All participants were evaluated for ICD-10 bipolar disorders using the MINI- International Neuropsychiatric Interview (MINI). Final diagnoses were made by two independent clinicians. The nature of the first episode of bipolar disorder was derived from patient history in the medical record, patient self-report, or family report. The first episode was often described in the medical record, though we would consult the patient or their relatives to better identify the first episode type if it was ambiguous in the chart. The general demographic data and disease clinical data were collected by questionnaire. In order to determine the state of disease including psychotic symptoms, all participants were measured by Bech-Rafaelsen mania rating scale (BRMS), the Hamilton depression scale 24-item version (HAMD-24) and the Positive and Negative Syndrome Scale (PANSS). These scores for a patient's current mental state were obtained primarily to establish that they met the study's selection criteria.

The BRMS was used to assess the severity of manic symptoms. A higher score correlates with greater symptom severity. The scores between 0 and 4 indicate no obvious manic symptoms, scores from 6 to 10 are mild manic symptoms, and scores ≥22 would be considered severe manic symptoms.

The HAM-D was used to assess the severity of depressive symptoms. Severe depression was marked by scores ≥35. The scores of mild or moderate depression were ≥20 but <35. Any patients with scores ≤ 7 were considered to have no depressive symptoms.

The PANSS is composed of seven items on the positive symptom scale, seven items of negative symptom scale and 16 items of general psychopathology. In this study, the positive symptom scale was used to assess whether the patients had psychotic symptoms and if so, these psychotic symptoms' severity. Data gathered from this assessment are applied to the PANSS ratings. Each of the 30 items is accompanied by a specific definition as well as detailed anchoring criteria for all seven rating points. These seven points represent increasing levels of psychopathology: 1-absent, 2-minimal, 3-mild, 4-moderate, 5-moderate severe, 6-severe, and 7-extreme.

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