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First published in Bipolar Life's newsletter in December 2019
Though bipolar disorder affects the same number of men as women , there are differences in how it manifests. This may be due to the combination of hormonal changes throughout a woman’s life which can affect both the condition itself and its treatment. We will look at the following factors, including onset of puberty, premenstrual mood changes, pregnancy, postpartum and menopause.
Women may be more likely to experience depression than mania 
Interestingly, it is a hotly debated discussion amongst experts about whether bipolar disorder in children under 12 years can be confidently diagnosed, for several reasons outside the scope of this article .
Premenstrual syndrome (PMS)
Premenstrual syndrome (PMS) is seen in up to about one in three women. It usually begins 4-10 days before a period and settles soon after bleeding starts. The symptoms can be physical, such as bloating and breast soreness, or mental such as mood changes – for example low mood, anxiety and irritability.
Around 3-8% of women with PMS have symptoms that include more severe levels of emotional distress .
A study of almost 300 women  suggested that women with bipolar disorder who experienced premenstrual exacerbation of their mental health tended to have:
Fortunately, some research reports that women whose bipolar disorder is treated optimally will have less mood fluctuation through their menstrual cycle .
As with any woman who does not wish to become pregnant, family planning is relevant to those with bipolar disorder. Part of the reason is that an unexpected pregnancy can have its challenges with symptoms such as mood worsening, but also because some medications are risky to an unborn baby.
The other thing to know is that some contraceptives don’t work well with some bipolar medications. For instance, carbamazepine can stop the combined oral contraceptive pill working properly.
For women who do not wish, or are unable to use contraception, there are options for bipolar maintenance treatment that would be relatively safe in the case of a planned or unplanned pregnancy.
If you have some questions about these issues, it’s an invaluable conversation to have with your doctor.
Pregnancy: Are there known factors that might increase risk of relapse?
Here are some factors which may be associated with relapse during pregnancy :
●Shorter period of being mentally stable before conception
●Stopping bipolar medications six months prior to, and 12 weeks after, conception
●Current additional mental health problems (this could mean alcohol or drug misuse, eating disorders etc.)
●Having had bipolar disorder for more than five years
●Having had at least one recurrent mood episode each year after onset of bipolar disorder
Pregnancy: What do we know about medication during pregnancy and breastfeeding?
Because of the ethical implications in research, including the testing of drugs for their efficacy and safety in pregnancy and breastfeeding, we have a more limited range of medication options during these times. Some medications that are considered safe in pregnancy are not recommended in breastfeeding, and vice versa. Certain medications such as sodium valproate and carbamazepine, for example, are not recommended in pregnancy.
A woman’s psychiatrist, obstetrician and GP might collaborate to ensure the best way to manage things for mother and baby. Medication advice depends on balancing factors such as whether the woman is stable, her past history of episodes, whether she is already on medications and whether she is/plans to be breastfeeding.
There is a risk of stopping medications in a woman whose bipolar is stable but is planning, or is already, pregnant. The change in drug regime along with the hormonal changes and new stressors around in preparing for a new baby can also sometimes cause negative changes in mental health .
On the other hand, some women will experience fewer recurrences during pregnancy .
A small study followed 89 women who stopped their bipolar medications for six months before, and 12 weeks after conception. The researchers found that:
What happens if there is a relapse?
Between one-quarter and one-half of women may experience a mood episode in the six weeks after delivery. This might be due to hormone changes, disturbed sleep and/or increased stress .
Hormonal changes can cause mood and behavioural fluctuations that may be hard to distinguish from “baby blues” or just the joy of welcoming a new baby into the family. A mood diary and regular check-ins with her partner might help a new mother with monitoring for significant changes more objectively.
It may be beneficial for the woman to have a plan drawn up before pregnancy, listing support persons such as her partner, friends and family, doctors etc. so that any early warning signs can trigger a set of practical actions including urgent medical review.
Ideally the woman would be able to be with her baby should she experience a relapse, and if hospital admission is needed then a mother and baby unit is ideal. Prolonged separation from her infant should be avoided so as not to affect the forming maternal-baby bond. We must also not forget to offer support to the woman’s partner too .
There is some interest in whether menopause increases risk of depression in women with bipolar disorder. Several sources suggest that menopause does exacerbate bipolar disorder [3, 9]
Although nearly one in five women report severe emotional disturbances during the transition into menopause , more research is needed to confirm these findings and to further guide clinicians on medical management during perimenopause.
Disclaimer: this content is not a substitute for individual medical advice.
1. UpToDate. 2019. Bipolar disorder in adults: Epidemiology and pathogenesis. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-adults-epidemiology-and-pathogenesis?search=bipolar%20epidemiology&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. [Accessed 9 December 2019].
2. WebMD. 2019. Women With Bipolar Disorder. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-women#1. [Accessed 9 December 2019].
3. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.
4. Jean Hailes. 2018. Premenstrual syndrome (PMS). [ONLINE] Available at: https://jeanhailes.org.au/health-a-z/periods/premenstrual-syndrome-pms. [Accessed 9 December 2019].
5. Dias, R., 2011. Longitudinal follow-up of bipolar disorder in women with premenstrual exacerbation: findings from STEP-BD. The American Journal of Psychiatry, [Online]. 168(4), 386-94. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21324951 [Accessed 9 December 2019].
6. UpToDate. 2019. Bipolar disorder in women: Contraception and preconception assessment and counseling. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-women-contraception-and-preconception-assessment-and-counseling?search=bipolar%20and%20women&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5. [Accessed 9 December 2019].
7. Pipich, M, 2018. Owning Bipolar, How Patients and Families Can Take Control of Bipolar Disorder. Citadel Press.
8. UpToDate. 2019. Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-postpartum-women-epidemiology-clinical-features-assessment-and-diagnosis?search=bipolar%20and%20women§ionRank=3&usage_type=default&anchor=H86457796&source=machineLearning&selectedTitle=6~150&display_rank=6#H86457796]. [Accessed 9 December 2019].
9. SANE. 2017. Does menopause affect mental health?. [ONLINE] Available at: https://www.sane.org/information-stories/the-sane-blog/wellbeing/does-menopause-affect-mental-health. [Accessed 9 December 2019].
10. Boyce, P., 2016. Management of bipolar disorder over the perinatal period. Australian Family Physician, [Online]. 45(12), Boyce. Available at: https://www.racgp.org.au/afp/2016/december/management-of-bipolar-disorder-over-the-perinatal-period/ [Accessed 13 December 2019].
First published on Hepatitis Australia's website in December 2019.
If you’ve been told that you are “just a healthy carrier”, read on for a myth-busting update.
Acute versus chronic
When a person is first infected with the hepatitis B virus, it’s called an acute infection. If that person cannot get rid of the infection after six months, then this becomes a chronic infection, which is lifelong .
In the past, people who seemed well despite chronic infection were labelled “healthy carriers”. However, this term is inaccurate as people with chronic hepatitis B:
• risk transmitting hepatitis B to others such as close contacts, sexual partners and unborn babies.
• have nearly a one in four risk of dying from cirrhosis, liver cancer or liver failure .
Where did the term “healthy carrier” come from?
The term “carriers” was initially used to identify people found to have the hepatitis B virus in their bloodstream for six months. However, these “carriers” varied widely. Some were highly contagious, some had no symptoms, and some had significant liver disease.
In simple terms, we didn’t understand the hepatitis B virus very well.
This led to many people being told by doctors that they were “just healthy carriers” and that they needed no follow up. Others were told their infection had “resolved” or was “inactive”, without being warned that it may reactivate, even without symptoms .
