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    Click on title description to find article.

 Articles

• Bipolar self-diagnosis test #1 (Goldberg Depression Scale)
• Bipolar self-diagnosis test #2 (Goldberg Mania Scale)
People diagnosing themselves with bipolar disorder.
• Medicare has a $4,250 Dental Benefits scheme available.
• An Audit of Treatment received for bipolar disorder.
• Revealing Lithium's Mode Of Action.
• Improving Your Memory.
• Lithium
• Lithium plus valproate combination therapy.
• Treatment Guidelines for Bipolar Disorder - RANZCP.
• A Forensic Psychology Dictionary.
• Lithium - Patient Information Leaflet.
• MoodSwings - an online intervention for bipolar disorder.   
• If I have bipolar disorder, how likely is it that my children will develop bipolar disorder as well?
The Australian Medical System - What to do and who to go to if something goes wrong.
Lithium for Bipolars

 Personal Stories

• When you are in your early twenties….
Rather than tell you my story…...


          
Bipolar self-diagnosis test #1 (Goldberg Depression Scale)

These tests  ARE NOT designed to diagnose any psychiatric disorder, nor are they intended to replace evaluation by a qualified psychiatrist.  They are only intended to measure the severity of depressive and/or manic symptoms, and thus to help the  reader decide whether to seek a psychiatric evaluation.

This section and the next involve the Goldberg Mood Scales, by Dr. Ivan K. Goldberg, M.D.  They are reprinted with his permission.

The Goldberg Depression Scale, below, is a self-administered  questionnaire designed to measure the severity of depressive   thinking and behavior.

Frequently, it is more obvious to those around us that we are depressed  than it is to ourselves.  Distorted judgment is part of having a mood  disorder, so it is not uncommon for our family and friends to recognize signs before we do.
This section and the next involve the Goldberg Mood Scales, by Dr. Ivan K. Goldberg, M.D.  They are reprinted with his permission.
The scales ARE NOT designed to diagnose any psychiatric disorder, nor are they intended to replace evaluation by a qualified psychiatrist.  They are only intended to measure the severity of depressive and/or manic symptoms, and thus to help the  reader decide whether to seek a psychiatric evaluation.
The Goldberg Depression Scale, below, is a self-administered questionnaire designed to measure the severity of depressive thinking and behavior.

 

Goldberg Depression Scale
-------------------------
1993  Ivan Goldberg

Frequently, it is more obvious to those around us that we are depressed than it is to ourselves.  Distorted judgment is part of having a mood disorder, so it is not uncommon for our family and friends to recognize signs before we do.
This section and the next involve the Goldberg Mood Scales, by Dr. Ivan K. Goldberg, M.D.  They are reprinted with his permission.

The scales ARE NOT designed to diagnose any psychiatric disorder, nor are they intended to replace valuation by a qualified psychiatrist.  They are only intended to measure the severity of depressive and/or manic symptoms, and thus to help the  reader decide whether to seek a psychiatric evaluation.

The Goldberg Depression Scale, below, is a self-administered questionnaire designed to measure the severity of depressive thinking and behavior.

The items  below  refer  to how  you have  felt  and behaved  DURING THE PAST WEEK. For each item, indicate the extent to which it is true, by circling one of  the numbers that follows it.  Using the following scale:

 

0 = Not at all                   1 = Just a little                2 = Somewhat
3 = Moderately                4 = Quite a lot                5 = Very much

==========================================================================

1.  I do things slowly.                                                                                                   0   1   2   3   4   5

2.  My future seems hopeless.                                                                                      0   1   2   3   4   5

3.  It is hard for me to concentrate on reading.                                                            0   1   2   3   4   5

4.  The pleasure and joy has gone out of my life.                                                         0   1   2   3   4   5

5.  I have difficulty making decisions.                                                                           0   1   2   3   4   5

6.  I have lost interest in aspects of life that used to be important to me.                     0   1   2   3   4   5 

7.  I feel sad, blue, and unhappy.                                                                                0   1   2   3   4   5

8.  I am agitated and keep moving around.                                                                 0   1   2   3   4   5

9.  I feel fatigued.                                                                                                        0   1   2   3   4   5

10. It takes great effort for me to do simple things.                                                     0   1   2   3   4   5

11.  I feel that I am a guilty person who deserves to be punished.                               0   1   2   3   4   5

12.  I feel like a failure.                                                                                                 0   1   2   3   4   5

13.  I feel lifeless - - - more dead than alive.                                                                 0   1   2   3   4   5

14.  My sleep has been disturbed---too little, too much, or broken sleep.                    0   1   2   3   4   5

15.  I spend time thinking about HOW I might kill myself                                             0   1   2   3   4   5

16.  I feel trapped or caught.                                                                                      0   1   2   3   4   5

17.  I feel depressed even when good things happen to me.                                      0   1   2   3   4   5

18.  Without trying to diet, I have lost, or gained, weight.                                          0   1   2   3   4   5

A score of 15 or higher on the depression scale indicates the possible need for a psychiatric evaluation.

 

Bipolar self-diagnosis test #2 (Goldberg Mania Scale)

Much like depression, mania is frequently more obvious to those around us that we are becoming manic or hypomanic than it is to us. Impaired judgment is every bit as much a part of mania as it is a part of depression, and it is not uncommon for someone on a manic upswing to think they simply feel so good because the damn depression is finally over.  Family and friends can usually tell the difference quite easily, although convincing the manic subject of his/her mania can be quite a different matter.

 

Goldberg Mania Scale
--------------------
1993  Dr Ivan Goldberg

The items  below  refer  to how  you have  felt  and behaved  DURING THE PAST WEEK. For each item, indicate the extent to which it is true, by  circling one of  the numbers that follows it.  Using the following scale:

0 = Not at all             1 = Just a little            2 = Somewhat
3 = Moderately          4 = Quite a lot            5 = Very much

==========================================================================
1.  My mind has never been sharper.                                                                         0   1   2   3   4   5

2.  I need less sleep than usual.                                                                                  0   1   2   3   4   5

3.  I have so many plans and new ideas that it is hard for me to work.                       0   1   2   3   4   5

4.  I feel a pressure to talk and talk.                                                                            0   1   2   3   4   5

5.  I have been particularly happy.                                                                             0   1   2   3   4   5

6.  I have been more active than usual.                                                                      0   1   2   3   4   5

7.  I talk so fast that people have a hard time keeping up with me.                              0   1   2   3   4   5

8.  I have more new ideas than I can handle.                                                              0   1   2   3   4   5

9.  I have been irritable.                                                                                              0   1   2   3   4   5

10. It's easy for me to think of jokes and funny stories.                                              0   1   2   3   4   5

11.  I have been feeling like "the life of  the party."                                                      0   1   2   3   4   5

12.  I have been full of energy.                                                                                   0   1   2   3   4   5

13.  I have been thinking about sex.                                                                           0   1   2   3   4   5

14.  I have been feeling particularly playful.                                                                 0   1   2   3   4   5

15.  I have special plans for the world.                                                                        0   1   2   3   4   5

16.  I have been spending too much money.                                                             0   1   2   3   4   5

17.  My attention keeps jumping from one idea  to another.                                       0   1   2   3   4   5

18.  I find it hard to slow down and stay in one place.                                                 0   1   2   3   4   5

A score of 20 or higher on the mania scale suggests the possible need for  an evaluation by a psychiatrist.
---------------------------------

People diagnosing themselves with bipolar disorder.

Psychiatrists in Britain claim to have discovered a new phenomenon - people diagnosing themselves with bipolar disorder.

Celebrities talking publicly about suffering from the illness are linked to the rise in self-diagnosis, London-based psychiatrists Dr Diana Chan and Dr Lester Sireling said on Monday. Bipolar disorder, which was previously known as manic depression, is a condition affecting an individual's mood where manic or depressive episodes can fluctuate between 'normal' periods.

Writing in the March issue of The Psychiatrist, Chan and Sireling claim celebrities talking openly about their personal experiences of bipolar disorder has led to increased awareness of the illness. "The increasing popularity of bipolar disorder may be attributed to increased media coverage, coupled with the high social status associated with celebrities such as (British TV personality) Stephen Fry talking about their own personal experiences of mental illness," they said.

Other high-profile celebrities such as actor Mel Gibson and rock star Axl Rose have also spoken publicly about bipolar disorder. Gibson said in a documentary in 2002 that his childhood alcohol abuse led to high and lows which resulted in him being diagnosed with the disorder.
About one in every 100 adults is said to suffer from bipolar disorder at some point in their lives although recent studies shows that figure could be as high as 11 in every 100. "Public awareness of bipolar disorder has spread through the internet, radio and television shows such as MTV's 'True Life: I'm Bipolar' and BBC's 'The Secret Life of the Manic Depressive," the report said. Referring to the BBC program, the psychiatrists said: "It appears to have portrayed mental illness from a fairly benign perspective, noticeably without the strong association of risk and violence that are often reported in the media."

However, Chan and Sireling say patients who 'want to be bipolar' may not always comprehend the consequences of being diagnosed with the disorder. "Current evidence suggests that bipolar disorder may be under diagnosed in the community, with a significant delay to diagnosis," they said. "The challenge for the primary care psychiatrist is in either making or excluding the diagnosis of bipolar disorder and then sensitively dealing with the patient who wants to be bipolar."

AAP - 2nd March 2010



Medicare has a $4,250 Dental Benefits scheme available to people with complex care needs.


Eligibility

The patient must be on a Health Care Plan, which is arranged by the GP. Generally this means the patient has an ongoing chronic illness (such as mental illness). If a patient is currently not on a Health Plan, this can be arranged with a GP. A criteria is that the patient is being treated by 3 health professionals. For instance this may be your GP, Psychiatrist and Dietician. The patient needs to obtain a referral from the GP (to the dentist).
The applicable Medicare item no’s are 85011-87777.

Details

These Medicare benefits are available for most services provided by a dentist (including dental prosthetist) in private dental surgeries. Once registered, the dental work performed under this scheme can go on for 2 years.

Many GP’s are not aware of this benefit, however dentists are, and they often will facilitate the paperwork for you.
The Government tried to close this scheme in 2008, but the Senate has repeatedly blocked the legislation, so this scheme may not last.  


Email  editor@MBPN.org.au  if you require further details.



An Audit of Treatment received for bipolar disorder.

Professor Michael Berk - Professor of Psychiatry, Clinical and Biomedical Sciences, University of Melbourne -14 September 2003.

http://www.mbpn.org.au/images/04.jpgBipolar disorder is under-recognised as a significant cause of disability in young adults and is associated with substantial disease burden and a high suicide risk. Treatment choices have been shown to strongly influence outcomes; treated cohorts with bipolar depression show a marked reduction in suicide compared with untreated cohorts, while treatment related adverse events, such as antidepressant-induced mania, are emerging as a significant cause of morbidity. In view of the recent publication of several new clinical guidelines for the management of bipolar disorder,it is useful to compare clinical practice with recommendations in current guidelines.

In 2002, an audit was conducted using medical records for 465 outpatients with a file diagnosis of bipolar disorder treated within the Northwestern Mental Health Program, Barwon Health and Austin Repatriation services. These patients were mainly receiving maintenance-phase care.

Results


The audit revealed that only 45% of this sample were receiving treatment with a mood stabiliser, despite recommendation of mood stabilisers as first-choice maintenance therapy in current guidelines. Lithium was prescribed for 31.2% of patients (as monotherapy in 7.3%), valproate for 15.3% (as monotherapy in 3.9%) and carbamazepine for 4.5% (as monotherapy in 1.1%). Only 3.7% of patients received lithium and valproate in combination and 1.9% received lithium in combination with carbamazepine.

Antipsychotic agents were currently used by 46% of patients. This rate was unexpectedly high, given that antipsychotics have not been demonstrated to be as effective as lithium and valproate in maintenance therapy in bipolar disorder,2 and that some guidelines explicitly advise that they should be discontinued unless required for control of persistent psychosis or prophylaxis against recurrence. Conventional antipsychotic agents were used by 17.6% and atypical antipsychotics by 19.1% of this sample. Depot formulations were used by 7.3% of patients. The 1:1 ratio of conventional to atypical antipsychotics was unexpectedly high compared with 1:8.2 for patients with a file diagnosis of schizophrenia in the same database and may reflect regulatory factors affecting access to atypical antipsychotics. An atypical antipsychotic was prescribed as monotherapy in 4.5% of patients and a depot antipsychotic as monotherapy in 3.5%.

