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<p class="title-left"><span class="bold">Mania Precipitated by COVID-19 Pandemic–Related Stress</span></p>
<p class="byline-regular">N. A. Uvais, MBBS, DPM<span class="superscript">a,</span><span class="asterisk">*</span></p>
<p class="drop-cap-with-body-text"><span class="bold-14pt-for-cap"><span class="bold">T</span></span>he coronavirus disease 19 (COVID-19) pandemic is a significant psychological stressor, impacting every facet of life worldwide.<span class="htm-cite"><a href="#ref1">1</a></span> Pandemics as major disrupters can influence the mental health of an individual just like any other severe negative life event. Our experiences from the past indicate that epidemics affect the mental health of not only the survivors and hospital staff but also the general public at large.<span class="htm-cite"><a href="#ref2">2</a></span> Literature is scarce regarding the impact of epidemics among the psychiatric patient population, particularly on the course of bipolar affective disorder among noninfected patients. Here, we report the case of a 37-year-old woman who developed a manic episode 17 years after her last episode, which was precipitated by stress related to the COVID-19 pandemic.</p>
<p class="subheads-subhead-2">Case Report</p>
<p class="body-text">Ms A, a 37-year-old married woman accompanied by her husband, came to the hospital’s outpatient psychiatry department in March 2020 with a 1-week history of increased talk, tall claims, overactivity, reduced sleep, and irritability. According to her husband, she was concerned about the COVID-19–associated changes happening around her and closely followed updates on television. After the media highlighted the risk of infection in social situations, she began staying inside her home and stopped social contacts with neighbors and family, which was 4 weeks before the onset of her symptoms. However, she increased her contacts with family members over the phone, many of them living in Middle Eastern countries, and regularly discussed the challenges they were facing. There was no history of any other recent significant life events. Her past psychiatric history revealed that she experienced 1 episode of mania 17 years ago. There were no comorbid medical conditions. There was no family history of any psychiatric illness. Her mental status examination revealed overfamiliar attitude, overproductive speech, euphoric affect, and grandiose delusion. Along with other grandiose ideas, she also stated that she was the coronavirus everyone fears, and the consulting doctor could remove his mask, as she would not infect him. Ms A was diagnosed with bipolar affective disorder, current episode mania with psychotic symptoms (<span class="italic">DSM-5</span> criteria). She was started on sodium valproate 700 mg/d and olanzapine 7.5 mg/d. Her symptoms significantly improved over a period of 1 week.</p>
<p class="subheads-subhead-2">Discussion</p>
<p class="body-text">The first case of COVID-19 reported in India was in the state of Kerala, which is where Ms A resides, on January 30, 2020. Following the appearance of COVID-19, Kerala state took gradual strict measures to control the spread of infection that affected everyone’s routine. For many vulnerable individuals like Ms A, such a rapid change in environment may act as a negative life event, precipitating psychiatric disorders. Moreover, the timeframe for significant life stressors precipitating relapse of bipolar affective disorder has been proposed to be 4 weeks for a manic episode, which holds true in Ms A’s case.<span class="htm-cite"><a href="#ref3">3</a></span></p>
<p class="body-text">Despite some contradictory findings, there is growing evidence to suggest that severe life events may precipitate manic and hypomanic episodes.<span class="htm-cite"><a href="#ref4">4</a></span> However, research<span class="htm-cite"><a href="#ref4">4</a></span> also indicates that the first episode of mania is more likely to be triggered by a life event unlike later episodes. In the case of Ms A, pandemic-associated abrupt change in the external environment might have precipitated the second episode of mania after a period of 17 years. The psychosocial factors that may have contributed as stressors in Ms A could be the following: fear of coronavirus infecting her and close family members, concerns for her relatives working in Middle Eastern countries where there were higher numbers of COVID-19 infection, financial concerns, and social restrictions. Moreover, the identification of a patient with the stressor and permeation of the psychopathology with the stressor is also interesting from a psychological point of view.</p>
<p class="end-matter"><span class="bold-italic">Received:</span> April 17, 2020</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> June 4, 2020.</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None. </p>
<p class="references_references-heading"><span class="bold">REFERENCES</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1. </span>Troyer EA, Kohn JN, Hong S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? neuropsychiatric symptoms and potential immunologic mechanisms [published online ahead of print April 13, 2020]. <span class="italic">Brain Behav Immun</span>. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=32298803&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/j.bbi.2020.04.027" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2. </span>Peng EY, Lee MB, Tsai ST, et al. Population-based post-crisis psychological distress: an example from the SARS outbreak in Taiwan. <span class="italic">J Formos Med Assoc</span>. 2010;109(7):524–532. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=20654792&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/S0929-6646(10)60087-3" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3. </span>Sam SP, Nisha A, Varghese PJ. Stressful life events and relapse in bipolar affective disorder: a cross-sectional study from a tertiary care center of southern India. <span class="italic">Indian J Psychol Med</span>. 2019;41(1):61–67. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=30783310&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a></p>
<p class="references-references-text-1-9"><a name="ref4"></a><span class="htm-ref"> 4. </span>Proudfoot J, Doran J, Manicavasagar V, et al. The precipitants of manic/hypomanic episodes in the context of bipolar disorder: a review. <span class="italic">J Affect Disord</span>. 2011;133(3):381–387. <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21106249&dopt=Abstract" target="_blank"><span class="pubmed-crossref">PubMed</span></a> <a href="https://doi.org/10.1016/j.jad.2010.10.051" target="_blank"><span class="pubmed-crossref">CrossRef</span></a></p><div id="pcccrend">
<p class="front-matter-rule"><span class="superscript">a</span>Department of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India</p>
<p class="front-matter"><span class="asterisk">*</span><span class="italic">Corresponding author:</span> N. A. Uvais, MBBS, DPM, Iqraa International Hospital and Research Centre, Calicut, Kerala, India <span class="hyperlink">(<a href="mailto:druvaisna@gmail.com">druvaisna@gmail.com</a>)</span>.</p>
<p class="front-matter"><span class="italic">Prim Care Companion CNS Disord 2020;22(3):20l02641</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Uvais NA. Mania precipitated by COVID-19 pandemic–related stress. <span class="italic">Prim Care Companion CNS Disord</span>. 2020;22(3):20l02641.</p>
<p class="doi-line"><span class="bold-italic">To share:</span> https://doi.org/<span class="doi">10.4088/PCC.20l02641</span></p>
<p class="front-matter"><span class="italic">© Copyright 2020 Physicians Postgraduate Press, Inc.</span></p></div>
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