Statement of Principles
concerning
BIPOLAR DISORDER
No. 27 of 2009
for the purposes of the
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
Title
1. This Instrument may be cited as Statement of Principles concerning bipolar disorder No. 27 of 2009.
Determination
2. The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a) revokes Instrument No. 25 of 2008 concerning bipolar disorder; and
(b) determines in its place this Statement of Principles.
Kind of injury, disease or death
3. (a) This Statement of Principles is about bipolar disorder and death from bipolar disorder.
(b) For the purposes of this Statement of Principles, "bipolar disorder" means a group of disorders which includes bipolar I disorder, bipolar II disorder, cyclothymia and bipolar disorder not otherwise specified. This definition includes substance-induced mood disorder with manic or mixed features and mood disorder due to a general medical condition with manic or mixed features.
"bipolar I disorder" means a psychiatric disorder that meets the following diagnostic criteria (derived from DSM-IV-TR):
(a) Bipolar I disorder, single manic episode:
A. Presence of only one manic episode and no past major depressive episodes.
B. The manic episode is not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified; or
(b) Bipolar I disorder, most recent episode hypomanic:
A. Currently (or most recently) in a hypomanic episode.
B. There has previously been at least one manic episode.
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The mood episodes in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified; or
(c) Bipolar I disorder, most recent episode manic:
A. Currently (or most recently) in a manic episode.
B. There has previously been at least one major depressive episode, manic episode, or mixed episode.
C. The mood episodes in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified; or
(d) Bipolar I disorder, most recent episode mixed:
A. Currently (or most recently) in a mixed episode.
B. There has previously been at least one major depressive episode, manic episode, or mixed episode.
C. The mood episodes in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified; or
(e) Bipolar I disorder, most recent episode depressed:
A. Currently (or most recently) in a major depressive episode.
B. There has previously been at least one manic episode or mixed episode.
C. The mood episodes in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified; or
(f) Bipolar I disorder, most recent episode unspecified:
A. Criteria, except for duration, are currently (or most recently) met for a manic, a hypomanic, a mixed, or a major depressive episode.
B. There has previously been at least one manic or mixed episode.
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
E. The mood symptoms in criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
"bipolar II disorder" means a psychiatric disorder that meets the following diagnostic criteria (derived from DSM-IV-TR):
A. Presence (or history) of one or more major depressive episodes.
B. Presence (or history) of at least one hypomanic episode.
C. There has never been a manic or a mixed episode.
D. The mood symptoms in criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
"bipolar disorder not otherwise specified" means a psychiatric disorder that includes bipolar features that do not meet criteria for any specific bipolar disorder. Examples (derived from DSM-IV-TR) include:
A. Very rapid alternation (over days) between manic symptoms and depressive symptoms that meet symptom threshold criteria but not minimal duration criteria for manic, hypomanic, or major depressive episodes; or
B. Recurrent hypomanic episodes without intercurrent depressive symptoms; or
C. A manic or mixed episode superimposed on delusional disorder, residual schizophrenia, or psychotic disorder not otherwise specified; or
D. Hypomanic episodes, along with chronic depressive symptoms, that are too infrequent to qualify for a diagnosis of cyclothymic disorder; or
E. Situations in which the clinician has concluded that a bipolar disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
"cyclothymia" means a psychiatric disorder that meets the following diagnostic criteria (derived from DSM-IV-TR):
A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. Note: in children and adolescents, the duration must be at least 1 year.
B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in criterion A for more than 2 months at a time.
C. No major depressive episode, manic episode, or mixed episode has been present during the first 2 years of the disturbance.
D. The symptoms in criterion A are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
"mood disorder due to a general medical condition with manic or mixed features" means a psychiatric condition that meets the following diagnostic criteria (derived from DSM-IV-TR):
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised by elevated, expansive or irritable mood, with or without depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.
In mood disorder due to a general medical condition with manic or mixed features, the signs of elevated mood would predominate clinically.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood in response to the stress of having a general medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
"substance-induced mood disorder with manic or mixed features" means a psychiatric condition that meets the following diagnostic criteria (derived from DSM-IV-TR):
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised by elevated, expansive or irritable mood, with or without depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.
