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.