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Australian treatment guide
for consumers and carers
The Royal Australian and New Zealand College of Psychiatrists, 2009
Key points about bipolar disorder
Compiled by The Royal Australian and New Zealand College of Psychiatrists (RANZCP),
this information and advice is based on current medical knowledge and practice as at the date of publication. It is intended as a general guide only, and not as a substitute
Treatment of mania and mixed episodes
for individual medical advice. The RANZCP and its employees accept no responsibility for any consequences arising from relying upon the information contained in this
Treatment of bipolar depression
Prevention of further episodes
The Royal Australian and New Zealand College of Psychiatrists
Further treatment choices
309 La Trobe StreetMelbourne Victoria 3000
Appendix 1: Mental health care teams
Appendix 2: Sources of information and support
Telephone: (03) 9640 0646Facsimile: (03) 9642 5652
Appendix 3: Terminology and acronyms
Appendix 4: Development of the guideline
Key points about bipolar disorder
1 Bipolar disorder is a disorder of mood, in which
a person has episodes of both elevated and
2 These episodes of major change of mood are
associated with distress and impairment of
3 If you think you or someone you care about
has bipolar disorder, check with your general
practitioner. A referral to a psychiatrist or
psychologist may be necessary.
4 Bipolar disorder is an illness for which there are
5 Those with bipolar disorder and their families can
do positive things to reduce the impact of the
illness, even though the illness can interfere with
6 People with bipolar disorder can take control of
their illness by working with a multidisciplinary
team of doctors, psychologists and other health
professionals, and utilising the support of family
This guide was written by consumers, carers and mental health
professionals to answer the most common questions consumers and
carers have about treatments for bipolar disorder and living with the
condition. It is a research summary of what is known about bipolar
disorder and its treatment. It is also an updated plain English version
of the Australian and New Zealand Clinical Practice Guideline for
the Treatment of Bipolar Disorder (RANZCP, 2003) written for mental
The purpose of this guide is to provide consumers and carers with the
information they need on the assessment, diagnosis and treatment
of bipolar disorder. It is important that its recommendations are not
taken as absolute. People with bipolar disorder and their carers should
consult their mental health professionals before using information in
The guide has been written in accordance with the National Health
and Medical Research Council recommendations for the development
of clinical treatment guidelines for consumers.
The guide covers the reasons why comprehensive assessment and
diagnosis are so important. It then outlines treatments for the different
phases of the illness:
• acute treatment of mania and mixed episodes
• acute treatment of depression
• prevention of further episodes of mania and depression.
Consumers, their partners, family, friends and other carers can locate
further information about bipolar disorder and sources of support in
What is bipolar disorder?
Recognising hypomania and mania
Bipolar disorder is a mood disorder. It is characterised by periods
of mania or hypomania, depression and ‘mixed episodes' (a mixture
Hypomania and mania are characterised by a distinct period of
of manic and depressive symptoms). The illness is commonly
abnormally and persistently elevated, expansive or irritable mood.
Mania usually lasts at least one week and causes significant difficulties
• Bipolar I disorder – at least one lifetime manic episode
in carrying out normal roles such as job or family responsibilities.
• Bipolar II disorder – only periods of a major depression
Hypomania usually lasts at least four days and does not cause
accompanied by at least one hypomanic (not manic) episode.
profound difficulties in job or family roles. During the period of mood
disturbance, some of the following symptoms will be present to a
Most people with bipolar disorder experience multiple episodes at
an average of one episode every two to three years, with each phase
lasting about three to six months.
• inflated self-esteem or sense of grandiosity, often of a
If a person has four or more episodes in a 12-month period, their
• decreased need for sleep (e.g. feels rested after only a few hours
condition is termed ‘rapid cycling' bipolar disorder.
• more talkative than usual, or pressure to keep talking
• ‘flight of ideas' or subjective experience that thoughts are racing
Do I have bipolar disorder?
• distractibility (i.e. attention too easily drawn to unimportant or
The criteria for making a diagnosis of bipolar disorder, as
irrelevant external stimuli)
defined by the Diagnostic and Statistical Manual (DSM) used by
• increase in goal-directed activity (either socially, at work or school,
health care professionals, are:
or sexually; or a mental and physical restlessness)
Bipolar I: occurrence over a lifetime of at least one manic
• excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g. engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business
Bipolar II: one or more major depressive episodes accompanied
by at least one hypomanic episode (not manic episodes).
It is best to go to a general practitioner as early as
possible if you have, or someone you know has,
mood swings that concern you.
Recognising major depression
Symptoms that may be concurrent with
People with major depression will experience some of the following
People with bipolar disorder often have symptoms of other mental
symptoms for at least two weeks. These symptoms represent a change
health issues. These symptoms should be assessed as part of the
from previous functioning and at least one of the symptoms is either
comprehensive assessment and may need specific treatment, as they
depressed mood or loss of interest or pleasure:
do not always get better even if the bipolar disorder is well controlled.
• depressed mood as indicated by either subjective reports (e.g.
Alcohol and drug use is very common among people with bipolar
feels sad or empty) or observations made by others (e.g. appears
disorder. They may consume alcohol or drugs to try to stop mood
swings or to help cope with the impact of the mood swings on their
• markedly diminished interest or pleasure in activities
work and family life. Sometimes it can be difficult to distinguish
• significant weight loss when not dieting, or weight gain, or
between alcohol-related problems and bipolar symptoms.
decrease or increase in appetite
Anxiety disorders also commonly co-occur with bipolar disorder. These
• insomnia or excessive sleep
include Generalised Anxiety Disorder (characterised by excessive worry
• mental and physical slowing or restlessness
about the future), Social Anxiety Disorder (excessive concern about
• fatigue or loss of energy
what others may think about you) and Panic Disorder (panic attacks).
• feelings of worthlessness, or excessive or inappropriate guilt
During severe episodes of mania and depression, a person may have
• diminished ability to think or concentrate, or indecisiveness
a psychotic experience such as hallucinations or delusions. Sometimes
• recurrent thoughts of death (not just fear of dying), recurrent
this can lead to an incorrect diagnosis of schizophrenia.
suicidal thoughts without a specific plan, or a suicide attempt, or
a specific plan for committing suicide.
