
influence of his peer and the pattern of use was 2-3 sticks per day. Two
days later of tobacco smoking, he started using marijuana out of
curiosity and the current pattern was 1-2 sticks every 3-4 days. Three
years later, he started using tablets of Nitrazepam 5 mg 2 tablets on
and off that, as per the patient, gave him more energy while working as
a conductor. Later, he used Spasmoproxyvon + Nitrazepam and Opidol in
combination, with 10 tablets per day, from his peer circle. If not
available, he also used cough syrup (opioids), shared among friends.~He
would occasionally use locally distilled alcohol, the amount being 50
ml/day. The last use of all substances was 7 days before the
presentation to our hospital.

After damaging a battery connecting to the wrong charging point and
asking the workplace supervisor for money with an excessive desire to
get married soon, he was fired from his job. He entered one of the
neighbor's houses without permission and requested a young girl to get
married to him. The patient started talking in a loud tone, the content
of being a billionaire, having excessive money and power, and changing
the topic frequently. He started playing television in a loud volume and
cleaning the television and furniture at night time.~He started
over-demanding for food items asking for tea without finishing the
current meal which was served to the patient. Despite a decreased number
of hours of sleep, he appeared fresh and energetic in the morning
roaming in his place. He was brought forcefully by his family members to
an emergency. Initially, he was admitted with a diagnosis of
substance-induced psychotic disorder with harmful use of nicotine,
cannabis,~benzodiazepine, opioids, and alcohol use. The Clinical Opiate
Withdrawal Scale (COWS) score was 3. Blood investigation parameters were
within normal limits. Young Mania Rating Scale (YMRS) was 36/60 at the
time of admission. However, during the ward course of 43 days, he had a
persistent mood elevation with the delusion of grandiosity and lack of
insight. The diagnosis was revised to mania with psychotic symptoms. He
gradually recovered after Olanzapine was optimized up to 30 mg. Lithium
900 mg was added as an augmenting agent for the predominant euphoric
picture. Injectable Haloperidol 10 mg and Promethazine 50 mg were kept
initially for behavioral control. At the time of discharge, the YMRS was
2/60. He was non-compliant two months after the discharge and was in the
same pattern of substance use until the current illness started.

After the death of his parents, the eldest brother who was the primary
caretaker continued using alcohol in the problematic pattern.~The
patient was brought up in a community belonging to different ethnic
castes who were concerned about the patient's illness. Three years
later, the patient was brought to this hospital by his neighbors who
belong to different ethnicity castes (Rai and Tamang, i.e. Janjati and
Shrestha, i.e. Newar) {[}4{]}~due to abnormal behavior at home as his
eldest brother didn't show any concern towards his current behavior. He
got married to a girl during the current illness period but separated 5
days later when she became aware of the illness. Like the previous
episode, he had a similar elevated mood picture with the delusion of
grandiosity and was difficult to control at home over one month period.
So, he was admitted to our institution again on June 25, 2021, with a
diagnosis of bipolar affective disorder, current episode manic with
psychotic symptoms with cannabis and alcohol use. During the hospital
stay, initial financial support was provided by three neighbors with
frequent visits to our ward. The YMRS was 30/60 at the time of
admission. Olanzapine 30 mg, Divalproex 1000 mg, and Lorazepam up to 6
mg were required during the ward course. Injectable Haloperidol and
Promethazine were needed for behavioral control as the patient had
multiple attempts of trying to escape from our institution. Gradual
recovery occurred after 17 days and the YMRS was 7 on day 23. The
patient developed fever and running nose before discharge, however, PCR
for COVID-19 was negative. After fever decreased, the patient was
discharged from our ward, with identification and psycho-education to
the caretakers, including the neighbors, to ensure compliance and
follow-up.~The patient was doing well in the follow-up period of 2
months.

\textbf{Discussion}

Early parental loss is one of the specific life events linked with risk
for mood/bipolar disorder which was present in our case {[}1{]}. Family
history of substance use, history of suicide in father, lack of familial
support, multiple substance use by patients including alcohol, and
non-compliance are the major risk factor for relapse in our patient
{[}5{]}. Cannabis use has been reviewed to be associated with increased
incidence of bipolar disorder{[}6{]}~and our case was using cannabis
every 3-4 days. There is a complex relationship between marriage and
mood disorders. Being married is protective. However, the illness period
can be distressing for spouses and can result in separation which can
itself be a risk factor for future relapses~{[}5{]}. The patient support
system should be strong; neither over-involved nor withdrawing from the
patient. Rapidly deteriorating symptoms and lack of a usual support
system are some of the indications of hospitalization in bipolar
disorder~{[}7{]}. This case needed hospitalization in the second episode
even during COVID-19 pandemic time to prevent further complications as
the patient's condition was deteriorating. The patient's familial
support system was broken and neighbors actively took a role in the
management of current illness. Social support plays a protective role in
bipolar disorder. One important parameter in prognosis is a decrement in
the future relapse by improving medication adherence~{[}5, 8{]}.
Consideration of non-bipolar patients with improved cardiovascular and
immune function by social support gives an indirect benefit of improved
physical condition in bipolar patients~{[}8{]}. This is particularly
important after discharge as continued support would help in decreasing
future relapses.

