case study on mania slideshare

Nursing Case Study for Mania (Manic Syndrome)

Watch More! Unlock the full videos with a FREE trial

Included In This Lesson

Study tools.

Access More! View the full outline and transcript with a FREE trial

Approximately 24 hours after being admitted to a psychiatric facility, Kelli, a 20-year-old suspected bipolar disorder patient, is brought back to the ER. The staff was worried about her behavior and vital signs. The charge nurse from the facility gives a report to the ER nurse saying, “She has not slept at all, talks constantly, and has a flight of ideas. She seems really grumpy and refuses to participate in group activities.”

V/S as follows: BP 170/90 SpO2 96% on Room Air HR 122 bpm and regular RR 20 bpm Temp 37.5°C

What does the nurse understand about the term “flight of ideas?

• Flight of ideas is where your thoughts move very quickly from idea to idea, making links and seeing meaning between things that other people don’t. It differs from racing thoughts (which is when your thoughts go through your head very fast. It can involve them racing so fast that they feel out of control.) Also, it may indicate Kelli is suffering from delirium which, for her, is a sign her condition is worsening.

The nurse should be concerned about what complication Kelli may be experiencing? Why does the nurse think this?

• A more therapeutic way to document the patient being “grumpy” is to describe mood changes, irritability, anxiety, agitation, and/or social isolation. These are all hints that this is a manic episode because irritability is not uncommon and, “Irritable patients often make hostile comments, swear more than usual, or go off on angry tirades.” The term grumpy is too subjective to document as it can mean different things to different people.

Upon entering the exam room, the nurse finds Kelli standing on the stretcher trying to reach the tops of the privacy curtains. Her speech is rapid but clear as she says, “The goddess of creativity talks to me, and I have to change the curtains and I will need paint for the walls. If you can also get me some different clothes so I can dress up for the party.” She proceeds to talk about redecorating her home and school with interspersed comments about clothes and shoes, grades, her friends, and many other topics. She also says that she does not like the facility she was at because the staff is using mind control.

• Psychosis (possibly brought on by delirium from not sleeping) or a medical condition not noticed in the initial ER visit. “In individuals with an acute or exacerbated chronic medical condition, psychosis is a common manifestation of delirium. Careful attention to the key features of acute onset, fluctuating course, altered consciousness, and cognitive decline can help distinguish delirium from primary psychiatric illness. When in doubt, the most useful rule-of-thumb is to assume delirium and attempt to rule out common medical etiologies. This is true even for patients with known psychiatric illness (including dementia), since they, too, are susceptive to delirium when acutely ill.

After sharing her thoughts about possible psychosis with the provider, he concurs and asks the nurse to interview the patient to get more information. He also says he will come in and conduct a mental status exam.

What are some things the nurse should ask during the interview?

• The staff has some background on this patient, but a current assessment of the situation is needed. Questions to help understand what may have triggered or preceded this episode are necessary. Has there been any substance use? Did something happen within the patient’s social support system? Was there trauma (i.e. did someone harm/hurt her at the facility?) Were there new medications administered at the facility?

What does the nurse know about a mental status exam?

• Whenever possible, mental status examinations should be conducted in a quiet room, without distractions. This may be difficult in a busy hospital or clinic setting. For someone experiencing a manic episode, the focus will probably be on the following:
• General behavior and demeanor – Level of awareness of surroundings, cooperation with the interviewer, eye contact
• Assessment of mood – Presence of depression or mania
• Affect – Intensity, appropriateness, lability and range of affect
• Thought process – Loosening of associations, flight of ideas, thought blocking
• Thought content – Paranoia, delusions, referential thinking (messages from television, radio, or others), internal preoccupations, thought control
• Perceptual disturbance – Hallucination (auditory, visual, tactile, olfactory, gustatory)
• Thoughts of self-harm or harm to others
• Cognitive screen – Attention, concentration, memory

Kelli answers questions during both the nurse and provider exams. Her heart rate continues to be elevated and she is sweating profusely.

What type of medication (s) does the nurse anticipate the provider to order?

• Possibly an antipsychotic (examples: Haldol (haloperidol), Thorazine (chlorpromazine), Geodon (ziprasidone). Maybe a benzodiazepine such as lorazepam (Ativan) to treat anxiety dependent on patient symptoms.

The provider verbally prescribes ziprasidone (Geodon) 10 mg IV once now.

Should the nurse clarify this order? Why?

