Dr-tony-mander.com.au

August 2009
Australian treatment guide
for consumers and carers


The Royal Australian and New Zealand College of Psychiatrists, 2009 Key points about bipolar disorder Compiled by The Royal Australian and New Zealand College of Psychiatrists (RANZCP), this information and advice is based on current medical knowledge and practice as at the date of publication. It is intended as a general guide only, and not as a substitute Treatment of mania and mixed episodes for individual medical advice. The RANZCP and its employees accept no responsibility for any consequences arising from relying upon the information contained in this Treatment of bipolar depression Prevention of further episodes The Royal Australian and New Zealand College of Psychiatrists Further treatment choices 309 La Trobe StreetMelbourne Victoria 3000 Appendix 1: Mental health care teams Appendix 2: Sources of information and support Telephone: (03) 9640 0646Facsimile: (03) 9642 5652 Appendix 3: Terminology and acronyms Email: ranzcp@ranzcp.org Appendix 4: Development of the guideline Acknowledgements Key points about bipolar disorder 1 Bipolar disorder is a disorder of mood, in which
a person has episodes of both elevated and
depressed mood.

2 These episodes of major change of mood are
associated with distress and impairment of
function.

3 If you think you or someone you care about
has bipolar disorder, check with your general
practitioner. A referral to a psychiatrist or
psychologist may be necessary.

4 Bipolar disorder is an illness for which there are
effective treatments.
5 Those with bipolar disorder and their families can
do positive things to reduce the impact of the
illness, even though the illness can interfere with
personal autonomy.

6 People with bipolar disorder can take control of
their illness by working with a multidisciplinary
team of doctors, psychologists and other health
professionals, and utilising the support of family
and friends.

This guide was written by consumers, carers and mental health professionals to answer the most common questions consumers and carers have about treatments for bipolar disorder and living with the condition. It is a research summary of what is known about bipolar disorder and its treatment. It is also an updated plain English version of the Australian and New Zealand Clinical Practice Guideline for the Treatment of Bipolar Disorder (RANZCP, 2003) written for mental The purpose of this guide is to provide consumers and carers with the information they need on the assessment, diagnosis and treatment of bipolar disorder. It is important that its recommendations are not taken as absolute. People with bipolar disorder and their carers should consult their mental health professionals before using information in The guide has been written in accordance with the National Health and Medical Research Council recommendations for the development of clinical treatment guidelines for consumers.
The guide covers the reasons why comprehensive assessment and diagnosis are so important. It then outlines treatments for the different phases of the illness: • acute treatment of mania and mixed episodes • acute treatment of depression • prevention of further episodes of mania and depression.
Consumers, their partners, family, friends and other carers can locate further information about bipolar disorder and sources of support in What is bipolar disorder? Recognising hypomania and mania Bipolar disorder is a mood disorder. It is characterised by periods (DSM-IV criteria) of mania or hypomania, depression and ‘mixed episodes' (a mixture Hypomania and mania are characterised by a distinct period of of manic and depressive symptoms). The illness is commonly abnormally and persistently elevated, expansive or irritable mood. Mania usually lasts at least one week and causes significant difficulties
• Bipolar I disorder – at least one lifetime manic episode in carrying out normal roles such as job or family responsibilities. • Bipolar II disorder – only periods of a major depression Hypomania usually lasts at least four days and does not cause
accompanied by at least one hypomanic (not manic) episode.
profound difficulties in job or family roles. During the period of mood disturbance, some of the following symptoms will be present to a Most people with bipolar disorder experience multiple episodes at significant degree: an average of one episode every two to three years, with each phase lasting about three to six months.
• inflated self-esteem or sense of grandiosity, often of a If a person has four or more episodes in a 12-month period, their • decreased need for sleep (e.g. feels rested after only a few hours condition is termed ‘rapid cycling' bipolar disorder.
• more talkative than usual, or pressure to keep talking • ‘flight of ideas' or subjective experience that thoughts are racing Do I have bipolar disorder?
• distractibility (i.e. attention too easily drawn to unimportant or The criteria for making a diagnosis of bipolar disorder, as
irrelevant external stimuli) defined by the Diagnostic and Statistical Manual (DSM) used by
• increase in goal-directed activity (either socially, at work or school, health care professionals, are:
or sexually; or a mental and physical restlessness) Bipolar I: occurrence over a lifetime of at least one manic
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business Bipolar II: one or more major depressive episodes accompanied
by at least one hypomanic episode (not manic episodes).
It is best to go to a general practitioner as early as
possible if you have, or someone you know has,
mood swings that concern you.