Why we should stop using the term “healthy carrier
Some people still use this term even though it is unhelpful. Here are some possible consequences:
• People may miss out on receiving proper healthcare if they hold a false belief that they are healthy.
• People who describe themselves as healthy carriers may feel they are less likely to experience stigma and discrimination  than those who say they have chronic hepatitis B virus. Unfortunately, this can actually increase stigma surrounding the condition by making it more hidden. You may like to read more about your rights and responsibilities on this page, or by phoning the Hepatitis Infoline.
• Using the term “healthy carriers” might falsely imply that there are additional ways of passing on the virus as well as the usual transmission routes, or that healthy carriers are unlikely to transmit the infection to others.
What we know now
The reason people with chronic hepatitis B vary widely is that hepatitis B has four identifiable phases :
• Silent (Immune tolerance - phase 1): Hepatitis B virus is replicating but there is no active liver damage.
• Damage (Immune clearance – phase 2): Hepatitis B virus is attacking the immune system and the immune system is fighting back. Liver is getting damaged.
• Control (immune control – phase 3): Immune system has virus under control and there is no further liver damage.
• Escape (immune escape – phase 4): Virus is active again and liver is being damaged.
Your doctor can order tests* to see which phase your hepatitis B is in, and therefore what screening and/or treatment would be best. You should visit your doctor for liver check-ups every six months longterm to reduce the risk of liver damage.
Screening may comprise blood tests, or scans such as liver ultrasound and ultrasound elastography (commonly known as Fibroscan®).
Treatment may be anti-viral replication medication, or interferons to stimulate immune control  – as well as other actions like having a healthy lifestyle .
Living with hepatitis
The goal of screening and treatment is to prevent, stop or even reverse the effects of hepatitis B on your liver .
Screening is important for those felt to be at higher risk groups, such as Asian men over 40, Asian women over 50, and Aboriginal and Torres Straits Islanders over 50. One study found that more than one-third of people with chronic hepatitis B lived much longer if they had six-monthly screening, compared to no screening .
In general, treatment is recommended to people whose hepatitis B is in the Damage (phase 2) and Escape (phase 4) phases, and all those with cirrhosis which is a severe form of liver scarring .
International research shows that appropriate treatment for chronic hepatitis B can reduce the risk of liver cancer by up to 75%, or three-quarters . Treatment also reduces risk of transmission to others, and most importantly, gives you the best chance to live a long and healthy life.
You can find out more about testing, monitoring and treatment here.
1. Hepatitis B Foundation. 2019. Acute vs. Chronic Infection. [ONLINE] Available at: https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/acute-vs-chronic/. [Accessed 3 October 2019].
2. Australasian Society for HIV Medicine. 2019. Prevalence and epidemiology of hepatitis B. [ONLINE] Available at: http://22.214.171.124/prevalence-and-epidemiology-of-hepatitis-b/. [Accessed 3 October 2019].
3. Hoofnagle, J., 1987. Chronic Type B Hepatitis and the “Healthy” HBsAg Carrier State. Hepatology, [Online]. 7/4, 758-763. Available at: https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.1840070424 [Accessed 3 October 2019].
4. Ellard, J., 2013. Stigma, Discrimination and Hepatitis B - A review of current research. Australian Research Centre in Sex, Health & Society (ARCSHS), [Online]. Available at: https://siren.org.au/wp-content/uploads/2016/08/Stigma-Discrimination-and-Hepatitis-B-A-review-of-current-research.pdf [Accessed 18 November 2019].
5. Chronic Hepatitis B: Phases (2018). [ebook] Available at: https://www.hepqld.asn.au/wp-content/uploads/2018/06/FACTSHEET_-_Chronic_Hepatitis_B_Phases-1.pdf [Accessed 13 Nov. 2019].
6. Zhang, B., 2004. Randomized controlled trial of screening for hepatocellular carcinoma. Journal of Cancer Research and Clinical Oncology, [Online]. 130(7), 417-22. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15042359 [Accessed 21 November 2019].
7. Australasian Society for HIV Medicine. 2018. Treatment of chronic hepatitis B virus infection. [ONLINE] Available at: http://126.96.36.199/treatment-of-chronic-hepatitis-b-virus-infection/. [Accessed 3 October 2019].
8. Cancer Council Victoria. N.D. Hepatitis and liver cancer. [ONLINE] Available at: https://www.cancervic.org.au/for-health-professionals/community-health-professionals/hepatitis-b-and-liver-cancer. [Accessed 3 October 2019].
First published in Bipolar Life's newsletter in November 2019
Do you already use supplements, or are you thinking of trying some for your bipolar disorder?
A study in the USA found that one in five people with bipolar used a supplement long term. The most commonly taken supplements were fish oil, B vitamins, melatonin and multivitamins.
Even with such popular usage and marketing messages like “safe” and “natural”, one should bear in mind that many supplements:
Because the amount of information can be quite confusing, in this article we’ll try to summarise current knowledge. You can read all the way through or just skip to the section that most interests you. Abbreviations are expanded in the footnotes.
As an aside, diet and supplements are not recommended as replacements for medication. However, there is hope that in the future, individual dosing could be used to minimise or possibly eliminate medication, according to Dr William Walsh, scientist and expert in nutritional medicine of the Walsh Research Institute.
Omega-3 fatty acids
Omega-3 fatty acids are nutrients that are naturally occurring and found in the form of EPA and DHA in foods like salmon, tuna, sardines, free-range chicken and omega-3 fortified eggs. A third form of omega-3 called ALA is found in dark green leafy vegetables like spinach, walnuts, flaxseeds and soybean.
Only small amount of dietary ALA can be converted into useful EPA and DHA. It is thought most people in the United States get enough ALA from the foods they eat, as well as small amounts of EPA and DHA.
Some research suggests that there is body inflammation in acute mania, and to a lesser extent, in bipolar depression. It is possible that omega-3 fatty acids may reduce inflammation in the nervous system.
However, though there are conflicting studies on whether omega-3 helps treat or prevent episodes of mania or depression, Dr. Jeffrey Rakofsky (Assistant Professor in the Mood and Anxiety Disorders Program at Emory University School of Medicine in Atlanta, Georgia, USA) and Dr. Boadie Dunlop (Director of the Mood and Anxiety Disorders Program at Emory University) reviewed data from multiple trials and felt there was reasonably strong evidence compared to other supplements for bipolar depression.
Dr. Candida Fink, an experienced psychiatrist in New York (who co-authored a book for patients along with John Kraynak, who has lived experience of bipolar disorder) writes that most doctors would suggest 1-2 grams daily EPA for antidepressant effect.
SAMe is found in the body and is made from methionine, an amino acid found in foods. It has been widely studied in people with unipolar depression and bipolar disorder.
It has been advised that SAMe should not be taken for bipolar depressive symptoms as SAMe may induce or worsen symptoms of mania. There is also concern that SAMe may interact with other supplements and medications by increasing levels of serotonin (a chemical produced by nerve cells), such as antidepressants, L-tryptophan, and St. John’s wort.
Dr William Walsh even states that some people with bipolar disorder could already have excessive SAMe in their bodies.
St. John’s Wort
This yellow flower has been used as a medicine since ancient times as “the devil’s scourge” to ward off evil spirits. It was popular in the early 2000’s but popularity has waned due to concerns about lack of efficacy and risk of interaction with other medications e.g. may reduce benzodiazepine effectiveness.
