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First published on Bipolar Life's July 2020 newsletter
Even 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 , 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.
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What to expect
Some 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 :
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
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There 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 , 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.
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After discharge from hospital
It 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 .
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 . In any case, it is recommended to have around eight hours sleep per night  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 .
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.
1. 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].
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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.
Many 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 . 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 . 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 . 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 .
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 . 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  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 .
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 .
"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."
Many 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  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 . 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 :
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.
1. 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].
First published in Bipolar Life's April 2020 newsletter
Most 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 :
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 . It is effective for mania, and is gold standard for maintenance therapy, and may help bipolar depression .
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 .
People taking lithium are recommended to have regular blood tests to check lithium levels, kidney and thyroid function .
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 . You must seek immediate medical attention if you suspect you are having this reaction to a medication.
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 . The SGAs are helpful in reducing mania and in strengthening antidepressant treatment .
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 .
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) .
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 . 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  and MAOIs here .
ANTI-ANXIETY AND SLEEP MEDICATIONS
Anti-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 . 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 .
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 .
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 . 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 .
WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTS
Keeping 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 EFFECTS
Here are some tips for specific issues. Once again, these are ideas for you to discuss with your doctor first.
MEMORY AND COGNITIVE ISSUES 
HAIR LOSS (SODIUM VALPROATE]
Medication 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.
1. 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
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 sex
Hepatitis 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) .
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 .
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 . By the way, vaccination is usually free for the above groups .
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 diagnosis
After you have had time to come to terms with your diagnosis , 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 :
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
First published in Consumers Health Forum of Australia’s newsletter May 2019
A recent study in 2018 by the Australian Bureau of Statistics (ABS) revealed that people with three or more long-term health conditions felt less socially supported compared to people without.
As cited in this newsGP article, the average person attends their GP on average six times a year, and a specialist once a year. It is therefore evident that health literacy and quality of healthcare has never been so important.
Having worked as a GP for 16 years, and living with my own health issues, I can see the health system from both sides. Over the years, I’ve shared the journey of thousands of patients and advocated on their behalf countless times.
In this article, I’d like to offer some practical suggestions for the health consumer in order to get the very best out of your GP.
Booking your appointment
The receptionist is the gatekeeper to your GP. Often GPs will allow long appointments to be booked for certain issues (like mental health and women’s health) or if it is for multiple issues. Without pre-planning, it is not always possible for the GP to just extend the consultation if they have others waiting to be seen. Don’t worry if your GP recommends that you return for a further appointment if the condition is complex, as some things can’t be dealt with in the standard 15-minute slot.
If it is the first time you will see Dr X, it will take some time for them to get to know your past medical history so they can put your current issues into context. It can save time to bring in a health summary from your last GP, or to write one of your own beforehand. List any serious medical problems and hospital admissions, operations, medications and allergies, and family history.
What you want from your consultation may be different from your GP. Unless they know you well and you have a good mutual understanding, there is a risk that you will leave the room dissatisfied. If you can, clarify your needs beforehand (including thoughts, concerns and any expectations) about your health. If you have more than one problem, tell your GP at the beginning so that you can both prioritise and set aside the appropriate amount of time. Rushing through a list just to get them ticked off in one go is not good news in the long run.
Photo by Alice Lam @AliceLamWriter
On the record
Writing things down before and during the consultation can be beneficial if you’d like to have a record for later. Sometimes I provide a typed or written summary of major ‘take home’ points for my patients, especially if a lot has been covered in a session. I started doing this after a few occasions when patients returned, having completely forgotten points discussed, or to carry out certain agreed actions from the last consultation!
Is your GP listening?
GPs are trained to listen first, and speak later. Unfortunately, not all GPs abide by that saying. A study in the USA found that many patients will have stated their agenda by about six seconds, though some took as long as almost two minutes. Doctors only elicited a health consumer’s agenda half the time (contrasting with specialists who lagged behind, only getting the patient’s agenda one-fifth of the time).
So, that first minute or more when you start talking is golden and should be uninterrupted. It’s that precious time when you bring up your agenda in your own time and style. Many GPs, myself included, have been tempted at times to start bombarding the patient with questions, thinking we already have the answers.