Recognising mixed episodes (DSM-IV criteria)
People who have mixed episodes will experience symptoms of both
mania and depression nearly every day for about one week.
Treatment of mania and
Often the diagnosis is not clear at the first assessment. Sometimes
this is because a person's symptoms overlap with other psychiatric
conditions they may have (e.g. psychosis, schizophrenia or anxiety).
For others, alcohol and drug use may distort or hide the symptoms of
depression and mania.
Because there have been very few specific treatment studies on
DSM-IV bipolar II disorder, our recommendations refer to bipolar
There is no scan or blood test that can diagnose bipolar disorder.
disorder generally. Most studies have either described a group of
However, a doctor will often request some investigations to rule out
people with bipolar I, or have not identified separate bipolar I and II
physical diseases. Also, it is essential to know if a woman with bipolar
subgroups. This guide discusses the initial clinical assessment, how
disorder is pregnant.
bipolar disorder presents when people first experience it and the main
During the comprehensive assessment (and during other assessments)
treatment approaches including mood stabilising and anti-depressant
the doctor or other health professional should assess any risk. A
person with depression may have thoughts or plans of suicide. Mania
sometimes leads to out-of-character and high-risk behaviour such as
How can I be sure that I have
sexual indiscretion, over-spending or other financial recklessness or
uninhibited and inappropriate disruptive behaviour. This can damage a
In order to diagnose bipolar disorder, a health practitioner must
person's reputation and standing in the community.
undertake a detailed, comprehensive assessment. Referral to
The doctor or health professional will also typically assess the person's
a psychiatric service is usually needed. However, some general
level of insight and judgement. Some people with mania do not
practitioners have sufficient experience and expertise to assess,
realise how unwell they are and lack insight into their condition. They
diagnose and treat bipolar disorder. Psychologists can also assist
may temporarily lose the capacity to judge appropriate behaviour.
general practitioners in assessing and treating bipolar disorder.
Occasionally they may develop false beliefs such as ‘I am the saviour of
During the assessment, you will typically be asked in detail about the
the world'. This is called psychosis and is one of the signs of mania.
type of symptoms, their severity and how they affect your work and
An assessment of risk and insight is necessary so that your safety and
relationships. You will typically also be asked about previous episodes
the safety of others can be assured and appropriate treatment given.
of depression and mania/hypomania. With your permission, your
Most people with bipolar disorder can have treatment without needing
family or carer will be asked for their perspective. In mania it is often
admission to hospital. If there are severe symptoms, major risk issues
others who notice the symptoms most, whilst the person experiencing
and limited insight, involuntary treatment may be necessary.
the manic episode is usually unaware of the change in their behaviour.
In contrast, a person with depression often tries to hide the symptoms
– family and friends may not know the severity of the depression.
Second, an anti-psychotic or benzodiazepine (or a combination of
these) is prescribed, to be taken as well as the mood stabiliser. These
The charts on page 14 and 15 show the approach mental health
medications calm or sedate the person with mania as a temporary
professionals usually take in the initial management of a person
procedure, until the mood stabiliser starts to help the person to
who presents with acute mania. Although community or outpatient
treatment is always preferable, and admission with the patient's
consent is sometimes possible, involuntary hospitalisation under the
Research shows that lithium is effective as a mood stabiliser when
relevant health legislation may be needed. Going to hospital can
compared to placebo. Studies show that carbamazepine and valproate
protect the person and their family from the damage that may result
are of similar value to lithium, although there have been few trials,
from the impaired judgement associated with the illness. The decision
particularly for carbamazepine. Research also shows that the second-
to go to hospital may be traumatic for the person with bipolar disorder
generation anti-psychotic medications are also more effective
and their family.
For lithium and sodium valproate, the therapeutic dosages for acute
Acute treatment of manic episodes
mania are reasonably well established. For carbamazepine, however,
the dosage used is the same as the dosage for epilepsy (some people
As insight can be affected by both depression and mania (more
with epilepsy also take this medication). However, dosage is mainly
commonly in mania than depression), often the person affected does
determined by the assessment of your individual response to
not see a need for treatment. This can mean disagreement over the
need for admission to hospital. Poor insight and judgement also lead
to poor compliance with taking medication, and some people resort to
It is important to discuss with your mental health
hiding their medication.
professional/s the risks you face if you do not get
This is not a wilful or defiant act, but is part of the impact of having
treatment for bipolar disorder.
bipolar disorder. It can be a challenging time for family and carers,
Timely treatment of mania can reduce disruption to
who can often see the benefits of medication. Sometimes it can take
your career, the likelihood of relationship problems,
several episodes of illness before the person with bipolar disorder
or risky financial mistakes being made during
agrees to take medication.
episodes of mania.
Medications are the main way of managing an acute manic episode.
Treatment may also help to prevent self-harm and
The aim of the medications is to stabilise mood and stop all symptoms.
suicidal thinking as a result of mania or depression.
There are two components to managing acute mania with medication.
First, a mood stabiliser is prescribed, such as lithium, sodium valproate,
carbamazepine or one of the new second-generation anti-psychotics.
Mood stabilisers act upon the elevated mood but take about one
week to start to take effect for most people.
Initial clinical assessment hypomanic/manic episode
Treatment of a manic episode
INITIAL SCREENING ASSESSMENT
• Severity of symptoms
• Level of functional and cognitive impairment
• Degree of insight
• Presence/absence of psychosis
• Risk to self (suicide, financial, sexual, reputation) or
• Extent of family support and/or community services
Legal aspects (e.g. informed consent, mental capacity)
Care in least restrictive environment ensuring safety (risk of self-harm)
WITH OR WITHOUT
Additional treatments for other symptoms
• Contain aggressive/overactive/disturbed behaviour • Treat psychosis • Manage sleeping difficulties
1 Taken orally • Benzodiazepines (diazepam, clonazepam, lorazepam) • Anti-psychotics (such as risperidone, olanzapine, quetiapine, haloperidol)
2 Taken by injection (only use if oral administration is not possible, or is ineffective) • Benzodiazepines (midazolam i.m., diazepam i.v.) • Anti-psychotics (olanzapine i.m., haloperidol i.m., zuclopenthixol i.m.)
physical complications could arise from its use in a particular patient's
How are mixed episodes (mania,
case. It has a variety of uses in the treatment of bipolar disorder and is
depression) of bipolar disorder
covered again in the guideline on depression.