Antidepressants were currently used by 32.9% of the sample, most commonly SSRIs (25.4%). Of patients receiving an antidepressant, 38.8% were not taking a mood stabiliser, 26.2% received one mood stabiliser and 22.2% received two mood stabilisers. The combination of an antidepressant and an antipsychotic was prescribed for 15.6% of patients. Antidepressants were prescribed as monotherapy in 8% of this group. Benzodiazepines were used by 21% of patients; 18.1% received one benzodiazepine and 3.0% received two.

Other published studies of actual prescribing patterns for patients with bipolar disorder in the UK, US and Australia have documented similarly high rates of antipsychotic use, ranging from 29–46%.6,8These studies also report lower-than-expected lithium prescribing rates of approximately 30%.

Conclusions

The audit found that maintenance pharmacotherapy was suboptimal for the majority of patients in this sample, with less than half of patients taking mood stabilisers and almost half of the group using antipsychotic agents, particularly conventional antipsychotics. Except in the management of acute mania, there is no compelling evidence for the use of conventional antipsychotics in bipolar disorder and these agents may aggravate the depressive phase of the illness. While emerging data suggest a role for atypical antipsychotics in the management and maintenance of bipolar depression, these studies had not been published at the time of the audit.

The audit also revealed high rates of antidepressant use without coadministation of a mood stabiliser. This practice is not supported by clinical evidence for the efficacy of antidepressants during maintenancephase treatment for bipolar disorder. Antidepressant use has been associated with treatment-induced mania and cycle acceleration.

Given that this audit was conducted in a tertiary care setting, it is unlikely that Australian practice, overall, better reflects current guidelines. Further investigation is required to identify the reasons for the observed prescribing patterns. It is likely that the treatment of bipolar disorder falls outside the core competency range of both the public and private health care systems.



Revealing Lithium's Mode Of Action

Though it has been prescribed for over 50 years to treat bipolar disorder, there are still many questions regarding exactly how lithium works. However, in a study appearing in this month's Journal of Lipid Research, researchers have provided solid evidence that lithium reduces brain inflammation by adjusting the metabolism of the health-protective omega-3-fatty acid called DHA.

Inflammation in the brain, like other parts of the body, is an important process to help the brain combat infection or injury. However, excess or unwanted inflammation can damage sensitive brain cells, which can contribute to psychiatric conditions like bipolar disorder or degenerative diseases like Alzheimers.

It's believed that lithium helps treat bipolar disorder by reducing brain inflammation during the manic phase, thus alleviating some of the symptoms. Exactly how lithium operates, though, has been debated.

Mireille Basselin and colleagues at the National Institute of Aging and University of Colorado, Denver, took a detailed approach to this question by using mass spectrometry analysis to analyze the chemical composition of brain samples of both control and lithium-treated rats stressed by brain inflammation.

They found that in agreement with some other studies, rats given a six-week lithium treatment had reduced levels of arachidonic acid and its products, which can contribute to inflammation.

In addition, they also demonstrated, for the first time, that lithium treatment increased levels of a metabolite called 17-OH-DHA in response to inflammation. 17-OH-DHA is formed from the omega-3 fatty acid DHA (docosahexaenoic acid) and is the precursor to a wide range of anti-inflammatory compounds known as docosanoids. Other anti-inflammatory drugs, like aspirin, are known to also enhance docosanoids in their mode of action.

Basselin and colleagues noted that the concentration of DHA did not increase, which suggests that lithium may increase 17-OH-DHA levels by affecting the enzyme that converts DHA to 17-OH-DHA.

By reducing both pro-inflammatory AA products, and increasing anti-inflammatory DHA products, lithium exerts a double-protective effect which may explain why it works well in bipolar treatment. Now that its mechanism is a little better understood, it may lead to additional uses for this chemical.

From the article: "Lithium modifies brain arachidonic and docosahexaenoic metabolism in rat lipopolysaccharide model of neuroinflammation" by Mireille Basselin, Hyung-Wook Kim, Mei Chen, Kaizong Ma, Stanley I. Rapoport, Robert C. Murphy and Santiago E. Farias


Source: Nick Zagorski - American Society for Biochemistry and Molecular Biology



Improving Your Memory

Poor Memory is a Myth
You do not have a weak memory, even though you think so. In fact, did you know you don’t even have a "memory" or "place" in your brain where you store pictures or information? Memory is actually a mental activity by which information is "impressed" either faintly or strongly in your nervous system. Be encouraged! You can organize and direct your mental activity, or remembering, to make strong information "impressions" (neural traces). In other words, you can remember--lots better than you do now. "How?" you ask. Follow these principles:

The Four R’s of Remembering

RESOLVE: Have a serious intention to remember the lecture or textbook material. This differs from trying to concentrate. When you try to concentrate, you focus on your own emotions and mental condition. Don’t do this. Simply try to remember the information--your focus is then on the subject instead of yourself. This way, you will remember the information better. Research claims that one of the most important factors in a memory task is the "predisposition to remember."

REACT: Actively respond to the things you want to remember. Becoming a more highly reactive person has the side benefit of raising your level of mental activity in general. When you get involved in a subject by reacting several ways, it won’t "pass in one ear and out the other." Ways you can react: Think about it, making a picture of it mentally, write it down, generate a feeling (emotional research) to it, talk it over (to self or others), or apply it practically to daily life activities.

REFLECT: Think deeply about the information you want to remember. Associate the new idea or fact with something you already know about and are interested in. Make an analogy (comparison of similar aspects) between your subject and what you already knew. For example, when presented with the fact that a tomato is really a fruit, connect the information with all that you know about the category "fruits." Asking yourself questions helps you associate facts and ideas. For example, ask what the qualities of a tomato are that cause it to be categorized as a fruit. The more interested you become, and the more you learn about this fact, the better you will remember it.

REFRESH: Brush up your memories as soon as you learn the new information. Review immediately to make stronger "neural traces" or "information impressions" in your brain. To make sure you don’t start forgetting the information, go over it (preferably from notes, so you don’t recall it inaccurately) right after class or study session, once again at bedtime, and then a few times in the following two weeks. If you wait till the semester ends, you’ll have to relearn the material by cramming. By refreshing right away, you’ll really learn and remember the material.

How to Put the Four R’s of Remembering to Work for You

The following two exercises are models for you to follow in using principles of remembering in daily life. We assume you’re already applying the first principle of resolving (intending) to remember.

EXERCISE 1: Memorising a List of Non-Related Items in Sequence

First, break the items into three groups of 2-4 parts. Say them (react) aloud with pauses between the groups, as you would if repeating your social security number. Like this - "100, 49, 1884." (This is using a rhythmic device to retain sequential order). Now, relate each group to something you know or enjoy (reflect). For example, if you were interested in the history of the California Gold Rush, you could make a little story to attach "significance" to the numbers. Like this: "There were only a hundred (100) forty-niners (49-big gold rush year) left in California in 1884." Next, refresh this memory (100-49’ers-in 1884) several times the day you learn it, and a couple of times within the following two weeks.

EXERCISE 2: Memorising an Idea, Theory, or Abstract Statement

Sample conceptual statement: Sigmund Freud introduced the importance of the unconscious mind in relation to human behavior.
First, be sure you understand what the professor means by "introduced", "importance", "unconscious mind", and "human behavior". You can’t remember what you don’t know (haven’t learned). If the information has significance (meaning) for you, it will be more easily remembered, so try to find a reason that you would like to remember this concept. Like this: "I would like to know if my problems with anger have anything to do with my unconscious fears". (This is reaction). Now, relate this concept to a body of knowledge that already exists in your mind. Like this: "Freud’s theory of the unconscious is related to what I used to call the ‘hidden motives of my heart’, which they talk about in novels and in church. (You are practicing reflection). Now refresh your memory of this concept by thinking about it, or reviewing notes on it, or better yet, by explaining it to someone else. Refresh the day you learn the information, and again a couple of times in the following two weeks.

Principles of Memory

MEMORY PRINCIPLE

WHEN TO DO THIS

WHY THIS PRINCIPLE IS IMPORTANT

1. Intend to remember/learn.

Before beginning study

Your intention is crucial. If you don’t actively plan to remember something, you won’t remember it very well.

2. Get an "overview" of the     task.

Whenever you begin a new learning project

Getting a preview of the whole process you’re trying to learn will help you later as you read, practice, etc. You’ll be able to fill in details of each part if you start with a simplified version of the whole task first.

3. Review immediately after    learning.

At the end of each study session

Most forgetting takes place immediately after learning occurs--not two hours or two days later. Therefore, review immediately, even if just for a few minutes.

4. Learn actively.

Always

Most learning time should be actively self-testing and practice rather than passively re-reading. Expose as many senses as possible to the material--read it, hear it, visualize it, etc.

5. Use an hour or two.

When you’re trying to read a whole chapter

Complex learning such as understanding new relationships learning how to solve a problem requires longer periods of time for efficient learning.

6. Use two to five minutes.

When you have a simple mechanical task or rote-memorization

Simple tasks and especially anything you have to memorize task are better learned in short, frequent practice sessions rather than an hour or two.

7. Practice what you have    learned.

In between the time you first learn something and the time you’re tested on it

Most forgetting takes place because people haven’t periodically practiced or reviewed what they learned.

8. Learn in an organized way.

Always

You’ll remember much more when you have a systematic, orderly view of what you have learned. If you have studied facts as isolated events without seeing relationships between them, then you will forget more quickly.

9. Set and understand the     goals/objectives for your     study session.

At the beginning of any learning or retrieving session

This gives you a purpose and a complete overview of each study session, and it will help you become a more systematic and organized learner.


Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial

The Lancet,  30 January 2010

Summary

Background

Lithium carbonate and valproate semisodium are both recommended as monotherapy for prevention of relapse in bipolar disorder, but are not individually fully effective in many patients. If combination therapy with both agents is better than monotherapy, many relapses and consequent disability could be avoided. We aimed to establish whether lithium plus valproate was better than monotherapy with either drug alone for relapse prevention in bipolar I disorder.

Methods

330 patients aged 16 years and older with bipolar I disorder from 41 sites in the UK, France, USA, and Italy were randomly allocated to open-label lithium monotherapy (plasma concentration 0·4—1·0 mmol/L, n=110), valproate monotherapy (750—1250 mg, n=110), or both agents in combination (n=110), after an active run-in of 4—8 weeks on the combination. Randomisation was by computer program, and investigators and participants were informed of treatment allocation. All outcome events were considered by the trial management team, who were masked to treatment assignment. Participants were followed up for up to 24 months. The primary outcome was initiation of new intervention for an emergent mood episode, which was compared between groups by Cox regression. Analysis was by intention to treat. This study is registered, number ISRCTN 55261332.

Findings

59 (54%) of 110 people in the combination therapy group, 65 (59%) of 110 in the lithium group, and 76 (69%) of 110 in the valproate group had a primary outcome event during follow-up. Hazard ratios for the primary outcome were 0·59 (95% CI 0·42—0·83, p=0·0023) for combination therapy versus valproate, 0·82 (0·58—1·17, p=0·27) for combination therapy versus lithium, and 0·71 (0·51—1·00, p=0·0472) for lithium versus valproate. 16 participants had serious adverse events after randomisation: seven receiving valproate monotherapy (three deaths); five lithium monotherapy (two deaths); and four combination therapy (one death).

Interpretation

For people with bipolar I disorder, for whom long-term therapy is clinically indicated, both combination therapy with lithium plus valproate and lithium monotherapy are more likely to prevent relapse than is valproate monotherapy. This benefit seems to be irrespective of baseline severity of illness and is maintained for up to 2 years. BALANCE could neither reliably confirm nor refute a benefit of combination therapy compared with lithium monotherapy.

