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 Image by Mabel Amber, still incognito... from Pixabay 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 chronicWhen 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 [1]. 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 [2]. 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 [3]. 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 [4] 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 nowThe reason people with chronic hepatitis B vary widely is that hepatitis B has four identifiable phases [5]: • 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 [7] – as well as other actions like having a healthy lifestyle . Living with hepatitisThe goal of screening and treatment is to prevent, stop or even reverse the effects of hepatitis B on your liver [7]. 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 [6]. 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 [7]. International research shows that appropriate treatment for chronic hepatitis B can reduce the risk of liver cancer by up to 75%, or three-quarters [8]. 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. If you think this article might help someone else too, please like and share References1. 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://54.66.239.154/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. Hepatitis QLD. 2021. Hepatitis B | Hepatitis QLD. [ONLINE] Available at: https://www.hepqld.asn.au/hepatitis-b/. [Accessed 23 February 2021] 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://54.66.239.154/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]. * As the range of HBV tests can be confusing, your GP may appreciate being pointed to this handy decision-making aid.
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 Thankfully, our collective efforts have led to real progress with managing the COVID-19 pandemic. The number of new daily reported cases in Australia has remained relatively low since September 2020 [1]. So the next obvious step is protecting our population is vaccination – in addition to hand hygiene, social distancing, and wearing masks. You probably have a few important questions by this stage. Let’s have a look at some of the most frequently asked.  Q: Who will get vaccinated, and when? A: The first priority groups wo;; start receiving vaccinations from next week. Q: What is the planned rollout in Australia? A: There are five planned phases, as follows: The first phase, 1a, consists of quarantine and border workers, priority frontline healthcare workers, aged care and disability care staff and residents. The second phase, 1b, consists of those aged 70 and over, other healthcare workers, Aboriginal and Torres Strait Islander people > 55 years, younger adults with an underlying medical condition or disability, and critical and high risk workers including defence, police, fire, emergency services and meat processing. The third phase, 2a, includes adults aged 50-69 years, Aboriginal and Torres Strait Islander people aged 18- 54 years, and other critical and high risk workers. The fourth phase, 2b, includes any other unvaccinated adults and anyone who missed vaccination in the earlier phases. The fifth and final phase, 3, will be those aged under 18 years, if this is the recommendation [2].  Photo by Jake Weirick on Unsplash Q: What vaccines will be available in Australia? A: We have received the first batch of the Pfizer/BioNTech COVID-19 vaccine. In total, 20 million doses have been secured by the Government. In addition, the Oxford/AstraZeneca COVID-19 vaccine will be manufactured in Broadmeadows, Victoria. Both of these vaccines have received TGA approval. Australia have also entered into agreements for supply with Novavax and COVAX, if they are deemed safe and effective [3]. Vaccines are only made available once they pass TGA approval (Therapeutic Goods Administration being the Government’s health regulatory agency). Q: How effective and safe are the different vaccines? A: The Pfizer vaccine was shown in trials to be 95% effective in preventing COVID-19 after receiving the two-dose course (shots given 21 days apart), whether the recipient is aged 16 or over 65 [4]. There is insufficient data to prove benefit from a single dose [5]. Side effects are usually mild and last a few days at the most. The most common adverse effects are: pain at the injection site, fatigue, headache, muscle ache, chills, joint pain, and fever. The Oxford/AstraZeneca vaccine can be given 4-12 weeks apart [6] and has a reported efficacy of 63% [7]. Side effects appear similar to those of the Pfizer vaccine i.e. injection-site tenderness/pain, headache, fatigue, muscle aches, feeling unwell, fever, chills, joint pain and nausea. Most of these reactions were mild to moderate in severity and also resolved within a few days [8]. It’s recommended to take paracetamol if you do get side effects, if you need to. More information on the Pfizer vaccine can be found on this webpage by the Department of Health, or here (please note this is a US website but has excellent information). More information on the Oxford/Astrazeneca vaccine can be found on this webpage by the Department of Health, or this webpage by the World Health Organization.  Photo by Anastasiia Chepinska on Unsplash Q: What should I do if I am pregnant, planning pregnancy or breast feeding? A: Essentially, if you are planning pregnancy or breastfeeding, the latest advice is that it appears to be safe to have the COVID-19 vaccine. If you are pregnant, it is a decision worth discussing with your doctor, as there is little data about the outcomes of women who receive the vaccine while pregnant. On the other hand, it seems that pregnant women have an increased risk of complications such as higher rates of admission to intensive care or having their babies prematurely. More severe illness from COVID-19 is also seen in pregnant women over the age of 35, overweight, or who have certain medical conditions. This leaflet has some useful information to help with the question of vaccination. The Australian Government Department of Health has a great webpage here to answer many more popular questions.  And finally, for an informative and lively debate on COVID vaccines, I recommend this recent episode of ABC's Q&A. Topics included effectiveness of different vaccines at preventing breakthrough cases, what evidence we have so far for new variants to be covered by these vaccines, herd immunity, and more passionately argued topics. #ABCqanda Panellists: Nick Coatsworth, Federal Government infectious diseases advisor; Sharon Lewin, Leading infectious diseases expert and Director of the Doherty Institute; Michelle Ananda-Rajah, Associate director, Monash Institute of Medical Engineering; and Tony Blakely, Epidemiologist, University of Melbourne. References
