The study aimed determine the prevalence and associated factors of absconding from the hospital following admission among individuals with BAD using a retrospective chart review of the inpatient from January 2018 to December 2021 at Mbarara Regional Referral psychiatry ward.

The prevalence of absconding across the entire study period was 7.8%, a percentage similar to that found among psychiatric patients of various diagnoses in South Africa of 7.83 [19]. However, the prevalence observed in this study was much lower than that of 45.4% seen among participants with BAD in a two months prospective study in India [16]. This difference could be due to the significant difference in the study duration, study design, study setting and probably because the study by Khisty et al. (2008) had a small overall sample size of participants with BAD of 63 [16]. Similarly, the prevalence observed in this study was lower than that of 21.4% among those with BAD in a one year prospective study in Iran [23]. This difference could also be due to the significant difference in the study duration, study design, study setting and probably because the study by Sheikhmoonesi et al. (2012) had a small overall sample size of participants with BAD of 12 [23].

The likelihood of absconding increased with having affective lability, a finding congruent with that of Andoh et al. (2004), who discovered that having a very labile mood is strong associated with absconding from mental health facilities [24]. Patients with affective lability are most likely have exaggerated impairments in inhibitory control due to exaggerated activation in several regions of the Prefrontal cortex (PFC) as well as the anterior cingulate gyrus and caudate by the over stimulated amygdala from excess serotonin to this region [25–27]. This makes them prone to making impulsive decisions such as absconding. Additionally, affective lability is associated with greater severity in the clinical expression of BAD with more frequent comorbidities of anxiety disorders and substance use disorders [28], that are likely to cause impairment in decision making. It is possible that patients with affective lability may abscond from hospitals due to other factors, including a lack of understanding of their condition, frustration with the hospital environment or treatment, or a desire to escape from the perceived constraints or structure of the hospital setting [18].

Comorbid use of cannabis among participants with BAD increased the likelihood of absconding. This finding was congruent with that by Wilkie et al. (2014) who reported that comorbid substance use almost triples the odds of absconding among forensic patients [29]. The explanation for this finding is most likely because substances like cannabis use causes brain atrophy impairing one’s cognition and executive functioning [30], worsening decision-making, increasing impulsive acts, and further complicating the course of BAD with a worsening prognosis [31]. In addition, the following reasons may lead to the increased likelihood of absconding of patients with BAD who use cannabis. (i) Lack of understanding: Some people may not fully understand the risks associated with using cannabis while receiving treatment for a mental health condition like bipolar disorder. They may feel that the cannabis is helping them feel better and are unaware of the potential negative effects on their treatment. (ii) Relief of symptoms: Cannabis can potentially help to reduce anxiety and improve mood [32–34], which may make someone feel better in the short term. This could lead them to believe that they no longer need treatment and they may abscond from the hospital. (iii) Difficulty with treatment: Being in a hospital can be overwhelming and stressful, particularly if someone is not used to being in a hospital setting [35]. This stress, combined with the symptoms of bipolar disorder, could make someone feel like they want to leave and find relief elsewhere, potentially leading to absconding. It is important to emphasize to patients not to use cannabis while receiving treatment for bipolar disorder, as it can interfere with the effectiveness of treatment and potentially worsen symptoms in the long term [36–38].

Having a current in-patient treatment with haloperidol was protective against absconding in participants with BAD. This finding is congruent with studies that point out the protective role of haloperidol in challenging behavior, an example of which is absconding, among mental illness patients [39, 40]. This is likely because manic symptoms of BAD, like excitation, irritability, and elevated mood, which are more likely to increase absconding tendencies, are possibly due to elevated levels of extracellular Dopamine (DA) in areas receiving dopaminergic innervation, with the consequent activation of DA receptors [41–43]. Haloperidol is a high-potent DA antagonist [44], alleviating manic symptoms of BAD. In addition, haloperidol, compared to other antipsychotics in the present study is associated with more extrapyramidal side effects associated with disturbances in mobility and motivation [45], which could interfere with the desire to abscond. However, the present study did not capture information regarding the dosage, route of administration, and frequent of use, that may influence the pharmacodynamics of the medications.

Psychotherapy was also protective against absconding. This finding is congruent with various studies that state the role of psychotherapy in alleviating absconding among those with mental illness [3, 46, 47]. This is likely because the first step of the intervention involving effective educational interventions of psychotherapy, like description of the problem to be treated, its causes if known, and the methods of intervention to be used to alleviate the problem, is a predictor of better outcomes of interventions for psychiatric disorders [48]. This can make them feel more in control of their lives and more able to cope with their challenges. Psychotherapy can also provide a safe and supportive environment where individuals can discuss their thoughts and feelings without fear of judgment [49, 50]. This can help them feel more connected and less isolated, which may reduce the likelihood of them wanting to leave treatment. In addition, psychotherapy can help individuals develop healthy coping skills and strategies for managing their symptoms [50, 51]. This can improve their overall well-being and reduce the need for hospitalization or other forms of treatment. It is important to note that psychotherapy is just one part of a comprehensive treatment plan for bipolar disorder and may be used in combination with medication and other therapies. With multiple factors involved in absconding, holistic modalities and care plans should be emphasized in dealing with absconding.