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Objective: The manic defence theory of bipolar disorder suggests that manic symptoms arise from an attempt to overcompensate for underlying depression. This depression avoidance may also be active ...

The aim of this study was to assess changes in mental health and wellbeing measures across a 50-day physical activity workplace program. The secondary aims assessed the relationship between demographic and pre-program physical activity self-reported variables, mental health, wellbeing and program engagement measures. The study utilized a naturalistic longitudinal design with a study population of 2903 people. Participants were engaged in the 10,000 step daily physical activity program for 50-days and measures of engagement were tracked. 1320 participants provided full pre/post-program data across a range of standardized mental health and wellbeing measures alongside demographic and program engagement measures. For individuals providing pre and post program data there was a significant reduction in anxiety (18.2%, p = .008), stress (13.0%, p = .014) and sleep related impairment (6.9%, p

Background Cannabis is the most widely used illicit substance by Australian young people, including those engaged with youth alcohol and other drug (AOD) systems. While recreational cannabis use in young people may be a developmental activity for some, for others, this usage becomes regular and be associated with poorer long term outcomes. This study reports on the rates of cannabis use and co-existing psychosocial complexity factors in the Youth Needs Census (2013 and 2016) where workers report on all clients in the youth AOD system, a cohort considered highly vulnerable. Methods Data was examined for two rounds of data collection for the Youth Needs Census, including 823 youth AOD service engaged young people in 2016 and 1000 AOD service engaged young people in 2013, to identify usage rates, psychosocial outcomes, and changes over time. Results Daily use of cannabis alone significantly exceeded daily usage rates for methamphetamines, alcohol, and cannabis used alongside other substances. Daily cannabis use was significantly associated with mental health problems, employment problems, education problems, family problems, and housing problems. Daily cannabis use was associated with most psychosocial complexity factors to the same extent as daily methamphetamine use and daily alcohol use, with daily cannabis users only showing lower incidence of the drug-related harm measure. Notably, daily cannabis use also increased from 2013 (47.5%) to 2016 (54.2%). Conclusions It is imperative that the number of individuals using cannabis is considered alongside the severity of harm when assessing the social impact of this substance. Within cannabis users engaged with the youth AOD system, who often have high levels of psychosocial complexity, cannabis is used daily by a large proportion of these youths and may play a role in negatively impacting their lives.

INTRODUCTION All young people seeking assistance from youth alcohol and other drug services require support to help them minimise the harms from their substance use and continue to develop healthy and meaningful lives. A particular focus on young people in residential out of home care (OoHC) highlights the increased risks of substance use, mental health issues and continued vulnerabilities in this group. While in the past, research contrasted this group with young people living at home, this study contrasted young people in OoHC with homeless youths alongside those living with parents. METHODS The research contrasted these three groups of young people on substance use profiles, mental health and wellbeing and vulnerability to abuse (historic and current) in the Youth Needs Census conducted in Victoria and Queensland over 2013-2017. RESULTS The results demonstrate a clear risk of increased casual and daily methamphetamine use in the homeless youth group and occasional heroin use in the OoHC group. Mental health measures for both the OoHC and homeless youths were worse than the young people living at home. Trauma was similarly higher in these groups, with both historical and ongoing risks of violent crime for homeless youths. DISCUSSION AND CONCLUSIONS The results demonstrate the similar and serious health and wellbeing risks facing both youths in residential OoHC and homeless youths. These results are concerning as one of these groups is ostensibly in the care of the community and government, while the other group is experiencing unstable accommodation and associated physical risks.

Research has consistently demonstrated that young people who identify as lesbian, gay, bisexual, or queer (LGBQ) show greater levels of psychosocial risk than general cohorts of young people. Young...

Aim Tobacco use is decreasing in the general youth population yet little evidence is tracking changes in young people who are engaged with youth alcohol and other drug (AOD) services that are often disengaged from school and wok settings. Method This study reviews tobacco use amongst 1823 young people engaged with youth AOD services in Victoria in 2013 and 2017 from the Youth Needs Census. This study contrasted use patterns over the three-year period against Australian population data. Results The results show tobacco use is not declining in the youth AOD engaged population as observed with other young Australians. Further, reductions in tobacco use observed in the community sample were not evident in the youth AOD group. Finally, high rates of tobacco dependence are shown in the 2016 cohort. Conclusion The results highlight a need for the adoption of evidence-based tobacco early intervention programs in youth AOD services to address this significant health risk.

