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 Photo by Anh Nguyen on Unsplash First published on Hepatitis Australia's website in May 2020 People with chronic hepatitis B have higher rates of depression and anxiety than the general population [1]. Let’s have a look at why this happens, and what we can do about it. Reacting to your diagnosis Adjustment to having a chronic (lifelong) disease may mean having to [2]:
Research [3] has found that many people worry about getting liver cancer or infecting others, and that these concerns could increase the risk of mental health problems, particularly depression. Not understanding enough about hepatitis B or having no one to confide in can also cause social isolation and affect mental health [4]. Hepatitis B treatment There is no cure yet for chronic hepatitis B, but there are medications which can control the virus and reduce the risk of serious complications from the condition. However, like all medications, the treatment for hepatitis B can cause side-effects for some people, including affecting your mental health. This is something you should discuss with your doctor, as well as whether you’d like any additional support during your treatment. There are two main options for treatment [5]. Usually, the preferred option is nucleoside analogues (NAs), such as tenofovir and entecavir. These have fewer side effects than interferon, but often need to be taken for a long time, or even for life. Pegylated interferon (PEG-IFN) is an alternative and is usually given over 48 weeks. Researchers [6] reviewed studies of people on interferon, and found:
It is also possible that a history of depression, anxiety, bipolar disorder or post-traumatic stress disorder (PTSD), combined with interferon may cause worsening symptoms, or relapse [2]. Now let’s look at how to get help. Learn and connect Learning about hepatitis B is a good way of combatting misconceptions. Great resources include the Hepatitis Australia website and the National Hepatitis Infoline (1800 437 222), which directs you to the community-based hepatitis organisation in your state or territory who provide friendly and confidential help. In addition you can look at the Hep B Help website which has links to hepatitis B organisations plus multilingual factsheets, audio and video resources too. You could also contact the hepatitis organisation in your state or territory and perhaps link up with people who have similar experiences. Alternatively, you could join an online forum like Hep Forums. Talk to your partner, friends and family. By sharing your knowledge, you can reduce stigma - which might otherwise isolate you or interfere with you receiving treatment - while getting the support you need. You can read these tips on telling others you have hepatitis. Get healthy Eat a healthy, balanced diet and maintain a healthy weight. Avoid alcohol and smoking. You should talk to your doctor before using any non-prescription drugs or supplements. Try to keep to a regular sleep pattern and regular exercise. For general support for mental health you can check out Head To Health as well as Lifeline and Beyond Blue. If you need more support, don’t forget you can speak with your GP, specialist or ask for a referral to a psychologist or psychiatrist. Medications and talking therapy When mental health issues arise, many people find it helps see a psychologist for one‑to‑one, confidential talking therapy. Sessions usually include learning about the mental health condition, why it has happened and why it has persisted. The psychologist can work with you to use tools like relaxation, mindfulness and cognitive behavioural therapy (CBT) as a way of coping with difficult emotions [7,8]. It is also thought that antidepressants and anti-anxiety medications can work well for interferon-related depression and anxiety [9,10]. Pre-existing psychiatric medication may need to be changed or adjusted during antiviral treatment, for example to one less toxic to the liver. Psychiatric medications and support might need to continue for at least 6 to 12 weeks after finishing antiviral treatment [10]. For people at higher risk for depression, such as those with a history of depression or alcohol overuse, pre-emptive treatment with antidepressants can be started before beginning antiviral therapy [10]. References