This educational article was written on behalf of Arrotex Pharmaceuticals, and was published in The Australian Journal of Pharmacy on 8/1/21.    Vector created by vectorpouch - www.freepik.com< First published on Bipolar Life's July 2020 newsletter IntroductionEven if you do your best to lead a healthy lifestyle and follow your prescribed treatment plan, unfortunately hospitalisation may still be necessary. Around one in ten psychiatric admissions are for bipolar disorder [1], with depression and schizophrenia being the most common reasons. In this article we’ll explore why admission might be helpful, what to expect during your stay, and how to transition being back to living at home after discharge.  Photo by cottonbro from Pexels What to expectSome people may be nervous or frightened about an impending hospital stay, whereas others may actively wish to be admitted for relief of distressing symptoms. Either way, it is important to remember that the benefits of admission can include [2]:
The hospital will advise you of what to bring. As well as packing comfortable clothes (which should be conservative in style so as not to cause any stress to others), toiletries and so on, it can be comforting to bring something to personalise your room such as pictures without glass, a favourite blanket or pillow, and books, music and simple journaling/art materials. Initially you may find that certain items are prohibited until the doctor is happy that you are not at risk of self-harm but these are returned as you get better. Usually you are seen within 24 hours of admission by your psychiatrist, who will assess you and propose a treatment plan. Nurses will also check in on you regularly. Don’t forget to talk to staff if you have any concerns or questions. Visiting hours and option to leave the building whilst unattended will vary on a case by case basis. Typically, there will be a timetable which will include meal and snack times, group therapy (such as cognitive behavioural, assertiveness/communication skills, mindfulness, relaxation, meditation, art or music) and exercise. At first you may be too ill or sedated from medications to attend many of the sessions, but your psychiatrist and nurses will encourage you to do more as you are able. Many of the sessions may be new and daunting, especially if you are not used to groups; but do your best to have an open mind as you will find that you are more likely to benefit from the activities. Your friend or loved one may be invited to meet with the psychiatrist (or they can request a meeting), so that you can both air concerns and questions. This can be helpful so that everyone is on the same page. This is especially helpful on admission as sometimes people are too distressed or unwell to give a good description of how things have been going. In addition to counselling and other therapies, medication additions and changes are usual during admission. Needless to say, the aim is to get you feeling better as quickly as possible, but side effects can occur, so it is important to report them to staff so you can be reviewed in a timely manner. Sedation is common from treatments for agitation and psychosis, for instance. The transition from admission to discharge will likely include a stepped approach of increasing periods of day leave. This can help with improving confidence in tackling daily activities such as going to the shops or taking public transport  <a href='https://www.freepik.com/free-photos-vectors/background'>Background vector created by freepik - www.freepik.com</a> Involuntary admissionThere are circumstances when it is deemed necessary for a person to be admitted against their will. This might be for a variety of reasons. SANE Australia has a useful summary below [3], as follows. “The laws covering involuntary hospitalisation vary from state to state, but generally, you can only be hospitalised involuntarily if you’re judged to meet all of the following criteria:
and one or both of these criteria:
SANE Australia also point out that almost a third of specialist psychiatric unit admissions were involuntary in the period 2014-2015, which shows that this is not such a rare situation at all. You can find out more about involuntary treatment, including treatment orders, legal rights and advocacy services on their website here.  <a href="https://www.freepik.com/free-photos-vectors/food">Food vector created by studiogstock - www.freepik.com</a> After discharge from hospitalIt can be daunting to find yourself outside the safe ‘bubble’ of a psychiatric unit. Home, work, relationships and other potential stressors may look intimidating, so it might be helpful to ask for support from a loved one or good friend in addition to your psychiatrist, GP and/or case worker. Emotional reactions about the hospital stay might include anxiety, shame or anger; or worry that you may be admitted again in the future. Whatever you are thinking or feeling, it is always worth exploring and considering talking this through with a trusted person whether that is a loved one, your doctor, a therapist, or a support group [7]. Research in bipolar disorder suggests that there is an association between sleep disturbance and mood episodes; although it is unclear whether sleep disturbance causes the mood episode or the other way round [4]. In any case, it is recommended to have around eight hours sleep per night [5] or as advised by your doctor, Try to timetable in regular meals, snacks, and sleep. The zeitgeber theory suggests that episodes of depression and mania or hypomania arise as a consequence of life events that disturbs social zeitgebers such as mealtimes and bedtimes, and these changes then derail the circadian rhythm, causing relapse [6]. If you find setting a routine difficult, perhaps you could build on what you were following in hospital. Try making small realistic goals such as having a daily shower, going for a daily walk, establishing regular meals or sleep routine. Finally, when it comes to returning to work or other responsibilities, a gradual, stepped approach is usually best especially after a long period of illness. You could speak to your doctor about how to do this in a way that does not cause you undue stress, whilst helping you regain confidence–for instance asking friends and family for help, or initially asking your workplace for shorter and fewer shifts, or alternative duties as you return to normal life. Suggested readingReferences1. Australian Institute of Health and Welfare. 2020. Mental health services in Australia. [ONLINE] Available at: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/overnight-admitted-mental-health-related-care/specialised-overnight-admitted-patient-mental-health-care. [Accessed 27 June 2020]. 2. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc. 3. SANE Australia. 2020. Involuntary treatment. [ONLINE] Available at: https://www.sane.org/information-stories/facts-and-guides/involuntary-treatment. [Accessed 27 June 2020]. 4. Fast, J. and Preston, J., 2006. Take Charge of Bipolar Disorder, A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability. 1st ed. New York, USA: Hachette Book Group. 5. 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]. 6. 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]. 7. 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]. Although it is my pleasure to write every article about bipolar disorder without remuneration., please feel free to support the costs of running this website by making a purchase.
I will earn a small commission, at no extra cost to you, if you purchase through any of the Amazon affiliate links on this website. But it's also totally fine if you want to Google them instead. Thank you!  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
#hepatitisB #HepB #HepFreeAus @ASHMMedia @NO_hep @Hep_Alliance
@HepAus @LifelineAust @beyondblue #mentalhealth #depression #anxiety #stigma  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.
#covid19 #coronavirus #mentalhealth #stress #depression #anxiety #wellness #goals #CBT  Image by Emilian Danaila from Pixabay First published in Bipolar Life's April 2020 newsletter INTRODUCTIONMost people living with bipolar disorder understand the importance of medication in the management of their condition. We know that medications are to be taken lifelong, with a few exceptions. We also understand that they are taken in addition to, not as a replacement for, other treatments such as psychotherapy, healthy lifestyle and a good routine; this includes a good sleep pattern, regular exercise, good nutrition and strong social support. So, what happens if we don’t treat bipolar disorder in the right way, for instance self-treating? The following scenarios could happen [1]:
Therefore, it makes sense for you to work with your doctor to ensure the medications prescribed are right for you. As all medications can cause side effects, it is essential to be open and honest with your prescribing doctor if you are experiencing any problems. It is inadvisable to reduce or stop a medication without consulting with your doctor first. In this article we are going to look at:
Bipolar disorder is treated with three main classes of medication: mood stabilisers, antipsychotics and antidepressants. Sometimes your doctor may prescribe (usually short term) anti-anxiety and sleep aids–benzodiazepines and Z drugs. In this article we won’t go into much detail how they are used, such as acute treatment versus maintenance, or what is used for mania versus depression. Instead we’ll just concentrate on the side effects aspect to keep the article reasonably short. MOOD STABILISERS – LITHIUM [1,5]Around 75% of people of people taking lithium for bipolar disorder get side effects [2]. It is effective for mania, and is gold standard for maintenance therapy, and may help bipolar depression [1]. Important note on lithium toxicity This can be caused by various factors such as taking too many tablets, dehydration, or having a sudden drop in kidney function. This can be a dangerous condition and needs urgent medical attention. Symptoms can include nausea, vomiting, diarrhoea, drowsiness, unsteadiness, confusion, agitation, blurred vision, severe tremors, muscle jerks or seizures [4]. People taking lithium are recommended to have regular blood tests to check lithium levels, kidney and thyroid function [5]. How to avoid dehydration To avoid dehydration, it’s important to keep well hydrated especially if exercising, or in hot weather. Try not to have too much caffeine or alcohol as they can dehydrate. Medications such as diuretics and non-steroidal anti-inflammatory drugs (such as ibuprofen) can also cause lithium levels to rise so care is needed. We’ll now look at the anticonvulsants which are also used as mood stabilisers. MOOD STABILISERS – ANTICONVULSANTS [1,6]Important note on Stevens-Johnson syndrome This is a rare, serious disorder of the skin and mucous membranes. It usually begins with flu-like symptoms (such as fever, fatigue, cough), then a red or purplish blistering