Introduction and aims Youth work specialises in helping vulnerable young people face life challenges during critical stages of their development. It is a complex and demanding role and factors influencing occupational stress in youth workers are rarely investigated. This study examined whether youth alcohol and other drug workers with greater compassion satisfaction, self-care practice and self-care agency experienced different rates of occupational stress including burnout and secondary traumatic stress. Design and methods A convenience sample of 258 Australian youth alcohol and other drug workers completed an online questionnaire battery. A four-stage data analysis was conducted utilising multivariate analysis of variance, bivariate correlations, linear multiple regression models and mediation modelling. Results Burnout and secondary traumatic stress exhibited moderate negative correlations with compassion satisfaction, self-care practice and the different forms of self-care agency. Further, a decrease in lacking power for self-care, a form of self-care agency, was the strongest contributor to both burnout and secondary traumatic stress. Support was found for a mediation pathway whereby self-care agency led to greater self-care practice, which in turn increased compassion satisfaction, lowering burnout and secondary traumatic stress. Discussion and conclusions The findings suggest that it would be beneficial for self-care agency to be a key focus of youth worker training and professional development programs.

Yeast based spreads (YBS) such as marmite and vegemite, made from leftover brewer’s yeast extract are one of the world’s richest source of B vitamins. We evaluated symptoms of depression, anxiety, stress scores (DASS) in participants who consume or do not consume YBS. 520 participants completed a survey consisting of 70–94 questions relating to the consumption of YBS, dietary and lifestyle habits and mood symptoms of DASS. Parametric analysis co-varying for gender, diet, supplement use, soy milk and alcohol consumption and history of psychiatric disorders including depression and anxiety were utilized to analyse the results. A significant improvement was noted in anxiety and stress but not depressive symptoms in those consuming YBS. Furthermore, those who consumed vitamin B12 fortified YBS showed even greater improvement in stress symptomology. Vitamin B supplementation appears to be an important additive supplementary source to improved stress and anxiety in the general adult population.

Background An increased awareness of the health benefits of walking has emerged with the development and refinement of accelerometer equipment. Evidence is beginning to highlight the value of promoting walking, particularly focusing on the Japanese mark of obtaining 10,000 steps per day. Workplace based step challenges have become popular to engage large cohorts in increasing their daily physical activity in a sustainable and enjoyable way. Findings are now highlighting the positive health effects of these medium-term programs (typically conducted over a few months) in terms of cardiovascular health, reducing diabetes risk and improving lifestyle factors such as weight and blood pressure. As yet, research has not focused on whether similar improvements in psychological health and wellbeing are present. Methods This study investigated the impact of a 100-day, 10,000 step program on signs of depression, anxiety and stress as well as general wellbeing using standardised psychological scales. Results The results indicated a small but consistent effect on all of these measures of mental health over the term of the program. This effect appeared irrespective of whether a person reached the 10,000 step mark. Conclusions These results highlight improved mental health and wellbeing in people undertaking this 100-day 10,000 step program and indicates the efficacy and potential of these programs for a modest, yet important improvement in mental health. Notably, targets reached may be less important than participation itself.

Self-efficacy is positively associated with adherence behaviours and rehabilitation outcomes following Anterior Cruciate Ligament (ACL) reconstruction. An internet resource can be an effective way to provide information, goal setting, patient monitoring and hence support overall self-management.This study examined the feasibility of a three month 'internet-based intervention' (mobile-oriented site) to enhance recovery for patients following ACL reconstruction. The potential effect of the internet-based intervention on knee pain, function, self-efficacy and fear of pain were also assessed.This was a pilot randomised controlled trial (RCT) with pre and post intervention design (assessments at one week and three months following ACL reconstruction) comparing: (1) a control group and (2) an intervention group (internet-based intervention). A set of qualitative and quantitative assessments were included to evaluate potential improvements in self-efficacy, pain and function and perception of the internet intervention.Seventeen participants were available for analysis (n = 10 intervention and n = 7 control group). Participants reported the internet-based intervention to be a useful tool for information, reminder and reinforcement for performing their exercise rehabilitation with 30.3% (±35.3%) adherence to the internet-based intervention. No differences were observed between the groups over time on the outcome questionnaires (p 0.05). Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001379404.

