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].