Recognising major depression Symptoms that may be concurrent with (DSM-IV criteria) People with major depression will experience some of the following People with bipolar disorder often have symptoms of other mental symptoms for at least two weeks. These symptoms represent a change health issues. These symptoms should be assessed as part of the from previous functioning and at least one of the symptoms is either comprehensive assessment and may need specific treatment, as they depressed mood or loss of interest or pleasure: do not always get better even if the bipolar disorder is well controlled.
• depressed mood as indicated by either subjective reports (e.g. Alcohol and drug use is very common among people with bipolar feels sad or empty) or observations made by others (e.g. appears disorder. They may consume alcohol or drugs to try to stop mood swings or to help cope with the impact of the mood swings on their • markedly diminished interest or pleasure in activities work and family life. Sometimes it can be difficult to distinguish • significant weight loss when not dieting, or weight gain, or between alcohol-related problems and bipolar symptoms.
decrease or increase in appetite Anxiety disorders also commonly co-occur with bipolar disorder. These • insomnia or excessive sleep include Generalised Anxiety Disorder (characterised by excessive worry • mental and physical slowing or restlessness about the future), Social Anxiety Disorder (excessive concern about • fatigue or loss of energy what others may think about you) and Panic Disorder (panic attacks). • feelings of worthlessness, or excessive or inappropriate guilt During severe episodes of mania and depression, a person may have • diminished ability to think or concentrate, or indecisiveness a psychotic experience such as hallucinations or delusions. Sometimes • recurrent thoughts of death (not just fear of dying), recurrent this can lead to an incorrect diagnosis of schizophrenia.
suicidal thoughts without a specific plan, or a suicide attempt, or a specific plan for committing suicide.
Recognising mixed episodes (DSM-IV criteria) People who have mixed episodes will experience symptoms of both mania and depression nearly every day for about one week.
Treatment of mania and Often the diagnosis is not clear at the first assessment. Sometimes this is because a person's symptoms overlap with other psychiatric conditions they may have (e.g. psychosis, schizophrenia or anxiety). For others, alcohol and drug use may distort or hide the symptoms of depression and mania.
Because there have been very few specific treatment studies on DSM-IV bipolar II disorder, our recommendations refer to bipolar There is no scan or blood test that can diagnose bipolar disorder. disorder generally. Most studies have either described a group of However, a doctor will often request some investigations to rule out people with bipolar I, or have not identified separate bipolar I and II physical diseases. Also, it is essential to know if a woman with bipolar subgroups. This guide discusses the initial clinical assessment, how disorder is pregnant.
bipolar disorder presents when people first experience it and the main During the comprehensive assessment (and during other assessments) treatment approaches including mood stabilising and anti-depressant the doctor or other health professional should assess any risk. A person with depression may have thoughts or plans of suicide. Mania sometimes leads to out-of-character and high-risk behaviour such as How can I be sure that I have sexual indiscretion, over-spending or other financial recklessness or bipolar disorder? uninhibited and inappropriate disruptive behaviour. This can damage a In order to diagnose bipolar disorder, a health practitioner must person's reputation and standing in the community.
undertake a detailed, comprehensive assessment. Referral to The doctor or health professional will also typically assess the person's a psychiatric service is usually needed. However, some general level of insight and judgement. Some people with mania do not practitioners have sufficient experience and expertise to assess, realise how unwell they are and lack insight into their condition. They diagnose and treat bipolar disorder. Psychologists can also assist may temporarily lose the capacity to judge appropriate behaviour. general practitioners in assessing and treating bipolar disorder.
Occasionally they may develop false beliefs such as ‘I am the saviour of During the assessment, you will typically be asked in detail about the the world'. This is called psychosis and is one of the signs of mania.
type of symptoms, their severity and how they affect your work and An assessment of risk and insight is necessary so that your safety and relationships. You will typically also be asked about previous episodes the safety of others can be assured and appropriate treatment given. of depression and mania/hypomania. With your permission, your Most people with bipolar disorder can have treatment without needing family or carer will be asked for their perspective. In mania it is often admission to hospital. If there are severe symptoms, major risk issues others who notice the symptoms most, whilst the person experiencing and limited insight, involuntary treatment may be necessary. the manic episode is usually unaware of the change in their behaviour. In contrast, a person with depression often tries to hide the symptoms – family and friends may not know the severity of the depression.
Initial management Second, an anti-psychotic or benzodiazepine (or a combination of these) is prescribed, to be taken as well as the mood stabiliser. These The charts on page 14 and 15 show the approach mental health medications calm or sedate the person with mania as a temporary professionals usually take in the initial management of a person procedure, until the mood stabiliser starts to help the person to who presents with acute mania. Although community or outpatient feel better.
treatment is always preferable, and admission with the patient's consent is sometimes possible, involuntary hospitalisation under the Research shows that lithium is effective as a mood stabiliser when relevant health legislation may be needed. Going to hospital can compared to placebo. Studies show that carbamazepine and valproate protect the person and their family from the damage that may result are of similar value to lithium, although there have been few trials, from the impaired judgement associated with the illness. The decision particularly for carbamazepine. Research also shows that the second- to go to hospital may be traumatic for the person with bipolar disorder generation anti-psychotic medications are also more effective and their family.
For lithium and sodium valproate, the therapeutic dosages for acute Acute treatment of manic episodes mania are reasonably well established. For carbamazepine, however, the dosage used is the same as the dosage for epilepsy (some people As insight can be affected by both depression and mania (more with epilepsy also take this medication). However, dosage is mainly commonly in mania than depression), often the person affected does determined by the assessment of your individual response to not see a need for treatment. This can mean disagreement over the the medication.
need for admission to hospital. Poor insight and judgement also lead to poor compliance with taking medication, and some people resort to It is important to discuss with your mental health
hiding their medication.
professional/s the risks you face if you do not get
This is not a wilful or defiant act, but is part of the impact of having treatment for bipolar disorder.
bipolar disorder. It can be a challenging time for family and carers, Timely treatment of mania can reduce disruption to
who can often see the benefits of medication. Sometimes it can take your career, the likelihood of relationship problems,
several episodes of illness before the person with bipolar disorder or risky financial mistakes being made during
agrees to take medication.
episodes of mania.
Medications are the main way of managing an acute manic episode. Treatment may also help to prevent self-harm and
The aim of the medications is to stabilise mood and stop all symptoms.
suicidal thinking as a result of mania or depression.
There are two components to managing acute mania with medication. First, a mood stabiliser is prescribed, such as lithium, sodium valproate, carbamazepine or one of the new second-generation anti-psychotics. Mood stabilisers act upon the elevated mood but take about one week to start to take effect for most people.
Initial clinical assessment hypomanic/manic episode
Treatment of a manic episode
INITIAL SCREENING ASSESSMENT • Severity of symptoms • Level of functional and cognitive impairment • Degree of insight • Presence/absence of psychosis • Risk to self (suicide, financial, sexual, reputation) or others (violence) • Extent of family support and/or community services TREATMENT CONSIDERATIONS Legal aspects (e.g. informed consent, mental capacity) Care in least restrictive environment ensuring safety (risk of self-harm) WITH OR WITHOUT
Additional treatments for other symptoms
• Contain aggressive/overactive/disturbed behaviour • Treat psychosis • Manage sleeping difficulties 1 Taken orally • Benzodiazepines (diazepam, clonazepam, lorazepam) • Anti-psychotics (such as risperidone, olanzapine, quetiapine, haloperidol) 2 Taken by injection (only use if oral administration is not possible, or is ineffective) • Benzodiazepines (midazolam i.m., diazepam i.v.) • Anti-psychotics (olanzapine i.m., haloperidol i.m., zuclopenthixol i.m.) physical complications could arise from its use in a particular patient's How are mixed episodes (mania, case. It has a variety of uses in the treatment of bipolar disorder and is depression) of bipolar disorder covered again in the guideline on depression.
