Real-World Evaluation of Treatment Response and Adherence in Bipolar Disorder: A Cross-Sectional Study from a Semi-Urban South Indian Tertiary Care Hospital

Real-World Evaluation of Treatment Response and Adherence in Bipolar Disorder: A Cross-Sectional Study from a Semi-Urban South Indian Tertiary Care Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Real-World Evaluation of Treatment Response and Adherence in Bipolar Disorder: A Cross-Sectional Study from a Semi-Urban South Indian Tertiary Care Hospital Krishna Kumar Dhakchinamoorthi, Pavithra Krishna Moorthy, Ramanandha Mishra Annadurai, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7192695/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Bipolar disorder (BD) is a chronic psychiatric condition characterized by recurrent episodes of mania and depression, significantly impairing quality of life. Although pharmacological treatment remains central to management, data on prescribing patterns and clinical outcomes from Indian tertiary care centers are limited. Methods This cross-sectional observational study included one hundred patients diagnosed with BD according to the International Classification of Diseases (ICD) criteria. Symptom severity was evaluated using the Young Mania Rating Scale (YMRS) for mania and the Hamilton Depression Rating Scale (HAM-D) for depressive symptoms. Patients received individualized treatment regimens, including mood stabilizers, antipsychotics, and benzodiazepines. Pre- and post-treatment symptom scores were compared using paired t-tests. Medication adherence was evaluated using the chi-square test, with p < 0.05 considered statistically significant. Results The majority of patients were female (65%), aged 29–38 years (38%), and from semi-urban areas (68%). A family history of psychiatric illness was present in 70%, and 51% reported suicidal ideation. Post-treatment, YMRS and HAM-D scores showed significant reductions (mean difference: 5.14 and 3.15, respectively; p < 0.0001), with higher treatment responsiveness observed in mild and moderate severity groups. Diazepam, trihexyphenidyl, haloperidol, lithium, and sodium valproate were the most commonly prescribed agents. Medication adherence improved significantly post-treatment ( p < 0.001), particularly among patients with mild symptoms. Conclusion Standard pharmacological therapy effectively reduced manic and depressive symptoms in bipolar disorder. Improved adherence was linked to better clinical outcomes. Taken together, these findings underscore the importance of early diagnosis, individualized treatment, and comprehensive psychosocial support in optimizing BD management in tertiary care settings. Bipolar Disorder Pharmacotherapy Symptom Severity Medication Adherence YMRS HAM-D Figures Figure 1 Figure 2 Introduction Bipolar disorder (BD), previously referred to as manic-depressive illness, is a chronic psychiatric condition characterized by alternating periods of mania or hypomania and depression. These mood disturbances significantly impair quality of life and functional ability, and are associated with increased risks of suicide, self-harm, and social dysfunction [ 1 , 2 ]. Contemporary classifications of BD distinguish between major depressive episodes and manic/hypomanic phases, reflecting the episodic and variable nature of the disorder [ 3 ]. According to the World Mental Health Survey, BD-I has a prevalence of 0.6%, BD-II accounts for 0.4%, and subthreshold forms comprise approximately 1.4% [ 4 , 5 ]. In the Indian context, however, epidemiological data remain limited. Recent multicentric studies report a prevalence between 0.04–0.39% for bipolar spectrum disorders [ 6 ]. The etiology of BD is multifactorial. Genetic predisposition plays a significant role, accounting for nearly 80% of the risk. Concurrently, neurotransmitter dysregulation (dopamine, serotonin, and noradrenaline), neurotrophic deficits, inflammatory processes, and oxidative stress contribute to disease manifestation and progression [ 7 , 8 ]. External triggers—including psychosocial stressors, sleep disruption, substance abuse, and physical illness—may precipitate episode onset [ 9 ]. At the cellular level, mitochondrial dysfunction, calcium dysregulation, and impaired endoplasmic reticulum (ER) stress response are believed to underlie neuronal vulnerability in BD. The accumulation of mitochondrial DNA mutations further compromises cellular resilience, exacerbating the disease course [ 10 ]. Clinically, BD presents with manic symptoms including impulsivity, rapid speech, inflated self-esteem, decreased need for sleep, irritability, and hyperactivity. Depressive episodes are characterized by anhedonia, social withdrawal, psychomotor retardation, suicidal ideation, changes in appetite and sleep, and persistent low mood [ 11 ]. BD is a complex illness with neurobiological, psychological, and immunological components. It is frequently associated with comorbidities such as substance use, anxiety disorders, metabolic syndrome, and cardiovascular conditions [ 12 , 13 ]. Clinical tools like the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HAM-D) are widely used for evaluating the severity of manic and depressive episodes, respectively [ 14 , 15 ]. Contemporary therapeutic approaches to bipolar disorder integrate pharmacological treatments with psychosocial and behavioral interventions. Mood stabilizers (e.g., lithium, sodium valproate), antipsychotics, and benzodiazepines are commonly prescribed alongside psychotherapy and lifestyle interventions such as sleep hygiene and psychoeducation [ 16 – 18 ]. Materials and Methods This cross-sectional observational study was conducted in the Department of Psychiatry at Government Medical College Hospital (GMCH), Tiruppur, over six months. Prior to commencement, the study received approval from the Institutional Ethics Committee (IEC). Its primary objective was to assess the prescribing patterns of therapeutic agents used in bipolar disorder treatment and to evaluate clinical outcomes using validated rating scales. A cohort of 105 patients with a confirmed diagnosis of bipolar affective disorder (BPAD) was recruited. However, four patients were lost to follow-up due to irregular hospital visits, and one patient died during the study period as a result of a road traffic accident. Inclusion criteria consisted of individuals aged 18 to 60 years, of either gender, meeting the diagnostic criteria for bipolar disorder according to the International Classification of Diseases (ICD). Exclusion criteria included pediatric or geriatric patients with severe medical complications or comorbidities requiring immediate intervention. Data were collected using a structured case report form encompassing demographic details, social and lifestyle habits, family history, clinical presentation, diagnostic findings, and treatment regimens. Treatment decisions were guided by symptom severity scores obtained via standardized rating scales. Manic and depressive symptoms were evaluated using the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HAM-D), respectively. Baseline scores were recorded in each patient’s case sheet and updated during hospital visits. A YMRS score of ≥ 20 was considered indicative of moderate to severe manic symptoms, while a HAM-D score of ≥ 14 reflected moderate to severe depressive symptoms. These thresholds supported decisions regarding pharmacological treatment initiation, adjustment, or escalation. Reductions in either scale were considered clinically significant. Final evaluations were conducted after six months. Pharmacological regimens were tailored based on individual