The Eastern part of Nepal, like other parts, is largely harmonious in
its multi-ethnic, multilingual, and multicultural social composition
despite traces of the caste system {[}4{]}. In developing countries like
Nepal, attitude towards mental illness is particularly based on
religious and magical beliefs {[}9{]} Integration of cultural and ethnic
values at the community and local level is essential to tackle the
negative cycle of social determinants like poverty, low socioeconomic
status, early childhood adverse experience, unemployment, stigma, and
poor access to health services which play a contributing role in
causation, severity, course, and outcome of chronic mental illness like
bipolar disorder {[}5,10{]}. This case report gives an exemplary idea
that the supportive role of neighbors who belong to native semi-urban
Nepalese society can be of great importance in all levels of management
of mental illness including bipolar mood. Support of other people
including neighbors helps the patient receive acute treatment, attain
symptom remission and achieve overall physical, intellectual, and
emotional health even during the COVID-19 crisis~{[}11{]}.

It would be pertinent to review the following table (Table~1) to
understand some of the major risk factors and protective factors which
might play varying roles for predisposition, precipitation, or
perpetuation and relapse, i.e. determining the overall fate of the
course of bipolar disorder {[}5{]}.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Factors}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Protective factors}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Risk factors}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Genetic loading\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Absence of family history\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Presence of Family history\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Traits, temperament and predictors of bipolarity\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Absence of trait bipolar (cyclothymia), hyperthymic temperament and
predictors of bipolarity\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Presence of trait bipolar, hyperthymic temperament and predictor of
bipolarity\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Age of onset\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Advance age of onset (Rule out organicity)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Early age of onset\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Social stressor\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Absence of stressor\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
a. Presence of stressor {[}12{]} (Childhood events, Adulthood events,
Acute stressor, Chronic stressor, Positive life events, Negative life
events) b. Subjective perception of life events more important than life
event itself\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Social support\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Presence of social network, social interaction and instrumental
support\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Poor social support\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Marital status\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Being married is protective as well as predictor for future
separation\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Being single, divorced or separated\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Socioeconomic factors\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Higher level of education, good income, living condition, employed
status is protective (over-representation in bipolar II patients)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Lower socio-economic status (lower level of education, lower level of
income, poorer living condition, higher level of unemployment)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Residence (Rural-Urban difference)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Rural communities (in relation to stressful life)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Urban communities\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Substance use (Comorbid Axis I diagnosis)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Absence of alcohol abuse or dependence\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Presence of alcohol abuse and dependence\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Treatment adherence\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Presence of treatment adherence\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Absence of treatment adherence\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table~1: Protective and risk factors of Bipolar Mood}

\textbf{Conclusion}

This case report entails highlighting some of the illustrated protective
and risk factors of bipolar mood through a 23 years old male from
eastern Nepal who became ill the second time during the second wave of
COVID-19. Even during adverse situations like this, harmonious
relationships displayed by the neighbors in the community can play a
role in the management of this recurring and chronic illness; such
favorable social support is associated with a potentially good outcome
even in bipolar illness. Considering the social context during admission
and targeting the approaches to enhance the neighborhood and social
support is one of the key strategies tied to improve patient outcomes.

\textbf{List of abbreviations}

YMRS: Young Mania Rating Scale

COWS: Clinical Opiate Withdrawal Scale

\textbf{Consent}

\subsection*{Informed consent was received from the
patient.}

{\label{informed-consent-was-received-from-the-patient.}}

\textbf{Author contributions}

DRS: involved in conception, design, collection of data, drafting and
editing of the manuscript, and SRU: collection of data, drafting of the
manuscript and both: final approval of the version to be published.

\textbf{Ethical approval}

\section*{Ethical approval was not
required.}

{\label{ethical-approval-was-not-required.}}

\textbf{Conflict of interest}

The authors state that there is no conflict of interest.

\textbf{Funding Information}

No sources of funding were declared for this study.

\textbf{Data Availability statement}

The authors confirm that the data supporting the findings of this study
are available within the article.

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