The Medical journal of Australia
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When a patient presents to hospital after a suicide attempt and appears to refuse treatment, clinicians should first assess if he or she should be treated under mental health legislation, regardless of competence to refuse treatment. When it is not possible or is inappropriate to treat under mental health legislation, the person's competence to refuse treatment should be assessed. ⋯ The law around the right to refuse treatment after a suicide attempt remains unclear and, if uncertain of what to do, clinicians should provide urgently required life-saving treatment and simultaneously seek an urgent court order to clarify how they should proceed. In all but extraordinary circumstances, a patient who refuses treatment after a suicide attempt can and should be given life-saving treatment, under either mental health legislation or the common law concept of necessity.
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General practitioners are often consulted for first presentations of bipolar disorder and are well placed to coordinate patient care. They can assist with early identification of bipolar disorder and monitoring for manic and depressive episodes. Delayed and incorrect diagnoses are common in bipolar disorder, and unipolar depression is a frequent misdiagnosis. ⋯ Early warning signs are less commonly observed for depressive episodes. Daily mood charts are useful for providing an overview of patient progress and for identifying and managing early warning signs. Families and carers can also play an active role in supporting patients with bipolar disorder.
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Rates of conditions comorbid with bipolar disorder are very high, with anxiety disorders, impulse-control disorders, and drug and alcohol problems being the most distinctly over-represented conditions. Although the high rates of comorbid conditions may be overestimates--owing to measurement distortions in community surveys, and because definitions of comorbidity generally include antecedent and consequential conditions (not merely coterminous ones)--they are clinically distinctive. ⋯ If the bipolar disorder and the comorbid conditions are deemed to be interdependent, two broad approaches are appropriate: hierarchical management strategies and sequential management strategies. Successful management of bipolar disorder often involves the development of a wellbeing plan that addresses comorbid issues iterative to the bipolar disorder.
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Bipolar affective disorders carry significant risks to the patient and sometimes others. The form of the illness relapse needs to be determined, and high-risk features such as psychosis and suicide considered. Gathering collateral information from others is invaluable. ⋯ Both mania and depression bring risks of substance misuse and disrupted relationships. Management requires an optimal therapeutic alliance with good communication, appropriate treatment and sometimes compulsory care during crises. Preventive strategies are invaluable.