profiles, symptom severity, and therapeutic response. Common prescriptions included mood stabilizers, antipsychotics, and benzodiazepines. Diazepam was used to manage acute episodes of agitation. Trihexyphenidyl was administered prophylactically to prevent extrapyramidal symptoms in patients receiving typical antipsychotics. Drug regimens were adjusted for severity and tolerability. Statistical Analysis Data were analyzed using GraphPad Prism version 8.0. Descriptive statistics were used to summarize patient demographics and clinical characteristics. Paired t-tests were applied to assess changes in YMRS and HAM-D scores before and after treatment, demonstrating statistically significant reductions in symptoms. To evaluate shifts in medication adherence, a chi-square test was performed comparing adherence rates pre- and post-treatment across severity groups. The results revealed a marked improvement in overall adherence ( p < 0.001), particularly among patients with mild symptoms. A p -value less than 0.05 was deemed statistically significant for all analyses. Power/Sample Size Analysis A post hoc power analysis assessed whether the sample size was sufficient to detect changes in symptom severity. With a significance level ( α ) of 0.05, paired t-tests were used to compare pre- and post-treatment scores for both YMRS and HAM-D. The YMRS showed a mean score difference of 5.14 (SD = 2.82, p < 0.0001), yielding a moderate-to-large effect size (Cohen’s d = 0.73). The achieved post hoc power exceeded 0.99. Similarly, the HAM-D scores decreased by a mean of 3.15 (SD = 1.82, p < 0.0001), with a large effect size ( d = 0.82) and post hoc power also above 0.99. The chi-square test for adherence (increase from 69–87%) produced an effect size (Cohen’s w ≈ 0.4), achieving a power greater than 95%. These values confirm that the study was adequately powered to detect statistically and clinically meaningful differences in symptom severity and adherence. Results Demographic and Clinical Characteristics ( Table 1 ) Among the 100 participants, the highest representation was in the 29–38 age group (38%), followed by 39–48 years (33%). Females constituted a majority (65%) of the sample. Employment status revealed that 72% were employed at the time of assessment. A considerable proportion resided in semiurban regions (68%), and 61% were married. Socioeconomic classification revealed a predominance of upper-lower status (66%), with no participants from the 'Upper' category. Financially, nearly 39% reported existing debt. Family history of psychiatric illness was present in 70% of participants, and medical comorbidities in 73%. Suicidal ideation history was documented in over half the sample (51%). Detailed breakdown of familial psychopathology revealed substance use (26%) and mood disorders (22%) as the most common conditions reported among relatives. Table 1 Sociodemographic and Clinical Characteristics of Study Participants (n = 100) Category Subgroup n 95% CI Age (years) 18–28 10 0.01–0.17 29–38 38 0.29–0.48 39–48 33 0.24–0.42 49–60 19 0.12–0.19 Gender Male 34 0.25–0.43 Female 65 0.65–0.73 Transgender 1 0.001–0.054 Employment Status Employed 72 0.62–0.79 Unemployed 28 0.20–0.37 Location Rural 20 0.13–0.28 Semiurban 68 0.58–0.76 Urban 12 0.07–0.19 Marital Status Married 61 0.51–0.69 Unmarried 34 0.25–0.63 Divorced 5 0.02–0.11 Socioeconomic Status Lower 19 0.12–0.27 Upper-lower 66 0.56–0.74 Lower-middle 11 0.06–0.18 Upper-middle 4 0.01–0.09 Upper - — Financial Status With debt 39 0.30–0.48 Without debt 61 0.31–0.50 Family History of Mental Illness Present 70 0.60–0.78 Absent 30 0.21–0.39 Medical Comorbidity Present 73 0.63–0.80 Absent 27 0.19–0.36 Suicidal Thoughts History Present 51 0.49–0.68 Absent 49 0.31–0.59 Family History — Specific Disorders Psychosis 11 0.06–0.18 Mood disorders 22 0.15–0.31 Substance use 26 0.18–0.35 Mood + substance use 3 0.01–0.08 Psychosis + substance use 3 0.01–0.08 Others 5 0.02–0.11 No history 30 0.21–0.39 Treatment effectiveness was assessed by comparing symptom severity before and after intervention using the Young Mania Rating Scale (YMRS) for manic symptoms and the Hamilton Depression Rating Scale (HAM-D) for depressive symptoms. Assessment of Manic Symptoms (YMRS) At baseline, among 100 participants, 36% exhibited mild manic symptoms, 20% showed moderate symptoms, and 7% were classified as having severe symptoms according to the YMRS. Following six months of treatment, the distribution shifted notably (Table 2 ). The mean YMRS score before treatment was 25.28 ± 6.92, which reduced to 20.14 ± 6.87 post-treatment. A paired t-test revealed this reduction to be statistically significant (t = 18.17, p < 0.0001), with a mean difference of 5.14 (95% CI: 4.57–5.70), and a standard error of the difference of 0.28. Table 2 Classification based on severity of manic symptoms (n = 100) SEVERITY YMRS BEFORE TREATMENT YMRS AFTER TREATMENT NO.OF PATIENTS % 95%CI NO.OF PATIENTS % 95% CI MILD 36 36% 0.27–0.45 22 22% 0.15–0.31 MODERATE 20 20% 0.13–0.28 13 13% 0.07–0.20 SEVERE 7 7% 0.03–0.13 2 2% 0.005–0.07 Before treatment, the mild group had a median YMRS score around 19–20 with a narrow IQR, indicating low variability and relatively consistent symptom severity (Fig. 1). The moderate group showed elevated scores, with a median around 25 and a wider range of variability. The severe group had significantly elevated scores, with a median around 40 and scores extending up to 50, reflecting acute manic states. After treatment, YMRS scores declined across all groups. The mild group demonstrated clear improvement, with the median score reduced to approximately 16–17. The moderate group also showed a downward trend, with median values closer to 20. The severe group, although still exhibiting high scores (median ∼35–40), had a broader range, suggesting heterogeneous treatment response—some patients improved substantially, while others remained highly symptomatic Assessment of Depressive Symptoms (HAM-D) In terms of depressive symptoms, 19% of patients were categorized as having mild depression, 13% had moderate depression, and 5% had severe symptoms at the start of the study. After treatment, mild depressive symptoms remained unchanged at 19%, whereas moderate symptoms declined to 6%, and severe symptoms reduced to 1% (Table 3 ). The mean HAM-D score before treatment was 13.18 ± 4.56, which decreased to 10.03 ± 4.07 following the intervention. Table 3 Classification based on severity of depressive symptoms (n = 100) Severity Ham-d before treatment Ham-d after treatment No.of patients % 95%CI No.of Patients % 95% CI Mild 19 19% 0.12–0.27 19 19% 0.12–0.27 Moderate 13 13% 0.07–0.20 6 6% 0.02–0.12 Severe 5 5% 0.02–0.11 1 1% 0.001–0.05 Statistical analysis using a paired t-test confirmed a significant improvement in depressive symptoms (t = 17.29, p < 0.0001), with a mean difference of 3.15 (95% CI: 2.78–3.51) and a standard error of 0.18. Before treatment, patients classified in the mild group exhibited a median HAM-D score of approximately 11, with interquartile ranges (IQR) between 8 and 16 (Fig. 2 ). The moderate group had a higher median around 17–18, and scores ranged more broadly, indicating a wider distribution of depressive symptom severity. The severe group demonstrated the highest and most consistent scores, with a median HAM-D score around 25–27 and minimal variation, reflecting uniformly high depressive burden. Following treatment, all patient groups demonstrated a reduction in depressive symptom severity as measured by the Hamilton Depression Rating Scale (HAM-D). Patients categorized with mild depression showed the most significant