If you don’t feel you’ve had a chance to say everything you need (within reason), ask your GP to let you finish. It is well known that not listening adequately to a health consumer leads to problems, such as missing particular details and as a result, doing the wrong examination, or ordering the wrong tests for instance. In the worst case scenario, you could get the wrong diagnosis and treatment.
What is your GP thinking?
Doctors may share similar training yet we develop our own methods of diagnosing and treating our patients. One GP might like to get a good understanding of all your past medical issues, family history, smoking and alcohol status etc. before moving on to your current problem. Having this knowledge at the start can often make a difference to the outcome.
An example: 30-year-old ‘Jenny’ comes in with a breast lump. She might receive a more conservative approach such as surveillance before having a scan further down the line, but if her family history is of cancers that increase her risk then management should, of course, be fast-tracked.
On the other hand, another GP may prefer to deal with a current issue and get to the less ‘urgent’ items on another occasion. That might make a health consumer feel happy that something has been done but may miss addressing items that could affect long term health.
An example: 50-year-old Joe comes in with a sore knee. It looks like arthritis and he is sent home with advice on painkillers and exercise. He feels better so he doesn’t return. But he hasn’t been asked about his father and uncle dying of heart disease in their 40s, so this might be a missed opportunity for screening
Do I need an examination?
Many patients feel embarrassed or apprehensive about having certain intimate examinations. That is quite understandable, and even doctors can feel the same way when they see another doctor. GPs are used to patients getting nervous, and if made aware beforehand, they can gently explain about the procedure and take it at the patient’s pace.
Personality and communication
These are aspects which have a significant impact on how your consultation will go. Is your GP rigid or flexible? Are they paternalistic, as in “Do as I say” or more about you – “What would you like to do?” It depends on your personality as to whether you’ll be able to work together towards your health goals.
Does your GP explain difficult terms, and answer your questions to your satisfaction? Are they patient with you? Do they encourage you to take on responsibility and autonomy in your health management, where possible?
Something that is not talked about much, is when GPs (and other doctors) talk within earshot of receptionists, other doctors, and worse still, other patients. Your GP should never discuss your health with anyone else without your permission. A good doctor never forgets about confidentiality and the circumstances where this trust can be broken are extremely rare.
Continuity of care
Ideally, you will have just one GP who works full time. This means they will know you and your issues and be able to manage you better than someone who only sees you occasionally. However, given that many GPs work part-time, and in any case all will take time off at some point, try to stick to a maximum of two GPs in the same practice. Not only will they be able to share your health record, they will be able to talk to each other to have more of a team approach to your care.
Getting a second opinion
When might you consider seeing a second GP? There can be times when your regular GP seems to have hit a roadblock with managing your health, or you just don’t gel for reasons of personality or communication style, for example.
If that happens, you have a right to seek a second opinion, either within the same practice or in a different clinic – the latter being a benefit of the Australian health system not available in countries like the UK. A fresh pair of eyes and a new perspective can make a big difference if progress has stalled. Some people feel guilty if they move to another doctor, which is understandable, but unfounded.
Asking for assistance
Apart from medical advice and treatment, what about navigating the health system? Only about a quarter of people surveyed by the ABS found it easy to navigate the health system, with increasing difficulty for people experiencing psychological distress. People may need help with booking an appointment for an outpatient clinic or an investigation, understanding a treatment plan, or working out the best options available. Again, ask your GP, receptionist or practice nurse if you need help.
Image by aj-garcia-454112-unsplash
Mental health issues
The Australian Institute of Health and Welfare (AIHW) found that during the period 2015-16, the number of people attending with mental health conditions was on the rise; a third of were attending with depression. And with an estimated four million Australians experiencing a common mental health condition in 2015, these statistics show how serious mental health care is.
There are many facets to a successful mental health consultation, and to go through them all would be outside the scope of this article.
In brief however, I would recommend that a long appointment be booked in advance, and if possible, that a partner/friend/relative accompanies you. In my experience, that gives the person emotional support, as well as the support person being able to ensure that their needs are met. In addition, more objective information can be provided this way, as often someone with mental health issues are too distressed or lacking in full insight to give a full explanation of their symptoms.