Although many studies suggest St. John’s Wort can help treat mild-moderate unipolar depression, there doesn’t seem to be any strong evidence for treatment of bipolar depression. It is also risky to take along with other antidepressants due to the possibility of developing serotonin syndrome (this can cause tremor, diarrhoea and confusion) or triggering mania[1O].
Melatonin is produced by the brain in reaction to the amount of ambient light, and thus helps us regulate our circadian rhythm. In turn, it is possible that the body rhythm helps regulate mood and vice versa.
In people with mania, some studies suggest there is an early rise of lower melatonin levels, compared to healthy people and those with unipolar depression.
Early research shows that taking melatonin at bedtime increases sleep duration and reduces manic symptoms in people with bipolar disorder who also have insomnia. But there is also a risk that taking melatonin might make symptoms worse in some people with bipolar disorder.
For now, there is a lack of clear consensus on whether melatonin is helpful in bipolar disorder.
Coenzyme Q10 - This vitamin-like substance is found in the body, and in small amounts in meats and seafood. It is commonly used for heart health. Early research shows that taking coenzyme Q10 may improve symptoms of depression in people over 55 years of age with bipolar disorder, but more research is needed.
5-HTP – This substance is produced by the body and present in the seeds of an African plant called Griffonia simplicifolia. It increases serotonin production which itself affects mood, sleep and other body functions. There is a little evidence it can help with depression, anxiety and sleep, but just as with St. John’s Wort, if taken along with other antidepressants there is a risk of developing serotonin syndrome[8,14].
GABA – Made by the brain, GABA is thought to help anxiety and mood by blocking brain signals. However, there is little evidence to confirm its efficacy for mood and anxiety, nor consensus on safe dosage.
Inositil[7,8] – Mood stabilising medication like lithium and valproate are thought to work by stabilising the vitamin-like inositol’s signals within cells. Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop found just one study that showed possibly efficacy. There is also a risk of triggering mania.
Kava – Part of the pepper family, this herb is native to islands in the South Pacific. Many people take this for anxiety. There are mixed conclusions about efficacy, and it has been linked to severe liver injury, especially if combined with alcohol.
NAC – this substance is used by the body to make antioxidants (such as glutathione) that help the body’s cells recover from stress and damage. A group of researchers reviewed multiple studies and could not advise NAC as a safe, effective treatment for bipolar disorder.
Valerian - this has a distinctive odour and is extracted from a plant native to Europe and Asia. Out of 250 species V. officinalis is most commonly used. A review of nine trials was inconclusive for valerian’s sleep benefits. It can interact with benzodiazepines and other supplements such as St. John’s wort, kava, and melatonin.
Vitamins and minerals
Vitamins B1, B6, B12 – there is a lack of good evidence to say these help people with bipolar disorder.
Vitamin D – some studies show a link between depression and low vitamin D. However, but there is insufficient evidence to recommend it for bipolar depression.
Folic acid – also known as vitamin B9 and found in the form L-methylfolate, it has been shown in some studies to enhance antidepressant response in people with unipolar depression;19]. However, in a review, Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop did not find good supporting data for folic acid in bipolar depression treatment.
Although taking folic acid does not appear to improve the antidepressant effects of lithium in people with bipolar disorder, WebMD suggests that taking folate with the medication valproate may improve the effects of valproate.
Dr Walsh comments that people with bipolar disorder may have folate under- or overload, so individual tailoring of folate supplementation may be beneficial.
Zinc – In earlier studies, lower blood levels of zinc were linked to depression. However, evidence seems to be pointing towards a use only in unipolar depression by increasing the efficacy of antidepressant therapy.
Magnesium – A 1990 study of rapid cycling bipolar patients suggested that taking magnesium might have had an effect as strong as lithium in about half the people. Another study in 2000 suggested that taking magnesium with the drug verapamil reduced manic symptoms better than verapamil alone. More studies are needed.
In short, with this array of frequently inconclusive data, it would be advisable to have a chat with your psychiatrist first before taking supplements for bipolar disorder.
What we know
People with bipolar disorder have a higher incidence of obesity, diabetes, high blood pressure, and unhealthy blood fat levels. The reasons for this may include:
There are even less well-understood possibilities, such as deliberately increasing sugar intake to reduce high levels of stress-induced blood cortisol.
An interesting recent study looked at the eating habits of 113 well people with bipolar and 160 people without bipolar. Those with bipolar were generally less adherent to a Mediterranean diet than the non-bipolar group, and 74% of the bipolar group were overweight versus 68% in the non-bipolar group. The levels of blood sugar and triglycerides (a type of blood fat) were also higher in the bipolar group.
A review of studies looking at diet in bipolar disorder suggest the following:
What we can do
As well as goal-setting towards regular healthier meals and snacks and restoring a regular circadian rhythm (there is more on this is in the October 2019 BipolarLife newsletter), the amount and type of food are also important for our mood and energy levels.
Dr Ellen Frank, Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania, recommends having three to four smaller meals per day to help keep mood and energy levels stable.
Depression and Bipolar Support Alliance (DBSA) suggests keeping a food and mood journal to see if a symptom is triggered by something dietary. An example might be agitation and nervousness after a certain amount of caffeine, or broken sleep, low mood and poorer impulse control after alcohol.
Given the above study findings, it may help to follow a portion-controlled Mediterranean-type diet (definitions vary) to help with mood and energy.
This diet typically looks like this:
fruits, vegetables, legumes
wholegrains and cereals
nuts and seeds
healthy fats like olive oil and avocado instead of butter
seafood, poultry, dairy
little or no red meat
If there are additional challenges to meet such as medication-related weight gain, you could also get support from your doctor and/or dietician. Don’t forget to check out online resources including:
Disclaimer: this content is not a substitute for individual medical advice.
Abbreviations used: EPA = Eicosapentaenoic acid, DHA = Docosahexaenoic acid, ALA = Alpha-Linolenic Acid, SAMe = S-adenosyl-L-methionine 5-HTP = 5-Hydroxytryptophan GABA = Gamma aminobutyric acid, NAC = N-acetyl cysteine
1. Bauer, M., 2015. Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study. International Journal of Bipolar Disorders, [Online]. 3, 12. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451053/ [Accessed 27 October 2019].
2. Depression and Bipolar Support Alliance (DBSA). 2019. What You Need to Know About Dietary Supplements. [ONLINE] Available at: https://secure2.convio.net/dabsa/site/SPageServer/TR/pdfs/pdfs/devo/PageServer;jsessionid=00000000.app274a?NONCE_TOKEN=BB856198664DE4815756376A410964EA&pagename=wellness_depression_dietary_supplements]. [Accessed 27 October 2019].
3. International Bipolar Foundation. (2019). Biochemistry Features of Bipolar Disorders and Advanced Nutrient Therapies. [Online Video]. 1 October 2016. Available from: https://www.youtube.com/watch?v=rQdsWVm9-sw. [Accessed: 27 October 2019].
4. Muneer, A., 2019. Bipolar Disorder: Role of Inflammation and the Development of Disease Biomarkers. Psychiatry Investigation, [Online]. 13(1), 18–33. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4701682 [Accessed 27 October 2019].
5. US Department of Health and Human Services, Office of Dietary Supplements, National Institutes of Health. 2019. Omega-3 Fatty Acids. [ONLINE] Available at: https://ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer/. [Accessed 27 October 2019].
6. WebMD. 2018. Bipolar Disorder Supplements. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-supplements#3. [Accessed 27 October 2019].