improvement, with median HAM-D scores decreasing to approximately 8 and a narrower interquartile range (IQR), indicating a more consistent therapeutic response across the group. The moderate depression group also experienced notable reductions, with median scores stabilizing around 14–15. In contrast, patients in the severe category showed only partial improvement, with median scores remaining elevated around 21. Although their score distribution was tight—suggesting uniform treatment effects—persistent depressive symptoms were evident in a subset of this group despite intervention. Pharmacological treatment patterns revealed that diazepam was the most commonly prescribed medication, administered to all patients (96%). This was followed by trihexyphenidyl (90%), haloperidol (77%), and lithium (75%). Sodium valproate was used in 65% of patients, indicating its role as a primary mood stabilizer. Atypical antipsychotics such as risperidone (54%), olanzapine (38%), and quetiapine (22%) were selectively used based on symptom profile. Additional agents included promethazine (39%), lorazepam (10%), chlorpromazine (5%), and phenergan (12%). Medication Adherence and Treatment Outcome Following treatment, adherence rates improved across all severity groups (Table 4 ). The mild group showed the greatest increase in adherence (from 37 to 47 patients), while non-adherence decreased notably (from 18 to 8). In moderate and severe groups, adherence also increased, and non-adherence declined. Table 4 Medication adherence (n = 100) Severity Before treatment After treatment P value Adherence Non-adherence Adherence Non-adherence Mild 37 18 47 8 p < 0.001 Moderate 23 10 30 3 Severe 9 3 10 2 A chi-square test confirmed this improvement was statistically significant (χ2 = 12.07, p < 0.001), suggesting a robust relationship between the treatment intervention and increased adherence. The results underscore the intervention’s effectiveness, particularly in mild and moderate conditions, where behavioral modifications may be more readily achieved. Discussion This study provides a comprehensive overview of the clinical profile, therapeutic management, and treatment outcomes of patients with bipolar disorder at a tertiary care center in South India. The findings contribute to existing knowledge by affirming known epidemiological patterns and emphasizing the real-world effectiveness of standard treatment protocols. BD was observed more frequently among females (65%) than males (34%), aligning with recent Indian studies that suggest increased recognition of BD in women due to greater awareness and diagnostic sensitivity [ 19 , 20 ]. The most affected age group was 29–38 years (38%), which mirrors global reports of peak onset in early adulthood [ 5 ]. Marital status showed that 61% of patients were married—this may reflect the influence of marital stress, interpersonal conflict, and psychosocial role burden on mood dysregulation, particularly in women [ 21 ]. Additionally, 61% of patients came from nuclear families, reinforcing literature that points to the role of family dynamics in the development and progression of mood disorders [ 17 ]. A family history of psychiatric illness was present in 70% of participants, predominantly involving mood disorders and substance use. This supports genetic studies highlighting bipolar disorder’s heritability [ 22 ]. Recent genome-wide association studies have identified susceptibility loci associated with BD subtypes and lithium responsiveness, underscoring the promise of precision psychiatry [ 23 , 24 ]. Statistically significant reductions in YMRS and HAM-D scores following treatment affirm the efficacy of guideline-based pharmacotherapy. Lithium, diazepam, and sodium valproate were the most prescribed agents, aligning with Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines recommending mood stabilizers for acute and maintenance phases of BD [ 25 ]. The YMRS assessment revealed the most notable improvements in mild and moderate cases, as evidenced by reduced median scores and narrower variability. Patients in the severe category showed more variable treatment responses, suggesting some may benefit from intensified or alternative therapies. Similarly, HAM-D assessments indicated stronger therapeutic effects in mild and moderate groups. Severe cases, however, showed only partial improvement and persistent depressive burden, emphasizing the need for multi-modal interventions. Sodium valproate, prescribed in 65% of cases, was comparably effective to lithium and more so than risperidone and carbamazepine for certain patients—an observation supported by Indian cohort data and meta-analyses [ 26 ]. Second-generation antipsychotics such as olanzapine and risperidone were frequently integrated into combination therapy strategies, reflecting contemporary prescribing trends [ 26 , 27 ]. Medication adherence was initially noted in 69% of patients and improved significantly post-treatment, particularly in cases with mild symptoms. This finding aligns with prior retrospective studies on nonadherence in BD populations [ 18 ]. Our findings suggest that symptom control and behavioral interventions positively impact compliance. A concerning 51% of participants reported suicidal ideation, a figure consistent with global literature indicating heightened suicide risk in BD [ 28 ]. This underscores the importance of routine suicide risk assessment and integrated prevention strategies in care protocols. Emerging evidence highlights mitochondrial dysfunction, oxidative stress, and circadian rhythm disruptions as contributing factors to treatment resistance and BD progression [ 10 , 29 ]. These insights may pave the way for developing novel therapeutic targets beyond conventional psychotropics. Conclusion In conclusion, this study reinforces the importance of early diagnosis, individualized treatment regimens, and psychosocial support in optimizing outcomes for patients with bipolar disorder. Standard pharmacological therapy was effective in reducing both manic and depressive symptoms, particularly among patients with mild and moderate severity. Improved medication adherence was strongly associated with better clinical outcomes. The study also highlights the high prevalence of comorbidities and suicidal ideation, emphasizing the need for comprehensive and patient-centered care models. Continued research aimed at personalizing treatment strategies and addressing biological underpinnings will be key to improving long-term outcomes in bipolar disorder. Declarations Acknowledgements The authors acknowledged all the nursing staff and technical personnel of the Government Medical College Hospital, Tiruppur, Tamil Nadu, India. Authors’ contributions Krishna Kumar Dhakchinamoorthi and Sanjay Bose conceived the idea. Pavithra Krishna Moorthy, Ramanandha Mishra Annadurai, Yoshni Regunathan, and Yuvaraj Jaisankar collected the data. Krishna Kumar Dhakchinamoorthi and Sanjay Bose analysed the data. All the authors contributed in writing the manuscript, and all of them reviewed the manuscript. Funding: Nil Ethics approval and consent to participate: Ethical approval for the study was obtained from the Ethics Committee of Government Medical College, Tiruppur (EC/ME/2022, dated July 26, 2022). Written informed consent to participate was taken from all participants and or their legal guardians. No human experiments were carried out during the study. All methods were carried out in accordance with relevant guidelines and regulations. Data availability statement: All data generated or analysed during this study are included in this published article Consent for publication: NA. Competing interests: The authors declare no competing interests. References Anderson IM, Haddad PM, Scott J (2012) Bipolar disorder. BMJ 345:e8508. Marton E, Murray G, Michalak EE, Law RW, Beaulieu S, Sharma V, et al. (2017) Quality of life in bipolar disorder. Psychol Med 48(7):1111–8. Tondo L, Vazquez GH, Baldessarini RJ (2017) Depression and mania in bipolar disorder. Curr Neuropharmacol 15(3):353–8. 