In substance-induced mood disorder with manic or mixed features, the signs of elevated mood would predominate clinically.
B. There is evidence from the history, physical examination, or laboratory findings that:
(1) the symptoms in criterion A developed during, or within 1 month of, substance intoxication or withdrawal; or
(2) medication use is aetiologically related to the disturbance.
C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced mood disorder (e.g., a history of recurrent major depressive episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
Basis for determining the factors
4. The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that bipolar disorder and death from bipolar disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
Factors that must be related to service
5. Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
Factors
6. The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting bipolar disorder or death from bipolar disorder with the circumstances of a person’s relevant service is:
(a) for bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise specified and cyclothymia only,
(i) experiencing a category 1A stressor within the one year before the clinical onset of bipolar disorder; or
(ii) experiencing a category 1B stressor within the one year before the clinical onset of bipolar disorder; or
(iii) experiencing a category 2 stressor within the one year before the clinical onset of bipolar disorder; or
(iv) experiencing the death of a significant other within the one year before the clinical onset of bipolar disorder; or
(v) experiencing the death from suicide of a close family member before the clinical onset of bipolar disorder; or
(vi) being within 90 days postpartum at the time of the clinical onset of bipolar disorder; or
(vii) having drug dependence or drug abuse at the time of the clinical onset of bipolar disorder; or
(viii) having alcohol dependence or alcohol abuse at the time of the clinical onset of bipolar disorder; or
(ix) having a clinically significant anxiety spectrum disorder within the 10 years before the clinical onset of bipolar disorder; or
(b) for substance-induced mood disorder with manic features only,
(i) taking a drug from the class of drugs in specified list 1 within the one month before the clinical onset of bipolar disorder; or
(ii) taking a drug in specified list 2 within the one month before the clinical onset of bipolar disorder; or
(iii) being treated with a drug which is associated in the individual with the development of symptoms of bipolar disorder during drug therapy, and the cessation or significant reduction of the symptoms of bipolar disorder within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical onset of bipolar disorder; or
(iv) having ceased or reduced antidepressant drug therapy within the one month before the clinical onset of bipolar disorder; or
(c) for substance-induced mood disorder with mixed features only,
(i) taking a drug from the class of drugs in specified list 3 within the one month before the clinical onset of bipolar disorder; or
(ii) taking a drug in specified list 4 within the one month before the clinical onset of bipolar disorder; or
(iii) being treated with a drug which is associated in the individual with the development of symptoms of bipolar disorder during drug therapy, and the cessation or significant reduction of the symptoms of bipolar disorder within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical onset of bipolar disorder; or
(iv) having ceased or reduced antidepressant drug therapy within the one month before the clinical onset of bipolar disorder; or
(d) for mood disorder due to a general medical condition with manic or mixed features only, having an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological disorder, where the general medical condition is a direct physiological cause of the mood symptoms at the time of the clinical onset of bipolar disorder; or
(e) having experienced severe childhood abuse within the 10 years before the clinical onset of bipolar disorder; or
(f) experiencing a category 1A stressor within the one year before the clinical worsening of bipolar disorder; or
(g) experiencing a category 1B stressor within the one year before the clinical worsening of bipolar disorder; or
(h) experiencing a category 2 stressor within the one year before the clinical worsening of bipolar disorder; or
(i) experiencing the death of a significant other within the one year before the clinical worsening of bipolar disorder; or
(j) experiencing the death from suicide of a close family member before the clinical worsening of bipolar disorder; or
(k) being within 90 days postpartum at the time of the clinical worsening of bipolar disorder; or
(l) having drug dependence or drug abuse at the time of the clinical worsening of bipolar disorder; or
(m) having alcohol dependence or alcohol abuse at the time of the clinical worsening of bipolar disorder; or
(n) having a clinically significant anxiety spectrum disorder within the 10 years before the clinical worsening of bipolar disorder; or
(o) taking a drug from the class of drugs in specified list 1 within the one month before the clinical worsening of bipolar disorder; or
(p) taking a drug in specified list 2 within the one month before the clinical worsening of bipolar disorder; or
(q) taking a drug from the class of drugs in specified list 3 within the one month before the clinical worsening of bipolar disorder; or
(r) taking a drug in specified list 4 within the one month before the clinical worsening of bipolar disorder; or
(s) being treated with a drug which is associated in the individual with the development of symptoms of bipolar disorder during drug therapy, and the cessation or significant reduction of the symptoms of bipolar disorder within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical worsening of bipolar disorder; or
(t) having ceased or reduced antidepressant drug therapy within the one month before the clinical worsening of bipolar disorder; or
(u) having a medical condition as specified at the time of the clinical worsening of bipolar disorder; or
(v) being deprived of at least one whole night's sleep within the two days before the clinical worsening of bipolar disorder; or
(w) having electroconvulsive therapy within the two weeks before the clinical worsening of bipolar disorder; or
(x) having a course of bright light therapy within the two weeks before the clinical worsening of bipolar disorder; or
(y) inability to obtain appropriate clinical management for bipolar disorder.