7. Psychiatric Times. 2014. To Supplement or Not to Supplement: That Is the Bipolar Depression Question. [ONLINE] Available at: https://www.psychiatrictimes.com/psychopharmacology/supplement-or-not-supplement-bipolar-depression-question. [Accessed 27 October 2019].
8. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.
9. National Center for Complementary and Integrative Health (NCCIH). 2017. S-Adenosyl-L-Methionine (SAMe): In Depth. [ONLINE] Available at: https://nccih.nih.gov/health/supplements/SAMe. [Accessed 27 October 2019].
10. Pipich, M, 2018. Owning Bipolar, How Patients and Families Can Take Control of Bipolar Disorder. Citadel Press.
11. De Berardis, D., 2015. The role of melatonin in mood disorders. ChronoPhysiology and Therapy, [Online]. 2015:5, 65-75. Available at: https://www.dovepress.com/the-role-of-melatonin-in-mood-disorders-peer-reviewed-fulltext-article-CPT [Accessed 27 October 2019].
12. WebMD. 2018. Melatonin. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-940/melatonin. [Accessed 27 October 2019].
13. WebMD. 2018. Coenzyme Q10. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-938/coenzyme-q10. [Accessed 27 October 2019].
14. WebMD. 2018. 5-HTP. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-794/5-htp. [Accessed 27 October 2019].
15. WebMD. 2018. GABA (Gamma-aminobutyric acid). [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-464/gaba-gamma-aminobutyric-acid. [Accessed 27 October 2019].
16. National Center for Complementary and Integrative Health (NCCIH). 2016. Kava. [ONLINE] Available at: https://nccih.nih.gov/health/kava. [Accessed 27 October 2019].
17. Zheng, W., 2019. N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials. Acta Psychiatrica Scandinavica, [Online]. 137(5), 391-400. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29457216 [Accessed 27 October 2019].
18. US Department of Health and Human Services, Office of Dietary Supplements, National Institutes of Health. 2013. Valerian. [ONLINE] Available at: https://ods.od.nih.gov/factsheets/Valerian-HealthProfessional/. [Accessed 27 October 2019].
19. Shelton, R., 2013. The Primary Care Companion for CNS Disorders. Assessing Effects of l-Methylfolate in Depression Management: Results of a Real-World Patient Experience Trial, [Online]. 15(4). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869616 [Accessed 27 October 2019].
20. WebMD. 2018. Folic acid. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-1017/folic-acid. [Accessed 27 October 2019].
21. Chouinard, G., 2019. A pilot study of magnesium aspartate hydrochloride (Magnesiocard) as a mood stabilizer for rapid cycling bipolar affective disorder patients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, [Online]. 14(2), 171-80. Available at: https://www.ncbi.nlm.nih.gov/pubmed/2309035 [Accessed 27 October 2019].
22. Giannini, A., 2000. Magnesium oxide augmentation of verapamil maintenance therapy in mania. Psychiatry Research, [Online]. 93(1), 83-7. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10699232 [Accessed 27 October 2019].
23. Sylvia, L., 2013. Nutrition, Exercise, and Wellness Treatment in bipolar disorder: proof of concept for a consolidated intervention. International Journal of Bipolar Disorders, [Online]. Available at: https://journalbipolardisorders.springeropen.com/articles/10.1186/2194-7511-1-24 [Accessed 27 October 2019].
24. Łojko, D., 2018. Is diet important in bipolar disorder? Psychiatria polska, [Online]. 52(5), 783–795. Available at: http://psychiatriapolska.pl/uploads/images/PP_5_2018/ENGver783Lojko_PsychiatrPol2018v52i5.pdf [Accessed 27 October 2019].
25. Łojko, D., 2019. Diet quality and eating patterns in euthymic bipolar patients.. European Review for Medical and Pharmacological Sciences, [Online]. 23(3), 1221-1238. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30779092 [Accessed 27 October 2019].
26. DBSAlliance. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].
27. Depression and Bipolar Support Alliance (DBSA). 2019. Nutrition. [ONLINE] Available at: https://www.dbsalliance.org/wellness/wellness-toolbox/lifestyle/nutrition/. [Accessed 27 October 2019].
28. CREST.BD Bipolar Wellness Centre. 2015. Why diet and nutrition are important to your quality of life. [ONLINE] Available at: http://www.bdwellness.com/Quality-of-Life-Areas/Physical/DietAndNutrition. [Accessed 27 October 2019].
First published in Bipolar Life's newsletter on 15th October 2019
Have you ever looked back on the day and wished you had done more? Or have you experienced any difficulty sticking to a waking and bedtime routine? Both are common problems, and a lack of regular circadian rhythm may significantly affect bipolar disorder.
What is circadian rhythm?
The brain’s hypothalamus gland controls the organ systems of our body via hormones, or chemical messengers. A fall in light (such as during the evening) is detected by our eyes then affects a group of cells called the Suprachiasmic Nucleus (SCN), or ‘master clock’; this in turn causes an increase in production and release of melatonin, which makes us sleepy.
This process provides us with a circadian rhythm, which can be affected by altered bedtime and waking times, shift work and jet lag.
By the way, our circadian rhythm is just over 24 hours long, as in ‘circa’ nearly and ‘dian’ day and it is believed to have significant effects on body temperature, stress-hormone cortisol, even regulation of mood and body weight.
Why is circadian rhythm so important?
Dr Yoshikazu Takaesu of Kyorin University, Tokyo suggests “…circadian rhythm dysfunctions may act as predictors for the first onset of bipolar disorder and the relapse of mood episodes” and therefore that “treatments focusing on sleep disturbances and circadian rhythm dysfunction in combination with pharmacological, psychosocial, and chronobiological treatments are believed to be useful for relapse prevention.”
In an article published in The American Journal of Psychiatry, Dr Allison Harvey states that a high proportion of people with bipolar disorder are symptomatic between episodes; even in those receiving medication and psychological treatment. In particular, sleep disturbance affects quality of life and increases risk of relapse. She also suggests that daytime mood regulation can affect sleep and vice versa.
Dr Harvey also explains that it seems sleep disturbance escalates just before an episode and worsens still further during an episode. Although there appears to be an association, it is difficult to conclude from studies whether sleep disturbance is simply a feature of bipolar disorder, or a trigger for relapse.
How much sleep is enough?
A regular sleep/wake schedule of roughly eight hours sleep a night, seven day a week is proven to help protect against relapse, according to Dr Ellen Frank, Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania. She explains that many people with bipolar disorder are late chronotypes (as are their relatives), which essentially means you sleep later and wake later than the average person. Dr Frank suggests if you can work your schedule around your chronotype, this could give you the most restful sleep but then make sure to stay on that schedule.
How can we optimise our circadian rhythm?
In the world of chronobiology, “zeitgeber” (German for “synchroniser”) is an external cue that affects the body clock, such as light alerting us to the time of day. Early research by physiologist Jürgen Aschoff found that social cues such as mealtimes or work schedules can also act as zeitgebers. Dr Ellen Frank recommends having three to four smaller meals per day to help keep mood and energy levels stable.
The zeitgeber theory suggests that episodes of depression and mania or hypomania arise as a consequence of life events: a life event disturbs social zeitgebers such as mealtimes and bedtimes, and these changes then derail the circadian rhythm, triggering relapse.
A treatment based on this idea, called “interpersonal and social rhythm therapy” (IPSRT), has been shown as effective in reducing relapse in bipolar disorder. Several studies[6,7] have shown that social rhythm therapy benefits people with bipolar disorder when added to medication.