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Jagannath A, Sundaram P, Nair K, Sinha R, Ramesh S (2023) Circadian disruption and BD: a mechanistic overview. Mol Psychiatry 28(4):1345–53. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Dhakchinamoorthi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDCCAwwMkg0MEgwGDAzMYAF+EJFQQIoWIA+oxYCgFgaEFoMDDBAuLsB3+wDjzZl7LOzNpZsfG/Pm2OUbn1+d+OGBAYM8v9gBrFokzyUwW254JpG4c84x42TebcmW22683SwBdJjhzNkJWLUYnGFgk3xwAKjmRoLxYd5tzAZmN85uAGlJMLiNX4u9wY30z0At9QbGM85u/kFQy4YDEowbbuSAHHbYwIC/dxteWyTPMDZbzjggkQjUUmw4d9txA4kbvNssEgwkcPqF7wzzwZs9B+pADtss8XZbtQF//9nNN39U2MjzS2PXwsDA2IAmIAFWKYFDOVbAf4AU1aNgFIyCUTACAADr52Iyx1QfMAAAAABJRU5ErkJggg==","orcid":"","institution":"The Erode College of Pharmacy and Government Medical College and Hospital","correspondingAuthor":true,"prefix":"","firstName":"Krishna","middleName":"Kumar","lastName":"Dhakchinamoorthi","suffix":""},{"id":489535196,"identity":"74992a84-f37e-49b1-aeba-1a9913a41125","order_by":1,"name":"Pavithra Krishna Moorthy","email":"","orcid":"","institution":"The Erode College of Pharmacy and Government Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pavithra","middleName":"Krishna","lastName":"Moorthy","suffix":""},{"id":489535197,"identity":"2b1b9f81-259c-4f43-9bef-c0e94c3a7d61","order_by":2,"name":"Ramanandha Mishra Annadurai","email":"","orcid":"","institution":"The Erode College of Pharmacy and Government Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ramanandha","middleName":"Mishra","lastName":"Annadurai","suffix":""},{"id":489535198,"identity":"1f345203-9d7f-43f9-81f1-abb3f5c64bac","order_by":3,"name":"Yoshni Regunathan","email":"","orcid":"","institution":"The Erode College of Pharmacy and Government Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yoshni","middleName":"","lastName":"Regunathan","suffix":""},{"id":489535199,"identity":"f6020dde-63f1-48d4-9f8b-1873eeb14ec1","order_by":4,"name":"Yuvaraj Jaisankar","email":"","orcid":"","institution":"The Erode College of Pharmacy and Government Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuvaraj","middleName":"","lastName":"Jaisankar","suffix":""},{"id":489535200,"identity":"86a68116-d34a-49ba-82aa-d52115359f21","order_by":5,"name":"Sanjay Bose","email":"","orcid":"","institution":"Government Medical College and Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sanjay","middleName":"","lastName":"Bose","suffix":""}],"badges":[],"createdAt":"2025-07-23 06:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7192695/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7192695/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87576548,"identity":"397a8155-7a5e-4e99-8f89-f9d3057a8712","added_by":"auto","created_at":"2025-07-25 11:43:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69408,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eYoung Mania Rating Scale (YMRS) scores before and after treatment (n=100)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7192695/v1/0cb9bcd75ed1c806691b3ce2.png"},{"id":87576549,"identity":"65d64ccf-8bc9-4dc8-a5e9-7e1016c8bdf3","added_by":"auto","created_at":"2025-07-25 11:43:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":74505,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHamilton Depression Rating Scale (Ham-D) scores before and after treatment (n=100)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7192695/v1/0ffa1a04fdc9b82bc2e705b6.png"},{"id":90028827,"identity":"efc08a3e-0fbf-469c-8c00-1f9ee0f10229","added_by":"auto","created_at":"2025-08-27 14:39:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":991179,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7192695/v1/6cb19533-34f6-4281-a467-cd5cddfd4377.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real-World Evaluation of Treatment Response and Adherence in Bipolar Disorder: A Cross-Sectional Study from a Semi-Urban South Indian Tertiary Care Hospital","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBipolar disorder (BD), previously referred to as manic-depressive illness, is a chronic psychiatric condition characterized by alternating periods of mania or hypomania and depression. These mood disturbances significantly impair quality of life and functional ability, and are associated with increased risks of suicide, self-harm, and social dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Contemporary classifications of BD distinguish between major depressive episodes and manic/hypomanic phases, reflecting the episodic and variable nature of the disorder [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the World Mental Health Survey, BD-I has a prevalence of 0.6%, BD-II accounts for 0.4%, and subthreshold forms comprise approximately 1.4% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the Indian context, however, epidemiological data remain limited. Recent multicentric studies report a prevalence between 0.04\u0026ndash;0.39% for bipolar spectrum disorders [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The etiology of BD is multifactorial. Genetic predisposition plays a significant role, accounting for nearly 80% of the risk. Concurrently, neurotransmitter dysregulation (dopamine, serotonin, and noradrenaline), neurotrophic deficits, inflammatory processes, and oxidative stress contribute to disease manifestation and progression [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. External triggers\u0026mdash;including psychosocial stressors, sleep disruption, substance abuse, and physical illness\u0026mdash;may precipitate episode onset [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the cellular level, mitochondrial dysfunction, calcium dysregulation, and impaired endoplasmic reticulum (ER) stress response are believed to underlie neuronal vulnerability in BD. The accumulation of mitochondrial DNA mutations further compromises cellular resilience, exacerbating the disease course [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Clinically, BD presents with manic symptoms including impulsivity, rapid speech, inflated self-esteem, decreased need for sleep, irritability, and hyperactivity. Depressive episodes are characterized by anhedonia, social withdrawal, psychomotor retardation, suicidal ideation, changes in appetite and sleep, and persistent low mood [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. BD is a complex illness with neurobiological, psychological, and immunological components. It is frequently associated with comorbidities such as substance use, anxiety disorders, metabolic syndrome, and cardiovascular conditions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Clinical tools like the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HAM-D) are widely used for evaluating the severity of manic and depressive episodes, respectively [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Contemporary therapeutic approaches to bipolar disorder integrate pharmacological treatments with psychosocial and behavioral interventions. Mood stabilizers (e.g., lithium, sodium valproate), antipsychotics, and benzodiazepines are commonly prescribed alongside psychotherapy and lifestyle interventions such as sleep hygiene and psychoeducation [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis cross-sectional observational study was conducted in the Department of Psychiatry at Government Medical College Hospital (GMCH), Tiruppur, over six months. Prior to commencement, the study received approval from the Institutional Ethics Committee (IEC). Its primary objective was to assess the prescribing patterns of therapeutic agents used in bipolar disorder treatment and to evaluate clinical outcomes using validated rating scales.