Factors that apply only to material contribution or aggravation
7. Paragraphs 6(f) to 6(y) apply only to material contribution to, or aggravation of, bipolar disorder where the person’s bipolar disorder was suffered or contracted before or during (but not arising out of) the person’s relevant service.
Inclusion of Statements of Principles
8. In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
Other definitions
9. For the purposes of this Statement of Principles:
"a category 1A stressor" means one or more of the following severe traumatic events:
(a) experiencing a life-threatening event;
(b) being subject to a serious physical attack or assault including rape and sexual molestation; or
(c) being threatened with a weapon, being held captive, being kidnapped, or being tortured;
"a category 1B stressor" means one of the following severe traumatic events:
(a) being an eyewitness to a person being killed or critically injured;
(b) viewing corpses or critically injured casualties as an eyewitness;
(c) being an eyewitness to atrocities inflicted on another person or persons;
(d) killing or maiming a person; or
(e) being an eyewitness to or participating in, the clearance of critically injured casualties;
"a category 2 stressor" means one or more of the following negative life events, the effects of which are chronic in nature and cause the person to feel on-going distress, concern or worry:
(a) being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;
(b) experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce;
(c) having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful work loads, or experiencing bullying in the workplace or school environment;
(d) experiencing serious legal issues including: being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;
(e) having severe financial hardship including: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy;
(f) having a family member or significant other experience a major deterioration in their health; or
(g) being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability;
"a clinically significant anxiety spectrum disorder" means any Axis I anxiety disorder that attracts a diagnosis under DSM-IV-TR and is sufficient to warrant ongoing management. The ongoing management may involve regular visits (for example, at least monthly), to a psychiatrist, clinical psychologist or general practitioner;
"a close family member" means a parent, child or sibling with whom the person has a close relationship;
"a drug from the class of drugs in specified list 1" means:
(a) amphetamines, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);
(b) anabolic-androgenic steroids;
(c) antidepressants;
(d) antiepileptics, except valproate, lamotrigine and levetiracetam;
(e) atypical antipsychotics;
(f) corticosteroids, other than topical steroids;
(g) dopaminergic anti-Parkinsonian drugs (e.g., levodopa, bromocriptine);
(h) fluoroquinolones;
(i) hallucinogens; or
(j) interferons;
"a drug from the class of drugs in specified list 3" means:
(a) alpha-adrenoceptor agonists;
(b) amphetamines, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);
(c) anabolic-androgenic steroids;
(d) angiotensin converting enzyme (ACE) inhibitors;
(e) antidepressants;
(f) antiepileptics;
(g) atypical antipsychotics;
(h) benzodiazepines;
(i) beta adrenergic blocking agents;
(j) calcium channel blockers;
(k) centrally acting antihypertensives;
(l) corticosteroids, other than topical steroids;
(m) dopaminergic anti-Parkinsonian drugs (e.g., levodopa, bromocriptine);
(n) fluoroquinolones;
(o) gonadotropin releasing agents;
(p) hallucinogens;
(q) inhalants;
(r) interferons;
(s) opiate analgesics; or
(t) oral contraceptive agents;
"a drug in specified list 2" means:
(a) alprazolam;
(b) baclofen;
(c) chloroquine;