Objective: Past traumatic events have been associated with poorer clinical outcomes in people with bipolar disorder. However, the impact of these events in the early stages of the illness remains unclear. The aim of this study was to investigate whether prior traumatic events were related to poorer outcomes 12 months following a first episode of psychotic mania. Methods: Traumatic events were retrospectively evaluated from patient files in a sample of 65 participants who had experienced first episode psychotic mania. Participants were aged between 15 and 28 years and were treated at a specialised early psychosis service. Clinical outcomes were measured by a variety of symptomatic and functioning scales at the 12-month time-point. Results: Direct-personal traumatic experiences prior to the onset of psychotic mania were reported by 48% of the sample. Participants with past direct-personal trauma had significantly higher symptoms of mania ( p=0.02), depression ( p=0.03) and psychopathology ( p=0.01) 12 months following their first episode compared to participants without past direct-personal trauma, with medium to large effects observed. After adjusting for baseline scores, differences in global functioning (as measured by the Global Assessment of Functioning scale) were non-significant ( p=0.05); however, participants with past direct-personal trauma had significantly poorer social and occupational functioning ( p=0.04) at the 12-month assessment with medium effect. Conclusions: Past direct-personal trauma may predict poorer symptomatic and functional outcomes after first episode psychotic mania. Limitations include that the findings represent individuals treated at a specialist early intervention centre for youth and the retrospective assessment of traumatic events may have been underestimated.

Background:Since bipolar affective disorder has been recorded, clinicians treating patients with this disorder have noted the cyclic nature of episodes, particularly an increase in mania in the spring and summer months and depression during winter.Objective:The aim of this study was to investigate seasonality in symptom onset and service admissions over a period of 10 years in a group of patients (n= 359) with first-episode (FE) mania (n= 133), FE schizoaffective disorder (n= 49) and FE schizophrenia (n= 177).Method:Patients were recruited if they were between 15 and 28 years of age and if they resided in the geographical mental health service catchment area. The number of patients experiencing symptom onset and service admission over each month and season was recorded.Results:In terms of seasonality of time of service admission, the results indicate a high overall seasonality (particularly in men), which was observed in both the schizoaffective and the bipolar groups. In terms of seasonality of symptom onset, the results indicate that seasonality remains in the male bipolar group, but other groups have no seasonal trend.Conclusions:This provides further evidence that systems mediating the entrainment of biological rhythms to the environment may be more pronounced in BPAD than in schizoaffective disorder and schizophrenia. These results may help facilitate the preparedness of mental heath services for patients at different times of the year.

Background Interprofessional education (IPE) requires health students to learn with, from and about each other in order to develop a modern workforce with client-centred care at its core. Despite the client centred focus of IPE, training programs often utilize standard approaches across student cohorts without consideration of discipline, sociodemographic and personality variability that attract students to different health disciplines. Knowing the students who engage in IPE to tailor training may prove as beneficial as knowing the client to delivered individualized client centred care in interprofessional practice (IPP). This research investigates whether students commencing undergraduate nursing and paramedicine degrees ener training with existing demographic and personality differences and, if these are associated with different attitudes towards health care teams and interprofessional education. Method This online study recruited 160 nursing and 50 paramedicine students in their first week of their undergraduate course. Students completed questionnaires regarding their background, personality (General Perceived Self Esteem Scale, International Mini Markers) and the attitudes towards health care teams scale (ATHCTS) and interprofessional education perception scale (IEPS). Results Results show that commencing nursing and paramedicine students are demographically different on education, gender, speaking a language other than English at home (LOTE) and their own experience with healthcare. The results further demonstrate that LOTE, discipline being studied and personality factors play a role in perceptions regarding interprofessional training whilst discipline being studied impacted on attitudes towards health care teams in the workforce. Conclusion These results highlight a number of existing personal and psychological differences between individuals who choose to train in these selected professions. This suggests a need for tertiary education IPE programs to move towards tailoring their education to value this student diversity in the same client centred manner that students are asked to develop clinically.

Background: The concept of staging of disease in psychiatry has developed over the past years. A neglected component of this model pertains to people in the advanced stages of a mental illness, who remain symptomatic and functionally impaired despite treatment. These patients are often high service utilizers, receiving complex multimodal treatments where the balance of risk and benefit shifts perceptibly. In this paper, we argue the need to adopt ‘palliative’ models of care for some individuals, and consider changing the therapeutic goals to follow care pathways similar to those used in other chronic and refractory medical illnesses. Method: Data was sourced by a literature search using Medline and a hand search of scientific journals. Relevant articles were selected. Results: Clinical staging can help us better define subgroups of patients who will benefit from different goals and treatment. In the most advanced stage group, we find patients with persistent symptoms and treatment resistance. In these situations, it may be preferable to follow some of the principles of palliative care, which include the setting of attainable goals, reduction of side-effects, limited symptom control, targeting identified psychological and social problems, and attempting to attain the best quality of life for these patients and their families. Conclusions: It is in the interest of those in the advanced phases of a disorder that clinicians acknowledge the limitations of treatment and actively attempt to plan treatment utilizing alternate models. It is essential to be clear that such approaches do not equate to the abandonment of care, but rather to the reconceptualizing of feasible and personalized treatment goals, a rebalancing of the risks and benefits of intervention, the management of illness behaviour, and the approaches that allow the patient to live gainfully within their limitations.