It is a safe and painless procedure and can be life saving for severe There is some weak research evidence for the benefit of the depression. It is now administered to very specific target areas of the following treatments in mixed states of bipolar disorder: valproate, brain so that any side effects (such as short-term memory loss) are carbamazepine and all the second-generation anti-psychotics. Each state has legislation to ensure that ECT is only used safely and What if the manic episode does not respond to first-line treatment? Your doctor or health professional may decide to alter your treatment Failure of manic episode to respond to treatment
if you are not experiencing any or sufficient improvement in your symptoms. There are several options if you do not respond to the Optimize mood stabiliser (dose/blood levels) initial medication chosen. Your doctor may: • increase the dose and/or blood levels of the mood stabiliser Switch/substitute mood stabiliser • switch mood stabilisers • combine mood stabilisers Combine mood stabilisers • add an anti-psychotic.
If you and your doctor have tried these strategies, and you have taken Add an anti-psychotic medication the medication correctly, and you still have no relief from symptoms, electroconvulsive therapy (ECT) may be considered.
Continuing failure to respond What is electroconvulsive therapy (ECT)? 1. Re-evaluate diagnosis - consider alternate causes (other ECT is sometimes a life-saving treatment in severe cases where the psychoses such as schizophrenia; organic disorders) person with bipolar disorder has not responded to other treatment, 2. Electroconvulsive therapy but is rarely used in contemporary practice. Electroconvulsive therapy involves the use of electricity to stimulate the brain and is administered on an inpatient or day treatment basis by psychiatrists who are specially trained to administer it. It is a physical treatment and is only able to be conducted after ensuring that no What about ongoing treatment? Treatment of bipolar depression Following remission of an initial episode of mania, the mood stabiliser would typically be continued for at least six months. This is because experience with most patients shows that this is the best way to prevent another episode.
Assessment of bipolar depression In most cases, the benzodiazepine or anti-psychotic would be The treatment for bipolar depression is sometimes different to how withdrawn once the acute episode has resolved and only the mood people with depression, but without bipolar disorder, are treated for depressive symptoms. This section discusses assessment and management of episodes of bipolar disorder depression. For those people with a well-established history of bipolar disorder, there are several recommended criteria for deciding if you are likely to Your doctor or health professional would typically conduct a full benefit from ongoing medication treatment. Most of these guidelines psychiatric history, analysis of your mental state and a physical are based on a consensus of medical opinions and clinical wisdom, examination in order to: taking into account how often illness happens, its severity and the • confirm diagnosis level of disability that it causes.
• exclude underlying complications (such as the presence of Those medications that are effective in long-term treatment (either any other illness) alone or in combination) are: lithium, valproate, carbamazepine, • identify physical complications olanzapine and quetiapine.
• assess any risk of self-harm.
The reason for the assessment for risk of self-harm is that people with bipolar disorder have a higher rate of self-harm and suicide than the general population. This is usually due to depression, sometimes due to impulsivity, and at other times can result from accidents during periods of manic behaviour. Stopping medication too soon is a common cause of depressive relapse, so the assessment would typically involve a full medication history and review, and consultation with carers where appropriate. Acute treatment of bipolar depression If you are already on a mood stabiliser, your dose and/or blood levels should be optimised. If this is unsuccessful, your doctor may prescribe There are two options that work for most people: an anti-depressant, or a second mood stabiliser.
• a mood stabiliser (such as lithium, valproate, carbamazepine, There are many effective anti-depressant medications available. If you lamotrigine, olanzapine and quetiapine) and anti-depressant have had a previously effective and well-tolerated anti-depressant before, this would typically be used again.
• a mood stabiliser alone. Those with proven efficacy in bipolar Anti-depressant therapy on its own may induce mania or rapid
depression are lithium, olanzapine, quetiapine or lamotrigine.
cycling, and should therefore be avoided.
The preferred options for treatment are selective serotonin reuptake Initial clinical assessment of bipolar depressive
inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs such as venlafaxine, duloxetine or desvenlafaxine). Newer anti- depressants (mirtazapine or reboxetine) have not been well researched INITIAL SCREENING ASSESSMENT for the treatment of bipolar disorder, but may be reasonable second- • Severity of symptoms line choices, if the first-line treatment proves ineffective. Monoamine • Level of functional and cognitive impairment oxidase inhibitors (MAOIs) and tricyclic anti-depressants (TCAs) • Presence/absence of psychosis or any other mental illness should be considered a third-line treatment choice. Upon remission • Risk to self (suicide, financial, sexual, reputation) and/or or recovery of the episode, anti-depressants should be gradually others (violence) reduced so as to minimise the risk of switching moods while the mood • Consultation with carer(s) as above stabiliser is continued.
• Extent of family support and/or community services Failure to respond to treatment The chart on page 24 shows the treatment approach if your depressive TREATMENT CONSIDERATIONS episode does not respond to initial treatment.
Legal aspects (e.g. informed consent, mental capacity) Care in least restrictive environment ensuring safety (risk of First, it is important to be sure that your medication is at the right dosage and that it is being taken as prescribed. If there is still no improvement, other mood stabilisers or anti-depressants can be tried instead, on your doctor's advice. A number of mood stabiliser combinations can be attempted in conjunction with anti-depressants. However, if despite all reasonable efforts you remain depressed or only partially respond, it is important to re-evaluate the diagnosis and review your therapy. Organic causes need to be ruled out. Furthermore, the impact of any additional Barriers to taking medication
medical or psychiatric conditions should be thoroughly reassessed. • Doubt about the diagnosis, reluctance to accept the illness
Family circumstances, social networks, and carer circumstances should and willingness to risk another episode to confirm it.
be examined.
• Possible side effects, including weight gain.
Most experts agree that electroconvulsive therapy is the most effective • Possible enjoyment of the experience of mania and a wish to
anti-depressant therapy for bipolar depression. It should therefore be experience it again.
used when indicated and especially if it has been previously effective or there are psychotic symptoms.
• Not realising that mania and depression may involve
negative consequences for you or for others.
Finally, the psychosocial factors in your life need to be assessed, such as how much support you have, and whether or not your living • Concerns over pregnancy or interactions with medications
circumstances will promote your recovery. used for other health problems.
All medications cause side effects. These cause many people
Ongoing treatment to stop taking medications. It is important to discuss all side
If you are in remission from the depressive episode, your doctor effects you experience with your doctor. Including carers in
will usually withdraw anti-depressant treatment after two to three these discussions can be very helpful.
months to avoid causing mania and/or rapid cycling. However, in every individual, it is necessary to balance the need to treat bipolar depression versus the risk of precipitating mania. If you have recurrent depressive episodes, you can continue taking the anti-depressant along with a mood stabiliser.
Pharmacological intervention - depressive episode
Prevention of further episodes NEW DEPRESSIVE EPISODE Initiate and optimise mood stabiliser People with bipolar disorder have different patterns of illness. Because the Initiate and optimise mood stabiliser and anti-depressant concurrently illness is episodic (at least 90% who experience one episode go on to have more episodes), it can be very hard at times to tell when you are well, or to BREAKTHROUGH DEPRESSIVE EPISODE ON SINGLE MOOD STABILISER distinguish between symptoms and the normal emotional experiences of daily Check blood levels life. It can be hard to judge when to stop or when to continue treatment.
If you stop taking medication (thinking you are well) and you relapse, it does Blood levels below the not mean that your attempts to stay well are a complete failure. It is possible therapeutic range that the experience will help you in future to better recognise the warning Optimise mood stabiliser Adequate blood levels signs and to respond by initiating treatment again. This guide provides some strategies for minimising the possibility of a full relapse and aims to help Add anti-depressant or you monitor your treatment outcomes and to prevent new episodes. If you Add second mood stabiliser haven't already done so, consider involving your carer(s) in your treatment.