(d) clarithromycin;
(e) cocaine;
(f) disulfiram;
(g) ephedrine;
(h) fenfluramine;
(i) ifosfamide;
(j) intravenous 5-flurouracil;
(k) iproniazid;
(l) isoetharine;
(m) isoniazid;
(n) marijuana;
(o) phencyclidine;
(p) phentermine;
(q) phenylephrine;
(r) phenylpropanolamine;
(s) pseudoephedrine;
(t) quinagolide;
(u) thyroxine; or
(v) varenicline;
"a drug in specified list 4" means:
(a) alprazolam;
(b) amantadine;
(c) baclofen;
(d) chloroquine;
(e) clarithromycin;
(f) clozapine;
(g) cocaine;
(h) depot medroxyprogesterone acetate;
(i) dextromethorphan;
(j) digoxin;
(k) disulfiram;
(l) ephedrine;
(m) eszopiclone;
(n) fenfluramine;
(o) fluphenazine;
(p) fluspirilene;
(q) hydralazine;
(r) ifosfamide;
(s) interleukin-2;
(t) intravenous 5-flurouracil;
(u) iproniazid;
(v) isocarboxazid;
(w) isoetharine;
(x) isoniazid;
(y) marijuana;
(z) mefloquine;
(aa) mycophenolate mofetil;
(bb) phencyclidine;
(cc) phentermine;
(dd) phenylephrine;
(ee) phenylpropanolamine;
(ff) pseudoephedrine;
(gg) quinagolide;
(hh) ramelteon;
(ii) reserpine;
(jj) rimonabant;
(kk) thiazide;
(ll) thyroxine;
(mm) varenicline;
(nn) zaleplon; or
(oo) zolpidem;
"a medical condition as specified" means an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological condition, that causes symptoms consistent with bipolar disorder, as a direct physiological consequence of the condition;
"a significant other" means a person who has a close family bond or a close personal relationship and is important or influential in one’s life;
"an eyewitness" means a person who observes an incident first hand and can give direct evidence of it. This excludes a person exposed only to media coverage of the incident;
"death from bipolar disorder" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s bipolar disorder;
"DSM-IV-TR" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000;
"inhalants" means breathable chemicals that produce psychoactive vapours and include organic solvents, aerosols, some anaesthetics, and other chemicals;
"relevant service" means:
(a) operational service under the VEA;
(b) peacekeeping service under the VEA;
(c) hazardous service under the VEA;
(d) warlike service under the MRCA; or
(e) non-warlike service under the MRCA;
"severe childhood abuse" means:
(a) serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or
(b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;
where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child;
"terminal event" means the proximate or ultimate cause of death and includes:
(a) pneumonia;
(b) respiratory failure;
(c) cardiac arrest;
(d) circulatory failure; or
(e) cessation of brain function;
"the general medical condition is a direct physiological cause of the mood symptoms" means signs or symptoms of depressed, elevated, expansive or irritable mood are directly related to the pathological process of the general medical condition, and
(a) the bipolar disorder has a close temporal relationship with the onset or exacerbation of the general medical condition, and the bipolar disorder developed at the same time or after the onset of the general medical condition;
(b) treatment which causes remission of the general medical condition also results in remission of the bipolar disorder symptoms; or
(c) features of the bipolar disorder, such as an unusual age of onset, a qualitative difference in symptoms, or disproportionately severe or unusual symptoms, are inconsistent with a primary diagnosis of any of the bipolar disorders.
Application
10. This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
Date of effect
11. This Instrument takes effect from 6 May 2009.
Dated this twenty-fourth day of April 2009
The Common Seal of the )
Repatriation Medical Authority )
was affixed to this instrument )
in the presence of: )
KEN DONALD
CHAIRPERSON