Aim: There is a scarce literature describing psychological interventions for a young, first-episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population. Methods: The study was an open-label design, drawn from a larger pharmacotherapy trial. All participants in the pharmacotherapy trial were offered a manualized psychological intervention in addition to case management. Inclusion in the psychotherapy group was based on participant's choice, and on completion of four or more of the eight modules offered. All clinical files were audited to ensure accuracy of group allocation. Forty young people aged 15 to 25 years old who had experienced a manic episode with psychotic features were recruited into the study, with 20 people in the combined treatment as usual plus psychotherapy group (P+TAU), and an equal number of matched control participants who received treatment as usual (TAU) within the same service. All participants were prescribed antipsychotic and mood-stabilizing medication. Symptomatic, functional and relapse measures were taken both at baseline and at 18-month follow-up. Results: Manic symptoms improved significantly for both groups, with no differences between groups. Depression scores and overall symptom severity were significantly lower in the P + TAU group. No differences were evident between groups with regard to numbers or type of relapse. The P + TAU group had significantly better social and occupational functioning after 18 months. Conclusion: This study suggests that a manualized psychological intervention targeted to a first-episode population can be effective in reducing depression and overall symptom severity, and can improve functional outcome following a first episode of psychotic mania.

To review the evidence that supports early intervention in the treatment of bipolar disorder.Bipolar disorder is a pleomorphic condition, with varying manifestations that are determined by a number of complex factors including the "stage" of illness. It is consequently a notoriously difficult illness to diagnose and as a corollary is associated with lengthy delays in recognition and the initiation of suitable treatment.A literature search was conducted using MEDLINE augmented by a manual search.Emerging neuroimaging data suggests that, in contrast to schizophrenia, where at the time of a first-episode of illness there is already discernible volume loss, in bipolar disorder, gross brain structure is relatively preserved, and it is only with recurrences that there is a sequential, but marked loss of brain volume. Recent evidence suggests that both pharmacotherapy and psychotherapy are more effective if instituted early in the course of bipolar disorder, and that with multiple episodes and disease progression there is a noticeable decline in treatment response.Such data supports the notion of clinical staging, and the tailored implementation of treatments according to the stage of illness. The progressive nature of bipolar disorder further supports the concept that the first episode is a period that requires energetic broad-based treatment, with the hope that this could alter the temporal trajectory of the illness. It also raises hope that prompt treatment may be neuroprotective and that this perhaps attenuates or even prevents the neurostructural and neurocognitive changes seen to emerge with chronicity. This highlights the need for early identification at a population level and the necessity of implementing treatments and services at a stage of the illness where prognosis is optimal.

Objective:Among potential endophenotypes proposed for bipolar affective disorder focusing on circadian abnormalities associated with the illness has particularly high face validity. Melatonin sensitivity to light is one circadian endophenotype proposed as useful in bipolar disorder. The aim of this study was to investigate melatonin sensitivity to light over a range of light intensities in order to compare and contrast responses in bipolar I patients with those of healthy adult volunteers.Methods:The study included seven patients (4 females, 3 males) with bipolar I disorder and 34 control participants (22 females, 12 males) with no personal or family history of affective illness. Melatonin sensitivity to light was determined in all patients and participants across a range of light intensities (0, 200, 500 and 1000 lux).Results:The results indicated that patients showed melatonin super-sensitivity to light in comparison with controls, a response that was consistent across the entire light intensity range investigated.Conclusion:The study provides further evidence for a super sensitive response in bipolar I patients and suggests that its potential usefulness as an endophenotypic marker of the illness is deserving of further research.

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

While ECT is widely used for the management of severe and refractory depression, its utility in bipolar disorder is not extensively studied. The aim of this study was to examine the reported effectiveness of ECT in patients with unipolar and bipolar depression as reported by psychiatrists, nurses and patients (i.e. using objective and subjective measures). The records of 787 consecutive inpatient admissions to the Geelong Clinic, a private psychiatric centre based outside Melbourne, Victoria were reviewed in this file audit. Routine assessment measures were completed at admission and discharge, and included patient rated measures (Medical Outcomes Short Form SF-14 and Depression Anxiety and Stress Scale, DASS), nurse rated measures, (The Health of the Nation Outcome Scale, HoNOS) and a psychiatrist rated measure, the Clinical Global impression scale (CGI). In contrast to individuals with unipolar depression, where improvement was seen on all measures, in bipolar disorder, while improvement in clinician rated measures was seen (CGI, HoNOS), there was an absence of improvement in subjective measures of mood (DASS, SF14). This study suggests that in bipolar disorder, there is a poorer subjective response to ECT than in unipolar disorder.