I’d also suggest keeping a daily journal, however brief. Even if it’s just a score out of ten for mood and sleep plus a sentence or two, it can be invaluable for dealing with the issues at hand.
Your health is of the utmost importance, and should be top priority for your doctor as well.
Look for a doctor with good communication skills, empathy and a collaborative approach that empowers you.
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Or, why shopping for health is now a 'thing'...
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Living In Denial
I have a confession to make.
As a doctor, I used to secretly grit my teeth when I heard patients being called ‘consumers’. And my blood pressure would rise sharply if I heard clinicians being called ‘health care providers’.
Why? Maybe it was because it felt as if the recognition of nine gruelling years of medical training were being reduced in some way. That the complexities of delivering personalised, holistic healthcare might be simply dissolved into discrete, saleable commodities.
Within doctor circles, I know that I have not been alone in this thinking.
Image by Steve Buissinne from Pixabay
How patients see the healthcare system
However, in viewing healthcare as a patient, I started to realise that the terminology wasn’t exactly incorrect either.
It's easy to argue that a patient makes choices and consumes services, with a freedom that is on the rise. And like it or not, anyone providing a health service is being appraised for more than just their clinical acumen. Patients are increasingly sharing feedback on third party sites including social media. Their posts then influence the next person's choice to use that service. For instance, a survey commissioned by Binary Fountain revealed:
Just for fun, let's consider 30-year-old Natalie who badly twists her ankle while playing netball one Sunday morning. Sensibly, she takes the home remedy option (rest, ice, compression, elevation, a good swear and some painkillers). She decides to ring her GP in case it’s more than a sprain. But it’s a Sunday morning, appointments are all booked out.
So she looks online for appointments at other nearby clinics – a benefit that we are lucky to have in Australia. Or she could attend the Emergency Department and risk a long wait to be seen. Or Natalie might drive with her one good leg to the private Emergency Department 10 kilometres away.
Hang on. We’re not out of options yet. She might attend the Urgent Care Clinic run by GPs next to the Emergency Department. She might Google the local private orthopaedic surgeon, orthotist, or physiotherapist. And not to forget she has telehealth up her sleeve (maybe not the best option for a musculoskeletal issue).
In the end, Natalie decides to drive by the supermarket for frozen peas and the pharmacy up the road for an ankle strap. Don't worry, she makes a full recovery.
Image by 3D Animation Production Company from Pixabay
Patients are migrating away from traditional models of health care because they are dissatisfied with it for various reasons. Some of those reasons may include a cultural and societal campaign for wellness and desire for increased personal responsibility. So even in the traditional setting of the family doctor giving a referral to their patient, choice still can take place afterwards.
Carrie Liken is head of industry for healthcare at Yext, a U.S. company that has helped multiple health organisations manage their digital presence. During her time working at Google, she found that many patients receiving a referral from their doctor would often search for alternatives after leaving the office.
I have no problem with that. I think the days of the borderline paternalistic consultation directing the compliant patient are coming to an end, and that is a good thing. And with the digital age, patients should be able to research and select beneficial services.
My main concern is that factors such as cost-saving or misinformation, may come to replace the ethical, family-orientated evidence-based management of traditional clinical practice.
Image by Tumisu from Pixabay
In true dialogue, both sides are willing to change. Thich Nhat Hanh
Care To Converse?
I recently listened to a conversation between David Shifrin of Health:Further, and Patrick Spear of Global Market Development Center (GMDC). For more on the concept of self-care, ‘patients-as-consumers’ and how U.S. healthcare and retail industries intersect, you might like to check out their fascinating podcast.
I am no longer gritting my teeth, but experiencing a deep curiosity about where Australian healthcare is heading.
It sound a little clichéd to say that we should stop competing and start collaborating. But realistically, health care providers need to begin an urgent exchange with one another. Only by doing so we will be able to provide health treatment options that are (a) in the patient’s best interests and (b) within the patient’s personal preferences.
Things will never be the same again. They might even be better.
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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
Dr Alice Lam
I'm a doctor who is passionate about writing quality health content.