As well as improving our circadian rhythms, having some sort of routine can assist us in setting and reaching time-based goals, which can improve mental health. For instance, small manageable goals can help lower stress from overwhelm and reduce unhelpful procrastination.
How do we end up with poorly structured days?
Routine can be disrupted through illness, whether it be physical or bipolar disorder. This can cause a multitude of symptoms such as poor motivation, low or excessive energy, low/high/unstable mood, poor concentration, and other problems with cognition such as difficulty with judgement and planning.
Life events such as loss of job, loss of regular social contact or interpersonal problems can also upset our balance.
Unhelpful thought processes where we over-identify with our thinking, known as cognitive fusion, can make it difficult to move forwards to a helpful behaviour. Examples might include: “I’m too lazy to do X” or negative thinking like “I’ll never get through everything I need to do. Might as well give up now” or “I don’t think I’m up to doing job Z perfectly so there’s no point.”
It is common human behaviour to experience habitual leaning towards ‘avoidant’ behaviours which usually make us feel better in the immediate moment (e.g. binge-watching TV or drinking excessive amounts of alcohol); unfortunately these avoidant behaviours are performed in place of healthier actions that could build our self-esteem and self-confidence because they follow our true values (e.g. going for a daily walk to improve physical/mental health, making sure to have a daily shower to practise self-care).
However, the thought of building a healthy, meaningful routine for ourselves can sometimes feel overwhelming.
Let’s look at some recommendations in line with Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT), where discovering and continually reviewing our personal values can help us to set useful personal goals.
What if I’m struggling to make changes?
Behavioural activation is an evidence-based treatment and maintenance therapy. It is one part of CBT and is used in mood disorders to increase a person’s positive behaviours and reduce negative ones.
Here’s an example of a negative behaviour cycle:
Sleep in for hours to avoid facing a task –>
Feel groggy and poorly motivated with low mood –>
Fell less able to perform the task –>
Experience low mood, motivation and feel guilty and frustrated –>
Sleep in late again.
On the other hand, a person making a conscious effort to perform a positive behaviour (even if they don’t feel very motivated and aren’t enjoying it) will usually find that when the goal has been achieved, their mood, motivation and confidence improve, making it easier to continue positive behaviours.
In addition to behavioural activation, it can help to explore our own values, in order to set meaningful goals.
Values & how they can help us set goal-orientated actions
Identification of values helps us work out our personal wishes and motivations, regardless of expectations from other people or society.
It is important to note that values are not describing our internal states (thoughts, feelings and emotions) as it would soon become clear that having a value of wanting to be happy and to always have positive thoughts would be impossible. Values are also not descriptions of how others behave towards us, as that is another thing we don’t have a great deal of control over either e.g. I want to be loved by person X.
By seeing where our current actions are aligned with our values, we are more confident in continuing and strengthening those actions. On the other hand, where we are not heading towards a value we feel is important, this can help focus our efforts. And if we are feeling ‘stuck’ and unsure as to what our values are, it can stimulate a thinking process to move us forwards.
We can prioritise the goals which will lead us to values we find most important. They can help us with time management. For instance, we may decide that initially we need to set aside ten minutes a day on a goal.
It’s also useful if we can keep an open mind for what comes up for us when we plan a goal or are actioning the goal. For instance, we may need to deal with negative thinking like “this needs to be perfect or there will be consequences” or cognitive fusion like “I’m too lazy to do Y”. Or we might spot potential barriers and decide how to work around them.
Some examples of personal values include
From identifying which values are most important to you, and ones that could benefit from more attention, you have a starting point from which you can begin to set meaningful goals. You might simply categorise your values into Very Important all the way through to Not Important, or just choose the 5-10 most important to you today. As with all things, they are subject to change so review them when you feel ready.
The SMART acronym apparently first appeared in 1981 in Management Review. Since then, SMART has been used by a tool by countless organisations and individuals to help people identify and reach their goals. There are a few different versions, but we will use a commonly used one for the purposes of the article.
Don’t forget that we may need to break down a single goal into smaller ones, and more than one goal can run at the same time, so write down your ideas and plans.
To make sure your goals are clear and reachable, each one should be:
Reward yourself for completion of a goal if that helps, as some tasks are an effort and not always enjoyable.
Of course, setting and achieving goals is not always straightforward. Don Kattler, a peer researcher for The Collaborative RESearch Team (CREST.BD) recommends that if you find yourself unable to reach a goal, first practise self-compassion (for instance “struggling to achieve is the human condition”, “I’m doing the best I can”), kindness and non-judgement. Next you could gently investigate any internal (e.g. feeling tired) and external barriers (e.g. insufficient time) that got in the way of success this time. Problem-solving an issue increases your chance of success next time. Another realisation might be that the goal was unrealistically high, so you might reduce the difficulty of the goal to maximise success.
And finally, don’t forget you can also check in with friends, family, your GP, psychiatrist or psychologist to if you need more support.
1. National Institute of General Medical Sciences. 2019. Circadian Rhythms. [ONLINE] Available at: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx. Accessed 10 October 2019].
2. Takaesu, Y., 2018. Circadian rhythm in bipolar disorder: A review of the literature.. Psychiatry and Clinical Neurosciences, [Online]. 72(9), 673-682. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29869403 [Accessed 10 October 2019].
3. The American Journal of Psychiatry. 2008. Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation. [ONLINE] Available at: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2008.08010098. [Accessed 10 October 2019].
4. DBSAlliance. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].
5. Association for Psychological Science. 2016. Controlling Mood Disorders: A Matter of Routine. [ONLINE] Available at: https://www.psychologicalscience.org/observer/controlling-mood-disorders-a-matter-of-routine. [Accessed 10 October 2019].
6. Frank, E., 2005. Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder. Archives Of General Psychiatry, [Online]. 62(9), 996-1004. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1108410#26048444 [Accessed 10 October 2019].
7. National Institute of Mental Health. 2007. Questions and Answers About the STEP-BD Depression Psychosocial Treatment Trial. [ONLINE] Available at: https://www.nimh.nih.gov/funding/clinical-research/practical/step-bd/questions-and-answers-about-the-step-bd-depression-psychosocial-treatment-trial.shtml. [Accessed 10 October 2019].
8. ACT Mindfully. 2019. Acceptance & Commitment Therapy. [ONLINE] Available at: https://www.actmindfully.com.au. [Accessed 10 October 2019].
9. William Miller, University of New Mexico, (2019), Personal Values Card Sort [ONLINE]. Available at: https://www.guilford.com/add/miller2/values.pdf?t [Accessed 10 October 2019].
10. Don Kattler, Collaborative RESearch Team to study Bipolar Disorder, UBC. (2015). CREST.BD Home & Bipolar Disorder Slides. [Online Video]. 6 March 2015. Available from: https://www.slideshare.net/crestbd/crestbd-home-webinar-slides. [Accessed: 10 October 2019].
First published on Hepatitis Australia's website in September 2019.
If you’ve just been diagnosed with hepatitis B, it might help to know you’re not alone.
In 2018 there were 226,612 people in Australia (257 million people worldwide) living with hepatitis B.
After being diagnosed with hepatitis, people can experience a range of reactions including shock and uncertainty, even if they had been expecting a positive test result.
It’s not uncommon to feel depressed, anxious, fearful, or worry about possible stigma. In addition, there may also be self-blame, guilt, or embarrassment.
Take your time working through difficult thoughts and emotions. Try to be patient and have self-compassion. Sometimes talking things through with your doctor or a counsellor can help.