Objective: Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention. Methods: Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature. Results: Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified. Conclusions: In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

The secretion of the hormone melatonin is particularly robust to the effect of pharmacological agents. Medications may alter melatonin levels through either altering adrenergic activity or affecting liver enzymes involved in melatonin metabolism. The aim of this study was to investigate the effect of venlafaxine, a third generation antidepressant with known adrenergic properties on melatonin secretion. A further aim of the study was to investigate the correlation between plasma and salivary measures on this medication. Eight healthy adult participants (four males, four females) took part in this double blind placebo controlled randomised trial. Participants were tested on 3 nights after taking venlafaxine XR (75 mg), venlafaxine IR (75 mg) or placebo. Participants were placed in a darkened room between 1900 and 0300 h and regular temperature readings, blood and saliva samples were drawn to assess melatonin and cortisol secretion in each condition. There was no significant effect of venlafaxine IR or XR on melatonin concentrations in plasma or saliva and no effects on other circadian parameters including cortisol and temperature. It was notable that the correlation between plasma and salivary melatonin levels became poor after drug treatment. These results indicate that at low doses the mixed serotonergic and noradrenergic drug venlafaxine has no effect on nocturnal melatonin concentrations.

Large disruptions of chronobiological rhythms are documented as destabilizing individuals with bipolar disorder; however, the impact of small phase altering events is unclear. Australian suicide data from 1971 to 2001 were assessed to determine the impact on the number of suicides of a 1-h time shift due to daylight saving. The results confirm that male suicide rates rise in the weeks following the commencement of daylight saving, compared to the weeks following the return to eastern standard time and for the rest of the year. After adjusting for the season, prior to 1986 suicide rates in the weeks following the end of daylight saving remained significantly increased compared to the rest of autumn. This study suggests that small changes in chronobiological rhythms are potentially destabilizing in vulnerable individuals.

Bipolar disorder is common, and both difficult to detect and diagnose. Treatment is contingent on clinical needs, which differ according to phase and stage of the illness. A staging model could allow examination of the longitudinal course of the illness and the temporal impact of interventions and events. It could allow for a structured examination of the illness, which could set the stage for algorithms that are tailored to the individuals needs. A staging model could further provide as structure for assessment, gauging treatment and outcomes. The model incorporates prodromal stages and emphasizes early detection and algorithm appropriate intervention where possible. At the other end of the spectrum, the model attempts to operationalize treatment resistance. The utility of the model will need to be validated by empirical research.

Objective: To compare executive, memory and visuospatial functioning of DSM-IV anorexia nervosa (AN), bulimia nervosa (BN), and normal controls (NC). Method: A comparison of women involving: (i) 16 AN with body mass indices (BMI) 17.5 kg/m2; (ii) 12 AN with BMI[18.5 kg/m2 for at least 3 months; (iii) 13 BN; and (iv) 16 NC participants was performed with groups of similar age and intelligence. Groups were assessed with EDE-12, MADRS, HAMA, Cognitive Drug Research (CDR) battery, and Bechara tasks. Results: Significant impairments in CDR Power of Attention were present in underweight AN and BN participants. CDR Morse Tapping was significantly impaired in all clinical groups. The BN and weight-recovered AN groups were significantly impaired on CDR immediate word recall. The BN group alone was significantly impaired on CDR delayed word recall. Conclusion: Attentional impairment is similar in AN and BN. Impaired motor tasks in AN persist after ‘‘weight-recovery’’ and are similar to impairments in BN. BN may be discriminated from AN on word recall.

Background Atypical antipsychotics may be beneficial in treating the core psychopathology of anorexia nervosa (AN). Methods An 8 week open-label study of quetiapine was conducted in eight severely ill DSM-IVAN patients consecutively admitted to a specialist eating disorders unit. Participants were assessed by EDE-12, MADRS, YBOCS, SAPS-delusions and CDR neuropsychological battery at baseline, 4 weeks and 8 weeks, and by weekly body mass index (BMI), CGI and extrapyramidal scores. Quetiapine doses ranged from 50 mg to 800 mg per day, according to efficacy and tolerability. Results Seven participants completed 4 weeks and five participants completed 8 weeks. All participants had clinically significant levels of specific eating disorders psychopathology, and mild to moderately severe depressive symptomatology. Apart from initial mild sedation, no subjects experienced any significant adverse events. Over 4 weeks there was no significant difference in BMI, but a significant difference in the EDE-12 restraint score. There were significant differences on BMI and EDE-12 restraint subscale scores over 8 weeks. Conclusions A double-blind placebo controlled study is required to further evaluate the therapeutic utility of quetiapine in severely ill AN patients beyond multidisciplinary specialist intervention.