Failure of depressive episode to respond to treatment
Attitude to medication and coping with FAILURE TO RESPOND Deciding not to take your medication can lead to a relapse of mania or depression, which can result in severe social, financial and relationship loss.
Switch/substitute mood stabilisers There are many reasons why people do not take their medication. They may experience adverse side effects or lack of feelings of general health and wellbeing, successful social interaction and intellectual activity. People who manage to live well with bipolar disorder tend to agree that even when Continuing failure to respond treatment is seemingly effective, all other life issues must be taken into account. Your carer, friends and others may be able to help.
• Confirm correct diagnosis Weight gain is often a significant problem for people taking medication • Re-evaluate psychological/social factors responsible for for bipolar disorder. This is especially so for people taking lithium, sodium maintaining depression valproate or anti-psychotics. Managing diet and exercise can help lift • Consider additional psychological therapies depression and manage weight gain.
• Consult and involve carers when appropriate Not taking medication properly is the most common cause of relapse. How do I tell if I need long-term Your mental health professional should discuss with you how you manage your medication, and your attitude and response to it, to try to prevent the possibility of your symptoms recurring. Approaches Long-term treatment is often called the ‘maintenance' phase of treatment or ‘relapse prevention'. The goal of long-term treatment for bipolar disorder is to help you maintain a stable mood and to • providing you with education about the recurrent and prevent a relapse of mania or a depressive episode. Your GP or mental disabling nature of this condition and potential side effects of health professional would typically discuss with you, and your carer if appropriate, your pattern of illness and suggest what maintenance • providing methods by which you can manage or control the therapy is best for you.
side effects e.g. diet and exercise There is strong evidence from clinical trials of the long-term effectiveness • addressing the fear people with bipolar disorder often of lithium olanzapine and quetiapine (the latter only in combination have about the potential sudden loss of control of their with lithium or valproate) in treating the symptoms of bipolar disorder. behaviour and the embarrassing consequences (it is sometimes Lamotrigine is effective in preventing bipolar depressive episodes, though only after several episodes that many individuals come to accept it is only weakly effective in preventing mania. While there have been the diagnosis and need for ongoing medication or treatment) studies indicating that carbamazepine works to about the same extent as • helping you to locate support groups – these operate in most lithium, there have been no long-term studies of either carbamazepine parts of Australia and provide information about living with a or valproate confirming their superiority over placebo.
mood disorder (see Appendix 2).
If you are taking lithium, your kidney function, serum creatinine and electrolytes should be monitored every three to twelve months. Your Continuity of care thyroid function, including Thyroid-Stimulating Hormone (TSH) should be monitored every six to twelve months, in addition to clinical assessment.
The importance of continuity of care is an under-acknowledged issue in the long-term management of bipolar disorder. Ongoing contact If you suddenly stop taking lithium you are likely to experience a with the same mental health professional increases the likelihood relapse of mania (or, less likely, depression) within the next few months. of early identification of recurrences, and helps raise awareness of Therefore, if you are going to stop taking lithium, your intake should the impact of the illness. Unfortunately, mental health professionals gradually be reduced over at least one to two months.
change often. Research suggests that the best outcomes are achieved If you are taking carbamazepine and valproate, your blood levels and if you consult with the same mental health professionals who know liver function should be monitored at least every three to six months you well and know the pattern of your illness episodes. Your carer may after treatment has begun. If you are taking anti-psychotics, your also have much of this information and can assist.
glucose, cholesterol and triglyceride levels should be monitored regularly.
Failure to prevent recurrences of bipolar disorder
So far, research has not shown that any of the mood stabilizers are very • Exclude non-compliance effective in the treatment of rapid-cycling bipolar disorder. Valproate has • Treat any additional substance misuse• Exclude anti-depressant-induced affective instability been reported to be effective in some studies, but this finding is yet to • Exclude subclinical hypothyroidism be confirmed by further research.
• Trial alternative mood stabiliser alone or in combination with current mood stabiliser (strongest evidence is for lithium + valproate) Failure to prevent recurrences of bipolar disorder Relapse prevention plans and mental health care plans
There is some evidence that adding a second mood stabiliser enhances Relapses can be prevented and minimised for people with bipolar disorder. You long-term mood stability.
and your doctor and carer can develop a plan that can identify situations where relapse is likely, early signs to lookout for, what you can do to minimise your symptoms (e.g. limiting alcohol use or using extra medication) and who you can First, potential causes of rapid-cycling bipolar disorder should be excluded contact if you experience any symptoms. This plan should be in writing and your and managed. These may include substance misuse, anti-depressant family/carer and doctor and other health professional should have a copy. medications, and possible physical conditions such as hypothyroidism.
As several doctors and health professionals may be involved in your care, it is Medications for long-term treatment of
important to have a care plan. This can be co-ordinated through your GP who may refer you to a psychiatrist or psychologist.
Your care plan should cover:
• situations that are stressful and may cause symptoms (e.g. family
Christmas gatherings)
• what I can do to stay well (e.g. get at least 7 hours sleep at night, stop
drinking alcohol)
(in combination with lithium or valproate) • what signs might indicate that my depression or mania may be
recurring (e.g. arguing with my boss)
• what change I can make to my medication (e.g. increase my sedating
medication for the next week)
• who I can talk to (e.g. let my partner know)
• when I will contact my doctor/health care worker (e.g. phone my
(For prevention of bipolar depressive episodes in particular) doctor if symptoms last longer than two days)
Further treatment choices counselling to help you deal with these issues can reduce the impact of having bipolar disorder.
Developing a balanced lifestyle can also help you to minimise the risk of relapse. In particular, establishing a regular sleep pattern is very So far the guide has outlined the range of medications available important in helping you avoid further episodes.
for treating bipolar disorder that have been shown to be effective. Psychologists have an important role in all of these treatments. There are further treatment choices, such as psychological and They can also provide specific treatments for depression, including psychosocial therapies, which can be a valuable part of a treatment cognitive behavioural therapy or CBT (looking at how we think and plan. These therapies are most effective in preventing recurrences if what we do), which can ease depression. One aspect of this treatment you have treatment when you are not currently depressed or manic. involves identifying patterns of early warning signs and triggers that Psychological and psychosocial treatments work best when used in precede episodes, and developing strategies to minimise them. Some conjunction with medication. psychological treatments are now covered by Medicare (through the Better Access initiative). Interpersonal and social rhythms therapy What is the role of psychosocial focuses on the roles of relationship difficulties and changes in daily patterns for those with bipolar disorder.
In some other psychiatric illnesses, there is often an ‘either/or' choice If you have problems with substance abuse and anxiety disorders between taking a medication OR using a psychological treatment. as well as bipolar disorder, medications can help, but psychological However, in bipolar disorder medication remains essential rather than treatments, especially CBT, are the most effective. These therapies are optional. Psychological treatments are called ‘adjunctive', which means often undertaken with a psychologist.
that they are effective but should be used in addition to medications.
Learning to live with a continuous, episodic illness is a huge challenge The role of psychological treatments is to help you
for people with bipolar disorder and their families. Education about cope with the experience of bipolar disorder and its
the illness leads to better coping strategies and fewer relapses.
effects. Better outcomes can be achieved with these
additional therapies. Many other medical conditions