It is a safe and painless procedure and can be life saving for severe
There is some weak research evidence for the benefit of the
depression. It is now administered to very specific target areas of the
following treatments in mixed states of bipolar disorder: valproate,
brain so that any side effects (such as short-term memory loss) are
carbamazepine and all the second-generation anti-psychotics.
Each state has legislation to ensure that ECT is only used safely and
What if the manic episode does not
respond to first-line treatment?
Your doctor or health professional may decide to alter your treatment
Failure of manic episode to respond to treatment
if you are not experiencing any or sufficient improvement in your
symptoms. There are several options if you do not respond to the
Optimize mood stabiliser (dose/blood levels)
initial medication chosen. Your doctor may:
• increase the dose and/or blood levels of the mood stabiliser
Switch/substitute mood stabiliser
• switch mood stabilisers
• combine mood stabilisers
Combine mood stabilisers
• add an anti-psychotic.
If you and your doctor have tried these strategies, and you have taken
Add an anti-psychotic medication
the medication correctly, and you still have no relief from symptoms,
electroconvulsive therapy (ECT) may be considered.
Continuing failure to respond
What is electroconvulsive therapy (ECT)?
1. Re-evaluate diagnosis - consider alternate causes (other
ECT is sometimes a life-saving treatment in severe cases where the
psychoses such as schizophrenia; organic disorders)
person with bipolar disorder has not responded to other treatment,
2. Electroconvulsive therapy
but is rarely used in contemporary practice.
Electroconvulsive therapy involves the use of electricity to stimulate the
brain and is administered on an inpatient or day treatment basis by
psychiatrists who are specially trained to administer it. It is a physical
treatment and is only able to be conducted after ensuring that no
What about ongoing treatment?
Treatment of bipolar depression
Following remission of an initial episode of mania, the mood stabiliser
would typically be continued for at least six months. This is because
experience with most patients shows that this is the best way to
prevent another episode.
Assessment of bipolar depression
In most cases, the benzodiazepine or anti-psychotic would be
The treatment for bipolar depression is sometimes different to how
withdrawn once the acute episode has resolved and only the mood
people with depression, but without bipolar disorder, are treated
for depressive symptoms. This section discusses assessment and
management of episodes of bipolar disorder depression.
For those people with a well-established history of bipolar disorder,
there are several recommended criteria for deciding if you are likely to
Your doctor or health professional would typically conduct a full
benefit from ongoing medication treatment. Most of these guidelines
psychiatric history, analysis of your mental state and a physical
are based on a consensus of medical opinions and clinical wisdom,
examination in order to:
taking into account how often illness happens, its severity and the
• confirm diagnosis
level of disability that it causes.
• exclude underlying complications (such as the presence of
Those medications that are effective in long-term treatment (either
any other illness)
alone or in combination) are: lithium, valproate, carbamazepine,
• identify physical complications
olanzapine and quetiapine.
• assess any risk of self-harm.
The reason for the assessment for risk of self-harm is that people
with bipolar disorder have a higher rate of self-harm and suicide than
the general population. This is usually due to depression, sometimes
due to impulsivity, and at other times can result from accidents
during periods of manic behaviour. Stopping medication too soon
is a common cause of depressive relapse, so the assessment would
typically involve a full medication history and review, and consultation
with carers where appropriate.
Acute treatment of bipolar depression
If you are already on a mood stabiliser, your dose and/or blood levels
should be optimised. If this is unsuccessful, your doctor may prescribe
There are two options that work for most people:
an anti-depressant, or a second mood stabiliser.
• a mood stabiliser (such as lithium, valproate, carbamazepine,
There are many effective anti-depressant medications available. If you
lamotrigine, olanzapine and quetiapine) and anti-depressant
have had a previously effective and well-tolerated anti-depressant
before, this would typically be used again.
• a mood stabiliser alone. Those with proven efficacy in bipolar
Anti-depressant therapy on its own may induce mania or rapid
depression are lithium, olanzapine, quetiapine or lamotrigine.
cycling, and should therefore be avoided.
The preferred options for treatment are selective serotonin reuptake
Initial clinical assessment of bipolar depressive
inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors
(SNRIs such as venlafaxine, duloxetine or desvenlafaxine). Newer anti-
depressants (mirtazapine or reboxetine) have not been well researched
INITIAL SCREENING ASSESSMENT
for the treatment of bipolar disorder, but may be reasonable second-
• Severity of symptoms
line choices, if the first-line treatment proves ineffective. Monoamine
• Level of functional and cognitive impairment
oxidase inhibitors (MAOIs) and tricyclic anti-depressants (TCAs)
• Presence/absence of psychosis or any other mental illness
should be considered a third-line treatment choice. Upon remission
• Risk to self (suicide, financial, sexual, reputation) and/or
or recovery of the episode, anti-depressants should be gradually
reduced so as to minimise the risk of switching moods while the mood
• Consultation with carer(s) as above
stabiliser is continued.
• Extent of family support and/or community services
Failure to respond to treatment
The chart on page 24 shows the treatment approach if your depressive
episode does not respond to initial treatment.
Legal aspects (e.g. informed consent, mental capacity)
Care in least restrictive environment ensuring safety (risk of
First, it is important to be sure that your medication is at the right
dosage and that it is being taken as prescribed. If there is still no
improvement, other mood stabilisers or anti-depressants can be tried
instead, on your doctor's advice.
A number of mood stabiliser combinations can be attempted in
conjunction with anti-depressants. However, if despite all reasonable
efforts you remain depressed or only partially respond, it is important
to re-evaluate the diagnosis and review your therapy. Organic causes
need to be ruled out. Furthermore, the impact of any additional
Barriers to taking medication
medical or psychiatric conditions should be thoroughly reassessed.