BackgroundCognitive deficits have been reported during the early stages of bipolar disorder; however, the role of medication on such deficits remains unclear. The aim of this study was to compare the effects of lithium and quetiapine monotherapy on cognitive performance in people following first episode mania.MethodsThe design was a single-blind, randomised controlled trial on a cohort of 61 participants following first episode mania. Participants received either lithium or quetiapine monotherapy as maintenance treatment over a 12-month follow-up period. The groups were compared on performance outcomes using an extensive cognitive assessment battery conducted at baseline, month 3 and month 12 follow-up time-points.ResultsThere was a significant interaction between group and time in phonemic fluency at the 3-month and 12-month endpoints, reflecting greater improvements in performance in lithium-treated participants relative to quetiapine-treated participants. After controlling for multiple comparisons, there were no other significant interactions between group and time for other measures of cognition.ConclusionAlthough the effects of lithium and quetiapine treatment were similar for most cognitive domains, the findings imply that early initiation of lithium treatment may benefit the trajectory of cognition, specifically verbal fluency in young people with bipolar disorder. Given that cognition is a major symptomatic domain of bipolar disorder and has substantive effects on general functioning, the ability to influence the trajectory of cognitive change is of considerable clinical importance.

BackgroundTreatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments.MethodsData from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures.ResultsEthics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate (P=.032) and earlier occurrence (P= .043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons.ConclusionsOlanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample.

This paper addresses the use of information management systems and IT capability to design and manage a university student teaching clinic in the Western suburbs of Melbourne. The clinic technology team had three main briefs, to support student learning and professional development, to provide quality health care to the community and to develop systems and platforms that facilitate the ability of the clinic to meet National Safety and Quality Health Standards (NSQHS). This paper highlights the role of health information systems in delivering on a clinic capable of these goals.

The super-sensitivity of the neurohormone melatonin to light in patients with bipolar disorder provides evidence of the circadian nature of the disorder. This response has been proposed as an endophenotype for identifying people at risk of the disorder and guiding investigations of molecular genetic targets. However, before this response is used as an endophenotypic marker, the heritable nature of melatonin sensitivity in the normal population must be established. The aim of this study was to investigate the heritability of nocturnal melatonin secretion and sensitivity to light in monozygotic and dizygotic twins with no psychiatric history. This study investigated overall melatonin levels (between 2000 and 2400 h) and suppression by 500 lx of light (between 2400 and 0100 h) in 20 pairs of twins (nine monozygotic, 11 dizygotic). The results indicate that melatonin secretion is highly heritable with secretion in one twin being a significant predictor of secretion in their twin in both monozygotic and dizygotic pairs. In relation to light sensitivity, genetic loading appears to play a significant role with the greatest concordance between monozygotic twins, followed by dizygotic twins and finally low concordance in unrelated individuals. This provides additional support for the usefulness of melatonin sensitivity to light as a potential endophenotypic marker of bipolar affective disorder.

Sensitivity of the pineal hormone melatonin to bright light at night has been proposed as a putative marker of bipolar affective disorder. Patients with bipolar disorder have a super-sensitive melatonin response to light. No studies have investigated whether super-sensitivity is due to agents used to treat the illness or is associated with the disorder per se. We investigated the effect of valproate on this phenomenon. Melatonin sensitivity to light was determined on two nights in 12 healthy volunteers (5M, 7F). Between testing nights participants received 200 mg of valproate b.d. for 5 days. Valproate significantly decreased the sensitivity of melatonin to light. On the other hand, valproate had no effect on overall melatonin secretion or dim light melatonin onset. The ability of valproate to decrease the sensitivity of melatonin to light may relate to its therapeutic effect in bipolar disorder--an ability to lengthen circadian period similar to that of lithium.