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 Image by @ AliceLamWriter First published in Bipolar Life's June 2020 newsletter In this article, we’ll look at how tracking symptoms can help, then we’ll consider the range of different tools available including apps for people with bipolar disorder. TrackersMany people already track their mood, sleep and energy as part of a treatment and maintenance plan. This is a good example of a way in which we can increase awareness of our moods, including early changes that might herald a mood episode, and monitor effectiveness of medications or other therapies [1]. Examples of printable trackers which you can of course customise can be found here and here. Making notes as you go along can help identify stressors and triggers too. As a regular circadian rhythm with sufficient sleep is important in bipolar disorder, a decrease or increase in sleep could be a sign of impending mania or depression; or the other way round might be the case, that is, mania may cause decreased need for sleep or depression cause increased need. In either case, early intervention would probably be beneficial than if things were left to spiral out of control. Perhaps you want to see the effect of walking 15 minutes a day on your mood and energy. Or you wonder if cutting out caffeine will improve your sleep. It may be that you are depressed and you’ve set a basic goal of showering three times a week because anything more feels overwhelming [2]. Recording via a paper or electronic tracker allows you to experiment with positive behavioural changes as you can measure when and how much of an effect a change makes. You can read more on how to use behavioural activation and goal-setting to beat low mood or negative thinking here and here. It is important to note that some people with bipolar disorder may become over-energised by goal progress and rewards, which may lead to a manic episode [3]. Therefore, it is important to ensure that we avoid setting goals that will require excessive activity that could in turn affect sleep or circadian rhythms [2]. If you’re feeling overactivated, you might use a tracker to add in regular calming activities such as relaxation and meditation, as well as avoiding too much goal seeking [2]. Here’s an online module on using behaviour to prevent mania. There are also more sophisticated trackers available, such as the Quality of Life (QoL) tool [4] produced by the Collaborative RESearch Team (CREST.BD). The QoL tool is a free online resource where you can intermittently fill in a simple questionnaire, rating satisfaction levels for energy, mood, sleep, work, money, relationships and other life domains. The tool then displays the data as a graph and table, helping you to see progress, which helps to validate your efforts and motivate ongoing efforts [5]. Regular tracking may lead you to a routine that includes a healthy lifestyle (diet, exercise, relaxation, regular sleep pattern, avoiding alcohol and drugs, minimising stress and maintaining consistent sunlight exposure throughout the year) which should help keep your symptoms and mood symptoms to a minimum [6]. Tips:
"If you educate your family and friends and involve them in treatment when possible, they can help you spot symptoms, track behaviours and gain perspective." AppsMany people with bipolar disorder turn to mobile apps and web programs (mHealth) to find information about the condition, to track symptoms, to record behavioural changes. Apps can appear attractive as they are easy to download, convenient, and are often low-cost or free. A review by the Australian Communications and Media Authority [7] confirms how prevalent mobile devices are in society. It was found that 89% of Australian adults accessed the internet in the six months to May 2018—74% going online three or more times a day. 90% of Australian adults were using more than one device to go online at May 2018. Researchers from the Black Dog Institute and Sydney’s School of Psychiatry decided to explore the apps aimed at bipolar disorder in both Google Play and iOS stores in Australia [8]. In particular, they evaluated the apps for features, quality and privacy. Out of the 571 apps identified, they reviewed 82 apps. Here are some of their conclusions [8]:
This is not to say that all apps are no good, but from the research above it shows that it is a good idea to be cautious when choosing and using an app. Update 27/5/20: The CREST.BD team is working on their Bipolar Bridges project to build an app for people with bipolar disorder. The final product aims to "empower[s] users to combine and learn from different forms of digital self-management and QoL (quality of life) data (for instance, sleep quality, mood management, activity levels, and social connectivity." You can go to their survey here to help them build a picture of how you use apps for your health and wellbeing. References1. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.