Funding : Stanley Medical Research Institute; Sanofi-Aventis.



RANZCP Treatment Guidelines for Bipolar Disorder

12–14 September 2003, Bipolar Disorder Scientific Meeting - Christchurch, New Zealand
Professor Philip Mitchell
Professor and Head of the School of Psychiatry, University of New South Wales, Australia

During 2003, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed Australasian guidelines for the treatment of bipolar disorderunder contract from Australia’s Commonwealth Department of Health and Ageing.
In accordance with National Health and Medical Research Council recommendations for guideline development, the Steering and Implementation Committee undertook a comprehensive literature review of publications up to June 2003, including previous guidelines developed in Australia and elsewhere and consulted with clinical experts and consumers. The resulting guidelines are intended to assist, but not dictate, clinical decisions. A version for consumers has been published on the RANZCP website (www.ranzcp.org).

Recommendations are set out according to phase of illness and include guidance on assessment as well as treatment. In the absence of randomised controlled clinical trials (RCTs) conducted specifically in patients with bipolar II disorder, the guidelines are based on clinical literature on bipolar I disorder.

Managing hypomania or mania

The structure of the guidelines reflects the recognition that the care of a person during a manic episode involves both an immediate response to the psychiatric emergency and later comprehensive assessment.
Treatment for hypomania or mania is based on a mood stabiliser, plus adjunctive treatments for specific symptoms. There is substantial evidence for the use of mood stabilisers, particularly lithium. Meta-analysis of RCTs has shown that valproate and carbamazepine are as effective as lithium in the management of acute mania.There have also been two RTCs confirming the effectiveness of olanzapine for mania. In contrast, there is only limited evidence available to guide the choice of adjuncts, despite their widespread use in practice.

Mixed episodes

Compared with acute mania, there is less high-level evidence to guide the management of mixed–mood episodes. RCTs support the use of valproate.
Failure of mania/hypomania to respond to initial treatment
There have been no systematic reviews and few RCTs to guide the management of mania non-responsive to initial therapy. Forinstance, there have been no clinical trials conducted to evaluate the well-accepted practice of optimising mood stabiliser serum levels before changing the regimen. Based on expert consensus and limited clinical data, the guidelines recommend any of the following: optimise the mood stabiliser dose, switch to another mood stabiliser, combine mood stabilisers, or augment mood stabiliser therapy with olanzapine, hypomania or mania
The structure of the guidelines reflects the recognition that the care of a person during a manic episode involves both an immediate response to the psychiatric emergency and later comprehensive assessment.
Treatment for hypomania or mania is based on a mood stabiliser, plus adjunctive treatments for specific symptoms. There is substantial evidence for the use of mood stabilisers, particularly lithium. Meta-analysis of RCTs has shown that valproate and carbamazepine are as effective as lithium in the management of acute mania.There have also been two RTCs confirming the effectiveness of olanzapine for mania. In contrast, there is only limited evidence available to guide the choice of adjuncts, despite their widespread use in practice.

Failure of mania/hypomania to respond to initial treatment

There have been no systematic reviews and few RCTs to guide the management of mania non-responsive to initial therapy. Forinstance, there have been no clinical trials conducted to evaluate the well-accepted practice of optimising mood stabiliser serum levels before changing the regimen. Based on expert consensus and limited clinical data, the guidelines recommend any of the following: optimise the mood stabiliser dose, switch to another mood stabiliser, combine mood stabilisers, or augment mood stabiliser therapy with olanzapine, risperidone or haloperidol.
In the event of continued failure to respond, the guidelines recommend reevaluation of the diagnosis, considering other psychoses or organic disorders. If the diagnosis is upheld, the use of electroconvulsive therapy (ECT) is supported by RCTs.

Maintenance therapy following a manic/ hypomanic episode

Although clinical consensus supports maintenance therapy protocols, there is no RCT evidence in this area. Based on systematically evaluated expert consensus, the guidelines recommend at least 6months’ maintenance treatment after the first manic episode. Forpatients with established long-term bipolar disorder who have recovered from a manic episode, various criteria for continuing therapyare supported by expert consensus.

Managing bipolar depression

As for mania, recommendations for the care of patients during a bipolar depressive episode are set out in order of initial assessment and management, followed by comprehensive clinical assessment.
In patients with a diagnosis of bipolar disorder who experience a denovo
depressed episode in the absence of mood stabiliser therapy, a large volume of good-quality evidence supports the introduction of a mood stabiliser. The guidelines recommend using lithium or lamotrigine, either alone or in combination with an antidepressant, as supported by expert consensus, but not RCTs. The use of SSRIs, tricyclic antidepressants and monoamine oxidase inhibitors in bipolar depression is supported by RCTs, while the use of venlafaxine is supported by uncontrolled trials. There is no evidence for the efficacy of an antidepressant in the absence of a mood stabiliser in bipolar depression.
For those who experience a breakthrough episode of bipolar depression during treatment with a single mood stabiliser, the guidelines recommend assessment and optimisation of mood stabiliser blood levels, followed by the addition of an antidepressant or second mood stabiliser if the patient has not responded. Both augmentation options are supported by RCTs.

Failure of bipolar depression to respond to initial treatment

No evidence is available from RCTs conducted specifically in patients with bipolar depression that has failed to respond to initial therapy. Based on expert consensus, the guidelines recommend either switching to another antidepressant, switching to another mood stabiliser, or ECT. In the case of persistent failure to respond, the guidelines recommend confirmation of the diagnosis, re-evaluation of contributing psychological or social factors and consideration of adjunctive psychological therapies.
The guidelines recommend withdrawing antidepressants 2–3 months after an episode of bipolar depression in order to minimise the risk of precipitating mania or rapid cycling.

Maintenance therapy following a depressive episode

The guidelines also acknowledge that maintenance antidepressant treatment may be appropriate in patients with recurrent depressive episodes, if administered in conjunction with a mood stabiliser and after balancing the patient’s treatment requirement with the risk of precipitating mania or rapid cycling. These practices are supported by expert consensus, but have not been evaluated in RCTs. 

Prophylactic therapy in bipolar disorder

Various criteria have been proposed for long-term prophylaxis in bipolar disorder.For patients with non-rapid cycling bipolar disorder, the guidelines recommend maintenance therapy with either lithium, lamotrigine, valproate or carbamazepine. The use of lithium at a serum target range of 0.6–0.8 mmol/L is supported by systematic reviews, which demonstrate that the ‘number needed to treat’ to prevent a mood episode is between 4 and 14.
There is very limited evidence to guide the choice of prophylactic treatment in patients with rapid-cycling bipolar disorder. Based on clinical case series and expert consensus, the guidelines recommend valproate,lamotrigine, carbamazepine or lithium.

Psychological interventions

The guidelines recommend psychoeducation (individual, family-focused or group therapy), cognitive-behavioural therapy (CBT) or interpersonal and social rhythm therapy (IPSRT) as prophylactic therapy in bipolar disorder. CBT and psychoeducation modalities for patients with bipolar disorder are well supported by RCTs. Since completion of the guidelines, new reported data indicate that IPSRT is not significantly more effective than standard care in patients with bipolar disorder. For all psychotherapies, the main therapeutic effect observed in bipolar disorder is the prevention of depressive episodes.

Failure to respond to prophylaxis

In the case of failure to respond to prophylaxis, the guidelines advise assessment of adherence to treatment and management of comorbid substance misuse before changing the drug regimen. In patients with rapid-cycling bipolar disorder, the possibilities of antidepressant-induced affective instability and subclinical hypothyroidism should also be considered and excluded.
1For patients who do not benefit from prophylactic therapy for bipolar disorder, there is some evidence that adding a second mood stabiliser (particularly using the combination of lithium and valproate) enhances prophylactic capacity.

References

1. Mitchell P, Malhi G, Redwood B, Ball J for the RANZCP Clinical Practice Guideline Team for Bipolar Disorder. RANZCP
clinical practice guidelines. Summary of guidelines for the treatment of bipolar disorder Australasian Psychiatry2003; 11 :39–53.
2. Macritchie K, Geddes JR, Scott J et al. Valproate for acute mood episodes in bipolar disorder (Cochrane Review). In:TheCochrane Library, Issue 3, 2003. Oxford: Update Software.
3. Hirschfeld RMA, Bowden CL, Gitlin MJ et al. Practice guideline for the treatment of patients with bipolar disorder (Revision). Am J Psychiat2002; 4 (Suppl.): 1–50.
4. Mood Disorders: Pharmacologic Prevention of Recurrences. NIH Consensus Statement Online 1984 Apr 4–26 [cited1October 2003]; 5: 1–23.
5. Grof P, Angst J, Karasek M, Keitner G. Patient selection for long-term lithium treatment in clinical practice. ArchGenPsychiatry 1979; 39 (8 Spec No): 894–7.
6. Goodwin FK, Jamison KR. Manic Depressive Illness. New York: Oxford University Press, 1990. 7. Calabrese JR, Delucchi GA.: Spectrum of efficacy of valproate in 55 patients with rapid-cycling bipolar disorder.
AmJPsychiatry 1990, 147 : 431–4.

A Forensic Psychology Dictionary

- A -
ABASEMENT - the need to comply, surrender, confess, or atone.  A need to accept punishment.
ACTUS REUS - the actual criminal act.  A legal term referring to the actions behind the offense that must successfully be proven by the prosecution so that the defendant may be found guilty.  SEE "mens reus"
AGGRESSION - the goal directed behaviour of harming another living being.  The behaviour may be indirect (upset person may break a window rather then hit some one) or displaced to someone else (road rage). SEE "hostile aggression"
AGGRESSION MACHINE - the apparatus used to measure physical aggression in a laboratory
ANAL EROTICISM - erotic/sexual pleasure  from activities associated with stimulation of the anal region.  Studies have linked such eroticism to aggression towards the individual being penetrated.
ANGER - an emotional reaction elicited by a number of unique stimulus, including restraint, aggression, threat, attack, and frustration.  Anger is characterized by a strong autonomic nervous system response, particularly the sympathetic component.
ANTISOCIAL PERSONALITY - a behavioral disorder characterized by a number of deviant acts, including delinquency, truancy, theft, promiscuity, vandalism, fighting, poor work record, impulsiveness, irrationality, reckless behavior, and aggressiveness.
ATAVISM (THEORY OF) - a classic theory of criminal behavior that has long been refuted.   The theory of atavism suggests that criminals are genetic throwbacks that react deviantly simply because their behavior matches those of our ancient ancestors.
AUTOEROTICISM - Sexual gratification or arousal in the absence of a partner.
AUTOMATISM - an act performed unconsciously.  Defendants have been found innocent due to an automatism defense (i.e., homicide while sleepwalking).
 
- B -
BALLISTICS - ballistic experts focus on the functioning of firearms.  Via microscopic analysis they can match up bullets with a particular weapon.  They also provide key information about the projectiles path.
BEHAVIOR MODIFICATION - a common psychological treatment used in both clinical and forensic environments.  The changing of human behavior by the application of conditioning and/or other learning techniques.
BLANK LINEUP - in order to assess the accuracy of a witness police officers may present a police lineup that does not contain the suspect.
 
BYSTANDER EFFECT - a scientifically proven finding that as the number of bystanders increases, the likelihood of a bystander helping someone in distress decreases.