\u003c/p\u003e\u003cp\u003eA cohort of 105 patients with a confirmed diagnosis of bipolar affective disorder (BPAD) was recruited. However, four patients were lost to follow-up due to irregular hospital visits, and one patient died during the study period as a result of a road traffic accident. Inclusion criteria consisted of individuals aged 18 to 60 years, of either gender, meeting the diagnostic criteria for bipolar disorder according to the International Classification of Diseases (ICD). Exclusion criteria included pediatric or geriatric patients with severe medical complications or comorbidities requiring immediate intervention.\u003c/p\u003e\u003cp\u003eData were collected using a structured case report form encompassing demographic details, social and lifestyle habits, family history, clinical presentation, diagnostic findings, and treatment regimens. Treatment decisions were guided by symptom severity scores obtained via standardized rating scales. Manic and depressive symptoms were evaluated using the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HAM-D), respectively. Baseline scores were recorded in each patient\u0026rsquo;s case sheet and updated during hospital visits. A YMRS score of \u0026ge;\u0026thinsp;20 was considered indicative of moderate to severe manic symptoms, while a HAM-D score of \u0026ge;\u0026thinsp;14 reflected moderate to severe depressive symptoms. These thresholds supported decisions regarding pharmacological treatment initiation, adjustment, or escalation. Reductions in either scale were considered clinically significant. Final evaluations were conducted after six months.\u003c/p\u003e\u003cp\u003ePharmacological regimens were tailored based on individual profiles, symptom severity, and therapeutic response. Common prescriptions included mood stabilizers, antipsychotics, and benzodiazepines. Diazepam was used to manage acute episodes of agitation. Trihexyphenidyl was administered prophylactically to prevent extrapyramidal symptoms in patients receiving typical antipsychotics. Drug regimens were adjusted for severity and tolerability.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using GraphPad Prism version 8.0. Descriptive statistics were used to summarize patient demographics and clinical characteristics. Paired t-tests were applied to assess changes in YMRS and HAM-D scores before and after treatment, demonstrating statistically significant reductions in symptoms. To evaluate shifts in medication adherence, a chi-square test was performed comparing adherence rates pre- and post-treatment across severity groups. The results revealed a marked improvement in overall adherence (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), particularly among patients with mild symptoms. A \u003cem\u003ep\u003c/em\u003e-value less than 0.05 was deemed statistically significant for all analyses.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePower/Sample Size Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA post hoc power analysis assessed whether the sample size was sufficient to detect changes in symptom severity. With a significance level (\u003cem\u003eα\u003c/em\u003e) of 0.05, paired t-tests were used to compare pre- and post-treatment scores for both YMRS and HAM-D. The YMRS showed a mean score difference of 5.14 (SD\u0026thinsp;=\u0026thinsp;2.82, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), yielding a moderate-to-large effect size (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.73). The achieved post hoc power exceeded 0.99. Similarly, the HAM-D scores decreased by a mean of 3.15 (SD\u0026thinsp;=\u0026thinsp;1.82, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with a large effect size (\u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82) and post hoc power also above 0.99. The chi-square test for adherence (increase from 69\u0026ndash;87%) produced an effect size (Cohen\u0026rsquo;s \u003cem\u003ew\u003c/em\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;0.4), achieving a power greater than 95%. These values confirm that the study was adequately powered to detect statistically and clinically meaningful differences in symptom severity and adherence.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDemographic and Clinical Characteristics (\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong the 100 participants, the highest representation was in the 29\u0026ndash;38 age group (38%), followed by 39\u0026ndash;48 years (33%). Females constituted a majority (65%) of the sample. Employment status revealed that 72% were employed at the time of assessment. A considerable proportion resided in semiurban regions (68%), and 61% were married. Socioeconomic classification revealed a predominance of upper-lower status (66%), with no participants from the 'Upper' category. Financially, nearly 39% reported existing debt. Family history of psychiatric illness was present in 70% of participants, and medical comorbidities in 73%. Suicidal ideation history was documented in over half the sample (51%). Detailed breakdown of familial psychopathology revealed substance use (26%) and mood disorders (22%) as the most common conditions reported among relatives.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic and Clinical Characteristics of Study Participants (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubgroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.01\u0026ndash;0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u0026ndash;38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.29\u0026ndash;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u0026ndash;48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.24\u0026ndash;0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.12\u0026ndash;0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25\u0026ndash;0.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.65\u0026ndash;0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransgender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u0026ndash;0.054\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.62\u0026ndash;0.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.20\u0026ndash;0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.13\u0026ndash;0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSemiurban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.58\u0026ndash;0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.07\u0026ndash;0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.51\u0026ndash;0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25\u0026ndash;0.