Stigma can arise in society or even within yourself. It can isolate you or interfere with you receiving treatment. For instance, a person may feel apprehensive about being seen attending an infectious diseases clinic if they are worried about what others might think.
A great way of reducing stigma is by learning more about hepatitis B. This will empower you to manage your condition together with your doctor, plus it’s helpful if you want to educate others.
The learning process
Be open to learning about hepatitis B at your own pace.
Feel free to explore the huge range of resources available such as via Hepatitis Australia. Information is available in other languages, audio/video formats including podcasts. There are also personal stories here and here about real people living with hepatitis B.
Having the right support is invaluable. Who you share your diagnosis with is a very personal decision. No matter who your trusted person(s) is; you should reflect on the pros and cons of disclosure to each one.
You can also join a support group through your local hepatitis organisation or online forums like Hep Forums. Do keep in mind that forums may include people from other countries who have differing access to healthcare and medications, and that any health information should be discussed with your doctor.
Finally, these tips might be useful when you see your doctor.
Being prepared will help you get the most out of your appointment. Having a set of questions ready is a great way for you to get the information you need.
Don’t be afraid to ask questions
Here are some common questions others ask:
Make notes for later
Research shows that people who are anxious or stressed are more likely to forget or incorrectly recall information later. So, it’s good to make notes during the appointment. Alternatively, ask your doctor for a written list of what you will both do after the appointment.
The right doctor for you
Because hepatitis B can be a lifelong condition, it’s ideal if you have a good and honest relationship with your doctor. Consider the following:
If you answered no to a few of these questions, then seeking a second opinion might be reasonable. If you need help to find a doctor with experience treating hepatitis B, you can call the National Hepatitis Infoline on 1800 437 222.
First published in Bipolar Life's newsletter on 17th September 2019
Why should we care about stigma?
Stigma affects many people in society, from race and gender inequality through to people living with mental health problems like bipolar disorder. It is a huge issue with myriad consequences, not least that individuals may experience knock-on effects of stigma that can even outweigh those of the mental health disorder itself. By extension, family and friends may also experience stigma, also known as ‘courtesy’ or ‘association stigma’.
How might an individual be affected by stigma?
An individual experiencing stigma may form negative attitudes and behaviours about him or herself (self-stigma), and may:
Isn’t stigma decreasing?
Despite the globally large number of public campaigns, high school education and media coverage about mental health, one might think that stigma would be less prevalent. However, according to the General Social Survey which collects data about U.S. residents, the public is in fact more stigmatising – despite increased knowledge about mental illness – than back in the 1950s.
The reasons for this surprising worsening of public opinion include:
What is stigma?
Ostracisation of members of society has existed as far back in history as ancient Greece. For example, in Athens, traitors and slaves were physically branded with ‘the mark of shame’ – ‘stigma’ in Greek.
Nowadays stigma is less visible, but most affected are those with mental illness, the homeless, and substance abusers. In one study, it was found that although people with bipolar disorders 1 and 2 experienced the same personal experience of stigma as those with unipolar depression, the impact (in terms of quality of life, social and familial relations and self-esteem) was much worse in people with bipolar disorder.
Stigma can include one or more of the following:
A survey by the Royal College of Psychiatrists in the U.K. looked at public perception of people with severe depression. The most commonly held beliefs were that these people:
Dr Kay Redfield Jamison, Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, U.S.A. is well known for her work on bipolar disorder as well as her autobiographical account of her own experience of the condition. She states that these study figures are even higher when applied to people with bipolar disorder.
It is possible bipolar disorder may appear unpredictable due to its sometimes-fluctuating nature, depending on whether the individual is relatively well and getting treatment and support, or experiencing a period of depression, mania or mixed state.
A little more about self-stigma
It is not uncommon for an individual with bipolar disorder to experience negative beliefs about him or herself, which may reduce self-esteem and self-confidence. Worse still, this state of mind may lead to avoidant behaviours like not pursuing opportunities, or not challenging negative self-beliefs by gathering evidence to the contrary.
Even within the medical profession there is stigma from, and towards, other healthcare providers. Compassion without sufficient knowledge may be a contributing factor in some cases.
Dr. Jamison offers an interesting observation that the ‘silently successful’ get well because they have sought and received good care, yet they remain silent for fear of personal or professional reprisal. This in turn perpetuates the public’s misconception that the mentally ill don’t get better.
Where to from here?
Fortunately, clinicians and researchers in many countries are increasingly aware of the rise of stigma and driving ongoing important work in this field. Though there is no one simple solution, here are some helpful, evidence-based suggestions for moving forward.
A Canadian study recommended six approaches to stigma reduction:
Individuals, friends and family
On an individual level, it should be noted that self-stigma can manifest and be managed in different ways. In CREST.BD's Stigma123 Webinar, Natasha Kolida, a student and researcher with bipolar disorder, encourages education as well as being holistic and self-compassionate in one’s journey. More about CREST.BD in a moment.
Dr. Jamison advises:
In 2014 Dr. Roumen Milev, Professor of Psychiatry and Psychology at Queen’s University, Canada ran a CREST.BD webinar about overcoming stigma in bipolar disorder. In this presentation, he describes a fascinating community-based recovery-orientated course provided to 8-10 participants with mood and anxiety disorders. Comprising seven closed two-hour sessions, content included education about stigma (covering self-stigma, family, friends and medical settings; education, housing and the workplace); some sessions taking the form of group workshops with brainstorming and role play.
Perhaps this is the sort of course we could make widely available in Australia to complement our current inpatient and community programmes for those with bipolar disorder.
Who is CREST.BD?
CREST.BD describes itself as “The Collaborative RESearch Team that studies psychosocial issues in Bipolar Disorder...CREST.BD is a multidisciplinary collaborative network of researchers, healthcare providers, people living with bipolar disorder, their family members and supporters.” Bipolar Life’s patron, Professor Greg Murray, is Deputy Lead and a key researcher with this inspiring international team.
CREST.BD’s website includes excellent resources and tools including videos on stigma, cognition, sleep, mood, physical health, home, self-esteem, leisure, relationships, spirituality, money, independence, identity, work and study for people with bipolar disorder.
Media and beyond
Finally, looking at how we can make a difference on a larger scale, StigmaWatch is a constructive program run by national mental health charity, SANE Australia. Its aim is to promote responsible reporting of mental illness and suicide in Australian media and is supported by Mindframe, an Australian Government initiative. This is a great example of protest being used as a tool to improve public perception of mental illness. SANE encourages anyone to report to StigmaWatch if they see inaccurate or inappropriate terminology or reporting of mental illness or suicide.
SANE’s website states that “Mindframe has also developed resources for media professionals, journalism students, scriptwriters, police and courts, and conduct briefing sessions with media organisations to discuss issues relating to mental illness and suicide”.
With so much research and an increasingly evidence-based approach to combating stigma, individuals have more power than ever to influence how bipolar disorder is seen in society. In addition, the many tools available can greatly assist an individual to reduce self-stigma and embrace life more fully.
YouTube. 2019. Discrimination and Stigma Against Patients with Depression and Bipolar Disorder. Johns Hopkins Medicine. [ONLINE] Available at: https://www.youtube.com/watch?v=9Hc0NF89ryg. [Accessed 17 September 2019].
YouTube. 2019. Bipolar Disorder Stigma, Suicide & Families. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=_eE8YSSo-tA&t=1582s. [Accessed 17 September 2019].