- C -

CATHARSIS HYPOTHESIS - The theory that states that if angry persons can express aggression in a safe manner, they will be less likely to engage in harmful behaviour.  Has possible implications with offender treatment.
CASTRATION - the surgical removal of the testes or ovaries.  In the past was used as a treatment for male sex offenders.  The ethicity and validity of this approach has come into question.
CHILD MALTREATMENT/ABUSE - actions either physical or psychological that harm children.  Can be either a voluntary or involuntary action.
COGNITIVE DISSONANCE - the unpleasant state that may occur when an individual has inconsistencies between their attitudes or attitudes and behaviour.  May occur in offenders concerning their morality and behaviour.
COGNITIVE THEORY OF AGGRESSION - a fairly modern theory that suggests that aggression stems from complex interactions between cognition, affective states (emotion), and other additional components.
COMBAT FATIGUE - a traumatic neurosis characterized by the presence of somatic disturbances and anxiety reactions that have been brought on by extended exposure to combat.  To layman's it has been called 'shell shock'.
CONFLICT - an action taken to block or interfere with others' interests, because of the perception that ones opponent is doing the same, or that each others actions are incompatible.
CONFORMITY - social influence that causes and individual to change his/her attitudes/behaviour in order to conform to social norms.  A strong example of this is the soldiers actions in NAZI germany.
COMPOS MENTIS - to be competent, or not to be legally insane or mentally deficient.  In contrast to non compos mentis.
CRIMINAL BEHAVIOUR PROFILING -  a criminal investigation technique in which crime scenes and additional evidence are analyzed in order to discern patterns in the offenders behaviour, with which a behavioural and physical description of the offender can be created.  Has also been called: "profiling", "offender profiling", "investigative profiling".
CRIMINAL TYPE - a category of individuals whom repeatedly engage in criminal and/or antisocial behavior.  They apparently have a constitutional tendency towards behaving in that direction.
CRIMINOLOGY - the scientific study of crime, criminals, and penology.  This science often considers both social and psychological aspects of criminality.
 
- D -
DACTYLOSCOPY - this is the scientific analysis of fingerprints.  Fingerprint experts have been involved with law enforcement for almost a hundred years.  Recent advances in dactyloscopy have continued to make fingerprint analysis of key importance (i.e., new methods pull fingerprints off underwater surfaces, skin, etc.).  
DEADLINE TECHNIQUE - a technique used in many areas, in which the target is told that they have only a limited time to accept an offer.  Often used in criminal interrogations (i.e. "if you confess now the crown attorney will go easy on you").
DEFENSIVE WOUNDS - wounds commonly found on a victims arms, hands, or fingers sustained when the victim was trying to defend self from an assault.
DELINQUENT - a juvenile offender under the age of 18, or one who commits an offense that is not considered a serious crime.
DELINQUENCY - a minor offense against the criminal code, or the characteristic of being a habitual offender.
DEPERSONALIZATION - an offenders attempt to eliminate the identity of the victim so that they do not represent or resemble the person whom has caused their psychological distress.  Actions can range from covering the victims face with a towel or blanket up towards extreme battery.
DEVIANCE - behaviour, ideas, and attributes that are responded to negatively by others.  Going against the social norm, whether it is criminal (murder/rape), social (wearing red to a funeral), or physical (facial tattoo's, physical abnormality).  Deviance can change depending on the setting of the act/attribute (cursing with friends vs. in church), the age of the actor (baby soiling cloths vs. teenager), etc.
DEVIANT - one who acts defiantly, have socially deviant thoughts, or has socially abnormal attributes.  Even though a "hunchbacked person" is not necessarily bad, society tends to look at them negatively as "deviant" from the norm.
DIRECT AGGRESSION - an attack placed upon what the individual believes is the source of their frustration.  As opposed to Displaced Aggression
DISORGANIZED - An offender classification used in many criminal profiling systems.  Such an offender tends to carry out spontaneous and impulsive acts in a manner that is sloppy  and at high risk of leaving evidence.  Such offenders tend to know the victims (at least by sight), stick to their own geographical locations, and use a blitz like assault with a weapon of convenience.  Sexual acts often occur postmortem.  SEE 'organized'
DISPLACED AGGRESSION - an attack against a person/object that is not the original source of frustration.  This act will occur when the source of the frustration is either unavailable or is likely to retaliate.
DISTRAUGHT WITNESS - The distraught witness bears a great deal of emotional distress.  This distress is the direct result of either witnessing the crime or indirectly  from their relationship with the victim.
DRIVE THEORIES OF AGGRESSION - the theory suggesting that aggression is created by external conditions that arouse the motive to harm others.  See "frustration aggression hypothesis".

- E-

ECOMANIA - a pathological attitude direct towards one's family.  It is characterized by domineering behavior.  This attitude has implications in familial abuse.
EROTOMANIA (1)- a pathological exaggerated sexual interest.  In males this condition is satyriasis; in females, nymphomania.
EROTOMANIA (2)- an obsessive love by  an individual towards one of particularly high status (i.e. celebrities).  Subject often believes that the other person shares mutual feelings of love.  Efforts to contact the object of their obsession, along with stalking and surveillance, is common.
EUNUCH - a castrated male.
EXHIBITIONISM - a compulsion to expose parts of the body, most often the sex organs, for the purpose of sexual excitement.
 
- F -
FAMILICIDE - when an individual kills his/her spouse and one or more of his/her children
FEAR-INDUCED AGGRESSION - responses believed to be biologically programmed into us so that we act in an aggressive manner towards any form of forced confinement.
FETISHISM - a pathological condition in which sexual arousal and gratification is induced by the handling of objects or nonsexual parts of the body.
FLAGELLATION - the practice of submitting to whipping for sexual or penitential purposes.
FLAGELLOMANIA - sexual excitement aroused by whipping.
FOLIE A DEUX - the occurrence of psychosis in two persons who are closely associated to each other (i.e., husband and wife).
FORCED FANTASY - an emotional fantasy that is deliberately promoted by the therapist (analyst).  This procedure has been criticized for its ability to create false memories.
FORENSIC - "pertaining to the courts".
FORENSIC ANTHROPOLOGY - The forensic anthropologist examines the victims bones to determine a number of key facts.  Information such as gender, age, looks, previous trauma, and disease can all be found.  The forensic anthropologist is often of key relevance to the identification of remains.  They use a number of means, including molecular DNA analysis.
FORENSIC ARTIST - the forensic artist provides an elaborate sketch of the offender.  This process is undertaken via the information from an eyewitness.  Many investigators now use computer programs to develop offender renditions.
FORENSIC CHEMISTRY - the forensic chemist studies the molecular aspects of the crime scene.  They can match fibers, paint, and dyes to particular objects.  They will identify relevant chemicals and particles.
FORENSIC DENTISTRY - these experts serve a identification function.  Via the analysis of a corpses teeth and previous dental records they can make a positive identification.  They also will analyze bite patterns so that they can identify who was eating a particular meal or even who bit somebody.
FORENSIC ENTOMOLOGY - the entomologist studies insects.  A number of pieces of key information can be discovered from this analysis.  The rate of body decay via insects can directly correlate to time of death.  The presence of certain insects can identify previous dump sites, etc.
FORENSIC GEOLOGY - the forensic geologist can determine where a person or object has been by analyzing soil samples.  Soil can be found on a pair of shoes, tire treads, or a body.  They can be matched up with common soil types to predict quite specifically where the object/person has been.
FORENSIC LINGUISTICS - the forensic linguist analyses either the spoken or written word.  They can identify whether a message was presented by the same individual, what the individuals underlying intent is, the individuals educational and cultural background, as well as the presence of pathology.
FORENSIC ODONTOLOGY - see 'forensic dentistry'
FORENSIC PATHOLOGY - the forensic pathologist analyzes the remains of a body.  They attempt to determine the cause and time of death via autopsy.
FORENSIC PHOTOGRAPHY - the crime scene photographer attempts to record every component of the crime scene via photograph.  They depict the scene from multiple angles, using multi-functional cameras, and through the consistent evaluation of size and distance.
FORENSIC PSYCHOLOGIST - a Ph.D. psychologist whom specializes in the realm of forensics.  The forensic psychologist may have either a Ph.D. in forensic psychology, clinical psychology with a forensic focus, or experimental psychology with a forensic focus.
FORENSIC PSYCHOLOGY - the discipline of psychology that deals with the legal system, including the front end operations (police work, investigation), legal proceedings (expert witness, competency & psychological assessment, jury selection), and institutionalization (confinement, treatment, parole hearings).  Forensic psychologists may also be called on to: evaluate new laws and programs, assist in the assessment and hiring of new police officers, etc.
FORENSIC SCULPTORS - like the forensic artist, the sculptor attempts to create an image of either an offender or a victim.  The sculptor's goal is to create a three dimensional version of the image.
FORENSIC SEROLOGY - the serologist studies blood and other bodily fluids for identification purposes.  The serologist is often involved in DNA fingerprinting (the identification of an individual based on body cells).
FRAUDULENT WITNESS - While not having any first hand knowledge of the crime, the fraudulent witness is an active attention seeker whom comes forward to offer fraudulent evidence.
FROTTAGE - sexual gratification achieved by rubbing against the clothing of a member of the opposite sex in a crowd.
FRUSTRATION-AGRESSION HYPOTHESIS - the drive theory of aggression that suggests frustration builds and creates aggression (ex. road rage, person losing job & family becoming homicidal).

- G -
GROUP POLARIZATION - the tendency for a group to shift toward more extreme position then those that they initially held as a result of group discussion.  This has been seen in jury deliberations.
GROUPTHINK - tendency for highly cohesive groups to assume their decisions can't be wrong, that all members support their decision, and that information to the contrary shall be ignored.  (i.e. cult behaviour)

- H -

HOSTILE AGGRESSION - aggression with the prime objective to inflict harm onto a victim.
HOSTILE ATTRIBUTIONAL BIAS - a tendency for some people to perceive others' actions as the result of a hostile intent, when this is clearly not the case.  Occurs in a number of criminal personality types.
HOSTILE WITNESS - This witness is deliberately antagonistic and/or noncompliant.  Such an individual may invent facts in order to purposefully mislead the law.  The hostile witness may react this way for two reasons: (1) their relationship to the offender, or (2) a underlying animosity towards the law.

- I -
INGRATIATION - a technique used to obtain compliance by inducing someone to like you, then attempt to change their behaviours (i.e. cult behaviour, could be used with 'good cop' interrogations).
INTERMALE AGGRESSION - physical violence or submissive behavior displayed by males towards each other.
INSERTIONAL NECROPHILIA - as a substitute of sexual intercourse the offender inserts foreign objects into the victims orifice.  Common with disorganized offenders.  This should not be mistaken as a form of mutilation.
INSTINCT THEORY - aggression theory that suggests aggression stems from universal innate tendencies.  In other words aggression is born into all of us.
INSTRUMENTAL AGGRESSION - aggression with the goal not to harm but rather to attain some other goal (i.e. sport aggression).
INTIMIDATED WITNESS - This witness fears retaliation from the offender(s) involved or from the criminal element in general.  As a result, the intimidated witness is quite apprehensive.
INVENTIVE WITNESS - These witnesses typically embellish and create details when being interviewed.  This is likely due to an inability to differentiate between fantasy and reality.  They may also have esteem motives, in that they wish to appear important.
IRRITABLE AGGRESSION - aggression and rage directed towards an object when the aggressor is frustrated, hurt, deprived, or stressed.  As a result one may aggress towards objects as an acceptable outlet of the aggression.
 
- L -
LEADING QUESTIONS - questions asked during an investigation that are worded in such a manner that will suggest specific answers.  This sort of questioning should be avoided and may become inadmissible in a court case.
LEGAL AUTHORITARIANISM - a juror whom tends to assume the worst about an accused defendant, and is found more likely to convict.  See "leniency bias".
LENIENCY BIAS - a juror whom tends to make favorable assumptions regarding the accused.  See "legal authoritarianism".
LONELINESS - an emotional state resulting from the desire for close relationships but being unable to attain them.  This is a common attribute of sex offenders.

- M -
MATERNAL AGGRESSION - aggressive behavior put forward by females (and most likely males as well) when an intruder is in the presence of ones children.
MAXIMIZATION - a questioning technique in which the interrogator exaggerates the strength of evidence gathered in order to elicit a confession.  See 'minimization'.
MENS REA - the legal terminology referring to a perpetrators criminal mind.  In order to be found guilty of a crime an individual must be proven to have acted within a criminal mind.
MICROEXPRESSIONS - a brief, incomplete, facial expression that occur on our faces very quickly after exposure to a stimulus.  It occurs before we can actively conceal them.  A trained observer may look for these to see what questions elicit certain responses during an interrogation or criminal trial.
MINIMIZATION - a questioning technique in which the interrogator plays down the evidence and the seriousness of the act, by providing an excuse for the act or shifting blame onto someone else (i.e. the victim).  See 'maximization'
MISSION ORIENTED - an offender typology.  The offender is directed by a self-imposed task without regard for the consequences of ones actions.  The offender is often unconcerned about escape or even survival once the offense has taken place.
MIXED CRIME SCENE - description for a crime scene the demonstrates the presence of both an organized and disorganized offender.  Can be caused by: multiple offenders, unanticipated events, youthfulness, substance abuse, and unexpected victim actions.
MODUS OPERANDI (MO) - The offenders actions during an offense.  This is variable behaviour that evolves over multiple acts due to offender sophistication and confident.

