Statement of Principles concerning bipolar disorder No. 129 of 1996 (Cth)
Instrument No.129 of 1996
Determination
of
Statement of Principles
concerning
BIPOLAR DISORDER
ICD CODES: 296.0, 296.4, 296.5, 296.6, 296.7, 296.80, 296.89, 301.13
Veterans’ Entitlements Act 1986
This Statement of Principles is determined by the Repatriation Medical Authority under subsection 196B(3) of the Veterans’ Entitlements Act 1986 (the Act).
Kind of injury, disease or death
(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” as defined in DSM-IV, means a group of disorders which includes Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar Disorder Not Otherwise Specified, attracting ICD code 296.0, 296.4, 296.5, 296.6, 296.7, 296.80, 296.89 or 301.13.
Note: For the purposes of this Statement of Principles, episodes of Substance-Induced Mood Disorder or of Mood Disorder Due To a General Medical Condition do not count towards a diagnosis of Bipolar Disorder.
Basis for determining the factors
On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that bipolar disorder and death from bipolar disorder can be related to relevant service rendered by veterans or members of the Forces.
Factors that must be related to service
Subject to clause 6, the factors set out in at least one of the paragraphs in clause 5 must be related to any relevant service rendered by the person.
Factors
The factors that must exist before it can be said that, on the balance of probabilities, bipolar disorder or death from bipolar disorder is connected with the circumstances of a person’s relevant service are:
(a) experiencing at least one severe psychosocial stressor within the six months immediately before the clinical onset of bipolar disorder; or
(b) being within 90 days postpartum at the time of the clinical onset of bipolar disorder; or
(c) experiencing at least one severe psychosocial stressor within the six months immediately before the clinical worsening of bipolar disorder; or
(d) being within 90 days postpartum at the time of the clinical worsening of bipolar disorder; or
(e) suffering from substance abuse involving alcohol or cocaine at the time of the clinical worsening of bipolar disorder; or
(f) using a specified drug as identified in the specified list of drugs at the time of the clinical worsening of bipolar disorder; or
(g) inability to obtain appropriate clinical management for bipolar disorder
.
Factors that apply only to material contribution or aggravation
Paragraphs 5(c) to 5(g) 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; paragraph 8(1)(e), 9(1)(e) or 70(5)(d) of the Act refers.
Other definitions
For the purposes of this Statement of Principles:
“Bipolar I disorder” means either:
(a) bipolar I disorder, single manic episode, attracting ICD code 296.0, that is:
A. Presence of only one manic episode and no past major depressive episodes; and
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, attracting ICD code 296.40, that is:
A. Currently (or most recently) in a hypomanic episode; and
B. There has previously been at least one manic episode or mixed episode; and
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
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, attracting ICD code 296.4, that is:
A. Currently (or most recently) in a manic episode; and
B. There has previously been at least one major depressive episode, manic episode, or mixed episode; and
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, attracting ICD code 296.6, that is:
A. Currently (or most recently) in a mixed episode; and
B. There has previously been at least one major depressive episode, manic episode, or mixed episode; and
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, attracting ICD code 296.5, that is:
A. Currently (or most recently) in a major depressive episode; and
B. There has previously been at least one manic episode or mixed episode; and
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, attracting ICD code 296.7, that is:
A. Criteria, except for duration, are currently (or most recently) met for a manic, a hypomanic a mixed, or a major depressive episode; and
B. There has previously been at least one manic episode or mixed episode; and
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
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; and
E. The mood symptoms in criteria A and B are not due to the direct physiological effects of a substance (eg., a drug of abuse, a medication, or other treatment) or a general medical condition (eg., hyperthyroidism);
“Bipolar II disorder”, attracting ICD code 296.89, means:
A. Presence (or history) of one or more major depressive episodes; and
B. Presence (or history) of at least one hypomanic episode; and
C. There has never been a manic episode or a mixed episode; and
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; and
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;
“bipolar disorder not otherwise specified”, attracting ICD code 296.80, includes disorders with bipolar features that do not meet criteria for any specific bipolar disorder. Examples include:
1. Very rapid alternation (over days) between manic symptoms and depressive symptoms that do not meet minimal duration criteria for a manic episode or a major depressive episode; and
2. Recurrent hypomanic episodes without intercurrent depressive symptoms; and
3. A manic or mixed episode superimposed on delusional disorder, residual schizophrenia, or psychotic disorder not otherwise specified; and
4. 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”, attracting ICD code 301.13, means:
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; and
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; and
C. No major depressive episode, manic episode, or mixed episode has been present during the first 2 years of the disturbance; and
Note: After the initial 2 years (1 year in children and adolescents) of cyclothymic disorder, there may be superimposed manic or mixed episodes (in which case both bipolar I disorder and cyclothymic disorder may be diagnosed) or major depressive episodes (in which case both bipolar II disorder and cyclothymic disorder may be diagnosed).