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.02\u0026ndash;0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocioeconomic Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.12\u0026ndash;0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUpper-lower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.56\u0026ndash;0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLower-middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06\u0026ndash;0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUpper-middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.01\u0026ndash;0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUpper\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinancial Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith debt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30\u0026ndash;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWithout debt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u0026ndash;0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily History of Mental Illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.60\u0026ndash;0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.21\u0026ndash;0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Comorbidity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.63\u0026ndash;0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.19\u0026ndash;0.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuicidal Thoughts History\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.49\u0026ndash;0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u0026ndash;0.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily History \u0026mdash; Specific Disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06\u0026ndash;0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMood disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.15\u0026ndash;0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubstance use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.18\u0026ndash;0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMood\u0026thinsp;+\u0026thinsp;substance use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.01\u0026ndash;0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychosis\u0026thinsp;+\u0026thinsp;substance use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.01\u0026ndash;0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.02\u0026ndash;0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo history\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.21\u0026ndash;0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTreatment effectiveness was assessed by comparing symptom severity before and after intervention using the Young Mania Rating Scale (YMRS) for manic symptoms and the Hamilton Depression Rating Scale (HAM-D) for depressive symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAssessment of Manic Symptoms (YMRS)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt baseline, among 100 participants, 36% exhibited mild manic symptoms, 20% showed moderate symptoms, and 7% were classified as having severe symptoms according to the YMRS. Following six months of treatment, the distribution shifted notably (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean YMRS score before treatment was 25.28\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92, which reduced to 20.14\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87 post-treatment. A paired t-test revealed this reduction to be statistically significant (t\u0026thinsp;=\u0026thinsp;18.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with a mean difference of 5.14 (95% CI: 4.57\u0026ndash;5.70), and a standard error of the difference of 0.28.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClassification based on severity of manic symptoms (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSEVERITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eYMRS BEFORE TREATMENT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eYMRS AFTER TREATMENT\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNO.OF PATIENTS\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e95%CI\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eNO.OF PATIENTS\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMILD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.27\u0026ndash;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.15\u0026ndash;0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMODERATE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u0026ndash;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.07\u0026ndash;0.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSEVERE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.03\u0026ndash;0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.005\u0026ndash;0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003cp\u003eBefore treatment, the mild group had a median YMRS score around 19\u0026ndash;20 with a narrow IQR, indicating low variability and relatively consistent symptom severity (Fig.\u0026nbsp;1). The moderate group showed elevated scores, with a median around 25 and a wider range of variability. The severe group had significantly elevated scores, with a median around 40 and scores extending up to 50, reflecting acute manic states. After treatment, YMRS scores declined across all groups. The mild group demonstrated clear improvement, with the median score reduced to approximately 16\u0026ndash;17. The moderate group also showed a downward trend, with median values closer to 20. The severe group, although still exhibiting high scores (median \u0026sim;35\u0026ndash;40), had a broader range, suggesting heterogeneous treatment response\u0026mdash;some patients improved substantially, while others remained highly symptomatic\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eAssessment of Depressive Symptoms (HAM-D)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn terms of depressive symptoms, 19% of patients were categorized as having mild depression, 13% had moderate depression, and 5% had severe symptoms at the start of the study. After treatment, mild depressive symptoms remained unchanged at 19%, whereas moderate symptoms declined to 6%, and severe symptoms reduced to 1% (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The mean HAM-D score before treatment was 13.18\u0026thinsp;\u0026plusmn;\u0026thinsp;4.56, which decreased to 10.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.07 following the intervention.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClassification based on severity of depressive symptoms (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSeverity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eHam-d before treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eHam-d after treatment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo.of patients\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e95%CI\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eNo.of\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatients\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.12\u0026ndash;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.12\u0026ndash;0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u0026ndash;0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.02\u0026ndash;0.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.02\u0026ndash;0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u0026ndash;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eStatistical analysis using a paired t-test confirmed a significant improvement in depressive symptoms (t\u0026thinsp;=\u0026thinsp;17.29, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with a mean difference of 3.15 (95% CI: 2.78\u0026ndash;3.51) and a standard error of 0.18. Before treatment, patients classified in the mild group exhibited a median HAM-D score of approximately 11, with interquartile ranges (IQR) between 8 and 16 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The moderate group had a higher median around 17\u0026ndash;18, and scores ranged more broadly, indicating a wider distribution of depressive symptom severity. The severe group demonstrated the highest and most consistent scores, with a median HAM-D score around 25\u0026ndash;27 and minimal variation, reflecting uniformly high depressive burden.