People with bipolar disorder often express embarrassment because can also improve with psychological treatment.
of the inappropriate behaviour, or sexual indiscretions, which might have happened when they were manic. Counselling about the trauma of embarrassing behaviour and coming to terms with the diagnosis is Repeated episodes of mania and depression tend to lead to greater risk of divorce and family breakdown, unemployment, a break in social networks and education, and financial difficulties. Support and Coping strategies Complementary (non-prescribed) People who are living with bipolar disorder tend to agree that there are several strategies that you can try to improve how you cope with Herbal remedies and other natural supplements have not been well the illness. These are: studied and their effects on bipolar disorder are not fully understood.
• being educated about how to identify the early signs and Omega-3 fatty acids (found in fish oil) are being studied to determine symptoms of either mania or depression their usefulness for long-term treatment of bipolar disorder, but the • encouraging family and friends to also be able to identify those results have been mixed.
St John's Wort (hypericum perforatum) is being studied as a treatment • staying in treatment and being aware of anything that may for depression, but there is some evidence that it can reduce the prevent you from taking your medication effectiveness of some medications (such as the oral contraceptive • remembering to focus upon the achievement of your goals, rather pill), can react with some prescribed anti-depressants, or may cause a than letting the illness take over your life switch into mania.
• keeping a mood diary to help you keep track of your treatment Pregnancy and breastfeeding progress and any side effects of any medications you are taking • using exercise, proper diet, vitamin supplements, yoga and The period following childbirth for all women is an extremely meditation to manage stress levels which can potentially trigger emotional period, but for women with bipolar disorder the risk of mania, depression or psychosis is particularly high. About 30% of women with pre-existing bipolar disorder will experience a manic or • keeping support around you from family and friends.
depressive episode following childbirth.
Support from family and friends is vitally important but it cannot During pregnancy and breastfeeding, the goal of treatment is to use always shield you from the effects of life stresses. Increased levels of the minimum effective dosage of medications and to limit the total support may be necessary if you have to cope with the death of a number of medications while sustaining the mother's mental health.
family member or close friend, loss of or interruption to your career, or experience psychological and social distress of other kinds. Ensuring adequate social, emotional and psychological support is also important.
How to improve the quality of your care
While types of support groups vary widely, this section looks at groups • Participate in active ways in your treatment
run by people who themselves have experienced bipolar disorder and planning.
its treatments.
• Write a relapse plan with your clinician.
There is now a growing awareness of the benefits of support groups for people with bipolar disorder. Being part of a support group can • Identify the symptoms or signs that precede an
help you recognise and satisfy your need for practical and experiential episode.
information about the illness, and the need to keep taking your • Discuss concerns about the quality of your care
medications. A support group can also help you cope with the with your doctor.
interpersonal difficulties you may experience with this condition.
• Raise suggestions for improvement with
A large survey of people with bipolar disorder by the United States management or with a consumer consultant in
National Depressive and Manic-Depressive Association found that the service.
95% stated that their participation in support groups had helped them • Participate in policy, advocacy and planning of
in communicating with their doctor, being motivated to follow medical mental health services through non-government
instructions, being willing to take medication, making the treatment agencies.
plan less complex, and/or making follow-up visits to their health • Give yourself permission to talk about your
feelings, your symptoms etc. with carers,
Such groups may also help people to cope with hospitalisation, friends and others. Don't forget: laughter is a
understanding mental health legislation and finding other important good medicine.
mental health information. Some provide support over the telephone For major complaints, each jurisdiction has a
and professional referral services.
confidential health care complaints tribunal through
Some groups also enable partners, relatives and friends to attend which complaints can be discussed and mediated.
groups with the person experiencing bipolar disorder. Separate groups for partners, relatives and friends are also available in Australia (see Appendix 2).
Speak with your case manager about how you can join the consumer workforce and network as a representative, advisor, consultant or advocate. This is a way of being actively involved in making a difference and learning at the same time about the many services and resources in the mental health sector.
Standards of care – what should I expect? • treatment provided in a particular setting (you may have a cultural preference for home or hospital treatment) People with any kind of mental illness should expect to be treated with courtesy and compassion by health professionals. There are published • special food or access to a prayer room if you need to go National Standards for Mental Health Services available in Australia which are a guide to what to expect from services.
• understanding of your family's expectations of treatment.
Currently, all public mental health services are aiming to achieve these It is very important to discuss cultural issues with your health care standards over time. There are some key ideas to keep in mind: provider to enable them to better understand you and so that your • Evidence-based treatments have the best chance of working if religious beliefs and cultural practices can be incorporated into your delivered by skilled staff who have up-to-date training.
treatment plan.
• You have a right to quality care and you also have a responsibility to work with your health professionals to get the What does treatment cost? best care outcomes.
It is important to discuss all potential costs involved in your treatment • There are complaints processes in mental health services that you with your health professional. can use if you are unhappy about the quality of your mental In Australia, some GPs bulk bill, which means that Medicare will health care.
cover the full cost of any visit. If your GP does not bulk bill, partial rebates are available through Medicare and you will need to pay any difference. There will also be an additional cost for any medication Health professionals should always respect and cater for the wide that may be prescribed. diversity of cultural groups in our community. Depending on your Your GP may refer you to appropriate services, such as for cultural background or religious beliefs, when you are seeking psychological services provided by a psychologist or an appropriately treatment, or helping a person you care for get treatment, you may trained social worker or occupational therapist. Any treatment have special requirements that you need to communicate to the health provided by these health professionals will only be rebated by professionals you encounter. You may need to request: Medicare if you have previously claimed a rebate for a GP Mental • a translator if your first language or that of the person you care Health Treatment Plan. A GP Mental Health Treatment Plan will be for is not English developed by your GP and tailored to your needs to find the treatment • explanations of medical or other terms that may not be clear that is right for you, monitor your progress and assist you in achieving your goals for recovery. • respect for your religious practices and understanding of the roles of males and females in your culture Medicare rebates are also available for assessment and treatment by a psychiatrist. A psychiatrist may also refer you for Medicare-subsidised treatment with a psychologist, an appropriately trained social worker or occupational therapist. You may receive up to 12 individual/and or group therapy sessions in a year. An additional six individual sessions may be available in exceptional circumstances. Your GP may also refer you to other government funded providers of psychological services depending on what is available in your Living with bipolar disorder This guide has covered what recent research and expert and consumer opinion tells us about living with bipolar disorder and its treatments according to each phase of illness.
People who manage their bipolar disorder well provide assurance and hope that living with it and achieving a good lifestyle is now possible. There are many examples of ordinary people and high-profile people successfully managing their condition and leading satisfying lives.
The wider community is now more aware and understanding of bipolar disorder, there is support and there are highly effective treatments now available. If you choose to, you can help spread this While there remains no cure, there is good reason to think that treatments will improve even further in the future. This guide has also discussed where research is limited or remains uncertain. Future research will aim to reduce the side effects of existing treatments and to develop better ones.
With treatment, and constant monitoring, it is
possible to achieve a good quality of life if you
have bipolar disorder.

