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].