YouTube. 2019. Overcoming Stigma in Bipolar Disorder: Challenges and Opportunities. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=yDJ4DSZ0Id0&t=2258s. [Accessed 17 September 2019].
YouTube. 2019. CREST.BD's Stigma123 Webinar Jan2016. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?time_continue=234&v=LKkpvPD903Y. [Accessed 17 September 2019].
Goodwin, J., 2014. The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty‐First‐Century Horror Film (Part II). Perspectives in Psychiatric Care, [Online]. 50/4, 224-234. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ppc.12044 [Accessed 17 September 2019].
Arboleda-Flórez, J., 2012. From sin to science: fighting the stigmatization of mental illnesses.. Canadian Journal of Psychiatry, [Online]. 57(8):, 457-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22854027 [Accessed 17 September 2019].
CREST.BD. 2019. New directions in bipolar disorder research, treatment and care. [ONLINE] Available at: http://www.crestbd.ca/. [Accessed 17 September 2019].
SANE. 2019. StigmaWatch. [ONLINE] Available at: https://www.sane.org/services/stigmawatch. [Accessed 17 September 2019].
First published in Consumers Health Forum of Australia’s newsletter May 2019
A recent study in 2018 by the Australian Bureau of Statistics (ABS) revealed that people with three or more long-term health conditions felt less socially supported compared to people without.
As cited in this newsGP article, the average person attends their GP on average six times a year, and a specialist once a year. It is therefore evident that health literacy and quality of healthcare has never been so important.
Having worked as a GP for 16 years, and living with my own health issues, I can see the health system from both sides. Over the years, I’ve shared the journey of thousands of patients and advocated on their behalf countless times.
In this article, I’d like to offer some practical suggestions for the health consumer in order to get the very best out of your GP.
Booking your appointment
The receptionist is the gatekeeper to your GP. Often GPs will allow long appointments to be booked for certain issues (like mental health and women’s health) or if it is for multiple issues. Without pre-planning, it is not always possible for the GP to just extend the consultation if they have others waiting to be seen. Don’t worry if your GP recommends that you return for a further appointment if the condition is complex, as some things can’t be dealt with in the standard 15-minute slot.
If it is the first time you will see Dr X, it will take some time for them to get to know your past medical history so they can put your current issues into context. It can save time to bring in a health summary from your last GP, or to write one of your own beforehand. List any serious medical problems and hospital admissions, operations, medications and allergies, and family history.
What you want from your consultation may be different from your GP. Unless they know you well and you have a good mutual understanding, there is a risk that you will leave the room dissatisfied. If you can, clarify your needs beforehand (including thoughts, concerns and any expectations) about your health. If you have more than one problem, tell your GP at the beginning so that you can both prioritise and set aside the appropriate amount of time. Rushing through a list just to get them ticked off in one go is not good news in the long run.
Photo by Alice Lam @AliceLamWriter
On the record
Writing things down before and during the consultation can be beneficial if you’d like to have a record for later. Sometimes I provide a typed or written summary of major ‘take home’ points for my patients, especially if a lot has been covered in a session. I started doing this after a few occasions when patients returned, having completely forgotten points discussed, or to carry out certain agreed actions from the last consultation!
Is your GP listening?
GPs are trained to listen first, and speak later. Unfortunately, not all GPs abide by that saying. A study in the USA found that many patients will have stated their agenda by about six seconds, though some took as long as almost two minutes. Doctors only elicited a health consumer’s agenda half the time (contrasting with specialists who lagged behind, only getting the patient’s agenda one-fifth of the time).
So, that first minute or more when you start talking is golden and should be uninterrupted. It’s that precious time when you bring up your agenda in your own time and style. Many GPs, myself included, have been tempted at times to start bombarding the patient with questions, thinking we already have the answers.
If you don’t feel you’ve had a chance to say everything you need (within reason), ask your GP to let you finish. It is well known that not listening adequately to a health consumer leads to problems, such as missing particular details and as a result, doing the wrong examination, or ordering the wrong tests for instance. In the worst case scenario, you could get the wrong diagnosis and treatment.
What is your GP thinking?
Doctors may share similar training yet we develop our own methods of diagnosing and treating our patients. One GP might like to get a good understanding of all your past medical issues, family history, smoking and alcohol status etc. before moving on to your current problem. Having this knowledge at the start can often make a difference to the outcome.
An example: 30-year-old ‘Jenny’ comes in with a breast lump. She might receive a more conservative approach such as surveillance before having a scan further down the line, but if her family history is of cancers that increase her risk then management should, of course, be fast-tracked.
On the other hand, another GP may prefer to deal with a current issue and get to the less ‘urgent’ items on another occasion. That might make a health consumer feel happy that something has been done but may miss addressing items that could affect long term health.
An example: 50-year-old Joe comes in with a sore knee. It looks like arthritis and he is sent home with advice on painkillers and exercise. He feels better so he doesn’t return. But he hasn’t been asked about his father and uncle dying of heart disease in their 40s, so this might be a missed opportunity for screening
Do I need an examination?
Many patients feel embarrassed or apprehensive about having certain intimate examinations. That is quite understandable, and even doctors can feel the same way when they see another doctor. GPs are used to patients getting nervous, and if made aware beforehand, they can gently explain about the procedure and take it at the patient’s pace.
Personality and communication
These are aspects which have a significant impact on how your consultation will go. Is your GP rigid or flexible? Are they paternalistic, as in “Do as I say” or more about you – “What would you like to do?” It depends on your personality as to whether you’ll be able to work together towards your health goals.
Does your GP explain difficult terms, and answer your questions to your satisfaction? Are they patient with you? Do they encourage you to take on responsibility and autonomy in your health management, where possible?
Something that is not talked about much, is when GPs (and other doctors) talk within earshot of receptionists, other doctors, and worse still, other patients. Your GP should never discuss your health with anyone else without your permission. A good doctor never forgets about confidentiality and the circumstances where this trust can be broken are extremely rare.
Continuity of care
Ideally, you will have just one GP who works full time. This means they will know you and your issues and be able to manage you better than someone who only sees you occasionally. However, given that many GPs work part-time, and in any case all will take time off at some point, try to stick to a maximum of two GPs in the same practice. Not only will they be able to share your health record, they will be able to talk to each other to have more of a team approach to your care.
Getting a second opinion
When might you consider seeing a second GP? There can be times when your regular GP seems to have hit a roadblock with managing your health, or you just don’t gel for reasons of personality or communication style, for example.
If that happens, you have a right to seek a second opinion, either within the same practice or in a different clinic – the latter being a benefit of the Australian health system not available in countries like the UK. A fresh pair of eyes and a new perspective can make a big difference if progress has stalled. Some people feel guilty if they move to another doctor, which is understandable, but unfounded.
Asking for assistance
Apart from medical advice and treatment, what about navigating the health system? Only about a quarter of people surveyed by the ABS found it easy to navigate the health system, with increasing difficulty for people experiencing psychological distress. People may need help with booking an appointment for an outpatient clinic or an investigation, understanding a treatment plan, or working out the best options available. Again, ask your GP, receptionist or practice nurse if you need help.
Image by aj-garcia-454112-unsplash
Mental health issues
The Australian Institute of Health and Welfare (AIHW) found that during the period 2015-16, the number of people attending with mental health conditions was on the rise; a third of were attending with depression. And with an estimated four million Australians experiencing a common mental health condition in 2015, these statistics show how serious mental health care is.
There are many facets to a successful mental health consultation, and to go through them all would be outside the scope of this article.