Pharmacist - A person licensed to sell or dispense prescription drugs.
Psychiatric nurse - A person specially trained to provide promotion,
maintenance, and restoration of mental health, including crisis and case management. Nurses can administer medications but cannot prescribe Mental health care teams them, whereas other allied health professionals can neither prescribe nor administer medications.
Services provided to people with bipolar disorder and their families, if delivered through the public health system, may include a range Psychiatrist - A medical doctor who specialised in psychiatry. Psychiatry
of professionals at different stages of community or hospital-based is a branch of medicine that deals with the study, treatment and treatment. The psychiatrist or a ‘case manager' usually co-ordinates prevention of mental illness and the promotion of mental health. A care provided to you by this team. Consumer consultants may also be psychiatry registrar is a trainee psychiatrist.
employed to provide support and advocacy.
Psychologist - A person usually trained at a post-graduate level who
Case manager - The health care provider whom you see the most
works to apply psychological principles to the assessment, diagnosis, for your mental health care in the public mental health system. The prevention, reduction, and rehabilitation of mental distress, disability, case manager co-ordinates all your care with other members of the dysfunctional behaviour, and to improve mental and physical wellbeing.
team. They can be medical doctors, or allied health specialists such Social worker - A person with specialised training in individual and
as psychologists, social workers, occupational therapists or trained community work, group therapies, family and case work, advocacy mental health nurses. With your agreement, carers may also consult and the social consequences of disadvantage and disability, including case managers and vice versa.
mental disorders. They can provide psychosocial treatments for mental Crisis team member - Mental health professionals from a wide
disorders and assist with welfare needs such as finance, legal matters range of professions, who work in teams to provide assistance, during and accommodation.
periods of high stress, including after hours (sometimes called Crisis Assessment Team).
GP / General practitioner / Local doctor/ Family doctor -
Registered medical practitioners who have a general training in all areas of medicine, including psychiatry, and manage your general health care.
Occupational therapist (OT) - A person trained to provide therapy
through creative or functional activities that promote recovery and Lifeline Australia conducts a referral service for rural Australia, combining the databases of Mental Health Associations, Lifeline Centres, Kids Help Lines and mental health branches of State and Territory health departments.
Lifeline Australia
Sources of information and support For further information about this guideline and other Clinical
Kids Help Line
Practice Guidelines, see www.ranzcp.org.
Freecall: 1800 55 1800 The list of organisations and information sources provided in this National Organisations
Appendix, whilst not exhaustive, may further support you in learning beyondblue
about and managing bipolar disorder. Inclusion of these organisations Phone: (03) 9810 6100 and information sources does not imply RANZCP endorsement but rather aims to help people find information and to encourage communication about mental illness. SANE Australia
Phone: (03) 9682 5933 These organisations and resources are not intended as a replacement Email: info@sane.org for formal treatment but as an adjunct to it. If you are unsure about Helpline: 1800 187 263 any of the information you find or would like to know if a treatment Helpline email: helpline@sane.org you read about may be appropriate for you, you should speak with Website: www.sane.org your mental health care professional. Black Dog Institute
Many of the organisations that provide information and support for Phone: (02) 9382 4523 those with bipolar disorders and their carers are community-managed Email: blackdog@blackdog.org.au and not-for-profit associations. They provide support, information and referral services for health, housing, rehabilitation, employment, and legal or advocacy services. They may also assist partners, relatives Mental Illness Fellowship of Australia
and friends of people with bipolar disorder over the telephone, or in Phone: (03) 8486 4200 mutual support groups.
Helpline: (03) 8486 4222 Email: enquiries@mifellowship.org Try looking in the front pages of your telephone book for a mental health information and referral service in your State or Territory and for clinical mental health services in your area.
Mind Australia
Phone: (03) 9455 7900 Your GP may also know the local mental health service nearest to you.
Email: info@mindaustralia.org.au Multicultural Mental Health Australia
Western Australian Association for Mental Health
Phone: (02) 9840 3333 Phone: (08) 9420 7277 Email: admin@mmha.org.au Website: www.mmha.org.au Victoria Organisations
Carers Australia
Mental Illness Fellowship of Victoria
Phone: (02) 6122 9900 Phone: (03) 8486 4200 Email: caa@carersaustralia.com.au Helpline: (03) 8486 4265 Email: enquiries@mifellowship.org Queensland Organisations
Mental Health Association (QLD) Inc