• Ziprasidone is administered either by mouth (PO) or intramuscular (IM). It is not provided in a form that can be given IV.
• “GEODON for Injection (ziprasidone mesylate) should only be administered by intramuscular injection and should not be administered intravenously. Single-dose vials require reconstitution prior to administration.
• Add 1.2 mL of Sterile Water for Injection to the vial and shake vigorously until all the drug is dissolved. Each mL of reconstituted solution contains 20 mg ziprasidone. To administer a 10 mg dose, draw up 0.5 mL of the reconstituted solution. To administer a 20 mg dose, draw up 1.0 mL of the reconstituted solution. Any unused portion should be discarded.
• It is always alright for a nurse to clarify orders that are unclear or ordered incorrectly. This is part of the 6 rights (in this case ROUTE).

What side effects might the nurse expect? Which are the highest priorities for monitoring/intervention?

• Dizziness, drowsiness, weakness, nausea, vomiting, trouble swallowing, feeling restless, tremors, vision problems are listed as side effects. Also, racing heart and shortness of breath. Kelli’s heart rate is already high so watch for worsening. Dizziness/drowsiness should prompt safety concerns due to patient SAFETY. She should be carefully monitored after administration.

Kelli is in on the stretcher with both side rails up. New vitals:

BP 120/60 SpO2 98% on Room Air HR 82 bpm and regular RR 12 bpm Temp 37.1°C

She is released back to the psychiatric facility with a new prescription for risperidone 20 mg PO daily.

What interactions and/or long-term effects should be monitored with this medication if it is prescribed (orally) long-term?

• Extrapyramidal Symptoms which include the following adverse reaction terms: extrapyramidal syndrome, hypertonia, dystonia, dyskinesia, hypokinesia, tremor, paralysis and twitching. None of these adverse reactions occurred individually at an incidence greater than 10% in bipolar mania trials.
• Dizziness which includes the adverse reaction terms dizziness and lightheadedness.
• Akathisia (agitation, distress)
• Abnormal Vision
• Asthenia (weakness, lethargy)

View the FULL Outline

When you start a FREE trial you gain access to the full outline as well as:

• SIMCLEX (NCLEX Simulator)
• 6,500+ Practice NCLEX Questions
• 2,000+ HD Videos
• 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

References:

View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
• 4 Questions

GI/GU Nursing Case Studies

• 2 Questions
• 8 Questions

Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

BULLET PSYCH

Your Daily Dose of Psych Knowledge

Day # 46: Mental Status Exam in Bipolar Disorder

Today we will cover elements of the mental status exam that are particularly important in bipolar disorder . The focus of today will be the MSE in mania/hypomania , since the MSE in depression was covered previously. These are important clues that will help you with diagnosis as well as gauge treatment response.

If you need a refresher on the mental status exam and a description of each component including important terms feel free to review here: Intro to Mental Status Exam .

Today's Content Level: Beginner; Intermediate

REMINDER OF THE MENTAL STATUS EXAM COMPONENTS

•Appearance

•Speech/Language

•Thought process

•Thought content

•Perceptual Disturbances

APPEARANCE & BEHAVIOR

•Like most disorders, there is no one-size fits all when it comes to appearance, but there are classic features.

•On one hand a patient with hypomania may present as well-groomed with appropriate hygiene and on the extreme a patient with severe mania may be grossly disorganized and psychotic and forgotten to bathe or properly groom and dress themselves or appear disheveled.

•Manic patients are energetic , excited , talkative , frequently hyperactive , and sometimes amusing. At times they may also be grossly psychotic , disorganized , or aggressive/hostile .

•Patients may have "intense" eye contact during conversation with less blinking and gaze diversion than expected in regular conversation.

• May have psychomotor agitation which is a term used to describe excessive motor activity associated with a feeling of inner tension. Behaviors seen include hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, and inability to sit still.

SPEECH / LANGUAGE

•One of the hallmark features of mania and bipolar disorder is their speech. It is often described as " pressured ".

• Pressured speech = speech that is fast , difficult or impossible to interrupt , and increased in quantity . It is also usually loud and emphatic. A person might not require social stimulation or an audience to speak.

•One manic patient that I spoke in the hospital before being treated did not stop talking for a single second the entire 30 minutes that I spent with him. I don't know how he was breathing he was talking so fast and without any breaks or pauses.

MOOD / AFFECT

Their mood is classically euphoric . Other related terms are elated, elevated, or expansive.

Euphoric : characterized by feeling intense excitement and happiness .

Elation : great happiness.