rash that spreads over the body. The mouth, eyes, nose and genitals can be affected [7]. You must seek immediate medical attention if you suspect you are having this reaction to a medication. ANTIPSYCHOTICS [1,8]The first antipsychotics developed, now known as first-generation typical antipsychotics (FGA), were used to treat people with schizophrenia in the 1950s. The second-generation antipsychotics (SGA) came out in the 1980s, and are commonly known as atypical antipsychotics [9]. The SGAs are helpful in reducing mania and in strengthening antidepressant treatment [1]. The SGAs generally are far less likely to cause a particular class of side effects, the extrapyramidal side effects such as restlessness, muscle stiffness, involuntary neck spasm, Parkinson’s like movements, involuntary facial and mouth movements [10]. It is recommended that people taking antipsychotics should have 6-12 monthly monitoring to check weight, blood pressure, fasting glucose and cholesterol, and ECG (heart trace) [11]. ANTIDEPRESSANTS [1,12]Treating depression in someone with bipolar disorder is less straightforward than for unipolar depression. For instance, in type 1 bipolar, antidepressants may be less effective [1]. Also, mania can be triggered by use of an antidepressant, particularly if the person is not also taking a mood stabiliser. There are several classes of antidepressant. Some of their brain actions are similar, some are different, and this is reflected in the differing side effect profiles in the table below.  There are some less commonly used antidepressants available in Australia. These include mirtazapine, trazodone, the Tricyclic Antidepressants (TCAs, such as amitriptyline and nortriptyline) and MAOIs (monoamine oxidase inhibitors such as phenelzine and tranylcypromine). You can read more about TCAs here [15] and MAOIs here [16]. ANTI-ANXIETY AND SLEEP MEDICATIONSAnti-anxiety medications (anxiolytics) and sleep aids (hypnotics) can be immensely helpful in the acute phase of depression and mania treatment. These are generally within the class of benzodiazepines (such as diazepam, temazepam, lorazepam) or Z drugs (such as zopiclone, zolpidem). Both benzodiazepines (“benzos” for short) and Z drugs pose a risk of dependence, so these medications are usually prescribed for as short a time as possible. Some people do require them longer term, but this requires strict monitoring by their doctor. Side effects can range from mild to severe. This can include daytime sedation, or impaired ability to drive, operate machinery or perform certain tasks. In overdose, or if taken with certain other drugs (prescribed, over-the-counter or illicit), or alcohol, adverse effects can be severe and even result in coma or death. The elderly are also at particular risk from these medications. It is possible to become dependent after just a few weeks of taking them regularly [17]. Signs of this process happening include:
Withdrawal from benzos needs to be done with regular review by your doctor. Some people can feel unwell if reducing too quickly, and may experience agitation, insomnia, hallucinations and seizures [17]. WHO MIGHT BE AT INCREASED RISK FOR SIDE EFFECTS?Older people are less able to metabolise their medications through the kidney and liver. At any age, but often more commonly seen in the elderly, being on a cocktail of medications can increase the risk for drug interactions and adverse effects. This is an important issue that needs regular monitoring by their doctor [20]. People who have pre-existing medical conditions may find them aggravated by weight gain, increased glucose or cholesterol. These conditions include high blood pressure, heart disease, history of stroke, diabetes, liver disease, kidney disease and arthritis. Substance use disorder can be seen in one-third to one-half of people with bipolar disorder [1]. People who drink alcohol, particularly if in excess of recommended levels, or take illicit drugs, may be at higher risk for side effects–in addition to the drugs and alcohol potentially worsening control of their bipolar disorder. Alcohol may cause dangerous interactions, especially when taken with lithium and benzodiazepines [1]. WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTSKeeping a journal when you start or change a drug regimen can be helpful in working out if a symptom is really a side effect or whether it is the illness, or something else entirely. If you think you are getting side effects, regardless of whether they are new or longstanding, it is a good idea to check in with your doctor. It might be decided that they side effects are mild and non-serious, and the benefits of the medication outweigh the adverse effects, in which case you could opt to continue. Possible other scenarios include:
TIPS FOR SPECIFIC SIDE EFFECTSHere are some tips for specific issues. Once again, these are ideas for you to discuss with your doctor first. TREMOR [3]
NAUSEA [3]
SEDATION [1]
WEIGHT GAIN
SEXUAL DYSFUNCTION
MEMORY AND COGNITIVE ISSUES [3]
HAIR LOSS (SODIUM VALPROATE]
ConclusionMedication is vital to most people’s bipolar treatment plan. It is important to be aware of possible side effects and to bring them to your doctor’s attention as soon as possible, so that you can both decide on the best course of action for your health. If you think this article might help someone else too, please like and share. All content within this article is for informational purposes only and is not intended to serve as a substitute for individual consultation with a qualified physician. References1. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc. 2. WebMD. 2018. Lithium for Bipolar Disorder. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-lithium#2. [Accessed 22 March 2020]. 3. UpToDate. 2019. Bipolar disorder in adults and lithium: Pharmacology, administration, and management of side effects. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-adults-and-lithium-pharmacology-administration-and-management-of-side-effects?search=lithium&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H182696807. [Accessed 22 March 2020]. 4. UpToDate. 2018. Lithium poisoning. [ONLINE] Available at: https://www.uptodate.com/contents/lithium-poisoning?search=lithium&topicRef=15317&source=see_link#H5. [Accessed 22 March 2020]. 5. UpToDate. 2019. Unipolar depression in adults: Treatment with lithium. [ONLINE] Available at: https://www.uptodate.com/contents/unipolar-depression-in-adults-treatment-with-lithium?search=lithium&source=search_result&selectedTitle=4~148&usage_type=default&display_rank=3#H2519581674. [Accessed 22 March 2020]. 6. UpToDate. 2020. Antiseizure drugs: Mechanism of action, pharmacology, and adverse effects. [ONLINE] Available at: https://www.uptodate.com/contents/antiseizure-drugs-mechanism-of-action-pharmacology-and-adverse-effects?search=valproate&source=search_result&selectedTitle=3~148&usage_type=default&display_rank=2#H1398705747. [Accessed 22 March 2020]. 7. Mayo Clinic. 2018. Stevens-Johnson syndrome. [ONLINE] Available at: https://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/symptoms-causes/syc-20355936. [Accessed 22 March 2020]. 8. UpToDate. 2020. Second-generation antipsychotic medications: Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/second-generation-antipsychotic-medications-pharmacology-administration-and-side-effects?search=antipsychotic&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H466014692. [Accessed 22 March 2020]. 9. National Center for Biotechnology Information. 2012. First-Generation Versus Second-Generation Antipsychotics in Adults: Comparative Effectiveness [Internet].. [ONLINE] Available at: https://www.ncbi.nlm.nih.gov/books/NBK107237/. [Accessed 22 March 2020]. 10. UpToDate. 2020. Second-generation antipsychotic medications: Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/second-generation-antipsychotic-medications-pharmacology-administration-and-side-effects?search=extrapyramidal%20side%20effects&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H191681745. [Accessed 22 March 2020]. 11. National Prescribing Service Limited. 2011. Antipsychotic monitoring tool. [ONLINE] Available at: https://resources.amh.net.au/public/antipsychotic-monitoring-tool.pdf. [Accessed 22 March 2020]. 12. Hu, X., 2004. Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate.. Journal of Clinical Psychiatry, [Online]. 65(7), 959-65. Available at: https://www.ncbi.nlm.nih.gov/pubmed?term=15291685 [Accessed 22 March 2020]. 13. UpToDate. 2020. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/serotonin-norepinephrine-reuptake-inhibitors-snris-pharmacology-administration-and-side-effects?search=venlafaxine§ionRank=1&usage_type=default&anchor=H276509267&source=machineLearning&selectedTitle=2~148&display_rank=1#H18324389. [Accessed 22 March 2020]. 14. UpToDate. 2020. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/serotonin-norepinephrine-reuptake-inhibitors-snris-pharmacology-administration-and-side-effects?search=duloxetine§ionRank=1&usage_type=default&anchor=H1409194297&source=machineLearning&selectedTitle=3~99&display_rank=2#H1409194297. [Accessed 22 March 2020]. 15. myDr.com.au. 2018. Tricyclic antidepressants. [ONLINE] Available at: https://www.mydr.com.au/mental-health/tricyclic-antidepressants. [Accessed 22 March 2020]. 16. myDr.com.au. 2018. Monoamine oxidase inhibitors (MAOIs) for depression. [ONLINE] Available at: https://www.mydr.com.au/mental-health/monoamine-oxidase-inhibitors-maois-for-depression. [Accessed 22 March 2020]. 17. benzo.org.uk. 2002. Benzodiazepines: how they work and how to withdraw. [ONLINE] Available at: https://www.benzo.org.uk/manual/bzcha00.htm. [Accessed 22 March 2020]. 18. Patient. 2017. Benzodiazepines and Z Drugs. [ONLINE] Available at: https://patient.info/mental-health/insomnia-poor-sleep/benzodiazepines-and-z-drugs. [Accessed 22 March 2020]. 19. WebMD. 2019. Benzodiazepine Abuse. [ONLINE] Available at: https://www.webmd.com/mental-health/addiction/benzodiazepine-abuse#2. [Accessed 22 March 2020]. 20. Dols, A., 2013. The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar disorder from a clinical perspective: a review.. International Clinical Psychopharmacology, [Online]. 28(6), 287-96. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23873292 [Accessed 22 March 2020]. 21. Nelson, J., 2017. Mindful Eating: The Art of Presence While You Eat. Diabetes Spectrum, [Online]. 30(3), 171–174. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556586/ [Accessed 22 March 2020]. 22. Better Health Channel. 2012. Weight loss - a healthy approach. [ONLINE] Available at: https://www.betterhealth.vic.gov.au/health/healthyliving/weight-loss-a-healthy-approach. [Accessed 22 March 2020]. 23. NHS. 2019. Start losing weight. [ONLINE] Available at: https://www.nhs.uk/live-well/healthy-weight/start-losing-weight/. [Accessed 22 March 2020]. 24. La Torre, A., 2013. Sexual dysfunction related to psychotropic drugs: a critical review part II: antipsychotics.. Pharmacopsychiatry, [Online]. 46(6), 201-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed?term=23737244 [Accessed 22 March 2020]. 25. Kakunje, A., 2018. Valproate: It's [sic] Effects on Hair. International Journal of Trichology, [Online]. 10(4), 150–153. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6192236/ [Accessed 22 March 2020]. @BipolarLifeVic @finkshrink @WebMD @UpToDate @MayoClinic @NPSMedicineWise @mydrwebsite