New South Wales Organisations
Phone: (07) 3271 5544 Schizophrenia Fellowship of NSW
Phone: (02) 9879 2600 Email: admin@sfnsw.org.au Mental Illness Fellowship of North Queensland Inc
Phone: (07) 4725 3664 Email: fellowship@mifng.org.au Mental Health Association NSW Inc
Phone: 1300 794 991 / (02) 9399 6000 Email: info@mentalhealth.asn.au Mental Illness Fellowship of Queensland
Brisbane: Phone: (07) 3358 4424 South Australia Organisations
Email: admin@sfq.org.au Mental Illness Fellowship of South Australia
Phone: (08) 8221 5160 Gold Coast: Email: mifsa@mhrc.org.au Phone: (07) 5591 6490 Website: www.mifsa.org Email: sfbranch@bigpond.net.au Website: www.sfa.org.au ACT Organisations
Western Australia Organisations
Mental Illness Fellowship of ACT Inc
Phone: (02) 6205 1349 Mental Illness Fellowship of Western Australia
Email: admin@mifact.org.au Phone: (08) 9228 0200 Email: info@mifwa.org.au Mental Health Foundation ACT
Phone: (02) 6230 5789 Website: www.mhf.org.au Northern Territory Organisations
ARAFMI Western Australia
Mental Health Association of Central Australia
Perth: (08) 9427 7100 Phone: (08) 8950 4600 Rural Freecall: 1800 811 747 Email: info@mhaca.org.au Hillarys: (08) 9427 7100 Midland: (08) 9347 5741 Mandurah: (08) 9535 5844 Mental Health Carers NT
Broome: (08) 9194 2665 Phone: (08) 8948 2473 Canarvon: (08) 9941 2803 Associations for the Relatives and Friends of
ARAFMI Tasmania (Carer support)
the Mentally Ill (ARAFMI)
Phone (North): (03) 6331 4486 ARAFMI Australia Phone (South): 03) 6228 7448 Phone: (08) 9427 7100 Email (North): north@arafmitas.org.au Email: arafmi@arafmi.asn.au Email (South): south@arafmitas.org.au ARAFMI New South Wales
ARAFMI (Victoria)
Central Coast ARAFMI: (02) 4369 4233 Phone: (03) 9810 9300 ccarafmi@bigpond.net.au Carer Helpline: 1300 550 265 ARAFMI Illawarra: (02) 4254 1699 ARAFMI Hunter: (02) 4961 6717 ARAFMI North Ryde: (02) 4961 6717 Support: 1800 655 198 (NSW rural); (02) 9332 0700 (Sydney) Website: www.arafmi.org ARAFMI Queensland
Phone: (07) 3254 1881 Email: info@arafmiqld.org NATIONAL, STATE AND TERRITORY
What is the website
useful for?
What is the website
useful for?