Elevated : component of euphoria that is positive feelings of enthusiasm, well-being, confidence, and/or energy.

Expansive : an extreme expression of emotion, often accompanied with inflated self-worth, excessive friendliness, grandiosity, or superiority.

•Aside from euphoric, manic patients may also present with irritability , particularly when mania has been present for some time. This is honestly what I have seen more commonly in the hospital setting so far in my training.

•They may also have a low frustration tolerance , which can lead to feelings of anger and hostility .

•They may be labile -> switching back and forth between euphoria, laughter, irritability, and depression in minutes to hours.

•They may have an intense affect -> high emotional intensity and responsiveness.

THOUGHT PROCESS / THOUGHT CONTENT

•Another classic term used to describe bipolar patients is "flight of ideas". Not only is their speech pressured as discussed above, but they quickly bounce from topic to topic.

• Flight of ideas = a nearly continuous flow of accelerated speech with abrupt changes from topic to topic. These shifts in topic are usually based on understandable associations, distracting stimuli, or plays on words. When the condition is severe, speech may have loosening of associations or become completely disorganized and incoherent.

•Thought content is focused on themes of self-confidence and self-aggrandizement . This means they promote themselves as being powerful or important.

•They are often easily distracted .

PERCEPTUAL DISTURBANCES

•Manic patients with delusions or hallucinations are said to have a manic episode with psychotic features. Also consider schizoaffective disorder depending on timing of symptoms.

These features are very common in patients with bipolar disorder. 1

Delusions occur in 75% of all manic patients.

51% experience hallucinations .

47% had paranoid features.

• Mood-congruent manic delusions are often concerned with great wealth, power, extraordinary abilities, or an important "calling in life". Bizarre and/or mood-incongruent delusions and hallucinations also appear in mania. Some studies suggest that mood-incongruent (depressive themes) are actually more common even in manic patients.

•Less has been written about cognitive deficits in patients with mania when compared to schizophrenia, however some deficits can be seen and hypothesized due to diffuse cortical dysfunction in the manic phase.

•Typically orientation and memory are intact although patients may be so euphoric or distracted or grandiose that they may answer orientation testing incorrectly.

INSIGHT / JUDGEMENT / IMPULSIVE

•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?

• Impaired judgement is a hallmark of manic patients. This may lead to sexual indiscretion, excessive gambling or poor financial management, breaking the law, etc.

•Manic patients often have little insight into their disorder.

•Manic (and demented) patients are the most likely patient to be assaultive or threatening . Some studies cite that about 75% can have threatening behaviors. They also have a higher rate of suicide and homicide. 2

Nice work today. We covered some important factors regarding the mental status exam in patients with bipolar disorder. Next lesson will be a discussion on the medical workup for mania.

Resources used today include Kaplan and Sadock's Synopsis of Psychiatry , The Psychiatric Interview , and Pocket Psychiatry .

Bullet Psych is an Amazon Associate and we receive a small commission if you use our links.

• Mental Status Exam

Recent Posts

Day 114: Mental Status Exam in Dissociative Disorders

Day # 93: Mental Status Exam in Obsessive Compulsive Disorder (OCD)

Day # 63: Mental Status Exam in Anxiety

Acute Onset of Mania and Psychosis in the Context of Long-COVID: A Case Study

Affiliations.

• 1 Department of Psychiatry & Behavioral Health, Houston Methodist, Houston, Texas.
• 2 Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center at Houston, Texas.
• 3 The Center for Performing Arts Medicine, Houston Methodist, Houston, Texas.
• 4 Primary Care, Internal Medicine, Houston Methodist, Houston Texas.
• 5 Houston Methodist Academic Institute, Houston, Texas.
• 6 Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas.
• 7 Department of Psychiatry, Weill Cornell Medical College, New York.
• 8 Department of Neurology, Houston Methodist, Houston, Texas.
• 9 Department of Neurology, Weill Cornell Medical College, New York.
• 10 Primary Care Group, Houston Methodist Hospital, Houston, Texas.
• PMID: 38620128
• PMCID: PMC10290767
• DOI: 10.1016/j.psycr.2023.100138

Acute phase COVID-19 has been associated with an increased risk for several mental health conditions, but less is known about the interaction of long COVID and mental illness. Prior reports have linked long COVID to PTSD, depression, anxiety, obsessive compulsive symptoms, and insomnia. This case report describes a novel presentation of mania arising in the context of long COVID symptoms with attention given to possible interacting etiological pathways. The case report also highlights the need for integrated, multidisciplinary treatment to support patients whose alarming, confusing, and multidetermined symptoms increase risk of psychological deterioration.