@patient @BetterHealthGov @NHSuk  Photo by Shelby Deeter on Unsplash First published on Hepatitis Australia's website in March 2020 "Having HBV is only a small facet of who you are, and not a reason to give up on a loving relationship. A partner who accepts you as you are and wants the best for you is someone who will not see HBV as a barrier to getting to know you.” Although most people get hepatitis B at birth, it can be transmitted in other ways including sex. This article contains information about how it is spreads, and how you can keep your partner safe. How Hepatitis B is spread through sexHepatitis B contained in blood, semen or other fluids can be spread through unprotected vaginal, anal or oral sex. As it is very infectious, it transmits easily through breaks in the skin or mucous membranes (the lining of the nose, mouth, eyes and other soft tissues) [2]. We also need to remember that hepatitis B infection can occur through non-sexual contact such as sharing toothbrushes, razors or contact with an infected open wound. However, it is not spread through normal hugging or kissing, or sharing meals, showers or toilets with someone who has hepatitis B [3]. How can we prevent the spread of hepatitis B?The best way to prevent hepatitis B infection, is to get vaccinated. Given hepatitis B can be spread in many different ways, it is strongly advised that all household contacts and sexual partners should be vaccinated, as well as using condoms with sexual partners [4]. By the way, vaccination is usually free for the above groups [5]. If you are concerned you may have been put at risk of hepatitis B, or that you may have put someone else at risk, contact your GP or local sexual health clinic straight away. Your doctor can also contact a sexual partner for you, without including your details if you wish to stay anonymous. Telling others about your diagnosisAfter you have had time to come to terms with your diagnosis [6], you may wish to start thinking about disclosing your condition to others.There are many possible reasons for disclosure, such as:
Knowing when and how to disclose can be difficult. Some people may be supportive, whereas others may withdraw or even be angry. Often this is due to their lack of knowledge about the condition. Be prepared that a relationship may change or even end. Here are some tips that may help with the process [7]:
Finally, you may find these insights help you to negotiate your own relationships and communicate your diagnosis. “My personal philosophy and method is to be selective about the people I choose to date. To me, it is important if the potential date has common sense and good character. Once I feel this person is worthy of my time and attention, I have the talk about my hepatitis B, and that HBV is vaccine preventable. If they are interested in continuing a romantic relationship with me, they need to be vaccinated to protect against HBV. Some may have already been vaccinated, and if so, HBV is no longer an issue.” “You need to approach dating, not as who will ‘accept’ you, but rather who ‘deserves’ you. Perspective is everything. If you see a health issue like HBV as a unique barrier to intimacy others will not understand and might reject you for, you will create self-defeating thoughts that not only limit your happiness, but are inaccurate. Everyone has issues. Whether it is health, mental, social or financial, we all feel alone at times and want a connection with another soul.” If you think this article might help someone else too, please like and share References
 Image by Gerhard Gellinger from Pixabay First published in Bipolar Life's newsletter in February 2020 It is so important to remember that you are not defined by your illness. Though bipolar disorder is thought to be biological in origin, with changes in genes accounting for maybe 60-70% of BPAD [1], it is also believed that the other factors are environmental, meaning there is so much that you can do to get better and stay well. Making use of the medical modelThe medical model emphasises regular monitoring, medications and psychotherapy to treat the condition in the acute and maintenance phase. Side effects such as weight gain or tremor from medications may need to be addressed in a collaborative manner with your doctor. Regular testing for medication levels, organ health (like kidney and liver function, cholesterol and sugar may also be necessary, especially as it has been found that there are higher rates of diabetes and cardiovascular disease in people with bipolar disorder [1]. Your team may include a psychiatrist, GP, psychologist, dietician, exercise physiologist and more. It’s important to find the right health care professionals so that you can feel comfortable and confident working with them towards your health goals. This article [2] might help you with some ideas on what to look for in your healthcare provider. In addition to talking therapy with your psychiatrist and one-to-one sessions with a psychologist, therapy may be available in the form of inpatient or outpatient group programs. Depending on where you live in relation to public and private psychiatric facilities, available programs might include: Cognitive Behavioural Therapy (CBT), Mindfulness, Schema therapy, Acceptance and Commitment Therapy (ACT), Interpersonal therapy, Art and Music therapy to name a few. Many people have found such courses invaluable, not just because they are taught in a kind, supportive environment but also because the benefits of these tools can last a lifetime. Ask your psychiatrist about these if you are interested. You can also speak to your GP about the following Care Plans, which can help eligible persons with allied health costs: Bringing in a wellness and recovery focusA more person-centred, holistic approach complements your other treatments by strongly encouraging appropriate lifestyle modifications and personal strategies. Some of these personal stories [5] on the Depression and Bipolar Support Alliance (DBSA) website by people with lived experience of bipolar disorder may inspire you further on your own journey. Here are some of their experiences:
Remember you are not alone – a helpful exercise might be to write down the people who are in your support network. This might include a partner, peers from a local group (or online forum), friends, family, doctor or psychologist. These people can offer not only a listening ear but can also help you reach your goals. Dr.Holly Swartz, Professor of Psychiatry at University of Pittsburgh School of Medicine, U.S.A. highly recommends optimising lifestyle factors given bipolar disorder doubles the rate of cardiovascular disease and medications exacerbate it. Healthy schedules, routine and sleep are all therefore needed to support bipolar disorder recovery and to achieve goals [6]. The Quality of Life Tool (QoL) tool [7] was produced by The Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder. It is a free online resource for a user to intermittently fill in a simple questionnaire where they can rate satisfaction levels for energy, mood, sleep, work, money, relationships and other domains. The tool then displays the data as a graph and table where the user can easily see where they’ve progressed, and where they might want to focus more attention. You can find some tips in our October [8] newsletter on Routine, Goal Setting and Values and the DBSA has some useful information here too [9]. Check the BipolarLife newsletter for the next monthly support group meeting.in your area. If you think this article might help someone else too, please like and share References
First published on Hepatitis Australia's website in January 2020  Image by marker_photography from Pixabay “Detox diets”, supplements and Traditional Chinese Medicine are marketed as beneficial for the liver, but do they work? First let’s look at where the liver is and what it does. Liver anatomyIts functions include:
Detox dietsAlso known as a liver cleanse or flush, some people believe a detox diet helps remove excess waste after too much alcohol, unhealthy foods, or just for daily liver health. The first days may begin with fasting or drinking fluids only. Most detox diets take out processed food from your diet and may include commercial products, such as herbal supplements. Some people feel better on these diets, often simply due to eating more healthily. This might cause them to believe that the liver cleanse works, but it’s important to consider the following:
For most people following a healthy lifestyle, the liver is well equipped to remove day-to-day toxins and you don’t need to do a detox. SupplementsSome studies in animals show milk thistle decreases liver inflammation, and turmeric protects against liver injury. However, there haven’t been enough studies done on humans to recommend their use in prevention of liver disease [4]. The US National Center for Complementary and Integrative Health (NCCIH) advises that milk thistle can cause allergic reactions in some people or low blood sugar in people living with diabetes [5]. We should also remember that detox products and liver supplements may not be standardised. Products could have different strengths and be of varying quality. Some may interact with medication or have side effects including causing liver damage. Traditional Chinese MedicineTraditional Chinese Medicine (TCM) views the liver in terms of vital energy (qi) and the storage of blood (xue). Together with the scheme of Yin Yang, TCM practitioners may diagnose liver disorders, and offer treatments like acupuncture or herbs [6]. There is no evidence that acupuncture helps people with liver conditions. However, it is relatively safe if performed correctly [7]. Because there have been very few good quality studies, we have no strong proof that Chinese herbal products work for liver health. Some products have also been found to have been contaminated with plant or animal material, drugs like the blood-thinner warfarin, and heavy metals like arsenic. Some products can even contain the wrong herbs, which may damage the liver [8]. Therefore, it is very important that you are confident of what is in the Chinese herbs you buy. If you decide to use Chinese herbs or other supplements, it is advisable that you talk to your doctor, especially if you have hepatitis B or C, or other chronic diseases. Finally, the best way to look after your liver is maintain a healthy weight, follow a balanced diet, exercise regularly, minimise alcohol intake, and avoid smoking. If you think this article might help someone else too, please like and share. References
 Image by PublicDomainPictures from Pixabay First published on Bipolar Life's website in December 2019 Though bipolar disorder affects the same number of men as women [1], 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. Top facts
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 [3]. 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 [4]. A study of almost 300 women [5] 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 [2]. ContraceptionAs 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 [6]:
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 [7]. On the other hand, some women will experience fewer recurrences during pregnancy [6]. 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 [8]. 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 [10]. MenopauseThere 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 [2], more research is needed to confirm these findings and to further guide clinicians on medical management during perimenopause. If you think this article might help someone else too, please like and share Disclaimer: this content is not a substitute for individual medical advice. References1. 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 Bipolar Life's website 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[1]. Even with such popular usage and marketing messages like “safe” and “natural”, one should bear in mind that many supplements:
In addition:
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[3]. SupplementsOmega-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[5]. Some research suggests that there is body inflammation in acute mania, and to a lesser extent, in bipolar depression[4]. It is possible that omega-3 fatty acids may reduce inflammation in the nervous system[8]. However, though there are conflicting studies on whether omega-3 helps treat or prevent episodes of mania or depression[6], 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[7]. 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[8]. SAMe 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[9]. Dr William Walsh even states that some people with bipolar disorder could already have excessive SAMe in their bodies[3]. 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[8] 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 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[11]. 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[12]. For now, there is a lack of clear consensus on whether melatonin is helpful in bipolar disorder[11]. Other supplements 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[13]. 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[15]. 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[16]. 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[17]. 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[18]. 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[8]. 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[7]. 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[20]. Dr Walsh comments that people with bipolar disorder may have folate under- or overload, so individual tailoring of folate supplementation may be beneficial[3]. 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[21]. Another study in 2000 suggested that taking magnesium with the drug verapamil reduced manic symptoms better than verapamil alone[22]. 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. DietWhat 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 [24]. An interesting recent study[25] 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[24] 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[26]. Depression and Bipolar Support Alliance (DBSA) suggests keeping a food and mood journal to see if a symptom is triggered by something dietary[27]. 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: HIGHER AMOUNTS: fruits, vegetables, legumes wholegrains and cereals nuts and seeds LOW-MODERATE AMOUNTS: 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:
If you think this article might help someone else too, please like and share 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 References1. 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].  Photo by Emma Matthews Content Production on Unsplash First published in Bipolar Life's website 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[1]. Why is circadian rhythm so important?Dr Yoshikazu Takaesu[2] 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[3] 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[4], 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[5]. Dr Ellen Frank recommends having three to four smaller meals per day to help keep mood and energy levels stable[4]. 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[5]. A treatment based on this idea, called “interpersonal and social rhythm therapy” (IPSRT), has been shown as effective in reducing relapse in bipolar disorder[3]. 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[8] (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.  Photo by Greg Rakozy on Unsplash 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. 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. 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. Of course, setting and achieving goals is not always straightforward. Don Kattler[10], 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. If you think this article might help someone else too, please like and share References1. 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].  Image by Waltteri Paulaharju from Pixabay 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. Emotional reactionsAfter 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. StigmaStigma 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 processBe 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. SupportHaving 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. Come prepared 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. If you think this article might help someone else too, please like and share References
 Image by Free-Photos from Pixabay First published on Bipolar Life's website 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-stigmaIt 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”. ConclusionWith 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. If you think this article might help someone else too, please like and share ReferencesYouTube. 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].  Image by Bruno Glätsch from Pixabay 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.  Photo by chuttersnap on Unsplash Patient patients 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. Agenda setting 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.  Image by Kristin Baldeschwiler from Pixabay 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? Confidentiality 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.  Image by Arek Socha from Pixabay 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.  Image by truthseeker08 from Pixabay 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. In conclusion 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. If you think this article might help someone else too, please like and share 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 Money Talks 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. If you think this article might interest someone else too, please like and share References 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.”
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 communicationHere'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”. Sounds bad. 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 contentAs 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 |
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