Effects of Bipolar Relapse on Bipolar Patients in Moi Teaching and Referral Hospital

Background: Social support plays a crucial role in the management of mental health conditions such as bipolar. Objective: The purpose of this study is to determine the effects of bipolar relapse in patients at MTRH. Methods: The study design that was used is a retrospective study which targeted bipolar inpatients at the mental unit in Moi Teaching and Referral Hospital. Patients’ hospital records for the past 5 years were reviewed by use of a chart review. Results:The findings revealed that majority of the patients agreed that relapse affected their work, relationship with family, friends and colleagues. Conclusion: It was concluded that Bipolar has certain effects to the day to day life conditions. As revealed in the study, most of the patients said that it affected their work/colleagues, patient family, relationships and problems in law to some extent. Recommendation: The study recommended that families with people suffering from bipolar disorder are urged to learn their patients and handle them with great care to avoid adverse effects in their daily living.


Introduction
Bipolar disorder statistics from the World Health Organization (WHO) indicate bipolar mood disorder is the 6th leading cause of disability in the world. Social support plays a crucial role in the management of mental health conditions. Bipolar affects the community at large because all need to make certain adjustments so as to help support and accommodate the bipolar patient. Bipolar patients need social support from family, colleagues and friends and this plays a crucial role. The support system also need to know the different roles they ought to play so as to ensure a good prognosis for the patient while at the same time manage to take care of themselves.

Problem Statement
Bipolar causes significant psychosocial morbidity, because it frequently affects patients' relationships with family members and colleagues at work (Vornik& Hirschfeld, 2005). It also leads to increased family burden due to the increased cost of care and need for monitoring and support. This research thus aims to identify the effects that lead to relapse in bipolar patients and inform management interventions that will help reduce the rate of relapse.

Justification
This study is of significance to health workers, informal caregivers, families, colleagues, relatives and friends of those with bipolar so as to create awareness about the effects of bipolar among all those affected. It will also be important to other research as an inclusion to current literature.

A. Broad objective
To determine effects of bipolar relapse on the patient.

B. Specific objectives
i.
To determine the effects of bipolar on patients' work ii.
To determine the effects of bipolar on patients' family iii. To determine the effects of Bipolar on school iv. To determine the effects of bipolar on patients' relationships