Keywords: Long COVID; bipolar disorder; complex comorbidities; integrated care; mania; personalized medicine.

© 2023 The Authors. Published by Elsevier B.V.

Publication types

• Case Reports

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Indian J Psychiatry
• v.64(5); Sep-Oct 2022

Course and outcome of bipolar I disorder among Indian patients: A retrospective life-chart study

Shallu dhiman.

Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, New Delhi, India

1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Subho Chakrabarti

Background:.

Indian studies on the course and outcome of bipolar disorder (BD) are scarce and their methodologies vary. Nevertheless, differences from Western ones have been noted.

A systematic random sample of 200 patients with BD attending a general hospital psychiatric unit was chosen. They were assessed using the clinician and self-rated versions of the National Institute of Mental Health—Retrospective Life Charts, the lifetime version of the Columbia Suicide Severity Rating Scale, the Medication Adherence Questionnaire, the Indian Disability Evaluation and Assessment Scale, and the Presumptive Stressful Life Events Scale.

The mean age of onset of BD was 26 years. About 11%–13% of the illness was spent in acute episodes, mostly in depression (60%). Episode frequency was 0.4–0.6 annually. The first episode was more likely to be manic, and manic episodes outnumbered depressive episodes. The average duration of episodes was 3 months. Depressive episodes were longer and the time spent in depression was greater than mania. Psychotic symptoms (48%), a mania-depression-interval pattern (61%), and recurrent mania (19%) were common while rapid cycling and seasonal patterns were uncommon. Comorbidity (40%), functional impairment (77%), and lifetime nonadherence (58%) were high, whereas lifetime suicide attempts (16%) were low. Stressful life events were very common prior to episodes (80%), particularly early in the illness.

Conclusion:

This study suggests differences between Indian and Western patients in the demographic profile and the course and outcome of BD. A more benign presentation in the current study including Indian studies is indicated by their later age of presentation and illness onset, higher rates of marriage, education, and employment, a mania predominant course, lower rates of rapid cycling, comorbidity, and suicidal attempts. Factors associated with better outcomes such as longer time to recurrence, Manic Depressive pattern of illness, and low rates of hospitalizations also appear to be commoner in our study and also in other Indian studies.

INTRODUCTION

Bipolar disorder (BD) is a chronic, highly recurrent illness, which is common and frequently disabling. The traditional view of bipolar disorder was that of a condition characterized by good outcomes and complete recovery from acute episodes of the illness. However, research over the past few decades has shown that the course of BD is usually characterized by multiple recurrences with incomplete remissions, persisting subsyndromal symptoms, and functional impairment.[ 1 , 2 , 3 ] Studies on epidemiology and course and outcome of BD from India are scarce.[ 4 ] In epidemiological studies, lifetime prevalance rates are 0.1% for bipolar spectrum disorders and 0.5% for BD.[ 5 , 6 ] These rates are considerably lower than those found in other countries, though this discrepancy is more likely to be due to differences in diagnostic practices and study designs. Studies on the course and outcome of BD from India are mostly hospital-based retrospective investigations, with many methodological shortcomings such as small numbers, nonprobabilistic sampling, and the lack of standardized assessments in many reports. Moreover, there is a relative lack of information on certain key aspects of the outcome of BD such as disability, comorbidity, medication adherence, and suicidal behavior. However, some of the more recent Indian studies that have used the National Institute of Mental Health- Retrospective Life Charts (LCM),[ 7 ] have assessed the course of BD more comprehensively among relatively larger samples of patients.[ 8 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ] The findings of these LCM-based studies suggest certain differences in the course and outcome of BD among Indian patients. For example, a consistent finding across these studies is the predominance of manic as opposed to depressive pathology. Favorable demographic characteristics, later onset, low rates of rapid cycling, lower comorbidity, and less frequent suicidal attempts are some of the other findings of these studies, which are different from the Western reports.

These considerations prompted the current retrospective, longitudinal study of the long-term course, and outcome of BD among adult patients attending a general hospital psychiatric unit in India. The current study attempted to study long-term course, disability, physical and psychiatric comorbidity, stressful life events, disability, lifetime suicidal behavior, and medication adherence in BD

Participants

This study was carried out in a general hospital psychiatric unit of a multispecialty hospital in north India, after due approval from the Institute Ethics Committee. All the participants were recruited after obtaining written informed consent and other ethical safeguards were maintained during the study. Patients had to have a confirmed diagnosis of BD-1 according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria, were required to be aged 18–65 years at intake, and ill for at least 2 years. They had to be accompanied by a clinically healthy adult family member, who was staying with the patient for the past 5 years or more and was aware of the details of the patient’s illness and treatment. If more than one healthy family member accompanied the patient and fulfilled the selection criteria as mentioned above he/she was also incorporated as an informant in the study. Patients were excluded if they had an intellectual disability, medication- or substance-induced BD, were acutely ill and not able to participate in the study, or at risk of harm to self or others.