• Doubt about the diagnosis, reluctance to accept the illness
Family circumstances, social networks, and carer circumstances should
and willingness to risk another episode to confirm it.
• Possible side effects, including weight gain.
Most experts agree that electroconvulsive therapy is the most effective
• Possible enjoyment of the experience of mania and a wish to
anti-depressant therapy for bipolar depression. It should therefore be
experience it again.
used when indicated and especially if it has been previously effective
or there are psychotic symptoms.
• Not realising that mania and depression may involve
negative consequences for you or for others.
Finally, the psychosocial factors in your life need to be assessed,
such as how much support you have, and whether or not your living
• Concerns over pregnancy or interactions with medications
circumstances will promote your recovery.
used for other health problems.
All medications cause side effects. These cause many people
to stop taking medications. It is important to discuss all side
If you are in remission from the depressive episode, your doctor
effects you experience with your doctor. Including carers in
will usually withdraw anti-depressant treatment after two to three
these discussions can be very helpful.
months to avoid causing mania and/or rapid cycling. However, in
every individual, it is necessary to balance the need to treat bipolar
depression versus the risk of precipitating mania. If you have recurrent
depressive episodes, you can continue taking the anti-depressant
along with a mood stabiliser.
Pharmacological intervention - depressive episode
Prevention of further episodes
NEW DEPRESSIVE EPISODE
Initiate and optimise mood stabiliser
People with bipolar disorder have different patterns of illness. Because the
Initiate and optimise mood stabiliser and anti-depressant concurrently
illness is episodic (at least 90% who experience one episode go on to have
more episodes), it can be very hard at times to tell when you are well, or to
BREAKTHROUGH DEPRESSIVE EPISODE ON SINGLE MOOD STABILISER
distinguish between symptoms and the normal emotional experiences of daily
Check blood levels
life. It can be hard to judge when to stop or when to continue treatment.
If you stop taking medication (thinking you are well) and you relapse, it does
Blood levels below the
not mean that your attempts to stay well are a complete failure. It is possible
that the experience will help you in future to better recognise the warning
Optimise mood stabiliser
Adequate blood levels
signs and to respond by initiating treatment again. This guide provides some
strategies for minimising the possibility of a full relapse and aims to help
Add anti-depressant or
you monitor your treatment outcomes and to prevent new episodes. If you
Add second mood stabiliser
haven't already done so, consider involving your carer(s) in your treatment.
Failure of depressive episode to respond to treatment
Attitude to medication and coping with
FAILURE TO RESPOND
Deciding not to take your medication can lead to a relapse of mania or
depression, which can result in severe social, financial and relationship loss.
Switch/substitute mood stabilisers
There are many reasons why people do not take their medication. They may
experience adverse side effects or lack of feelings of general health and
wellbeing, successful social interaction and intellectual activity. People who
manage to live well with bipolar disorder tend to agree that even when
Continuing failure to respond
treatment is seemingly effective, all other life issues must be taken into
account. Your carer, friends and others may be able to help.
• Confirm correct diagnosis
Weight gain is often a significant problem for people taking medication
• Re-evaluate psychological/social factors responsible for
for bipolar disorder. This is especially so for people taking lithium, sodium
valproate or anti-psychotics. Managing diet and exercise can help lift
• Consider additional psychological therapies
depression and manage weight gain.
• Consult and involve carers when appropriate
Not taking medication properly is the most common cause of relapse.
How do I tell if I need long-term
Your mental health professional should discuss with you how you
manage your medication, and your attitude and response to it, to try
to prevent the possibility of your symptoms recurring. Approaches
Long-term treatment is often called the ‘maintenance' phase of
treatment or ‘relapse prevention'. The goal of long-term treatment
for bipolar disorder is to help you maintain a stable mood and to
• providing you with education about the recurrent and
prevent a relapse of mania or a depressive episode. Your GP or mental
disabling nature of this condition and potential side effects of
health professional would typically discuss with you, and your carer
if appropriate, your pattern of illness and suggest what maintenance
• providing methods by which you can manage or control the
therapy is best for you.
side effects e.g. diet and exercise
There is strong evidence from clinical trials of the long-term effectiveness
• addressing the fear people with bipolar disorder often
of lithium olanzapine and quetiapine (the latter only in combination
have about the potential sudden loss of control of their
with lithium or valproate) in treating the symptoms of bipolar disorder.
behaviour and the embarrassing consequences (it is sometimes
Lamotrigine is effective in preventing bipolar depressive episodes, though
only after several episodes that many individuals come to accept
it is only weakly effective in preventing mania. While there have been
the diagnosis and need for ongoing medication or treatment)
studies indicating that carbamazepine works to about the same extent as
• helping you to locate support groups – these operate in most
lithium, there have been no long-term studies of either carbamazepine
parts of Australia and provide information about living with a
or valproate confirming their superiority over placebo.
mood disorder (see Appendix 2).
If you are taking lithium, your kidney function, serum creatinine and
electrolytes should be monitored every three to twelve months. Your
Continuity of care
thyroid function, including Thyroid-Stimulating Hormone (TSH) should be
monitored every six to twelve months, in addition to clinical assessment.
The importance of continuity of care is an under-acknowledged issue
in the long-term management of bipolar disorder. Ongoing contact
If you suddenly stop taking lithium you are likely to experience a
with the same mental health professional increases the likelihood
relapse of mania (or, less likely, depression) within the next few months.
of early identification of recurrences, and helps raise awareness of
Therefore, if you are going to stop taking lithium, your intake should
the impact of the illness. Unfortunately, mental health professionals
gradually be reduced over at least one to two months.
change often. Research suggests that the best outcomes are achieved
If you are taking carbamazepine and valproate, your blood levels and
if you consult with the same mental health professionals who know
liver function should be monitored at least every three to six months
you well and know the pattern of your illness episodes. Your carer may
after treatment has begun. If you are taking anti-psychotics, your
also have much of this information and can assist.
glucose, cholesterol and triglyceride levels should be monitored regularly.
Failure to prevent recurrences of bipolar disorder
So far, research has not shown that any of the mood stabilizers are very
• Exclude non-compliance
effective in the treatment of rapid-cycling bipolar disorder. Valproate has
• Treat any additional substance misuse• Exclude anti-depressant-induced affective instability
been reported to be effective in some studies, but this finding is yet to
• Exclude subclinical hypothyroidism
be confirmed by further research.