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFollowing treatment, all patient groups demonstrated a reduction in depressive symptom severity as measured by the Hamilton Depression Rating Scale (HAM-D). Patients categorized with mild depression showed the most significant improvement, with median HAM-D scores decreasing to approximately 8 and a narrower interquartile range (IQR), indicating a more consistent therapeutic response across the group. The moderate depression group also experienced notable reductions, with median scores stabilizing around 14\u0026ndash;15. In contrast, patients in the severe category showed only partial improvement, with median scores remaining elevated around 21. Although their score distribution was tight\u0026mdash;suggesting uniform treatment effects\u0026mdash;persistent depressive symptoms were evident in a subset of this group despite intervention.\u003c/p\u003e\u003cp\u003ePharmacological treatment patterns revealed that diazepam was the most commonly prescribed medication, administered to all patients (96%). This was followed by trihexyphenidyl (90%), haloperidol (77%), and lithium (75%). Sodium valproate was used in 65% of patients, indicating its role as a primary mood stabilizer. Atypical antipsychotics such as risperidone (54%), olanzapine (38%), and quetiapine (22%) were selectively used based on symptom profile. Additional agents included promethazine (39%), lorazepam (10%), chlorpromazine (5%), and phenergan (12%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMedication Adherence and Treatment Outcome\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFollowing treatment, adherence rates improved across all severity groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The mild group showed the greatest increase in adherence (from 37 to 47 patients), while non-adherence decreased notably (from 18 to 8). In moderate and severe groups, adherence also increased, and non-adherence declined.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedication adherence (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSeverity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eBefore treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eAfter treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAdherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNon-adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA chi-square test confirmed this improvement was statistically significant (χ2\u0026thinsp;=\u0026thinsp;12.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting a robust relationship between the treatment intervention and increased adherence. The results underscore the intervention\u0026rsquo;s effectiveness, particularly in mild and moderate conditions, where behavioral modifications may be more readily achieved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a comprehensive overview of the clinical profile, therapeutic management, and treatment outcomes of patients with bipolar disorder at a tertiary care center in South India. The findings contribute to existing knowledge by affirming known epidemiological patterns and emphasizing the real-world effectiveness of standard treatment protocols.\u003c/p\u003e\u003cp\u003eBD was observed more frequently among females (65%) than males (34%), aligning with recent Indian studies that suggest increased recognition of BD in women due to greater awareness and diagnostic sensitivity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The most affected age group was 29\u0026ndash;38 years (38%), which mirrors global reports of peak onset in early adulthood [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Marital status showed that 61% of patients were married\u0026mdash;this may reflect the influence of marital stress, interpersonal conflict, and psychosocial role burden on mood dysregulation, particularly in women [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, 61% of patients came from nuclear families, reinforcing literature that points to the role of family dynamics in the development and progression of mood disorders [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A family history of psychiatric illness was present in 70% of participants, predominantly involving mood disorders and substance use. This supports genetic studies highlighting bipolar disorder\u0026rsquo;s heritability [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Recent genome-wide association studies have identified susceptibility loci associated with BD subtypes and lithium responsiveness, underscoring the promise of precision psychiatry [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Statistically significant reductions in YMRS and HAM-D scores following treatment affirm the efficacy of guideline-based pharmacotherapy. Lithium, diazepam, and sodium valproate were the most prescribed agents, aligning with Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines recommending mood stabilizers for acute and maintenance phases of BD [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The YMRS assessment revealed the most notable improvements in mild and moderate cases, as evidenced by reduced median scores and narrower variability. Patients in the severe category showed more variable treatment responses, suggesting some may benefit from intensified or alternative therapies. Similarly, HAM-D assessments indicated stronger therapeutic effects in mild and moderate groups. Severe cases, however, showed only partial improvement and persistent depressive burden, emphasizing the need for multi-modal interventions.\u003c/p\u003e\u003cp\u003eSodium valproate, prescribed in 65% of cases, was comparably effective to lithium and more so than risperidone and carbamazepine for certain patients\u0026mdash;an observation supported by Indian cohort data and meta-analyses [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Second-generation antipsychotics such as olanzapine and risperidone were frequently integrated into combination therapy strategies, reflecting contemporary prescribing trends [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Medication adherence was initially noted in 69% of patients and improved significantly post-treatment, particularly in cases with mild symptoms. This finding aligns with prior retrospective studies on nonadherence in BD populations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our findings suggest that symptom control and behavioral interventions positively impact compliance. A concerning 51% of participants reported suicidal ideation, a figure consistent with global literature indicating heightened suicide risk in BD [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This underscores the importance of routine suicide risk assessment and integrated prevention strategies in care protocols. Emerging evidence highlights mitochondrial dysfunction, oxidative stress, and circadian rhythm disruptions as contributing factors to treatment resistance and BD progression [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These insights may pave the way for developing novel therapeutic targets beyond conventional psychotropics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study reinforces the importance of early diagnosis, individualized treatment regimens, and psychosocial support in optimizing outcomes for patients with bipolar disorder. Standard pharmacological therapy was effective in reducing both manic and depressive symptoms, particularly among patients with mild and moderate severity. Improved medication adherence was strongly associated with better clinical outcomes. The study also highlights the high prevalence of comorbidities and suicidal ideation, emphasizing the need for comprehensive and patient-centered care models. Continued research aimed at personalizing treatment strategies and addressing biological underpinnings will be key to improving long-term outcomes in bipolar disorder.