The participants were recruited from September 2015 to October 2016 using systematic random sampling. From a pool of 1407 patients with BD who met selection criteria, a random sample was chosen using the random numbers table and a 1:7 ratio, yielding a sample of 201 patients. Only one patient refused to consent, yielding a final random sample of 200 patients.

Assessments

Diagnosis were confirmed using the Mini International Neuropsychiatric Interview, PLUS version (MINI PLUS).[ 17 ] Demographic parameters were recorded using the standardized departmental format used in our department. The demographic details included age at intake, gender, education status, marital status, socioeconomic status, family setup, etc. Current symptom-severity was assessed using the Young mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS). No cut off value for YMRS and HDRS was used for inclusion. Information about the long-term course was recorded using the clinician and self-rated versions of the LCM.[ 7 ] LCM is an easy-to-follow method of constructing a clear picture of the course of BD. The life chart provides an overview of the number and type of past episodes, their duration, frequency of comorbid symptoms, triggering life events, hospitalization, response to treatment, and other relevant information. Information was obtained from both patients and family members. Any discrepancies between the two versions of the LCM were resolved by consulting the medical records. In the current study, remission of the particular episode was defined clinically by information obtained from patients, family members, and medical records. In addition, disability was rated using the Indian Disability Evaluation and Assessment Scale (IDEAS)[ 18 ]; lifetime suicidal behavior was rated by the Columbia Suicide Severity Rating Scale-Lifetime version[ 19 ]; medication adherence was assessed by the Medication Adherence Questionnaire (MAQ)[ 20 ]; and stressful life events were assessed by the Presumptive Stressful Life Events Scale (PSLES).[ 21 ] The PSLES is a 51-item self-report scale for listing life events relevant to Indian conditions. The participants were asked to recall the type of life events and tick the appropriate item on the scale for each episode in their lifetime. If the participants reported life events in an episode then they were marked as present for that particular episode and if not then they are marked as not present for that particular episode.

Statistical analysis

Data were analyzed by using the SPSS-14 (Statistical Package for the Social Sciences, 2005, Chicago, IL, USA). Apart from the mean, standard deviation, and median values, frequencies and percentages were also estimated. Group comparisons were carried out using the Chi-square or the Students’ t -tests.

Demographic profile [ Table 1 ]

Demographic profile of the patients with bipolar disorder ( n =200)

# 7% of the patients were illiterate ¶ students/housewives/retired=27%

Patients were middle-aged, predominantly married men. The majority had more than 10 years of schooling, and very few were illiterate. About two-thirds were in paid employment, and about a third were either housewives, students, or retired people. Patients were predominantly from middle-class backgrounds. A little more than half of them were urban-based and from nuclear families.

Course and treatment profiles [Table ​ [Table2a 2a and ​ andb b ]

Course and outcome of patients with bipolar disorder ( n =200) #

# Findings based on the Mini International Neuropsychiatric Interview-Plus and the National Institute of Mental Health—Retrospective Life Charts: clinician and self-rated versions

# Findings based on the Mini International Neuropsychiatric Interview-Plus and the National Institute of Mental Health—Retrospective Life Charts: clinician and self-rated versions. ¶ Lithium carbonate=59%, Sodium valproate=35%