• Trial alternative mood stabiliser alone or in combination
with current mood stabiliser (strongest evidence is for lithium + valproate)
Failure to prevent recurrences of bipolar disorder
Relapse prevention plans and mental health care plans
There is some evidence that adding a second mood stabiliser enhances
Relapses can be prevented and minimised for people with bipolar disorder. You
long-term mood stability.
and your doctor and carer can develop a plan that can identify situations where
relapse is likely, early signs to lookout for, what you can do to minimise your
symptoms (e.g. limiting alcohol use or using extra medication) and who you can
First, potential causes of rapid-cycling bipolar disorder should be excluded
contact if you experience any symptoms. This plan should be in writing and your
and managed. These may include substance misuse, anti-depressant
family/carer and doctor and other health professional should have a copy.
medications, and possible physical conditions such as hypothyroidism.
As several doctors and health professionals may be involved in your care, it is
Medications for long-term treatment of
important to have a care plan. This can be co-ordinated through your GP who
may refer you to a psychiatrist or psychologist.
Your care plan should cover:
• situations that are stressful and may cause symptoms (e.g. family
• what I can do to stay well (e.g. get at least 7 hours sleep at night, stop
(in combination with lithium or valproate)
• what signs might indicate that my depression or mania may be
recurring (e.g. arguing with my boss)
• what change I can make to my medication (e.g. increase my sedating
medication for the next week)
• who I can talk to (e.g. let my partner know)
• when I will contact my doctor/health care worker (e.g. phone my
(For prevention of bipolar depressive episodes in particular)
doctor if symptoms last longer than two days)
Further treatment choices
counselling to help you deal with these issues can reduce the impact
of having bipolar disorder.
Developing a balanced lifestyle can also help you to minimise the risk
of relapse. In particular, establishing a regular sleep pattern is very
So far the guide has outlined the range of medications available
important in helping you avoid further episodes.
for treating bipolar disorder that have been shown to be effective.
Psychologists have an important role in all of these treatments.
There are further treatment choices, such as psychological and
They can also provide specific treatments for depression, including
psychosocial therapies, which can be a valuable part of a treatment
cognitive behavioural therapy or CBT (looking at how we think and
plan. These therapies are most effective in preventing recurrences if
what we do), which can ease depression. One aspect of this treatment
you have treatment when you are not currently depressed or manic.
involves identifying patterns of early warning signs and triggers that
Psychological and psychosocial treatments work best when used in
precede episodes, and developing strategies to minimise them. Some
conjunction with medication.
psychological treatments are now covered by Medicare (through the
Better Access initiative). Interpersonal and social rhythms therapy
What is the role of psychosocial
focuses on the roles of relationship difficulties and changes in daily
patterns for those with bipolar disorder.
In some other psychiatric illnesses, there is often an ‘either/or' choice
If you have problems with substance abuse and anxiety disorders
between taking a medication OR using a psychological treatment.
as well as bipolar disorder, medications can help, but psychological
However, in bipolar disorder medication remains essential rather than
treatments, especially CBT, are the most effective. These therapies are
optional. Psychological treatments are called ‘adjunctive', which means
often undertaken with a psychologist.
that they are effective but should be used in addition to medications.
Learning to live with a continuous, episodic illness is a huge challenge
The role of psychological treatments is to help you
for people with bipolar disorder and their families. Education about
cope with the experience of bipolar disorder and its
the illness leads to better coping strategies and fewer relapses.
effects. Better outcomes can be achieved with these
additional therapies. Many other medical conditions
People with bipolar disorder often express embarrassment because
can also improve with psychological treatment.
of the inappropriate behaviour, or sexual indiscretions, which might
have happened when they were manic. Counselling about the trauma
of embarrassing behaviour and coming to terms with the diagnosis is
Repeated episodes of mania and depression tend to lead to greater
risk of divorce and family breakdown, unemployment, a break in
social networks and education, and financial difficulties. Support and
People who are living with bipolar disorder tend to agree that there
are several strategies that you can try to improve how you cope with
Herbal remedies and other natural supplements have not been well
the illness. These are:
studied and their effects on bipolar disorder are not fully understood.
• being educated about how to identify the early signs and
Omega-3 fatty acids (found in fish oil) are being studied to determine
symptoms of either mania or depression
their usefulness for long-term treatment of bipolar disorder, but the
• encouraging family and friends to also be able to identify those
results have been mixed.
St John's Wort (hypericum perforatum) is being studied as a treatment
• staying in treatment and being aware of anything that may
for depression, but there is some evidence that it can reduce the
prevent you from taking your medication
effectiveness of some medications (such as the oral contraceptive
• remembering to focus upon the achievement of your goals, rather
pill), can react with some prescribed anti-depressants, or may cause a
than letting the illness take over your life
switch into mania.
• keeping a mood diary to help you keep track of your treatment
Pregnancy and breastfeeding
progress and any side effects of any medications you are taking
• using exercise, proper diet, vitamin supplements, yoga and
The period following childbirth for all women is an extremely
meditation to manage stress levels which can potentially trigger
emotional period, but for women with bipolar disorder the risk of
mania, depression or psychosis is particularly high. About 30% of
women with pre-existing bipolar disorder will experience a manic or
• keeping support around you from family and friends.
depressive episode following childbirth.
Support from family and friends is vitally important but it cannot
During pregnancy and breastfeeding, the goal of treatment is to use
always shield you from the effects of life stresses. Increased levels of
the minimum effective dosage of medications and to limit the total
support may be necessary if you have to cope with the death of a
number of medications while sustaining the mother's mental health.
family member or close friend, loss of or interruption to your career, or
experience psychological and social distress of other kinds.
Ensuring adequate social, emotional and psychological support is
How to improve the quality of your care
While types of support groups vary widely, this section looks at groups
• Participate in active ways in your treatment
run by people who themselves have experienced bipolar disorder and
• Write a relapse plan with your clinician.