- N -
NECROPHILIA - sexual gratification from intercourse with a deceased individual.  SEE 'insertional necrophelia'
NORMS - rules within a group (or society) that describe how its members should or should not behave.

- O -

OBEDIENCE - social influence in which one person obeys direct orders from another to perform some action.  High obedience levels were seen in nazi germany, in cults, and often in the childhood of psychopathic offenders.
ORGANIZED - offender typology characterized by a mobile (own transportation) offender who cons his victim into capture rather then using force.  Offender is often a stranger selected on the basis of specific criteria.  Use of restraints and weapons are preplanned, and rarely left behind.  The body is often transported to a novel dump site and concealed.  SEE 'disorganized'.
OVERKILL - injury and trauma that is excessive beyond that required to cause the death of the victim.

- P -
PERSONATION - An offenders ritualistic actions.  Seen with body positioning, mutilation, and other symbolic gestures.  This behaviour is only of significance to the offender.
PERSUASION - the effort to change someone's attitudes.
PREJUDICE - negative attitudes towards others of specific social groups.
PREDATORY AGGRESSION - our motivated attack behaviors.  This aggression is directed to natural prey and is deeply routed in our ancestors hunting behavior.  Today it can be seen in the behavior of normal individuals as hunting.
PROVOCATION - others actions that trigger aggression in the recipient because they are seen as stemming from malicious intent.
PSYCHOLOGICAL AUTOPSY - an investigative review and victimology interview procedure used to determine the victims psychological makeup.
PUNISHMENT - the use of an aversive consequence in order to decrease or eliminate certain behaviours.

- R -
REACTANCE - the negative reaction towards threats of personal freedom.
REALISTIC CONFLICT THEORY - the theory that prejudice stems from competition between groups over certain resources.
REPRESSION - the freudian defense mechanism by which the person attempts to lower anxiety by denial and forgetting.  The idea of this actually occurring in 'real life' has come under scientific scrutiny.
RELUCTANT WITNESS - Witness responds with reluctance due to a natural restraint that is a reflection of their personality.  This particular witness will be hesitant and reserved.  They will not find it easy to talk freely.  Others may feel that the act they have witnessed is "none of their business".

- S -
SELECTIVE RECALL - a phenomenon of extremely detailed memory recall when a suspect is asked to relate his whereabouts/actions during the offense.  This airtight and precise recall will not reflect similar recall of other time periods preceding or following the offense.
SEX RELATED AGGRESSION - aggressive behavior that is elicited by the same stimuli that elicits sexual behavior.  Any person who can evoke sexual desire can equally evoke aggression via jealousy, etc.
SEXUAL HARASSMENT - unwelcome sexual advances, requests, and conduct.
SEXUAL SADISM - an offender who obtains sexual gratification from the victims response to physical/psychological torture.
SIGNATURE - the repetitive ritualistic behaviour of a serial offender.  This is typically apparent at every crime scene and has little-to-nothing to do with the perpetration of the crime.
SOCIAL INFLUENCE - efforts by others to change ones attitudes, beliefs, or behaviours.
SOCIAL LEARNING VIEW OF AGGRESSION - view that aggression is learned through direct experiences and observations of others behaviours.
SOCIAL LEARNING VIEW OF PREJUDICE - view that prejudice is learned through direct experience, consistent with the manner other attitudes are learned.
SOCIAL PSYCHOLOGY - the psychological discipline that seeks to understand the nature and causes of individual behaviour and thought within social situations.
STAGING - the alteration of a crime scene in order to redirect the investigation in a way away from offender (or at least what the offender thinks logically will do this).
STRESS - a response to physical or psychological events that are at the leased perceived by a person to cause harm either emotional or physically.

- T -
TERRITORIAL AGGRESSION - threat or attack behavior displayed towards an invasion of ones territory or the submissive-retreat behavior displayed when confronted while intruding.
TYPE A BEHAVIOUR PATTERN - a pattern of behaviour consisting primarily of high levels of hostility and competitiveness.  This behaviour pattern is highly correlated to aggression.

- U -
UNDOING - offender whom has a close association with their victim with symbolically try to undo the crime (i.e. wash the victim, place a pillow under their head).

- V -
VICTIMOLOGY - the complete history of the victim (i.e. personality, lifestyle, traits etc.)
VOIR DIRE - the legal term used to refer to jury selection.  During this process the judge and the attorneys can dismiss prospective jurors for both specific and unstated reasons.  Attorneys often examine the prospective jurors age, intelligence, gender, attentiveness, occupation, and open-mindedness.


Lithium treatment: does the kidney prefer one daily dose instead of two?

P. Plenge, E. T. Mellerup, T. G. Bolwig, C. Brun, O. Hetmar, J. Ladefoged, S. Larsen O. J. Rafaelsen
Correspondence to  C. Brun Department of Clinical Chemistry Copenhagen Kommunehospital Copenhagen

ABSTRACT
Renal structure and function were investigated in two groups of long-term lithium treated patients. Lithium was administered in two different ways either in a one-dose per day schedule where the whole dose of lithium was given between 8 and 10 p.m. or in a schedule where the lithium dose was given, divided into two or three doses, during the day. Kidney biopsy was performed, and structural changes in the kidney tissue were determined together with 24-h urine volume in the individual patients. The functional as well as the structural changes were most pronounced in patients given their lithium in divided doses during the day.

Lithium may be more harmful to the kidney when the lithium administration gives a relatively constant serum lithium level than when the administration causes greater variations including peak values and low minimum levels in serum lithium. The reason for this might be that a number of regenerative processes only occur in periods with low lithium concentrations.

Lithium

Patient Information Leaflet
Andrew Nielsen
Updated 21 September 2007.

Introduction

Lithium was discovered to be effective in treating elevated mood in 1949 by the Australian psychiatrist John Cade.  Lithium is used to treat elevated mood (mania) and depressed mood (depression) in people with bipolar affective disorder.  Lithium also increases the effectiveness of antidepressant medications.  It is given with antidepressant medications to treat depression in people who are depressed but do not experience episodes of elevated mood.  (Lithium can also be used to decrease aggression, self-injury and steroid-induced psychosis.)  Lithium is also effective in treating depression in people with major depression who do not become manic or have bipolar disorder; however, antidepressants are more effective and have fewer side effects. 

Lithium is thought to have an effect via several mechanisms.  It substitutes for some of the sodium, potassium, magnesium and calcium ions that pass in and out of the nerve cells in the brain (neurons).  It also has an effect inside the brain cells by altering the mechanism of the cell and altering the chemical communication between cells.  Lithium can change the quantity of neurotransmitter receptors on cells, and this might be the mechanism by which lithium helps other drugs stop depression.  Lithium has been shown to protect neurons in the brain, and to restore the amount of cells in the hippocampus, a part of the brain that might be effected in some people by depression and/or posttraumatic stress disorder.   

Lithium is one of only two drugs that have been shown to decrease the risk of suicide.  This effect is not fully explained by its ability to make mood normal.  Lithium is the third element of the periodic table.  Technically, lithium is a metal; it is given as a salt, the same way iron in iron tablets is given as a salt.         

Taking Lithium

In Australia, lithium is sold in standard and slow-release preparations.  The standard preparation is called Lithicarb and the slow release formulation is called Quilonum SR.  The slow release preparations cause fewer side effects but are more expensive for the government; Quilonum is available in public hospitals only with a prescription to a community pharmacy.  Lithicarb comes in 250mg tablets and Quilonum comes in 450mg tablets; this helps stop mix-ups about which type of lithium tablets someone is on. 

Lithium can be taken once or twice a day.  Taking it twice a day might increase its effectiveness.  Taking it once a day is easier to remember.  A dosette box helps people to remember to take their tablets.  A dosette box is a box with separate compartments where tablets are stored for each day of the week, and sometimes, time of the day.  They can be bought from the pharmacy were you get your medication.  If even more help is needed, a pre-packaged Webster Pack containing tablets for two weeks can be obtained from the pharmacy where you get your medication.  If you miss a dose of lithium, you should not take an extra one the next day to catch up.

Before, or shortly after you start lithium, you need to have blood tests that check the function of your thyroid gland and kidneys, your levels of calcium, phosphate and glucose,  and to ensure that you are not pregnant.  An ECG (electrocardiogram) might be done to check the electrical impulses of your heart.  This is done by briefly attaching recording wires across your chest and to your arms.  You should have a physical examination done by a doctor, such as your GP, before, or shortly after, you start taking lithium.  Some authorities recommend that lithium treatment is started in hospital, but this is not necessary. 

Stopping Lithium

Lithium should not be stopped suddenly except in an emergency.  It should be stopped over 1 to 2 months.  If lithium is used to treat BPAD, stopping it suddenly can cause an episode of manic, elevated mood. 
There is some evidence that if lithium is stopped, it will not work as well for elevated mood when it is restarted.  It is also possible that intermittent treatment with lithium makes the overall course of bipolar disorder worse.  This means that once lithium is started, it should only be stopped after careful consideration.  Talk to your doctor before you stop the lithium (unless there is an urgent reason to stop the lithium).  In one study, stopping lithium increased the risk of suicide twenty fold.  

Side Effects of Lithium that Start Soon After Treatment

The side effects of lithium that might start soon after treatment are listed below.  Most are not common. 

  • Fine tremor, especially of the hands
  • Diarrhea
  • Muscle weakness
  • Thirst, which causes increased fluid intake and urine production
  • Memory and concentration problems
  • Changes in creativity
  • Weight gain
  • Epileptic seizures 
  • Psoriasis, acne and/or follicular keratosis (a lumpy rash)
  • Muscle stiffness or increased muscle tension 

The tremor that is caused by lithium usually stops with time.  On the other hand, it worsens during activities that need fine control.  The tremor can be reduced by stopping caffeine (tea, coffee, cola, energy drinks, chocolate), decreasing anxiety, and by taking medications called beta-blockers.  Beta-blockers include medications such as atenolol.  Beta-blockers should not be taken by people who have insulin-dependent diabetes, asthma, heart failure, heart rhythm/ECG (electrocardiogram) disturbances or low blood pressure.  Lithium also rarely causes a tremor like the one that occurs with Parkinson’s disease. 
Thirst can be decreased by taking lithium once a day. 

Lithium can cause thinking and memory problems.  On the other hand, studies of writers and artists found that most of them were more creative when they were taking lithium, because they were more organized.  Some people feel inspired by having a high mood and others just enjoy the feeling of being high.  This is unfortunate as the best thing for thinking and concentration is to have a mood that is neither elevated nor depressed.

Lithium can decrease the seizure threshold.  That is, it can make epilepsy worse, and if you do not have epilepsy, there is a very slight chance that you could have an epileptic seizure.  However, this is not usually a reason to stop people driving or to make them have supervised baths when they start taking lithium.
There is a theoretical risk of the side effect of tightening of the muscles in the throat making it hard to breath.  Lithium can also change the electrical reading of the heart when an ECG recording is make; this is of little practicable significance. 

Alcohol and Lithium

Because lithium causes drowsiness, it increases the effect of alcohol.  This is especially important in driving, operating machinery, caring for children or walking near traffic.  For example, if your blood alcohol level was 0.05, you might be just as impaired as if your blood alcohol level was, say, 0.08 and you were not taking lithium.  (If there are doubts about driving, driving ability can be tested by occupational therapists.)  Lithium also increases the drowsiness caused by other medications, such as antihistamines and benzodiazepines, or by other things, such as missing sleep.