The most recent episode at intake was almost equally likely to be either mania or depression while mixed episodes were much less common. Symptom scores suggested that most patients were in remission when assessed. The mean and median duration of any type of episode was about 3 months. Depressive episodes were significantly longer than manic episodes ( t = 5.29; P < 0.0001) as well as mixed episodes (− t = 3.82; P < 0.001). Mixed episodes were also significantly longer than manic episodes ( t = 3.84; P < 0.001). Only a small proportion of the illness, from 11% (median) to 13% (mean), was spent in acute episodes. Patients spent about 60% of the acute illness in depression, about 40% in mania, and about 1% in mixed episodes. Time spent in depression was significantly longer than that spent in mania ( t = 2.92; P < 0.01). The first episode was significantly more likely to be a manic episode than a depressive one ( X 2 = 21.38; P < 0.001). A total of nine episodes over 17 years meant that episode frequency ranged from 0.4 to 0.6 per year. Consequently, the time to recurrence of any mood episode varied from 21 to 28 months. Manic episodes were significantly more frequent than depressive (− t = 3.407; P < 0.01) as well as mixed episodes (− t = 12.51; P < 0.0001). Depressive episodes were also more frequent than mixed episodes ( t = 11.08; P < 0.0001). About half of the episodes were severe and a third were of moderate intensity. The majority (about 60%) of the manic and mixed episodes were severe while 64% of the depressive episodes were of moderate intensity. Psychotic symptoms were significantly more frequent in manic than depressive episodes ( t = 5.56; P < 0.0001). However, rapid cycling and seasonal patterns were uncommon. Both the proportion of patients hospitalized and the number of lifetime hospitalizations was low. Patients had received treatment for more than 80% of their illnesses.

Other parameters of outcome [ Table 3 ]

Comorbidity, disability, suicidal attempts, stressful life events, and medication adherence among patients with bipolar disorder ( n =200)

MINI-Plus, Mini International Neuropsychiatric Interview-Plus; IDEAS, Indian Disability Evaluation and Assessment Scale; C-SSRS, Columbia Suicide Severity Rating Scale—Lifetime/Recent version; MAQ, Medication Adherence Questionnaire; PSLES, Presumptive Stressful Life Events Scale

Current psychiatric comorbidity was present in 43% of the patients; anxiety and substance use disorders were the two most common comorbid conditions. More than a third of the patients had a physical illness; hypertension, diabetes mellitus, and hypothyroidism were the commonest conditions. A large proportion of the patients had been functionally impaired in the 2-year period before intake, although levels of disability were mostly moderate. Rates of full or partial nonadherence were high during the patients’ lifetimes. Bereavement and family conflict were the two most common such events. The rate of stressful life events prior to episodes was higher in those with fewer episodes [ Figure 1 ].

Stressful life events reported by the participants

A brief description of the LCM-based Indian studies has been provided in the Appendix . Although the methodology of this study was similar to the other LCM-based Indian studies of BD, unlike the other studies in our study systematic random sampling was used to generate the sample and standardized instruments were used to examine all aspects of the course of the illness. Moreover, our results were based on a relatively larger randomized sample of patients, a longer duration of follow-up, and a more comprehensive assessment of different outcome parameters [ Appendix ].

Although the findings of the present study were largely similar to earlier Indian ones, certain important differences were also observed.

Patients of this study were in their 40s, predominantly married men, who were educated and earning, or housewives and students. They came from middle-class, urban, and nuclear family backgrounds. This profile was comparable with other Indian studies including the LCM-based ones as well as general population surveys.[ 6 ] These demographic characteristics were somewhat different from Western studies, where BD is usually associated with younger ages, an equal gender distribution, single status, lower educational levels, unemployment, and low income.[ 22 , 23 ] The male predominance in Indian studies could be partly, but not wholly attributable to sociocultural differences in treatment-seeking between genders. Cultural differences could also account for high rates of marriage, literacy, and employment. However, since these demographic parameters are quite likely to be consequences of BD, this raises the possibility that Indian patients may have a more benign course of the illness.

One of the possible indicators of a benign course of BD is its relatively later onset among Indian patients. The majority of Indian studies including the current one, have found an age of onset between 25 and 30 years, with only 15%–20% of the patients having an onset less than 18 years.[ 10 , 14 , 16 ] This is in contrast to the more recent Western studies, where the age of onset has generally been between 18 and 22 years[ 2 , 3 , 22 , 23 , 24 ]; the proportion of patients with early onset is also greater, and the outcome poorer in the early onset groups.[ 3 , 24 ] Then again, this difference could be because Indian studies are hospital-based, or because of variations in diagnostic ascertainment. However, the major difference between Indian and Western studies is in the predominance of mania among the former. Most Indian studies including the LCM-based ones have found that first episodes are more frequently manic, manic episodes outnumber depressive episodes during the illness, the duration of manic episodes and time spent in mania is greater, and the proportion of recurrent manic episodes is higher.[ 4 , 25 , 26 ] In contrast, first episodes are often depressive in Western studies, depressive episodes outnumber manic ones, the time spent in depression is greater, and recurrent manic episodes without depression are uncommon.[ 1 , 2 , 3 , 4 ] It has been suggested that genetic variations or environmental variables such as sunlight or latitudinal gradients could explain this discrepancy between the Indian and Western studies,[ 4 , 11 , 25 ] but it is equally likely that underestimation of depression is common in Indian studies because of their retrospective and hospital-based nature, male predominant samples, and the inability to account for differences in help-seeking.[ 4 , 8 , 11 , 26 ] Some of the findings of the present study, which differed from the other LCM-based Indian studies, were relevant here [ Appendix ]. Though the first episode was significantly more likely to be a manic one in the current study, the proportion of depressive first episodes was considerably higher than in the other studies. Similarly, though manic episodes were more frequent, the number and proportion of depressive episodes were higher, and that of manic episodes lower than the other LCM-based studies. Unlike these studies, depressive episodes were significantly longer than both manic and mixed episodes in the present study; consequently, the time spent in depression was proportionately more than that spent in mania. Finally, the proportion of recurrent manic episodes was less than most of the other Indian studies. Thus, these discrepant findings of the current study seemed to indicate that an underestimation of the extent of depression could be a likely cause of a predominantly manic course found in the other Indian studies.