In brief however, I would recommend that a long appointment be booked in advance, and if possible, that a partner/friend/relative accompanies you. In my experience, that gives the person emotional support, as well as the support person being able to ensure that their needs are met. In addition, more objective information can be provided this way, as often someone with mental health issues are too distressed or lacking in full insight to give a full explanation of their symptoms.
I’d also suggest keeping a daily journal, however brief. Even if it’s just a score out of ten for mood and sleep plus a sentence or two, it can be invaluable for dealing with the issues at hand.
Your health is of the utmost importance, and should be top priority for your doctor as well.
Look for a doctor with good communication skills, empathy and a collaborative approach that empowers you.
For more unique insights, read on
Do you care about safety, quality and health literacy? Dip into Consumers Health Forum of Australia’s newsletter & see where we’re going wrong, & where we can do better. It includes this article, plus many others to stimulate a conversation.” 🙂
@CHFofAustralia @GPsDownUnder #generalpractice #gp #familydoctor #PrimaryHealthCare #patienteducation #patientexperience #patientempowerment
Or why shopping for health is now a 'thing'
Photo by Shalone Cason on Unsplash
Living In Denial
I have a confession to make.
As a doctor, I used to secretly grit my teeth when I heard patients being called ‘consumers’. And my blood pressure would rise sharply if I heard clinicians being called ‘health care providers’.
Why? Maybe it was because it felt as if the recognition of nine gruelling years of medical training were being reduced in some way. That the complexities of delivering personalised, holistic healthcare might be simply dissolved into discrete, saleable commodities.
Within doctor circles, I know that I have not been alone in this thinking.
Image by Steve Buissinne from Pixabay
How patients see the healthcare system
However, in viewing healthcare as a patient, I started to realise that the terminology wasn’t exactly incorrect either.
It's easy to argue that a patient makes choices and consumes services, with a freedom that is on the rise. And like it or not, anyone providing a health service is being appraised for more than just their clinical acumen. Patients are increasingly sharing feedback on third party sites including social media. Their posts then influence the next person's choice to use that service. For instance, a survey commissioned by Binary Fountain revealed:
Just for fun, let's consider 30-year-old Natalie who badly twists her ankle while playing netball one Sunday morning. Sensibly, she takes the home remedy option (rest, ice, compression, elevation, a good swear and some painkillers). She decides to ring her GP in case it’s more than a sprain. But it’s a Sunday morning, appointments are all booked out.
So she looks online for appointments at other nearby clinics – a benefit that we are lucky to have in Australia. Or she could attend the Emergency Department and risk a long wait to be seen. Or Natalie might drive with her one good leg to the private Emergency Department 10 kilometres away.
Hang on. We’re not out of options yet. She might attend the Urgent Care Clinic run by GPs next to the Emergency Department. She might Google the local private orthopaedic surgeon, orthotist, or physiotherapist. And not to forget she has telehealth up her sleeve (maybe not the best option for a musculoskeletal issue).
In the end, Natalie decides to drive by the supermarket for frozen peas and the pharmacy up the road for an ankle strap. Don't worry, she makes a full recovery.
Image by 3D Animation Production Company from Pixabay
Patients are migrating away from traditional models of health care because they are dissatisfied with it for various reasons. Some of those reasons may include a cultural and societal campaign for wellness and desire for increased personal responsibility. So even in the traditional setting of the family doctor giving a referral to their patient, choice still can take place afterwards.
Carrie Liken is head of industry for healthcare at Yext, a U.S. company that has helped multiple health organisations manage their digital presence. During her time working at Google, she found that many patients receiving a referral from their doctor would often search for alternatives after leaving the office.
I have no problem with that. I think the days of the borderline paternalistic consultation directing the compliant patient are coming to an end, and that is a good thing. And with the digital age, patients should be able to research and select beneficial services.
My main concern is that factors such as cost-saving or misinformation, may come to replace the ethical, family-orientated evidence-based management of traditional clinical practice.
Image by Tumisu from Pixabay
In true dialogue, both sides are willing to change. Thich Nhat Hanh
Care To Converse?
I recently listened to a conversation between David Shifrin of Health:Further, and Patrick Spear of Global Market Development Center (GMDC). For more on the concept of self-care, ‘patients-as-consumers’ and how U.S. healthcare and retail industries intersect, you might like to check out their fascinating podcast.
I am no longer gritting my teeth, but experiencing a deep curiosity about where Australian healthcare is heading.
It sound a little clichéd to say that we should stop competing and start collaborating. But realistically, health care providers need to begin an urgent exchange with one another. Only by doing so we will be able to provide health treatment options that are (a) in the patient’s best interests and (b) within the patient’s personal preferences.
Things will never be the same again. They might even be better.
Binary Fountain 2018, Healthcare Consumer Insight & Digital Engagement Survey Results Unveiled, accessed 10 May 2019, <https://www.binaryfountain.com/news/second-annual-healthcare-consumer-insight-digital-engagement-survey-results-unveiled/>
Shifrin, David (2018, October 23). Optimizing the Patient Journey | Carrie Liken | Yext [Podcast]. Retrieved from https://pca.st/o3RA
Shifrin, David (2019, May 1). A patient in the morning is a consumer in the afternoon – Patrick Spear of GMDC [Podcast]. Retrieved from https://www.healthfurther.com/the-future-of-health/2019/05/01/a-patient-in-the-morning-is-a-consumer-in-the-afternoon-patrick-spear-of-gmdc/
@AliceLamWriter @GMDCorg @HealthFurther
#PrimaryHealthCare #gp #familydoctor #generalpractice #healthcare #patientexperience #patientempowerment #collaboration
"Content is fire; social media is gasoline.” - Jay Baer, Bestselling Author and Marketing Expert
Do you work in a health centre/hospital, promote health products or run health-related content on a platform?
Is high quality, curated content important to you?
Then this article is for you.
As a doctor with 20 years’ experience, I specialise in health writing for a wide audience.
I’m ecstatic to see paternalistic attitudes dwindle in our profession. These days, health care providers are devoting more energy into patient-centred communication.
But before we look at how to do it, let’s look at the consequences of poor communication with patients/clients.
Dangers of inadequate communication
Here's an article looking at the consequences of not getting the message right. By the way, for ‘patient’ we can also extrapolate to ‘customer’ or ‘client.
The authors concluded an aftermath of “unnecessary pain, in avoidable deaths, in poor health outcomes, in the prolongation of illnesses” and “costs in terms of the financial part of the equation, in large sums of money that get spent unnecessarily because of the communication breakdowns and barriers”.
What is patient-centred communication?
This article published in PubMed Central® suggests that core concepts include:
When it comes down to written forms of such communication, I have some further recommendations for content.
How to succeed
With globalisation, the rise of small businesses, and a tsunami of social media and digital communications, there is no ‘one size fits all’. Here are some interesting statistics from the Australian Communications and Media Authority (ACMA):
We can collaborate to make great content
As a family physician, I'm able to write about most medical specialties. My particular interests are in mental health, women's health, health promotion, and chronic / complex medical issues.
I’ve ghostwritten health articles, re-written articles for clients, composed content for my own websites, and produced patient information leaflets for people attending my clinics.
I would also be delighted to work with patient and community groups too.
If you’re after fresh writing backed by clinical experience, please head on over to my Health Writer Service page. Let's start the ball rolling today.
@AliceLamWriter #generalpractice #healthcare #communication #patientexperience #patientempowerment #primaryhealthcare #health #patientsafety
Dr Alice Lam
I'm a doctor who is passionate about writing quality health content.