Lithium and Your Kidneys

Kidneys
Your kidneys are kidney-shaped organs that are about 10cm long and located in your back, deep to your lower ribs.  They produce urine which is stored in your bladder until you pass it.  The production of urine has several important roles.  If you drink more water than you need, you pass the un-needed water as urine.  If you are unable to drink water, your kidneys stop producing as much urine, so you do not become dehydrated.  In a similar way, the kidneys also regulate the amount of various salts (dissolved molecules) in your blood.  The kidneys also excrete wastes and medications from the body.  Lithium carbonate is a salt of a lithium atom and a carbonate molecule, and it is excreted from the body by the kidneys.

Polydipsia, Polyuria and Nephrogenic Diabetes Insipidus

If someone has been treated with lithium for some time, the ability of thier kidneys to concentrate urine is sometimes decreased.  If this has happened to someone, they will pass more urine.  Because they pass more urine, they need to drink more water.  The inability to concentrate urine caused by lithium is called ‘nephrogenic diabetes insipidus.’  Drinking extra water because of excess thirst is called ‘polydipsia.’  Passing extra urine is called ‘polyuria.’  People usually pass less than two liters of urine per day.  Someone with polydipsia might pass 10 liters of water per day.

Polyuria is diagnosed by collecting a whole day’s urine and sending it for analysis at a pathology laboratory, where the volume of urine and its make up are measured.  If someone develops polyuria, further investigation might require a brief admission to a medical hospital.    Lithium-induced nephrogenic diabetes insipidus is treated with a specific type of diuretic.  (Diuretics (“fluid tablets”) usually increase urine production, but when they are used in this way, they decrease urine production to normal levels.)    If someone with diabetes insipidus is unconscious, they might need to be given fluid in a drip, so they do not become dehydrated.

Lithium and Renal (Kidney) Failure.

The healthy kidneys have a great deal more capacity than they need.  The only importance of a small reduction in renal function is if it is either 1) followed by further decrease in renal function or 2) represents an underlying problem that should be fixed.  A small reduction in kidney function occurs in about 20% of people who take lithium for greater than 20 years.  This is significant only after a patient has been on lithium for many years and also is elderly or has other kidney disease.  Lithium very rarely causes another problem with the kidneys called interstitial nephritis.  This is an inflammation of the kidneys and is more damaging. 

Some authorities recommend that people on lithium have their kidney function checked each year by measuring their creatinine clearance.  Creatinine is a protein in the blood that is flushed out by the kidneys.  How quickly the kidneys flush it out reflects how well they are functioning in general.  The creatinine clearance test involves checking how much creatinine your kidneys flush out in a day and comparing it to how much creatinine is in your blood.  This is done by collecting  24 hours of urine and having a blood test when you bring it into the pathology centre.  Because this test measures the volume of urine passed over 24 hours, it can also detect polyuria before it becomes noticeable.   

Lithium and People who already have Renal Disease

If someone has renal disease, their kidneys might be vulnerable to further damage by lithium.  This means that they should not take lithium.  If someone all ready has complete renal failure, produces no urine, and is on dialysis, they can take lithium, as it will not further hurt their kidneys.  They might be eligible for a renal transplant in the future, however.   If someone has a renal (kidney) disease, their kidneys might flush out less than the usual amount of lithium.  If it was safe for them to take lithium, they would need to take less than the usual dose of lithium.

Lithium Toxicity

If the levels of lithium in your blood become too high, the lithium might become poisonous, or toxic. You need to know the symptoms of lithium toxicity.  If people around you know about your illness, it would be best if they knew about the signs of lithium toxicity too.  If you may be experiencing lithium toxicity, seek medical attention immediately.

Signs of lithium toxicity can be remembered by dividing them up into brain, digestive tract (gut) and muscle signs.  On the other hand, the first sign of lithium toxicity can be feeling generally unwell.  So, if you’re feeling yuck, think lithium. 

The signs of lithium toxicity are
•        feeling generally unwell or like you have ‘the flu’
•        drowsiness (sleepiness)
•        poor co-ordination
•        slurred speech
•        decreased appetite (being not hungry)
•        nausea (feeling like you want to throw up)
•        vomiting
•        diarrhea
•        worsening tremor (having ‘the shakes’)
•        muscle twitches
On the other hand, mild tremor is a normal side effect of lithium and does not necessarily mean that lithium toxicity has occurred. 
Lithium toxicity is caused by either taking too much lithium or by the kidneys flushing out less or not enough.  The kidneys flush out less lithium if you take medication that stops them working as well or if the blood supply to your kidney is reduced.  The blood supply to your kidney is reduced by dehydration or by heart failure.  All this sounds complicated, but the most important causes of lithium toxicity are listed below.   

The most important causes of lithium toxicity are:

  • Not drinking enough water or drinking less water than usual
  • Vomiting
  • Diarrhea
  • Increased sweating
    • from hot weather
    • from increased exercise 
  • Other medications.  These are discussed in the section ‘Lithium and Other Medications.’ 
  • Changing to a very low salt diet
  • Lithium overdose
    • accidental
    • intentional

Not drinking enough, vomiting, diarrhea and excessive sweating are all causes of dehydration.  You can get dehydrated by doing sport or exercise that you are not used to or by particularly hot weather.  Early signs of dehydration include feeling thirsty and having dark urine.  If you become dehydrated, the lithium levels will only become too high if you continue to take lithium before you replenish your fluid levels (and have pale urine again or the usual color).

That means that if the weather is particularly hot, or you can not keep up your fluid intake, or you have done unusual exercise, or have diarrhea or vomiting, you should make sure that your lithium levels do not get too high.  Do this by missing a dose or two until you have had enough fluid and given your kidneys time to flush out the same amount of lithium that they usually do before the next dose.  You can work this out by making sure that your urine is pale, that you are not thirsty and you have recovered from what might have made you dehydrated.  If you need to miss more than a dose or two, or if you are unsure, you should contact your doctor.

Severe lithium toxicity can cause renal (kidney) damage and brain damage.  Mild episodes of lithium toxicity increase the risk of long term kidney failure from lithium.

Lithium and Your Thyroid Gland

The thyroid gland is a gland in the neck, just in front of and below the voice box (larynx).  It controls the metabolic rate of the body, that is, the rate that the body burns food and energy.  It controls the body’s metabolic rate by releasing thyroid hormone.  The more thyroid hormone in the blood, the higher the metabolic rate.  A goitre is a large lump that appears at the front of someone’s neck if their thyroid gland is enlarged.  (The American spelling of goitre is ‘goiter.’) 

Lithium can have a number of effects on the thyroid gland.  It can cause the thyroid gland to produce too little thyroid hormone, a condition called ‘hypothyroidism.’ (‘Hypo-’ means ‘not enough’ of something.)  This makes the metabolic rate of the body decrease and weight gain to occur.  Low levels of thyroid hormone are detected by regular blood tests before any harm is done.  The problem is fixed by taking tablets with thyroid hormone, also called thyroxine.  Thyroid hormone tablets in Australia are called Oroxine or Eutroxsig.  The thyroid gland usually returns to normal if the lithium is stopped.  It is quite common for lithium to cause hypothyroidism.  It occurs in 20% of middle aged women on lithium, for example.  Taking thyroid hormone tablets with lithium can be an advantage, because thyroid hormone is often used to help manage bipolar affective disorder or depression. 

Lithium can also cause goitre with normal thyroid hormone levels.  This is also treated by taking thyroid hormone.  Rarely, lithium can cause thyroid hormone levels to be increased.  Lithium can very rarely cause exopthalmos, a condition where one’s eyes bulge forward a little, which is associated with the thyroid side effects of lithium.  

Lithium and your Parathyroid Gland

Lithium can occasionally effect the parathyroid glands.  These small glands are located in  the neck, beside the thyroid gland.  They control the body’s levels of calcium and phosphate.  The parathyroid glands are monitored by measuring calcium levels with the other blood tests that are done for lithium treatment.

Lithium and Peripheral Neuropathy

Lithium very rarely causes peripheral neuropathy.  That is, it very rarely decrease the sensation of the feet.  It very rarely can cause downbeat nystagmus, where the eyes have trouble moving up and down normally.

Lithium and Idiopathic Intracranial Hypertension

Very rarely, lithium can cause benign intracranial hypertension, a condition were the pressure in the cerebrospinal fluid around the brain increases.  This causes symptoms such as double vision, decreased vision, headache and ringing in the ears.  In the unlikely event that you have a new onset of these symptoms (particularly visual ones), you should see a doctor, who will make sure that you have not developed idiopathic intracranial hypertension.

Lithium and Your Heart

Lithium can slightly change the electrical pattern of the heart shown on an ECG (electrocardiogram).  These changes are usually of little importance.  Very rarely, lithium can exacerbate cardiac arrhythmias (abnormal electrical conduction of the heart) or cause new arrhythmias.  These problems can be detected by having an ECG.  Lithium does not alter the QTc (corrected QT interval) of the ECG; this is important as someone needs to have their ECG measured if they are on more than one drug that alters the QTc.

Lithium and Medical Illnesses

As mentioned above, if someone’s kidneys do not work well, they might need to take less than the usual amount of lithium.  Other things can stop the kidney flushing out as much lithium.  If someone has heart failure, or is elderly, they will also need to be on a lower dose of lithium.  Do not take lithium if you have low sodium (Na+) or Addison’s disease or are on a very low salt diet.  You should stop taking lithium 24 hours before having an operation.

Lithium and Blood Tests

Lithium Level
Blood tests need to be done to check to serum (blood) level of lithium.  This is because the amount of the drug in your blood stream needs to be kept in a narrow range.  If you have too little of the drug in your blood stream, it will be less effective.  If you have too much in your blood stream, side effects are more likely and toxicity might occur. 
The blood tests are usually done between 5 and 7 days after you start the lithium or change the dose of the lithium.  This is done so the level of the drug in your system has had time to stabilize at a particular level.  Levels stabilizing at (or reaching) a particular level is called reaching steady state.  Early in treatment, lithium levels are measured regularly.  After it is clear that the level is stable, it should be checked every 3 to 6 months.  Other blood tests mentioned can be done at the same time. 
The blood test is done about 12 hours after your last dose of lithium. (Between 10 and 14 hours after the last dose is alright, but between 11½ and 12½ is better).  This is done so that lithium is not still being absorbed into your blood stream when the blood test is taken.  This means that the blood test is taken first thing in the morning, whether you take all your lithium at night or take it twice a day.

The lithium level should usually be between 0.4 and 0.6 mmol/L (0.8 to 1.2 milli moles of lithium per liter of blood).  If someone is very unwell, they will need to have higher lithium levels.  Some people are very sensitive to lithium and need much lower blood levels.

Lithium and Other Medications

Lithium interacts with numerous other medications.  Sometimes this means they can not be taken with lithium.  At other times, other precautions, such as decreasing the dose of lithium, need to be taken.  Your doctor needs to know about all the prescription medications, over-the-counter (from the chemist or supermarket) medications, herbs, health foods and injections you take.  This section names many medications.  It is important to note that new medications are coming on the market all the time and that important medications might not be on this list. 

Lithium concentrations are reduced by medications that contain bicarbonates, such as sodium bicarbonate and potassium bicarbonate.  Many of these medications are available over-the-counter.  They include antacids used for reflux, indigestion and heartburn (Alka-Seltzer, Eno, De-Gas, De Witt’s Antacid Powder, Gaviscon, Meracote, Mylanta, Salvital).  Drugs used to make urinary tract infections less painful by making the urine less acidic (Citravescent, Uracol, Ural).  Drugs to fix low potassium levels in the blood (hypokalemia) (Chlorvescent, K-Sol).  Movicol, used to treat constipation.  Sodibic, used in some kidney disorders.  Gastrolyte, used to adjust salts in the blood of people with dehydration.  If these medications are taken with lithium, they decrease the blood levels of lithium.  If they are being taken in the long term with lithium, the dose of lithium might need to be increased.       