In terms of other indicators of a less severe course of illness among Indian patients with BD, the findings of the present study were similar to earlier Indian studies. For example, the time to recurrence was comparable with other Indian studies, but somewhat longer than Western ones.[ 10 , 26 ] A rapid-cycling pattern is less commonly found among Indian patients than Western ones.[ 3 ] This has been attributed to the predominance of mania and the lower use of antidepressants in Indian patients.[ 11 ] The findings of the current study were alike on both these counts. In contrast, a higher prevalence of an MDI pattern that is often associated with a better outcome was found in this and some other Indian studies.[ 8 ] In addition, the rates of both psychiatric and physical comorbidities were similar to Indian studies, but considerably lower than those found in Western reports.[ 2 , 3 ] Like this study, the lifetime rates of suicide attempts are lower than Western rates in other Indian studies, including the LCM-based ones.[ 12 ] The low proportion of seasonal episodes found in this study is also a common finding in other Indian studies, unlike Western ones.[ 9 , 27 ]

However, certain indicators of outcome found in the present study were quite different from both earlier Indian and Western reports. For example, the proportion of episodes preceded by stressful life events was higher than most Indian as well as Western studies, although the type of events and the evidence of sensitization were similar to earlier reports.[ 13 , 28 , 29 ] Moreover, though the high rates of current treatment and nature of such treatment found in this study were similar to other Indian studies, the duration of untreated illness was less than other Indian studies.[ 6 , 11 , 15 ] Consequently, the number and proportion of patients ever hospitalized were both lower than almost all Indian and Western studies.[ 1 , 9 ] This could partly explain the favorable course and outcome of BD among patients of this study.

Finally, some outcome parameters of the current study resembled previous Indian and Western reports of a recurrent, chronic, and disabling course of BD. These included the number and frequency of mood episodes, their average duration, the severity of episodes, the time spent in acute episodes, the presence of a family history of mental illness in about half of the patients, high rates of psychotic symptoms, especially during manic episodes, the high proportion of patients with disability, and the high rates of medication nonadherence.[ 1 , 2 , 3 , 4 ]

The study had few limitations. The study was conducted in a hospital, and cannot be extrapolated to general populations. Retrospective life chart-based method may be a source of potential recall bias. However, in our study we tried to overcome this by meticulously charting the course using a standardized life chart followed by corroborating with a reliable informants and the file records of the patient maintained by the trained psychiatrists. Because of the time bound nature of the study, sample size was not calculated. Future studies with large sample size in community population should be done to improve the generalization of the study results.

In conclusion, Indian studies including the present one have suggested that there might be differences in the demographic profile and the course and outcome among patients with BD. A more benign presentation among Indian patients is indicated by their later age of presentation and illness-onset, higher rates of marriage, education and employment, a mania predominant course, lower rates of rapid cycling, comorbidity, and suicidal attempts. Factors associated with better outcomes such as longer time to recurrence, an MDI pattern of illness, and low rates of hospitalizations also appear to be commoner in Indian patients. However, it is not clear whether these differences are due to genetic factors, geographical variations, sociocultural differences, or the retrospective, and hospital-based nature of the Indian studies. Some of the discrepant findings of the current study suggest that the failure to properly elicit the level of depressive symptoms may also have played a role in the mania predominant course found in most Indian studies. These issues can only be resolved if prospective studies that are both hospital and community-based are conducted in Indian settings. Such studies should ideally be supplemented by more methodologically refined studies of the etiology of BD among Indian patients, so that the true nature of the course and outcome of BD among Indian patients can be ascertained.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Comparisons of course of bipolar disorder with other Indian retrospective life chart-based studies *

* The National Institute of Mental Health—Retrospective Life Charts: clinician or self-rated versions

1035 Natoma Street, San Francisco

This exquisite Edwardian single-family house has a 1344 Sqft main…

What is the best custom essay writing service?