There is now a growing awareness of the benefits of support groups
for people with bipolar disorder. Being part of a support group can
• Identify the symptoms or signs that precede an
help you recognise and satisfy your need for practical and experiential
information about the illness, and the need to keep taking your
• Discuss concerns about the quality of your care
medications. A support group can also help you cope with the
with your doctor.
interpersonal difficulties you may experience with this condition.
• Raise suggestions for improvement with
A large survey of people with bipolar disorder by the United States
management or with a consumer consultant in
National Depressive and Manic-Depressive Association found that
95% stated that their participation in support groups had helped them
• Participate in policy, advocacy and planning of
in communicating with their doctor, being motivated to follow medical
mental health services through non-government
instructions, being willing to take medication, making the treatment
plan less complex, and/or making follow-up visits to their health
• Give yourself permission to talk about your
feelings, your symptoms etc. with carers,
Such groups may also help people to cope with hospitalisation,
friends and others. Don't forget: laughter is a
understanding mental health legislation and finding other important
mental health information. Some provide support over the telephone
For major complaints, each jurisdiction has a
and professional referral services.
confidential health care complaints tribunal through
Some groups also enable partners, relatives and friends to attend
which complaints can be discussed and mediated.
groups with the person experiencing bipolar disorder. Separate groups
for partners, relatives and friends are also available in Australia (see
Speak with your case manager about how you can join the consumer
workforce and network as a representative, advisor, consultant
or advocate. This is a way of being actively involved in making a
difference and learning at the same time about the many services and
resources in the mental health sector.
Standards of care – what should I expect?
• treatment provided in a particular setting (you may have a cultural
preference for home or hospital treatment)
People with any kind of mental illness should expect to be treated with
courtesy and compassion by health professionals. There are published
• special food or access to a prayer room if you need to go
National Standards for Mental Health Services available in Australia
which are a guide to what to expect from services.
• understanding of your family's expectations of treatment.
Currently, all public mental health services are aiming to achieve these
It is very important to discuss cultural issues with your health care
standards over time. There are some key ideas to keep in mind:
provider to enable them to better understand you and so that your
• Evidence-based treatments have the best chance of working if
religious beliefs and cultural practices can be incorporated into your
delivered by skilled staff who have up-to-date training.
• You have a right to quality care and you also have a
responsibility to work with your health professionals to get the
What does treatment cost?
best care outcomes.
It is important to discuss all potential costs involved in your treatment
• There are complaints processes in mental health services that you
with your health professional.
can use if you are unhappy about the quality of your mental
In Australia, some GPs bulk bill, which means that Medicare will
cover the full cost of any visit. If your GP does not bulk bill, partial
rebates are available through Medicare and you will need to pay any
difference. There will also be an additional cost for any medication
Health professionals should always respect and cater for the wide
that may be prescribed.
diversity of cultural groups in our community. Depending on your
Your GP may refer you to appropriate services, such as for
cultural background or religious beliefs, when you are seeking
psychological services provided by a psychologist or an appropriately
treatment, or helping a person you care for get treatment, you may
trained social worker or occupational therapist. Any treatment
have special requirements that you need to communicate to the health
provided by these health professionals will only be rebated by
professionals you encounter. You may need to request:
Medicare if you have previously claimed a rebate for a GP Mental
• a translator if your first language or that of the person you care
Health Treatment Plan. A GP Mental Health Treatment Plan will be
for is not English
developed by your GP and tailored to your needs to find the treatment
• explanations of medical or other terms that may not be clear
that is right for you, monitor your progress and assist you in achieving
your goals for recovery.
• respect for your religious practices and understanding of the roles
of males and females in your culture
Medicare rebates are also available for assessment and treatment by a
psychiatrist. A psychiatrist may also refer you for Medicare-subsidised
treatment with a psychologist, an appropriately trained social worker
or occupational therapist. You may receive up to 12 individual/and or
group therapy sessions in a year. An additional six individual sessions
may be available in exceptional circumstances.
Your GP may also refer you to other government funded providers of
psychological services depending on what is available in your
Living with bipolar disorder
This guide has covered what recent research and expert and consumer
opinion tells us about living with bipolar disorder and its treatments
according to each phase of illness.
People who manage their bipolar disorder well provide assurance and
hope that living with it and achieving a good lifestyle is now possible.
There are many examples of ordinary people and high-profile people
successfully managing their condition and leading satisfying lives.
The wider community is now more aware and understanding of
bipolar disorder, there is support and there are highly effective
treatments now available. If you choose to, you can help spread this
While there remains no cure, there is good reason to think that
treatments will improve even further in the future. This guide has
also discussed where research is limited or remains uncertain. Future
research will aim to reduce the side effects of existing treatments and
to develop better ones.
With treatment, and constant monitoring, it is
possible to achieve a good quality of life if you
have bipolar disorder.
Pharmacist - A person licensed to sell or dispense prescription drugs.
Psychiatric nurse - A person specially trained to provide promotion,
maintenance, and restoration of mental health, including crisis and case
management. Nurses can administer medications but cannot prescribe
Mental health care teams
them, whereas other allied health professionals can neither prescribe
nor administer medications.
Services provided to people with bipolar disorder and their families,
if delivered through the public health system, may include a range
Psychiatrist - A medical doctor who specialised in psychiatry. Psychiatry
of professionals at different stages of community or hospital-based
is a branch of medicine that deals with the study, treatment and
treatment. The psychiatrist or a ‘case manager' usually co-ordinates
prevention of mental illness and the promotion of mental health. A
care provided to you by this team. Consumer consultants may also be
psychiatry registrar is a trainee psychiatrist.
employed to provide support and advocacy.