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and can be bought over-the-counter from the chemist or supermarket.  Some NSAIDs need a prescription.  There are many different types of these medications.  There are only two NSAIDs that can be taken with lithium with out interactions - they are aspirin (which has many trade names) and sulindac (trade names Aclin and Clinoril).  All the other NSAIDs decrease how much lithium is flushed out by the kidney.  It is best to avoid taking these NSAIDs, but if you did, the dose of lithium could be reduced by between one third and one half and the blood levels of lithium would need to be monitored; this would usually not be practicable if you were starting and stopping the NSAID.  There are many trade names for the NSAIDs that interact with lithium. 

The generic names of these drugs are ibuprofen, naproxen, indomethacin, meloxicam, diclofenac, piroxicam, diflunisal, mefenamic acid, ketoprofen, tiaprofenic acid and ketorolac.  Some creams that are rubbed into sore joints contain NSAIDs; they should not be used with lithium because a small amount of the NSAID is released into the circulation.
ACE inhibitors are a group of medications that interact with lithium.  They are used to treat hypertension (high blood pressure) and heart failure.  There are many of these drugs on the Australian market.  The generic name of these drugs usually ends with the letters “-pril.”

Angiotensin II receptor antagonists are another class of drugs that interact with lithium.  They are used to treat hypertension.  There are lots of these medications on the Australian market.  The generic name usually ends with the letters “-sartan.”

Calcium channel blockers are another class of drugs that interact with lithium.  They are used to treat high blood pressure and heart failure.  The generic names of these medications are verapamil, diltiazem, nifedipine, amlodipine, lercanidipine and nimodipine.  They can increase the blood level of lithium, and even if they do not, they can increase toxicity. 
Carbamazepine (Tegretol, Teril) can increase the risk of toxicity with lithium.  In spite of this, lithium and carbamazepine are frequently and safely used together.  Carbamazapine and lithium can both be used to treat bipolar effective disorder.  Carbamazapine can be used to treat epilepsy (but lithium is not).

Methyldopa (Aldomet, Hydopa) is used to treat high blood pressure (hypertension) and can increase the toxicity of lithium without increasing the blood level of lithium. 
COX-2 inhibitors are a new type of NSAID.  They interact with lithium in the same way most NSAIDs do.  Their names are celecoxib (Celebrex) and parecoxib (Dynestat). 
Potassium iodide can increase the risk of lithium decreasing how much thyroid hormone the thyroid gland produces.  If the drugs are taken together, thyroid hormone levels should be monitored.  Iodine is sometimes added to vitamin supplements and to table salt.  

Serotonin syndrome involves symptoms such as agitation, confusion, high temperature, rapid pulse, diarrhea an muscle jerks.  Lithium can cause this side effect when given with certain other medications: some antidepressant, sibutramine and some migraine medications.  On the other hand, antidepressant medications are routinely used with lithium.  The antidepressants with an increased risk of toxicity are the serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac, Lovan, Auscap, Zactin and several brands with Fluoxetine in the name), fluvoxamine (Luvox, Faverin and Movox, and the antidepressant venlafaxine (Efexor, Efexor-XR).

If you start on an SSRI while you are on lithium, you should have your lithium level checked soon afterwards.  Sibutramine (Reductil) is a medication used for weight loss.  The effect of this drug is similar to the effect of antidepressant medications.  Sumatriptan (Imigran, Suvalan), zolmitriptan (Zolmig) and naratriptan (Naramig) are used to treat migraine headaches (after the headache has all ready started).  Theoretically, if they are used with lithium, they can cause serotonin syndrome. 
Some ‘fluid tablets’ or diuretics interact with lithium.  The most important ones belong to the group of drugs called the thiazide diuretics.

 There are only two drugs in this group; hydrochlorothiazide (which has numerous trade names and is in preparations with more than one drug in the same tablet) and chlorthalidone (Hugoton).  If these medications are used with lithium, the dose of lithium needs to be reduced by between a third and a half, and blood levels of lithium need to be monitored.  Thiazide diuretics are used to treat nephrogenic diabetes insipidus, which can be caused by lithium.
Another group of ‘fluid tablets’ that interact with lithium are called loop diuretics.  The loop diuretics are called frusemide, bumetanide and ethacrynic acid (they have numerous trade names).  These diuretics effect the level of lithium less than thiazide diuretics. 

A third group of diuretics is called the potassium-sparing diuretics.  They are spironolactone (Spiractin, Aldactone) and amiloride (Kaluril, Midamore), and they decrease the renal clearance of lithium.  Indapamide also decreases the renal clearance of lithium.    Herbal diuretics can increase the blood levels of lithium and cause toxicity.     
There might be an increased risk of toxicity if lithium is used with the antipsychotic medications clozapine (Clozaril, Clopine) and haloperidol (Serenase, Haldol).  They can still be used together.  Caffeine, found in tea, coffee, chocolate and cola, might decrease lithium levels.  Theophylline (Nuelin) might have the same effect.

There is much debate about whether or not lithium should be given at the same time as electroconvulsive therapy (ECT).  Lithium might increase the risk of confusion from ECT.  On the other hand, stopping and restarting lithium might decrease its effectiveness.  Some believe that taking lithium and having ECT at the same time can produce permanent neurological damage.

Lithium and Pregnancy

It is important to the baby that their mother has the best possible mental health.  If a mother-to-be has poor mental health, it can effect the baby through poor prenatal care, poor care of the baby after birth, poor self-care by the mother during pregnancy and self-harm by the mother during or after pregnancy.   

Overall, lithium is associated with 4 to 12 percent total birth defects, compared about 3 percent for the general population.  Lithium is better to take in pregnancy than the mood stabilizers such as valproate and carbamazapine.  Lithium is worse to take in pregnancy than other drugs that can treat mania, such as haloperidol.  Lithium is worse to take in pregnancy than other drugs used to treat depression, such as Zoloft/sertraline.  Antidepressant and antipsychotic drugs can be used instead of lithium during pregnancy.  In many cases, it is best for the mother to stay on lithium throughout pregnancy because the risks of stopping the lithium are greater than the risks of staying in the lithium. 

Lithium causes 1 in 1000 chance of heart (cardiac) defects (malformations) occurring in the unborn child if it is taken in the first seven weeks of pregnancy.  This means that the baby’s heart development starts before most women know they are pregnant.  The baby’s heart forms during the first seven weeks.  The 1 in 1000 risk of cardiac malformation is low compared to the normal birth defect rate of the general population of people taking no medication when they are pregnant of about 30 per 1000 babies borne.  Heart abnormalities in an unborn child can be detected early with an ultrasound scan.

If you wish to become pregnant and decide to stop taking lithium, the lithium should be stopped gradually over one or two months.  Stopping lithium suddenly can cause an episode of mania (high mood) which can be harmful.  If you stop lithium and start taking it again, it might not work as well as it used to.  This means that if you intend becoming pregnant, you should discuss this with your doctor, and if you do not intend to become pregnant, you need to use contraception.  If you are so busy that you occasionally forget to take the oral contraceptive pill, you might prefer to take a contraceptive injection every four months. 

During pregnancy, the kidneys flush out extra lithium and the dose might need to be increased.  After delivery, the kidneys flush out much less lithium and the lithium might need to be stopped temporarily (withheld) and the dose adjusted.  After birth, the kidneys rapidly return to removing lithium from the blood at the same rate they did before pregnancy; after delivery, the dose should be changed back to the dose before pregnancy.  Lithium can cause newborn babies to be ‘floppy,’ less responsive, have cardiac arrhythmias (abnormal electrical activity of their heart) and goitre.  This suggests that someone could consider stopping, or decreasing their dose of lithium before the time they are due to deliver.    However, giving birth is a high-risk time for relapse of bipolar affective disorder; as many as 7 in 10 women with bipolar affective disorder relapse after giving birth if they are not on mood-stabilizing medication.

Lithium and Breastfeeding

Lithium is transferred into breast milk and babies’ kidneys are not very good at flushing out the lithium.  This means that you should not breast feed if you are taking lithium.  If you did breastfeed when you were taking lithium, the baby would need various blood tests and examinations to make sure that (s)he had not become dehydrated.

Lithium and the Elderly

People who are elderly need less lithium than older people.  Their kidneys remove lithium from the blood slowly.  Even with the same blood levels, they will have more side effects.  Most of the medical conditions mentioned above are more frequent in the elderly. 

Falls

Lithium increases the risk of falls in the elderly; it can make people a little less alert and co-coordinated.  Lithium does not effect blood pressure.  (Many psychiatric medications decrease blood pressure, and this is one of the reasons psychiatric medications increase the risk of falls in the elderly).
 



MoodSwings - an online intervention for bipolar disorder               
Sue Lauder - August 10-12, 2007 (Bipolar Disorder Scientific Meeting – Brisbane,  Australia)
Sue Lauder has a background in nursing and psychology. She has experience in the development of a number of manualised psychosocial interventions and in health promotion and evaluation.
Sue has worked on a number of clinical randomised trials in a range of settings, including a group program for bipolar disorder. Her current work and PhD project involves the development of an online intervention for bipolar disorder known as MoodSwings: www.moodswings.net.au

Introduction
Randomised controlled trials have illustrated the benef ts of adjunctive psychosocial interventions in the treatment of bipolar disorder. However, access to these interventions is diff cult for many patients, particularly those who live in rural or remote locations. Apart from distance, other barriers to program participation include f nance, transport and time constraints. The use of the internet to deliver psychosocial interventions may help overcome some of these barriers, and over the past few years, there has been an emerging body of literature to support its use in this way.

The MoodSwings site is an online intervention for bipolar disorder that has been developed to provide an alternative means of delivering a psychosocial intervention to those who are unable to participate in other programs.

The benefi ts of using the internet for service delivery

Over 4.7 million households in Australia now have computers and internet access, and the disparity between metropolitan and non-metropolitan households is not large.  This f ags a real opportunity for the internet to become a medium for the delivery of specialist programs in areas where such programs may not otherwise exist.

Online interventions have a cost advantage – they reach more people and require less therapist involvement than face-to-face interventions.  Other advantages include the fact that the intervention can be undertaken at a convenient time without the need for transport, time off work, or additional f nance to participate.
For the provider of the program, internet technology allows us to understand how the intervention is being used: we know the times people log in, how long they stay on the site, the intervention module the participant worked on, and what information was downloaded.  This can be used to calculate dose effects and gives detailed information on the level of the program participant’s engagement.  Online interventions can provide support to the users via discussion boards and are beneficial for disorders where stigma is a factor.

People already use the internet to seek out health-related information.  In a typical day, around 8 million Americans are doing just that.12  The internet has been found to be the third most likely source of mental health information, behind mental health professionals and general practitioners.3   The top three reasons for using the internet have been shown to the convenience, anonymity, and the vast amount of information available. Those who seek online health information tend to be female and not employed full-time and are either diagnosed with a new health problem, have a chronic disorder or have commenced a new treatment regimen. 

Current online interventions

Interventions adapted for the internet are usually highly structured and often use Cognitive Behavioural Therapy (CBT). They typically have activities for skill development and contain interactive elements using graphics, animations, audio and video.  There may also be discussion boards and contact with a therapist via email. 

Since 2001, nineteen randomised controlled trials of internet interventions for mood and anxiety symptoms have been published.  A little more than half of these (57%) were published in the last two years, which highlights that this is a new and fastgrowing area of research.  Some of this research has investigated symptomatology, rather than a conf rmed diagnosis, and only nine of the published studies use some clinical interview process, while the other studies use self-report symptom scales only.  However, the results of the studies to date are encouraging.  

MoodSwings
MoodSwings is an adaptation of a group-based intervention, MAPS (Monitoring, Assessing, Prevention of relapse and Setting smart goals), developed by Lesley Berk under the stewardship of Professor David Castle.  MAPS is a 12-week program with 3 monthly boosters at the end. Its aim is to reduce episodes of relapse and improve functionality. The program includes psychoeducation, core skill development to manage triggers and medication, education on recognising and responding effectively to different mood states, and the development of personalised relapse prevention plans. 