Literature Review
Three types of life events have been studied in relation to BMD: negative, social rhythm disrupting, and goal-attainment [1]. Negative life events, low social support and low self-esteem predict bipolar depression but not manic symptoms [2]. Mania has been found to be preceded by schedule-disrupting life events [3]. Current findings indicate that manic symptoms are predicted by goalattainment life events [4]. Overall, studies of life events have found that bipolar individuals experience increased stressful events prior to first onset and recurrences of mood episodes. Moreover, most studies have found that negative life events precede the manic/hypomanic as well as the depressive episodes of bipolar individuals [5][6]. Social Rhythm Stability Hypothesis (SRSH) is one of the hypotheses that have been studied in relation to BMD. According to SRSH, the core problem in BMD is instability of regular daily patterns of activity. Ehlers and others coined a new term -Zeitstorer -to describe a person or a social demand that throws off the regularity of the daily pattern of activity.
Whenever you start a new relationship, get a new job, buy a new pet, or have a baby, your schedule is disrupted. If you have BMD, this will result in wild cycling until you get used to the new routine. It has been shown long ago that circadian rhythm disturbances are both causes and symptoms of BMD. During depressive episodes, the phase is advanced -you usually become more of a "lark", you wake up earlier andhave a lesser total amount of activity per day. During manic episodes, one is more of an "owl", staying up late and increasing total daily activity [5]. Another important aspect of an individual's current environment that affects the course of BMD is supportive or non-supportive interpersonal relationships. Social support from family and friends can buffer against the deleterious effects of stress or directly enhance functioning among bipolar individuals, whereas high expressed emotion or EEQ which refers to high levels of criticism, hostility, and/or emotional over involvement from a caregiving relative (typically a parent or spouse) during or immediately following a patient's acute episode of illness, from family members can provide additional stress and worsen the course of BMD. Four cross-sectional and one retrospective study found that bipolar individuals experience less social support than various control groups and that low social support is associated with mood episode relapses. A prospective study also found that poor social support predicts greater relapses and longer time to recovery [6].
BMD has far reaching effects, both into the lives of patients and those around them. BMD affects work, school, relationships, physical health and many other aspects of everyday life. In fact, in the early 1990s, it was calculated that the loss of productivity due to BMD cost $15.5 billion annually. The most severe effect of BMD is suicide. Unfortunately, 25% -50% of people with BMD attempt suicide and 11% commit suicide [7]. Psychological effects of BMD in the patient are broken down by the type of episodes the person is experiencing. Symptoms during mania/ hypomania may include: auditory and visual hallucinations, delusions including delusions of grandeur and thoughts that objects are sending special messages, intense anxiety, agitation, aggression, paranoia, obsessive worried thoughts and feelings like feeling the need to check something, feeling like life is spinning out of control, heightened mood, exaggerated optimism and self-confidence and racing thoughts like rapidly changing streams of thought and being easily distractible. Vast psychological effects are also seen during depressive episodes: prolonged sadness, feeling helpless, hopeless and worthless, feelings of guilt, pessimism, indifference, reoccurring thoughts of death and suicide, inability to concentrate, indecisiveness and inability to take pleasure in former interests [7].
The physical effects of BMD come from both the disorder itself as well as its indirect effects. For example, many people with BMD also develop substance abuse problems in an attempt to medicate the symptoms of BMD. The effects of BMD can also result in negative productivity -in depressive episodes, but productivity can increase during hypomanic episodes.This irregularity often leads to job loss and emotional instability results in relationship loss. Physical effects of BMD include: increased physical and mental activity and energy; hyperactivity, significant changes in appetite and sleep patterns, trouble breathing, racing speech, social withdrawal, loss of energy, persistent lethargy; aches and pains, unexplained crying spells, poor overall health, weight gain, blood pressure, heart problems and diabetes [7]. When BMD is not properly controlled with medical treatment, the family may experience: Emotional distress such as guilt, grief, and worry, disruption in regular routines, having to deal with bizarre or reckless behavior, financial stresses as a result of reduced income or spending sprees, strained marital or family relationships, changes in family roles, difficulty in maintaining relationships outside the family and health problems as a result of stress [8]. According to a research by (Chatterton, et.al, 2008), bipolar families used significantly more health care resources and incurred significantly greater costs, although nearly 90% of these resources and costs were used to treat conditions other than BMD.The impact of mental disorders on communities is large and manifold. There is the cost of providing care, the loss of productivity, and some legal problems (including violence) associated with some mental disorders, though violence is caused much more often by "normal" people than by individuals with mental disorders [9].

Study Design
The study was a retrospective study. Charts of the patients admitted in the mental health unit from 1st January 2012 to 31st December 2016 were reviewed.

Study Area
The research was carried out at the Moi Teaching and Referral Hospital at the Mental Health Unit in Eldoret.

Study Population
The study populations were in-patients who have been admitted in the mental unit as a result of BMD from 1st January 2012 to 31st December 2016. According to the medical records, there are at least nineteen BMD admissions monthly in the mental unit. Due to this the study population for the period of study of 5 years will be 1140 patients.

Sample Size
The study was a census therefore a sample size was notnecessary. All files within the stipulated period was reviewed

Sampling Technique
A sampling technique was not required as the study is a census.

A. Data Collection a. Data Collection Tools
This was done with the use of a data extraction sheetto collect relevant data.

b. Data collection techniques
Selection of charts was done by checking the mental health unit records office and screening if the charts fulfill the inclusion criteria required. Only charts that have fulfilled the inclusion criteria were assessed.

c. Data Analysis
The data collected were both quantitative and qualitative. The quantitative data were analyzed into percentages, pie charts, tables and graphs. The qualitative data was organized into themes that were further be linked to one another for a comprehensive explanation. The quantitative data were analyzed digitally with the help of Microsoft excel and Statistical Package for the Social Sciences (SPSS) data package.

d. Data Presentation
Tables, charts and graphs were used to present in the final report. Both hard copy and soft copy of the final report was availed to COBES committee, students and any authorized individual or institution.

e. Data Storage
All electronic information was stored in a password protected computer and all hard copies of patient information was kept in a locked cabinet that can only be accessed by agreed members of the research team.

f. Ethical Considerations
Ethical approval was sought from the Institutional Research and Ethics Committee (IREC) and from Moi Teaching and Referral Hospital before conducting the study. The patient's identity was kept confidential by the use of numbers and not names to prevent disclosure. The research was carried out under keen guidance and observation from the supervisors and other qualified personnel on the ground.