Psychologist - A person usually trained at a post-graduate level who
Case manager - The health care provider whom you see the most
works to apply psychological principles to the assessment, diagnosis,
for your mental health care in the public mental health system. The
prevention, reduction, and rehabilitation of mental distress, disability,
case manager co-ordinates all your care with other members of the
dysfunctional behaviour, and to improve mental and physical wellbeing.
team. They can be medical doctors, or allied health specialists such
Social worker - A person with specialised training in individual and
as psychologists, social workers, occupational therapists or trained
community work, group therapies, family and case work, advocacy
mental health nurses. With your agreement, carers may also consult
and the social consequences of disadvantage and disability, including
case managers and vice versa.
mental disorders. They can provide psychosocial treatments for mental
Crisis team member - Mental health professionals from a wide
disorders and assist with welfare needs such as finance, legal matters
range of professions, who work in teams to provide assistance, during
periods of high stress, including after hours (sometimes called Crisis
GP / General practitioner / Local doctor/ Family doctor -
Registered medical practitioners who have a general training in all
areas of medicine, including psychiatry, and manage your general
Occupational therapist (OT) - A person trained to provide therapy
through creative or functional activities that promote recovery and
Lifeline Australia conducts a referral service for rural Australia, combining the
databases of Mental Health Associations, Lifeline Centres, Kids Help Lines
and mental health branches of State and Territory health departments.
Sources of information and support
For further information about this guideline and other Clinical
Kids Help Line
Practice Guidelines, see www.ranzcp.org.
Freecall: 1800 55 1800
The list of organisations and information sources provided in this
Appendix, whilst not exhaustive, may further support you in learning
about and managing bipolar disorder. Inclusion of these organisations
Phone: (03) 9810 6100
and information sources does not imply RANZCP endorsement
but rather aims to help people find information and to encourage
communication about mental illness.
Phone: (03) 9682 5933
These organisations and resources are not intended as a replacement
for formal treatment but as an adjunct to it. If you are unsure about
Helpline: 1800 187 263
any of the information you find or would like to know if a treatment
Helpline email: email@example.com
you read about may be appropriate for you, you should speak with
your mental health care professional.
Black Dog Institute
Many of the organisations that provide information and support for
Phone: (02) 9382 4523
those with bipolar disorders and their carers are community-managed
and not-for-profit associations. They provide support, information
and referral services for health, housing, rehabilitation, employment,
and legal or advocacy services. They may also assist partners, relatives
Mental Illness Fellowship of Australia
and friends of people with bipolar disorder over the telephone, or in
Phone: (03) 8486 4200
mutual support groups.
Helpline: (03) 8486 4222
Try looking in the front pages of your telephone book for a mental
health information and referral service in your State or Territory and
for clinical mental health services in your area.
Phone: (03) 9455 7900
Your GP may also know the local mental health service nearest to you.
Multicultural Mental Health Australia
Western Australian Association for Mental Health
Phone: (02) 9840 3333
Phone: (08) 9420 7277
Mental Illness Fellowship of Victoria
Phone: (02) 6122 9900
Phone: (03) 8486 4200
Helpline: (03) 8486 4265
Mental Health Association (QLD) Inc
New South Wales Organisations
Phone: (07) 3271 5544
Schizophrenia Fellowship of NSW
Phone: (02) 9879 2600
Mental Illness Fellowship of North Queensland Inc
Phone: (07) 4725 3664
Mental Health Association NSW Inc
Phone: 1300 794 991 / (02) 9399 6000
Mental Illness Fellowship of Queensland
Phone: (07) 3358 4424
South Australia Organisations
Mental Illness Fellowship of South Australia
Phone: (08) 8221 5160
Phone: (07) 5591 6490
Western Australia Organisations
Mental Illness Fellowship of ACT Inc
Phone: (02) 6205 1349
Mental Illness Fellowship of Western Australia
Phone: (08) 9228 0200
Mental Health Foundation ACT
Phone: (02) 6230 5789
Northern Territory Organisations
ARAFMI Western Australia
Mental Health Association of Central Australia
Perth: (08) 9427 7100
Phone: (08) 8950 4600
Rural Freecall: 1800 811 747
Hillarys: (08) 9427 7100
Midland: (08) 9347 5741
Mandurah: (08) 9535 5844
Mental Health Carers NT
Broome: (08) 9194 2665
Phone: (08) 8948 2473
Canarvon: (08) 9941 2803
Associations for the Relatives and Friends of
ARAFMI Tasmania (Carer support)
the Mentally Ill (ARAFMI)
Phone (North): (03) 6331 4486
Phone (South): 03) 6228 7448
Phone: (08) 9427 7100
Email (North): firstname.lastname@example.org
Email (South): email@example.com
ARAFMI New South Wales
Central Coast ARAFMI: (02) 4369 4233
Phone: (03) 9810 9300
Carer Helpline: 1300 550 265
ARAFMI Illawarra: (02) 4254 1699
ARAFMI Hunter: (02) 4961 6717
ARAFMI North Ryde: (02) 4961 6717
Support: 1800 655 198 (NSW rural); (02) 9332 0700 (Sydney)
Phone: (07) 3254 1881
NATIONAL, STATE AND TERRITORY
What is the website
What is the website
Website on general
depression, anxiety and
Website for young people dealing with mental
illness in their family.
depression and anxiety.
depression and bipolar
bipolar disorder in
children and adolescents
Information and online
forums with 24 hour peer
Information for those
support and moderation
with depression and
for people living with
Information on postnatal
Information and advice
regarding mental health
problems and where young people can find
Information on general
help and support.
mental health including factsheets; also includes
Information on general
an online helpline.
Youth information portal on mental health.
Hypomania - Periods of pathologically elevated mood without
delusions. This is quite different to normal enthusiasm.
Inflated self-esteem or ‘grandiose ideas'
- During mania, a person
may experience or think of themself as being more capable, energetic
Terminology and acronyms
and competent in activities than they do normally, or competent or
superior in areas which they consider themselves not to be particularly
skilled at when they are well. Others would not see them as being
Some of the words or expressions that describe symptoms or
this capable in a particular area, so the inflated self-esteem is out of
treatment processes may require further explanation. The symptoms
proportion to reality and is potentially socially embarrassing.
of mania and depression are particularly hard to describe and they
Mania - Periods of pathologically elevated mood leading to change in
have been further explained here so that you may see if they relate to
functioning, sometimes associated with transient psychotic periods.
you, or, if you are a carer, to the person you are concerned about. The
different mental health professionals and their roles are also defined.