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledged all the nursing staff and technical personnel of the Government Medical College Hospital, Tiruppur, Tamil Nadu, India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKrishna Kumar Dhakchinamoorthi and Sanjay Bose conceived the idea. Pavithra Krishna Moorthy, Ramanandha Mishra Annadurai, Yoshni Regunathan, and Yuvaraj Jaisankar collected the data. Krishna Kumar Dhakchinamoorthi and Sanjay Bose analysed the data. All the authors contributed in writing the manuscript, and all of them reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Ethics Committee of Government Medical College, Tiruppur (EC/ME/2022, dated July 26, 2022). Written informed consent to participate was taken from all participants and or their legal guardians. No human experiments were carried out during the study. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u0026nbsp; \u0026nbsp;NA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnderson IM, Haddad PM, Scott J (2012) Bipolar disorder. BMJ 345:e8508.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarton E, Murray G, Michalak EE, Law RW, Beaulieu S, Sharma V, et al. (2017) Quality of life in bipolar disorder. 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Br J Psychiatry 133:429\u0026thinsp;\u0026ndash;\u0026thinsp;35. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1192/bjp.133.5.429\u003c/span\u003e\u003cspan address=\"10.1192/bjp.133.5.429\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 728692.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBobo W.V., Angler\u0026oacute; G.C., Jenkins G., Hall-Flavin D.K., Weinshilboum R., Biernacka J.M., et al. (2016) Validation of the 17-item Hamilton Depression Rating Scale definition of response for adults with major depressive disorder using equipercentile linking to Clinical Global Impression scale ratings: analysis of Pharmacogenomic Research Network Antidepressant Medication Pharmacogenomic Study (PGRN-AMPS) data. Human Psychopharmacology 31(3), 185\u0026ndash;192.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSachs GS (2003) Decision tree for the treatment of bipolar disorder. J Clin Psychiatry 64 Suppl 8:35\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRepetti RL, Taylor SE, Seeman TE (2002) Risky families: family social environments and the mental and physical health of offspring. Psychol Bull 128(2):330\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNarayanan D, Jith A, Bansal R (2020) Nonadherence in bipolar disorder patients: a 14-year retrospective study. Indian J Psychiatry 62(3):290\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrivedi JK, Sareen H, Yadav VS, Rai SB (2013) Prescription pattern of mood stabilizers for bipolar disorder at a tertiary healthcare centre in North India. Indian J Psychiatry, 55(2):131\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvasthi A, Grover S, Aggarwal M (2010) Research on mood stabilizers in India. 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Nat Genet 55(1):35\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYatham LN, Kennedy SH, Parikh SV, Kupka R, Goodwin GM, Fagiolini A, et al. (2018) Canadian Network for Mood and Anxiety Treatments (CANMAT) and ISBD 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 20(2):97\u0026ndash;170.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaldessarini RJ, Vazquez GH, Tondo L, Pompili SV, Salvatore F, Pompili M (2022) Comparative efficacy of lithium and valproate in BD: a meta-analysis. CNS Drugs 36(2):123\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMalhi GS, Chandra PS, Berk M, Scott J, Castle DJ (2022) Real-world prescribing in BD: lessons from multisite studies. BJPsych Open 8(2):e48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDome P, Dobos E, Rihmer Z, Gonda X (2023) Suicide risk in bipolar disorder: clinical implications. Front Psychiatry 14:1122123.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJagannath A, Sundaram P, Nair K, Sinha R, Ramesh S (2023) Circadian disruption and BD: a mechanistic overview. Mol Psychiatry 28(4):1345\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bipolar Disorder, Pharmacotherapy, Symptom Severity, Medication Adherence, YMRS, HAM-D","lastPublishedDoi":"10.21203/rs.3.rs-7192695/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7192695/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBipolar disorder (BD) is a chronic psychiatric condition characterized by recurrent episodes of mania and depression, significantly impairing quality of life. Although pharmacological treatment remains central to management, data on prescribing patterns and clinical outcomes from Indian tertiary care centers are limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional observational study included one hundred patients diagnosed with BD according to the International Classification of Diseases (ICD) criteria. Symptom severity was evaluated using the Young Mania Rating Scale (YMRS) for mania and the Hamilton Depression Rating Scale (HAM-D) for depressive symptoms. Patients received individualized treatment regimens, including mood stabilizers, antipsychotics, and benzodiazepines. Pre- and post-treatment symptom scores were compared using paired t-tests. Medication adherence was evaluated using the chi-square test, with \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe majority of patients were female (65%), aged 29\u0026ndash;38 years (38%), and from semi-urban areas (68%). A family history of psychiatric illness was present in 70%, and 51% reported suicidal ideation. Post-treatment, YMRS and HAM-D scores showed significant reductions (mean difference: 5.14 and 3.15, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with higher treatment responsiveness observed in mild and moderate severity groups. Diazepam, trihexyphenidyl, haloperidol, lithium, and sodium valproate were the most commonly prescribed agents. Medication adherence improved significantly post-treatment (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), particularly among patients with mild symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eStandard pharmacological therapy effectively reduced manic and depressive symptoms in bipolar disorder. Improved adherence was linked to better clinical outcomes. Taken together, these findings underscore the importance of early diagnosis, individualized treatment, and comprehensive psychosocial support in optimizing BD management in tertiary care settings.\u003c/p\u003e","manuscriptTitle":"Real-World Evaluation of Treatment Response and Adherence in Bipolar Disorder: A Cross-Sectional Study from a Semi-Urban South Indian Tertiary Care Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 11:42:57","doi":"10.21203/rs.3.rs-7192695/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da8f5bc6-60a9-4405-871b-c2e222c5af00","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-27T14:38:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 11:42:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7192695","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7192695","identity":"rs-7192695","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}