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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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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 :
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  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.
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The 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 .
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 .
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 
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.
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 actions
Identification 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:
The SMART acronym apparently first appeared in 1981 in Management Review. Since then, SMART has been used by a tool by countless organisations and individuals to help people identify and reach their goals. There are a few different versions, but we will use a commonly used one for the purposes of the article.
Don’t forget that we may need to break down a single goal into smaller ones, and more than one goal can run at the same time, so write down your ideas and plans.
To make sure your goals are clear and reachable, each one should be:
Reward yourself for completion of a goal if that helps, as some tasks are an effort and not always enjoyable.
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.
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 . 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.
1. Pfefferbaum, B., 2020. Mental Health and the Covid-19 Pandemic. The New England Journal of Medicine, [Online]. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2008017 [Accessed 3 May 2020].
2. Australian Government Department of Health: Factsheet Coronavirus (Covid-19) National Health Plan. Available at: https://www.health.gov.au/sites/default/files/documents/2020/03/covid-19-national-health-plan-supporting-the-mental-health-of-australians-through-the-coronavirus-pandemic.pdf [Accessed 3 May 2020].
3. National Institute of General Medical Sciences. 2019. Circadian Rhythms. [ONLINE] Available at: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx. Accessed 10 October 2019].
4. Mayo Clinic. 2019. How many hours of sleep are enough for good health?. [ONLINE] Available at: https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/how-many-hours-of-sleep-are-enough/faq-20057898. [Accessed 3 May 2020].
5. Association for Psychological Science. 2016. Controlling Mood Disorders: A Matter of Routine. [ONLINE] Available at: https://www.psychologicalscience.org/observer/controlling-mood-disorders-a-matter-of-routine. [Accessed 10 October 2019].
6. William Miller, University of New Mexico, (2019), Personal Values Card Sort [ONLINE]. Available at: https://www.guilford.com/add/miller2/values.pdf?t [Accessed 10 October 2019].
7. Don Kattler, Collaborative RESearch Team to study Bipolar Disorder, UBC. (2015). CREST.BD Home & Bipolar Disorder Slides. [Online Video]. 6 March 2015. Available from: https://www.slideshare.net/crestbd/crestbd-home-webinar-slides. [Accessed: 10 October 2019].
All content in this article is for informational purposes only and is not intended to serve as a substitute for individual consultation with a qualified physician.
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Dr Alice Lam
I'm a doctor who is passionate about writing quality health content.