2. Reiser, R.P., Thompson, L.W., Johnson, S.L., Suppes, T., 2017. Bipolar disorder, 2nd edition. ed, Advances in psychotherapy--evidence-based practice. Hogrefe, Boston, MA. 3. Johnson, S., 2012. The Behavioral Activation System and mania. Annual Review of Clinical Psychology. Annu. Rev. Clin. Psychol. 8, 243–267. 4.. CREST.BD. 2015. Quality of Life Tool. [ONLINE] Available at: https://www.bdqol.com/. [Accessed 15 May 2020]. 5. Morton, E, 2019. Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration. Journal of Medical Internet Research, [Online]. 6(12), e16121. Available at: https://mental.jmir.org/2019/12/e16121 [Accessed 15 May 2020]. 6. International Bipolar Foundation. n.d. Treatment. [ONLINE] Available at: https://ibpf.org/learn/education/treatment/. [Accessed 15 May 2020]. 7. Australian Communications and Media Authority Communications Report 2017-2018. 2019. AAA, [Online]. Available at: https://www.acma.gov.au/sites/default/files/2019-08/Communications%20report%202017-18.pdf [Accessed 15 May 2020]. 8. Nicholas, J., 2015. Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Journal of Medical Internet Research, [Online]. 17(8), e198. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642376/ [Accessed 17 May 2020].  Photo by Drew Coffman on Unsplash Is the Coronavirus pandemic affecting your mental health? Has your usual routine has gone out of the window? Do you feel like you’ve lost direction? It is well known that public health emergencies can affect individuals in myriad ways. Examples include the following [1]:
But it isn’t all bad. Let’s look at some positives. It’s important to remember that many of us have strengths and resilience, and that communities can pull together in innovative and mutually caring ways which combat the negatives of a pandemic. The Black Dog Institute have a wealth of practical information on their website specifically to help with anxiety, stress and wellbeing during Coronavirus. In addition, the Australian Government has pledged a number of packages [2] to support people in the community, such as phone and online support services, ongoing psychosocial support for Commonwealth community mental health clients for a further 12 months and expansion of the Government’s digital mental health gateway Head to Health. And perhaps we will have learnt some useful lessons by the time we are on the other side of the pandemic: how we want our relationships to be, or how we want to live in the future. The good news is that a healthy sleep-wake cycle and good routine are traditional ways that help many people manage their mental health.  Photo by @AliceLamWriter The circadian rhythmThe 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 [3]. How much sleep is enough?The Mayo Clinic suggests adults need between 7 and 9 hours of sleep per night, and teenagers 8 to 10 hours [4]. 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 [5] . As well as improving our circadian rhythms with regular mealtimes and exercise, 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.  Photo by Ethan Sykes on Unsplash How do we end up with poorly structured days?Routine can be disrupted through illness, whether it be physical or mental. This can cause a multitude of symptoms such as poor motivation, low energy, low/unstable mood and poor concentration. Life events such as loss of employment, 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 rebuilding a healthy, meaningful routine for ourselves can sometimes feel overwhelming. Let’s look at some recommendations in line with a nifty tool called Cognitive Behavioural Therapy (CBT), 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 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 actionsIdentification of values helps us work out our personal wishes and motivations, regardless of expectations from other people or society. 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:
 Image by Shad0wfall from Pixabay Be SMARTThe 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. Example 1 Value – I want to give more support to a friend who lives alone Goal — I will ring her today and suggest a weekly video chat or phone call. We both have computers and we can find a mutually agreeable time to do it. Example 2 Value – I want to get to healthier weight for my physical and mental health Goal — I will start walking 10 minutes after breakfast, starting tomorrow Of course, setting and achieving goals is not always straightforward. 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 [7]. Problem-solving an issue increases your chance of success next time [7]. 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. If you think this article might help someone else too, please like and share. References1. Pfefferbaum, B., 2020. Mental Health and the Covid-19 Pandemic. The New England Journal of Medicine, [Online]. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2008017 [Accessed 3 May 2020]. 2. Australian Government Department of Health: Factsheet Coronavirus (Covid-19) National Health Plan. Available at: https://www.health.gov.au/sites/default/files/documents/2020/03/covid-19-national-health-plan-supporting-the-mental-health-of-australians-through-the-coronavirus-pandemic.pdf [Accessed 3 May 2020]. 3. 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]. 4. Mayo Clinic. 2019. How many hours of sleep are enough for good health?. [ONLINE] Available at: https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/how-many-hours-of-sleep-are-enough/faq-20057898. [Accessed 3 May 2020]. 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. 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]. 7. 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]. All content in this article is for informational purposes only and is not intended to serve as a substitute for individual consultation with a qualified physician.
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