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; and
E. The symptoms are not due to the direct physiological effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hyperthyroidism); and
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;
“DSM-IV” means the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders;
“ICD code” means a number assigned to a particular kind of injury or disease in the Australian Version of The International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), effective date of 1 July 1996, copyrighted by the National Coding Centre, Faculty of Health Sciences, University of Sydney, NSW, and having ISBN 0 642 24447 2;
“relevant service” means:
(a) eligible war service (other than operational service); or
(b) defence service (other than hazardous service);
“severe psychosocial stressor” means an identifiable occurrence that evokes feelings of substantial distress in an individual, for example, being shot at, death or serious injury in a close friend or relative, assault (including sexual assault), severe illness or injury, experiencing a loss such as divorce or separation, loss of employment, major financial problems or legal problems;
“substance abuse involving alcohol or cocaine” means a maladaptive pattern of use of alcohol or cocaine, as derived from DSM-IV, attracting ICD code 303 or 304.2, that is indicated by either:
(a) continued use of alcohol or cocaine despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by use of the substance; or
(b) recurrent use of alcohol or cocaine when use is physically hazardous (for example, driving while intoxicated);
“substance induced mood disorder” as defined in DSM-IV, means a condition satisfying the following:
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised by either (or both) of the following:
(1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities; or
(2) elevated, expansive, or irritable mood; and
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) The symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal; or
(2) medication use is aetiologically related to the disturbance; and
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 (eg., 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 (eg., a history of recurrent Major Depressive Episodes); and
D. The disturbance does not occur exclusively during the course of a delirium; and
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning;
This group are ICD Coded as follows: 291.8 Alcohol; 292.84 Amphetamine (or Amphetamine-like substance); 292.84 Cocaine; 292.84 Hallucinogen; 292.84 Inhalant; 292.84 Opioid; 292.84 Phencyclidine (or Phencyclidine-Like Substance; 292.84 Sedative, Hypnotic or Anxiolytic; 292.84 Other (or Unknown) Substance;
“using a specified drug” means being treated with, or self-administering, any of the drugs (including any of the drugs contained in preparations) listed in the following Table of Drugs, under the circumstances as specified in the Table, with regard to the Mode of administration, Dose level, Minimum Duration of Treatment, and Temporality (time relationship between the administration of the drug and the onset of the disease), and which does not meet the criteria for Substance Induced Mood Disorder:
Specified list of drugs
Drug or Group of Drugs Mode * Dose
**Minimum Duration of Treatment Temporality Tricyclic antidepressants O M.T. 3 days At least 3 days of therapy within the 2 weeks prior to episode fluoxetine O M.T 3 days At least 3 days of therapy within the 2 weeks prior to episode MAOIs O M.T. 3 days At least 3 days of therapy within the 2 weeks prior to episode bupropion O M.T. 3 days At least 3 days of therapy within the 2 weeks prior to episode
Drug or Group of Drugs Mode * Dose
**Minimum Duration of Treatment Temporality corticosteroids O,IV,
IM SCM.T. 3 days At least 3 days therapy in the one to 210 days prior to episode ACTH A M.T. 3 days At least 3 days therapy in the one to 210 days prior to episode anabolic and androgenic steroids
A 240 mg/day of methyl-testosterone or equivalent or 100 mg per week for 6 weeks 3 days for high dose; 6 weeks for low dose Episode at any time during use or up to 1 year after stopping drug
* Abbreviations: IV = intravenous; IM = intramuscular; SC = subcutaneous; O = oral; A = all or any;
** M.T. means that all doses in the above table are the minimum calculated as appropriate therapeutic doses in the range of usual doses by the treating physician. Where other than usual doses or self-medication exist, these are stated.
Dated this Twenty-sixth day of September 1996
The Common Seal of the )
Repatriation Medical Authority )
was affixed to this instrument )
in the presence of )
KEN DONALD
CHAIRMAN
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