Findings
Bipolar disorder is believed to have some effects in the daily living activities of patients. The study assessed these effects and found the following:

A. Patient's work/colleagues
Relapse effects on patient's work/colleagues are presented in Table 1 The study found out that majority of the patients agreed that relapse affected their work and also with colleagues, while a small majority of 42.8% did not experience any effect on work or colleagues.  Relapse effects on patients' family are presented in Table 2. As depicted from the table majority of the patients 85.5% noted that the relapse had a major effect on their families, while 14.5% said that it didn't have any effect on their families.

C. Effect on School
Relapse effect on school of the patient is presented in Table  3 below. The findings revealed that majority of the respondents 69.4% noted that the bipolar relapse did not have any effect on their studies while 30.6% of the respondents noted that it had a direct effect in their education.  Table 4 Effect on Patient's friends and relationships. As revealed in the study majority of the respondents 78% agreed that the relapses had effects on their friends and relationships while 22% did not feel any effect.

E. Problems with the law
The findings revealed that majority 85.5% of the respondents did not have a problem with the law while 14.5% experienced problems with the law (Table 5).

F. Effect on Suicide
The study revealed that the patients 86.7% did not encounter any suicidal issues while 13.3% experienced such (Table 6).

Discussion
The study found out that majority of the patients agreed that relapse affected their work and also relationships with colleagues. Majority of the patients noted that the relapse had a major effect on their families, while a few said that it didn't have any effect on their families.Studies indicate that when BMD is not properly controlled with medical treatment, the family may experience: Emotional distress such as guilt, grief, and worry, disruption in regular routines, having to deal with bizarre or reckless behavior, financial stresses as a result of reduced income or spending sprees, strained marital or family relationships, changes in family roles, difficulty in maintaining relationships outside the family and health problems as a result of stress [8]. The findings revealed that majority of the respondents noted that the bipolar relapse did not have any effect on their studies while only a few of the respondents noted that it had a direct effect in their education. This is because majority of them got their first symptoms after they had either dropped out or had completed their education. This is attributed by the high number of individuals who had primary and secondary education as their highest level of education. This reveals that there was a high dropout rate. This is in agreement with a study carried out by Holtzman, Lolich, Ketter, & Vazquez whereby 20% of individuals had not completed primary education. Majority of the respondents agreed that the relapses had effects on their friends and relationships while a few did not feel any effect. This is brought about by the patient withdrawing from their environment and the presence of stigma that is associated with mental health. According to Latalova, Ociskova, Prasko, & Dana Kamaradova, stigmatization of patients with mental disorder is often presented like a stereotypical anticipation of unpredictability, danger, irresponsibility, and uncontrollability. Consistent with these negative anticipations, the behavior of the environment to the patient changes and the general public as a group keeps a significant distance. The patient becomes isolated with his or her problems.
The findings revealed that majority of the respondents did not have a problem with the law while a few experienced problems with the law. The study revealed that the patients did not encounter any suicidal issues while a few experienced such.According to World Health Organization [9], the impact of mental disorders on communities is large and manifold. There is the cost of providing care, the loss of productivity [10], and some legal problems (including violence) associated with some mental disorders, though violence is caused much more often by "normal" people than by individuals with mental disorders [11]. Previous studies haveshownthat individuals currently undergoing a depressive episode of bipolar disorders tend to withdraw from daily activities, spend less time working and with friends and more time alone at home, and spend time in passive leisure activities rather than healthy controls Barge-Schaapveld et al. Patients with bipolar disorders are also reported to make more use of avoidance and support-seeking strategies when coping with the stresses of everyday life than do non-depressed individuals Coyne et al. Episodes of depression continue to influence daily life activities even after recovery. Focus groups of individuals recovered from a depressive episode indicated that they actively avoided the demands of work and close relationships out of fear of relapse Coyne and Calarco, a result that has been replicated in questionnaire studies Coyne et al. and Kirk et al. Given the high risk of relapse and the often-devastatingeffects of full-blown episodes, it can be expected that individuals with a history of bipolar disorder also develop adaptive strategies involving coping and time use to regulate exposure and responses to daily stress [12].

Conclusion and Recommendations
Bipolar disorder was concluded to have certain effects on the day to day life conditions. As revealed in the study, most of the patients said that it affected their work/colleagues, patient family, relationships and problems in law to some extent. From the study findings, the study made a recommendation that families with people suffering from bipolar disorder are urged to learn their patients and handle them with great care to avoid adverse effects in their daily living.