Objectives: To assess the cognitive and psychomotor effects of single oral doses of valerian in healthy volunteers in comparison with a placebo and the hypnotic agent triazolam. Methods: In a double-blind, placebo-controlled, four-way crossover study nine healthy subjects (5 males, 4 females) received in random order valerian 500 mg, valerian 1000 mg, triazolam 0.25 mg and placebo. Doses were separated by a wash-out period of at least 1 week. Subjects were tested before each dose and at 2, 4 and 8 h after the dose of each compound using the critical flicker fusion (CFF), choice reaction time (CRT), digit symbol substitution test (DSST), symbol search test (SST), digit span test (DST) and visual analogue scales of mood. Results: Repeated measures ANOVA was used to examine the changes in performance on tests over time and significant effects were further analysed using simple main effects analysis with least significant difference corrections. Statistically significant differences were only noted for the cognitive tests: SST (F(3, 8)¼3.182, p

Objectives: Many people experience irritability when manic, hypomanic, or depressed, yet its impact on illness severity and quality of life in bipolar and schizoaffective disorders is poorly understood. This study aimed to examine the relationship between irritability and symptom burden, functioning, quality of life, social support, suicidality, and overall illness severity in a naturalistic cohort of people with bipolar I or schizoaffective disorder. Methods: We used data from 239 adult outpatients with bipolar I or schizoaffective disorder in the Bipolar Comprehensive Outcomes Study (BCOS) - a non-interventional observational study with a 2-year follow-up period. Baseline demographic and clinical characteristics of participants with and without irritability were compared. A mixed-model repeated measures analysis was conducted to examine the longitudinal effect of irritability on clinical and quality-of-life variables over follow-up using significant baseline variables. Results: At baseline, 54% of participants were irritable. Baseline irritability was associated with illness severity, mania, depression, psychotic symptoms, suicidality, poor functioning, and quality of life, but not diagnosis (schizoaffective/bipolar disorder). Participants with irritability were less likely to have a partner and perceived less adequate social support. On average, over follow-up, those with irritability reported more symptoms, functional impairment, and suicidality. Furthermore, the effects of irritability could not be fully explained by illness severity. Conclusions: Irritability was associated with more negative symptomatic, functional, and quality-of-life outcomes and suicidality. The identification, monitoring, and targeted treatment of irritability may be worth considering, to enhance health and wellbeing outcomes for adults with bipolar and schizoaffective disorders.

Bipolar disorder has a major deleterious impact on many aspects of a patient's functioning and health-related quality of life. Although the formal measurement of these deficits has been neglected until recently, many well-designed trials now include an assessment of functioning and health-related quality of life using one or more rating scales. This review describes recent developments in the measurement of functioning and health-related quality of life in bipolar disorder, and discusses the evidence that medications that improve symptoms in bipolar disorder also offer clinically relevant benefits in functioning and health-related quality of life. Direct comparisons of the benefits of medications including atypical antipsychotics are problematic due to differences in trial populations, study durations and rating scales. Data from quetiapine trials indicate that this medication offers prompt and sustained improvement of functioning in patients with mania and enhancement of health-related quality of life in patients with bipolar depression, to accompany the significant improvements in mood episodes.

Medication adherence contributes to the efficacy-effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.A search was conducted for articles that focused on medication adherence in bipolar disorder, with emphasis on publications from 1996 to 2008 using Medline, Web of Science, CINAHL PLUS, and PsychINFO. The following key words were used: adherence, compliance, alliance, adherence assessment, adherence measurement, risk factors, psychosocial interventions, and psycho-education.There are a number of challenges to understanding non-adherence including the difficulty in defining and measuring it and the various risk factors that need to be considered when aiming to enhance adherence. Nevertheless, the importance of addressing adherence is evidenced by the connection between adherence problems and poor outcome. Despite these challenges, a number of small psychosocial studies targeting adherence as a primary outcome point to the potential usefulness of psycho-education aimed at improving knowledge, attitudes, and adherence behavior, but more large scale randomized controlled trials are needed in this area. Evidence of improved outcomes from larger randomized controlled trials of psychosocial interventions that target medication adherence as a secondary outcome suggests that tackling other factors besides medication adherence may also be an advantage. While some of these larger studies demonstrate an improvement in medication adherence, the translation of these interventions into real life settings may not always be practical. A person centered approach that considers risk factors for non-adherence and barriers to other health behaviors may assist with the development of more targeted briefer interventions. Integral to improving medication adherence is the delivery of psycho-education, and attention needs to be paid to the implementation, and timing of psycho-education. Progress in the understanding of how medicines work may add to the credibility of psycho-education in the future.Enhancement of treatment adherence in bipolar patients is a necessary and promising management component as an adjunct to pharmacotherapy. The current literature on psychosocial interventions that target medication adherence in bipolar disorder points to the possibility of refining the concept of non-adherence and adapting psycho-education to the needs of certain subgroups of people with bipolar disorder. Large scale randomized controlled trials of briefer or more condensed interventions are needed that can inform clinical practice.