In the modern world, there is no problem finding a person who will write an essay for a student tired of studying. But you must understand that individuals do not guarantee you the quality of work and good writing. They can steal your money at any time and disappear from sight.

The best service of professional essay writing companies is that the staff give you guarantees that you will receive the text at the specified time at a reasonable cost. You have the right to make the necessary adjustments and monitor the progress of the task at all levels.

Clients are not forced to pay for work immediately; money is transferred to a bank card only after receiving a document.

The services guarantee the uniqueness of scientific work, because the employees have special education and are well versed in the topics of work. They do not need to turn to third-party sites for help. All files are checked for plagiarism so that your professors cannot make claims. Nobody divulges personal information and cooperation between the customer and the contractor remains secret.

Customer Reviews

Our writers always follow the customers' requirements very carefully

Finished Papers

Customer Reviews

Check your email for notifications. Once your essay is complete, double-check it to see if it falls under your expectations and if satisfied-release the funds to your writer. Keep in mind that our essay writing service has a free revisions policy.

Finished Papers

Customer Reviews

Emery Evans

Eloise Braun

What Can You Help Me With?

No matter what assignment you need to get done, let it be math or English language, our essay writing service covers them all. Assignments take time, patience, and thorough in-depth knowledge. Are you worried you don't have everything it takes? Our writers will help with any kind of subject after receiving the requirements. One of the tasks we can take care of is research papers. They can take days if not weeks to complete. If you don't have the time for endless reading then contact our essay writing help online service. With EssayService stress-free academic success is a hand away. Another assignment we can take care of is a case study. Acing it requires good analytical skills. You'll need to hand pick specific information which in most cases isn't easy to find. Why waste your energy on this when they're so many exciting activities out there? Our writing help can also do your critical thinking essays. They aren't the easiest task to complete, but they're the perfect occasion to show your deep understanding of the subject through a lens of critical analysis. Hire our writer services to ace your review. Are you struggling with understanding your professors' directions when it comes to homework assignments? Hire professional writers with years of experience to earn a better grade and impress your parents. Send us the instructions, and your deadline, and you're good to go.

Parents Are Welcome

No one cares about your academic progress more than your parents. That is exactly why thousands of them come to our essay writers service for an additional study aid for their children. By working with our essay writers, you can get a high-quality essay sample and use it as a template to help them succeed. Help your kids succeed and order a paper now!

2269 Chestnut Street, #477 San Francisco CA 94123

There are questions about essay writing services that students ask about pretty often. So we’ve decided to answer them in the form of an F.A.Q.

Is essay writing legitimate?

As writing is a legit service as long as you stick to a reliable company. For example, is a great example of a reliable essay company. Choose us if you’re looking for competent helpers who, at the same time, don’t charge an arm and a leg. Also, our essays are original, which helps avoid copyright-related troubles.

Are your essay writers real people?

Yes, all our writers of essays and other college and university research papers are real human writers. Everyone holds at least a Bachelor’s degree across a requested subject and boats proven essay writing experience. To prove that our writers are real, feel free to contact a writer we’ll assign to work on your order from your Customer area.

Is there any cheap essay help?

You can have a cheap essay writing service by either of the two methods. First, claim your first-order discount – 15%. And second, order more essays to become a part of the Loyalty Discount Club and save 5% off each order to spend the bonus funds on each next essay bought from us.

Can I reach out to my essay helper?

Contact your currently assigned essay writer from your Customer area. If you already have a favorite writer, request their ID on the order page, and we’ll assign the expert to work on your order in case they are available at the moment. Requesting a favorite writer is a free service.

Finished Papers

• Words to pages
• Pages to words

Deadlines can be scary while writing assignments, but with us, you are sure to feel more confident about both the quality of the draft as well as that of meeting the deadline while we write for you.

Customer Reviews

Paper Writing Service Price Estimation

Essay help services – sharing educational integrity.

Hire an expert from our writing services to learn from and ace your next task. We are your one-stop-shop for academic success.

Customer Reviews

Finished Papers