The aim of the booster sessions is to assist with the integration of skills in daily life and to troubleshoot any diff culties experienced. The content of the MoodSwings online intervention follows a similar format to MAPS, with modules initially focusing on the core elements of the disorder before looking at specif cs of particular bipolar mood states.  The format allows the program to be tailored to the individual.
The intervention has been designed so that small groups of participants work through the same modules and use a discussion board to share their experiences and respond to specif c issues raised in each of the modules.  This creates the supportive environment of face-to-face groups. All discussion board posts are moderated before going on the site.

There are number of active intervention features of the site. 
The “My Profile” section contains personal summary information such as triggers, medications, an illness prof le (which identif es early warning signs and symptoms of illness) and a personal plan for relapse reduction.  There is also an “About Me” page, which focuses on aspects of a person beyond the illness, in terms of strengths and things they appreciate and enjoy doing. 

The “My Tools” section contains a number of key strategies, including monitoring mood for early warning signs, developing a life chart to detect triggers of illness, strategies for solving problems, cognitive skills for challenging unhelpful thinking, and weighing up and reflectingon coping strategies.

The mood monitor is the most interactive tool, allowing participants to record mood, anxiety and irritability, which are then presented graphically.  Sleep, medication and events that may be stressors or triggers are also recorded on this chart.

All MoodSwings pages can be easily printed, and there is a help button on each page to allow participants to e-mail for further technical help. In addition, the site is not technologically heavy and therefore works well using dial up, which helps with access in rural areas.

The site is currently being reviewed by a number of consumer consultants and service providers. During this process, we are assessing both content and the usability of the site.  Once this is completed, we will be making the site public and actively recruiting to evaluate its effectiveness.

References
1  Fox S. Powell DC. Clarke A. Internet information-seeking in mental health. British Journal of Psychiatry 2006;189:273277.
2  Rice T. Influences, usage, and outcomes of internet health information searching: Multivariate results from the Pew surveys. International Journal of Medical Informatics 2006;75(1):8-28.




If I have bipolar disorder, how likely is it that my children will develop bipolar disorder as well? Should I have them evaluated?

There are  studies looking at children who have parents with bipolar disorder. And most of those studies, at least from the U.S., suggest that about 15-20 percent of those children already have some form of bipolar disorder. Now that's cross-sectionally. In the future, there may be more children who develop this type of disorder over time.

There are also children who have parents with bipolar disorder who have depression and many children who have ADHD. In fact, about half the children in these studies have some sort of psychiatric difficulty already.

So we think that those could be early precursors for full bipolar disorder. That being ADHD plus mood disregulation as well as full depression. Those children if they have a parent or a first degree relative with bipolar disorder could be at very high risk for going on to develop the full disorder.

Having said that, it's not just genetics. We really believe that it's a combination of the environment plus a genetic predisposition that leads to bipolar disorder.

Dr.Kiki Chang - Dir. Pediatric Bipolar Disorders Program, Lucile Packard Children’s Hospital at Stanford – March 2009



Personal Story (1).

(anonymous – May 2010)

When you are in your early twenties, when you are in your prime, the last thing you want to hear is that you have a mental health condition known as bipolar.

Acceptance of living with bipolar took me about three years, in and out of hospital. Every year, I would run into pressure at work and think I should put my head down and battle it out. Well that battling put me in hospital three times, sometimes for three months.

If I can give any advice to someone with bipolar, it is to know your limits. Have boundaries and don't cross them. Looking for a challenge is natural and everybody needs a bit of bounce in their life. However, it's important to know when to stop and when to take a break, because if your teacher doesn't know, or your boss or your lecturer doesn’t know, then you are your own teacher, lecturer and boss when it comes to your illness.

Don't let anyone tell you what you can and can't do. Listen to yourself first and listen to the medical staff as well. Friends and family are unbelievably important but they are not qualified to care for you when you are sick. Try and be open with your emotions and talk to the right people.

I went through three years thinking that a delusion I had was actually true. Then, I was in hospital one day and I talked to a friend who explained her delusion. It was so similar to mine that it had to be that both of us were experiencing an element of mental illness.

This was the start of my recovery. Nobody wants to accept they have faults. So I backtracked all my past delusions and realised that is all they were: delusions. It was a great feeling to get my grip back on reality. I've never experienced anything as special as gaining back my senses. It was like I was locked up in a tomb for three years and then crawled out of a small hole. Let the good days roll on and challenge the bad days.



Personal Story (2).
(Mary - May 2010)

Rather than tell you my story, I thought I'd mention something that came to me a few depressions ago because someone might be able to use it. Maybe other people can suggest other "kindnesses."

When my house is a total mess and the laundry and dishes are piled up and I am in bed for days ... I make believe that someone (me) is sick in bed, and that I am just a friend lending a little hand.

So whenever I get up (drink, bathroom, etc.) I just pick up one thing and put it where it belongs. If I pass laundry, I'll pick up one thing and put it in the basket. Or if I go to get a drink, I'll wash one dish and put it away. Or if I have any energy, I'll sort the laundry (not do it - hey, I'm just helping out here). Maybe later, I'll do one load (smallest one!).

Anyway, when I start feeling better, things don't look quite as horrible, and I feel like a friend popped in to help out. Because it made me feel good and "cared for", I started doing this when I was feeling good. Now, I'll do teeny parts of a job whenever I feel like it, so when I actually get down to doing the whole job, it's not quite as bad.

It makes me feel like I did something nice for myself instead of sabotaging myself as I usually do. Sometimes I can actually do a lot of little things to help myself out. But doing this really does give me good feelings toward myself when I actually get down to doing the "real" job. I sort of remember and "thank" myself for the break.

The Australian Medical System - What to do and who to go to if something goes wrong.

In a perfect world every time we sought help from a health professional we'd be 100 per cent satisfied with how we were treated. But the world isn't perfect, and like any provider of a service, doctors make mistakes. These mistakes can range from unprofessional behaviour to incompetence or simply a momentary lapse in judgement where the doctor makes a poor decision. It's important not to accept poor treatment, but to make a complaint about it. This doesn't just benefit you the consumer, it's also in the community's interests because it means there's less likelihood of someone else experiencing the same problem in the future.

Your rights

Health consumers have rights that guarantee them:
• a satisfactory service.
• dignity and privacy.
• adequate information.
• due skill.
• treatment in a professional manner.
• the right to redress if these measures aren't met.

These rights are covered by codes of conduct and are backed up by legislation – for example the Medical Practice Acts in each State, the Trade Practices Act, and common laws related to personal injury. In the past, when health consumers have taken action against medial practitioners, the professional bodies and the courts tended to favour doctors rather than patients. For years there's been a reluctance on the part of the medical profession to admit to doctors' mistakes and act on them. Nevertheless the rise of the consumer movement over the past 20 years or so have made consumers much more aware of their rights. Making a complaint is an important way of weeding out and re-educating health providers who are unprofessional or incompetent.

The most common complaints patients make relate to:
• poor treatment – misdiagnosis, wrong or inadequate treatment.
• inadequate provision of information – for example about the diagnosis or treatment.
• inappropriate nature of the relationship (a sexual relationship for example).
• impairment of the doctor due to drugs or alcohol. A smaller number involve administrative matters like lack of access to medical records, long waiting times, rude staff and so on.

Complaint options If the doctor is employed by a medical practice or hospital, the complaint should be made there in the first instance. The doctor should be given the opportunity to respond. If you are not satisfied, or the complaint is serious enough, you can make a complaint to the health care ombudsman in your State. This is a person whose job it is to handle complaints about health care providers. Each State has one, though they go under different names. If you are in Western Australia contact the Office of Health Review; in Queensland, the Health Rights Commission, in the Northern Territory the Health and Community Services Complaints Commission, in the ACT the Health Complaints Commission, Victoria, the Health Services Commissioner, and, in New South Wales, the Health Care Complaints Commission.

You should call them and discuss the problem over the phone, and then submit the complaint in writing. If they feel the complaint is unjustified or frivolous, they may dismiss it. Otherwise, depending on the nature of the complaint they may deal with it in different ways. For example they may refer it to their dispute resolution service. This is a forum in which patients and doctors are encouraged to come together and discuss and resolve their differences. It may result in an apology from the doctor for example. In more serious cases the complaint may be referred to another regulatory body for investigation.

In cases involving professional misconduct or where there is a question mark over the skill of the health practitioner, this might be the medical board. Each State and Territory in Australia has a medical act which outlines the conditions under which medical practitioners are allow to practice. The acts are administered by State medical boards. A board may investigate a doctor via a medical tribunal or professional conduct hearing, and if found guilty, the doctor may disciplined by a fines, suspension, the imposition of conditions on practice, or deregistration.

Litigation

If you feel you have been injured by a health professional you also have the option of suing that person. Under common law, a person has the right to sue a health provider for failing to exercise reasonable skill and care in their diagnosis, and treatment, and for failure to provide adequate information about their treatment. That person can seek damages for injuries. Those damages might include a sum of money to cover medical expenses (past, present and future), loss of income due to disability, expenses to cover nursing and domestic help, and an amount for the pain and suffering experienced.

The plaintiff (the person bringing the complaint) has to be able to prove that the doctor acted negligently, and that the negligence caused the injury. This can be difficult because:
• the direct link between the procedure and the damage is sometimes difficult to prove.
• to prove negligence, the plaintiff must prove the doctor breached his or her duty of care. Expert witnesses must give an opinion that what the doctor did was outside of normal acceptable practice. These experts are other doctors who may be reluctant to testify against members of their own profession. Even if they testify the conduct was normal practise, the court may still find the doctor negligent.

For the plaintiff, losing the case can be costly, because the court may order the plaintiff to pay the doctor's court costs as well as the plaintiff's. If the doctor loses, the costs don't come out of the doctor's pocket. Doctors must have professional negligence insurance (known as medical indemnity insurance) to be able to practice, and the insurance company makes the payout. Most cases don't go to court, because both sides usually settle out of court. Those cases that do go to court (about 10 per cent) are usually the ones that the doctor's medical insurance company thinks has a good chance of winning and will pursue to the end.

Studies have shown that a person who believes they have suffered from malpractice is much more likely to sue if they think:
• the doctor is hiding information from them.
• the doctor won't apologise and admit they've made a mistake.
• nothing is being done to ensure the mistake isn't repeated.

Health Ombudsmen

Lithium for Bipolars

OVERVIEW

Lithium carbonate was the first medication proven to stabilise mood in bipolar disorder. (Cade-1959). It also was shown to prevent manic and depressive episodes returning. Lithium does a better job of preventing manic episodes and controlling manic symptons than it does preventing depressive episodes, but it can still be an effectiive antidepressent when used alone.(Keck & McElroy-1996, Prien-1984, Zornberg & Pope-1993) Lithium has the most research support in psychiatric mood stabilizer medications.

SLOW RELEASE

The lithium slow release version (Quilonum-SR) maintains a more even therapeutic level in the bloodstream over a 24 hr period. There is a greater time lapse window (3 – 13hrs) for taking blood samples for accurate testing, although the 12 hr interval is still advisad.

SINGLE DOSE ADJUSTMENT OF RESULTS

When interpreting blood level concentrations for a patient taking a daily single dose, 12-hour concentrations are 10% to 25% higher after a single night time dose, so correspondingly higher blood levels than those seen with twice-daily dosing should be aimed for. This is important for patients who are at the lower end of the therapeutic range.

THEURAPATIC RANGE

The therapeutic range which should be aimed for is 0.5 to 1.2 mmol/L. Manic tendency patients should aim for a level higher in the range, depressive tendency patients should aim for a level lower in the range.

HYDRATION

Because lithium can be a threat to the long term health of the kidneys, maintaining a good level of hydration is important. In simple terms, if water intake increases, more flushing will take place in your system and less residual chemical will be retained in the kidneys. Any health advisor will recommend at least 2 litres of water a day for anyone (fruit etc. counts too).

INTERVAL BEFORE SAMPLING

It is important that blood samples be taken as close to the 12 hr interval (from last dose) as possible. A 1 hr margin (each way) is acceptable but not advisable.

EFFECTIVENESS

If the lithium blood level concentrations fall below the therapeutic range, lithium will not work.