Staging models are widely used in clinical medicine, and offer an insight into the progressive nature of many disorders. In general, the earlier stages of illness may be associated with a better prognosis and a higher treatment response. Once chronicity is reached, more complex and invasive treatments may be required, and the utility of treatments may decline. There is evidence that treatment response is greatest in the early phases of the disorder. There is also a progressive social and psychological burden of ongoing illness. This is paralleled by the twin notions of neuroprotection, which is supported by increasing evidence that structural changes in the disorder may be progressive and reversible with algorithm appropriate treatment, and that of early intervention, which posits that the optimal window for intervention is early in the illness course. A staging model compliments existing and proposed classifications of bipolar disorder, adding a temporal dimension to a cross sectional view. It may inform treatment choice and prognosis, and could have utility as a course specifier.

Objective: To provide a description of the service delivery model of an assertive community treatment (ACT) team in the management of a group of severely mentally ill patients and examine the effectiveness of this team in reducing readmissions to a psychiatric inpatient service. Method: A clinical case audit was performed on a single day in September 2001. Admission episodes and duration were collected for patients registered with the team in the 12 month period prior to ACT and for a period of 12 months ending on the day of the audit. Forty-three patients were registered with the team at the time of data collection. The majority (79%) were diagnosed with schizophrenia and there were high rates of comorbidity (76%) and disability (mean Global Assessment of Functioning score 45.9). The main outcome measures were the number of readmissions and readmission days before and after the institution of ACT. Results: The mean number of readmission days reduced from 70.9 to 10.2 (p < 0.05) following the institution of ACT. Conclusion: Assertive community treatment conducted in a naturalistic clinical environment is effective in signi?cantly reducing the number of readmission days in a group of patients suffering from long-term and persistent severe mental illness.

Administration of benzodiazepines is known to be associated with tolerance and a withdrawal syndrome on abrupt cessation. The aetiology of the withdrawal syndrome is not known but a role for the serotonin (5HT) system is suspected. The aim of the current study was to investigate the usefulness of 5-HT2 antagonists in the treatment of benzodiazepine withdrawal syndrome in the rat. Male Wistar rats were treated with either diazepam (4 mg/kg) or vehicle for 14 days, then abruptly withdrawn for 24 h. Animals were tested in the social interaction paradigm and elevated plus maze. Some diazepam-withdrawn rats were pre-treated with 5HT2 antagonists 60 min before behavioural testing. Acute withdrawal from benzodiazepines significantly reduced social interaction between pairs compared to vehicle or diazepam-treated animals. Similarly, for the elevated plus maze withdrawn animals made fewer entries and spent less time on the open arms than did vehicle or diazepam-treated animals. Single doses of 5-HT2 antagonists, mianserin (5 mg/kg) and ritanserin (1 mg/kg), effectively ameliorated withdrawal anxiety in the rat, returning behavioural function in the social interaction test and elevated plus maze to levels comparable to vehicle-treated animals.

Sensitivity of the pineal hormone melatonin to bright light at night has been posited as a putative marker of affective disorders. Research demonstrates melatonin supersensitivity to light in bipolar disorder, however the role that lithium carbonate plays in this response is unclear. This study assessed the effect of lithium on nocturnal melatonin secretion and sensitivity to light in healthy adults. Ten participants, tested on two nights, had blood samples drawn between 20:00 and 02:30 hours. On testing nights participants were exposed to 200 lux of light between 24:00 and 01:00 hours. Participants took 250 mg of lithium daily for 5 d between testing nights. The results indicated that lithium had a significant effect on sensitivity to light but not on overall melatonin synthesis. This finding has implications on the true magnitude of the melatonin light response in people with bipolar disorder and may elucidate possible mechanisms of action of lithium.

The early phases of bipolar disorders are difficult to diagnose and have specific treatment issues. The initial polarity of the illness is more commonly depressive, yet in counterpoint, mania is required for diagnosis; consequently, there is often a substantial delay in the initiation of appropriate therapy. There is good evidence that lithium in particular is most effective early in the illness course, and that its efficacy declines after multiple episodes. The notion of neuroprotection reflects this, and furthermore suggests that appropriate therapy may prevent the neurostructural and neurocognitive changes seen in the disorder. Inappropriate therapy may worsen the course of the illness. Patients with a first episode have specific psychosocial needs, and adherence to medication is relatively poor. There is a need for early identification, and to develop treatments and services applicable to the specific needs of this population.