Pressure of speech or to keep talking - A compulsion in which
the person may, or may not be aware they are talking too much, but
Deliberate self-harm - An act intended to cause injury or self-
feels unable to slow or stop speaking, even though it is not socially
poisoning, to relieve distress, and sometimes to cause death. It can be
appropriate to be so outspoken.
used to try to cope with a mental illness or stress of some kind but is
ineffective and detrimental. An RANZCP Self-Harm guideline exists for
Psychosis - Loss of touch with reality, characterised by delusions (fixed
those who have self-harmed.
false beliefs) and/or hallucinations (a false or distorted perception) of
objects or events, including sensations of sight, sound, taste, touch
Depression - A mood disorder ranging from passing sad moods to a
and smell, typically with a powerful sense of their reality. Psychosis can
serious disabling illness requiring medical and psychological treatment.
be experienced as part of mania or as part of psychotic depression and
Major depression is a ‘whole body' disorder impacting on emotions
is treatable with anti-psychotic medications.
(feelings of guilt and hopelessness or loss of pleasure in once enjoyed
activities), thinking (persistent thoughts of death or suicide, difficulty
Psychotherapy/Psychological intervention - A form of treatment
concentrating or making decisions), behaviour (changes in sleep
for mental disorders based primarily on verbal communication
patterns, appetite, or weight), and even physical wellbeing (persistent
between the patient and a mental health professional, often combined
symptoms such as headaches or digestive disorders that do not
with prescribed medications. Psychotherapy can be conducted in
respond to treatment).
individual sessions or in a group.
Flight of ideas - The experience of ideas entering the mind at a very
Symptom - A feeling or specific sign of discomfort or indication
rapid pace. The thoughts may be positive or negative, but their pace is
such that few make much sense or can be reasonably acted upon.
Crisis Assessment Team
Cognitive Behavioural Therapy
Diagnostic and Statistical Manual
Development of the guideline
This guide is a research-based clinical practice guideline based on a
thorough review of the medical and related literature. It was written in
association with people who have bipolar disorder and those working
Interpersonal and Social Rhythm Therapy
In 2009, the content of this guide was revised and expanded by an
MAOI Monoamine Oxidase Inhibitor
expert advisory panel comprising mental health professionals, and
consumer and carer representatives. The purpose of the revision was
Selective Serotonin Reuptake Inhibitor
to ensure the information contained in the booklet was current and
comprehensive in terms of treatment best-practice and therefore
remained relevant for people with bipolar disorder and their carers,
families, and friends.
The authors of the original edition, and their affiliations at the
The original edition of this guide was consulted upon bi-nationally
and drafts were available for comment on www.ranzcp.org. It was
Philip Mitchell - Chair, Clinical Practice Guideline Development Team,
appraised using DISCERN by a national workshop of consumer
Scientia Professor of Psychiatry, School of Psychiatry, University of New
consultants, and meets NHMRC criteria for presenting information
South Wales, Prince of Wales Hospital, Randwick, NSW.
on treatments for consumers. The 2009 revision sought to maintain
the integrity of this process by incorporating updated information
Gin Malhi - Senior Lecturer, School of Psychiatry, University of New
supported by research findings published in recent medical and other
South Wales, Prince of Wales Hospital, Randwick, NSW.
Bernette Redwood - Research Officer, Clinical Practice Guideline
Development Team, Prince of Wales Hospital, Randwick, NSW.
Jillian Ball Research - Psychologist, Prince of Wales Hospital,
The original edition was funded by Australia's National Mental Health
Strategy and New Zealand's Ministry of Health.
The expert advisory panel for the 2009 revision comprised:
Philip Mitchell - Chair, Scientia Professor and Head, School of
Psychiatry, University of New South Wales, Prince of Wales Hospital,
Anne Camac - Psychiatrist at St George Hospital, Sydney and Conjoint
Lecturer at University of New South Wales.
Diahann Lombardozzi - Multicultural Mental Health Australia
(MMHA) consumer advocate and national reference group member.
Eugene Schlusser - Filmmaker/carer with diverse experience of
The original edition of this booklet was edited by Jonine Penrose-Wall,
Consultant Editorial Manager, RANZCP Clinical Practice Guideline
The authors acknowledge the following people for their contribution
to this guide: Ms Yvette Cotton, Mr George Dibley, Ms Sharon Kohn,
Ms Larissa Mariner, Mr Michael Martin, Ms Jan Monson, Ms Anna
Saminsky and Ms Penny Mitchell.
This guide was commissioned by the Royal Australian and New
Zealand College of Psychiatrists and was funded by Australia's National
Mental Health Strategy, via the Commonwealth Department of Health
The authors used research that was developed with input by the wider
Clinical Practice Guideline team that developed the guideline for use
by professionals. Members of that team other than the
Associate Professor Meg Smith - School of Applied Social and
Human Sciences, University of Western Sydney, Australia.
Dr Bronwyn Gould - General Practitioner.
Professor Peter Joyce - Head, Department of Psychological Medicine,
University of Otago, Christchurch, New Zealand.
Professor Ken Kirkby - Head, Department of Psychiatry, University of
Tasmania, Hobart, Australia.
The RANZCP drew on material published by the Medical Practitioner's
Board of Victoria and the American Psychiatric Association in
preparing this brochure.
The 2009 revision of this booklet was undertaken with funding
provided by the Commonwealth Department of Health and Ageing.
DIVERSITY FRAMEWORK Policy, Planning and Practice 2012 - 2017 A strategy to meet the needs of clients and carers with diverse needs and from diverse backgrounds Home and Community Care (HACC) services provided by RDNS are jointly funded by the Victorian and Australian Governments. Name of publication: Diversity Framework: Policy, Planning and Practice 2012-2017
RAPID COMMUNICATIONS IN MASS SPECTROMETRY, VOL. 11, 1619-1623 (1997) Simulation of Interstellar Aromatic Hydrocarbons Using Ion Cyclotron Resonance. Preliminary Results + Christine Joblin1*, Christophe Masselon 2, Pierre Boissel3, Patrick de Parseval3, SuzanaMartinovic2 and Jean-françois Muller2 1CESR, Laboratoire du CNRS, BP 4346, 9 Av. du Colonel Roche, 31028 Toulouse Cedex, France