Website on general depression, anxiety and bipolar disorder.
Website for young people dealing with mental beyondblue's youth illness in their family.
website providing depression and anxiety.
Information regarding depression and bipolar bipolar disorder in children and adolescents Information and online forums with 24 hour peer Information for those support and moderation with depression and for people living with Information on postnatal Information and advice regarding mental health problems and where young people can find Information on general help and support.
mental health including factsheets; also includes Information on general an online helpline.
Youth information portal on mental health.
Hypomania - Periods of pathologically elevated mood without
delusions. This is quite different to normal enthusiasm.
Inflated self-esteem or ‘grandiose ideas'
- During mania, a person may experience or think of themself as being more capable, energetic Terminology and acronyms and competent in activities than they do normally, or competent or Common terms
superior in areas which they consider themselves not to be particularly skilled at when they are well. Others would not see them as being Some of the words or expressions that describe symptoms or this capable in a particular area, so the inflated self-esteem is out of treatment processes may require further explanation. The symptoms proportion to reality and is potentially socially embarrassing.
of mania and depression are particularly hard to describe and they Mania - Periods of pathologically elevated mood leading to change in
have been further explained here so that you may see if they relate to functioning, sometimes associated with transient psychotic periods.
you, or, if you are a carer, to the person you are concerned about. The different mental health professionals and their roles are also defined.
Pressure of speech or to keep talking - A compulsion in which
the person may, or may not be aware they are talking too much, but Deliberate self-harm - An act intended to cause injury or self-
feels unable to slow or stop speaking, even though it is not socially poisoning, to relieve distress, and sometimes to cause death. It can be appropriate to be so outspoken.
used to try to cope with a mental illness or stress of some kind but is ineffective and detrimental. An RANZCP Self-Harm guideline exists for Psychosis - Loss of touch with reality, characterised by delusions (fixed
those who have self-harmed. false beliefs) and/or hallucinations (a false or distorted perception) of objects or events, including sensations of sight, sound, taste, touch Depression - A mood disorder ranging from passing sad moods to a
and smell, typically with a powerful sense of their reality. Psychosis can serious disabling illness requiring medical and psychological treatment. be experienced as part of mania or as part of psychotic depression and Major depression is a ‘whole body' disorder impacting on emotions is treatable with anti-psychotic medications.
(feelings of guilt and hopelessness or loss of pleasure in once enjoyed activities), thinking (persistent thoughts of death or suicide, difficulty Psychotherapy/Psychological intervention - A form of treatment
concentrating or making decisions), behaviour (changes in sleep for mental disorders based primarily on verbal communication patterns, appetite, or weight), and even physical wellbeing (persistent between the patient and a mental health professional, often combined symptoms such as headaches or digestive disorders that do not with prescribed medications. Psychotherapy can be conducted in respond to treatment).
individual sessions or in a group.
Flight of ideas - The experience of ideas entering the mind at a very
Symptom - A feeling or specific sign of discomfort or indication
rapid pace. The thoughts may be positive or negative, but their pace is such that few make much sense or can be reasonably acted upon.
Crisis Assessment Team Cognitive Behavioural Therapy Diagnostic and Statistical Manual Development of the guideline This guide is a research-based clinical practice guideline based on a thorough review of the medical and related literature. It was written in association with people who have bipolar disorder and those working General Practitioner Interpersonal and Social Rhythm Therapy In 2009, the content of this guide was revised and expanded by an MAOI Monoamine Oxidase Inhibitor
expert advisory panel comprising mental health professionals, and consumer and carer representatives. The purpose of the revision was Selective Serotonin Reuptake Inhibitor to ensure the information contained in the booklet was current and comprehensive in terms of treatment best-practice and therefore Thyroid-Stimulating Hormone remained relevant for people with bipolar disorder and their carers, families, and friends. Quality statement The authors of the original edition, and their affiliations at the The original edition of this guide was consulted upon bi-nationally and drafts were available for comment on www.ranzcp.org. It was Philip Mitchell - Chair, Clinical Practice Guideline Development Team,
appraised using DISCERN by a national workshop of consumer Scientia Professor of Psychiatry, School of Psychiatry, University of New consultants, and meets NHMRC criteria for presenting information South Wales, Prince of Wales Hospital, Randwick, NSW.
on treatments for consumers. The 2009 revision sought to maintain the integrity of this process by incorporating updated information Gin Malhi - Senior Lecturer, School of Psychiatry, University of New
supported by research findings published in recent medical and other South Wales, Prince of Wales Hospital, Randwick, NSW.
Bernette Redwood - Research Officer, Clinical Practice Guideline
Development Team, Prince of Wales Hospital, Randwick, NSW.
Jillian Ball Research - Psychologist, Prince of Wales Hospital,
Randwick, NSW.
The original edition was funded by Australia's National Mental Health Strategy and New Zealand's Ministry of Health.
The expert advisory panel for the 2009 revision comprised: Philip Mitchell - Chair, Scientia Professor and Head, School of
Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick, NSW.
Anne Camac - Psychiatrist at St George Hospital, Sydney and Conjoint
Lecturer at University of New South Wales.
Diahann Lombardozzi - Multicultural Mental Health Australia
(MMHA) consumer advocate and national reference group member.
Eugene Schlusser - Filmmaker/carer with diverse experience of
mental illness.
The original edition of this booklet was edited by Jonine Penrose-Wall, Consultant Editorial Manager, RANZCP Clinical Practice Guideline (CPG) Program.
The authors acknowledge the following people for their contribution to this guide: Ms Yvette Cotton, Mr George Dibley, Ms Sharon Kohn, Ms Larissa Mariner, Mr Michael Martin, Ms Jan Monson, Ms Anna Saminsky and Ms Penny Mitchell.
This guide was commissioned by the Royal Australian and New Zealand College of Psychiatrists and was funded by Australia's National Mental Health Strategy, via the Commonwealth Department of Health The authors used research that was developed with input by the wider Clinical Practice Guideline team that developed the guideline for use by professionals. Members of that team other than the authors included: Associate Professor Meg Smith - School of Applied Social and
Human Sciences, University of Western Sydney, Australia.
Dr Bronwyn Gould - General Practitioner.
Professor Peter Joyce - Head, Department of Psychological Medicine,
University of Otago, Christchurch, New Zealand.
Professor Ken Kirkby - Head, Department of Psychiatry, University of
Tasmania, Hobart, Australia.
The RANZCP drew on material published by the Medical Practitioner's Board of Victoria and the American Psychiatric Association in preparing this brochure. The 2009 revision of this booklet was undertaken with funding provided by the Commonwealth Department of Health and Ageing.

Source: http://www.dr-tony-mander.com.au/downloads/1537251/AUS_Bipolar_disorder.pdf

Royal district nursing service

DIVERSITY FRAMEWORK Policy, Planning and Practice 2012 - 2017 A strategy to meet the needs of clients and carers with diverse needs and from diverse backgrounds Home and Community Care (HACC) services provided by RDNS are jointly funded by the Victorian and Australian Governments. Name of publication: Diversity Framework: Policy, Planning and Practice 2012-2017