What is Bipolar Disorder?

Bipolar Disorder is mental health condition consisting of alternating moods of Depression and Mania.

Bipolar Disorder is a serious Mental Illness where the sufferer experiences severe, exaggerated mood swings. These moods range from Depression in the low form and Mania in the high form.

Previously, it was known as Manic Depressive Disorder to indicate these mood swings, terminology has since been changed to Bipolar Disorder.

Everyone experiences mood swings, however those associated with Bipolar Disorder are much more serious. For example, during the Depressive stage, these symptoms are present for at least two weeks.

Symptoms of a Depressive stage can include:

~ Excessive levels of tiredness, wanting to sleep all the time
~ The feeling of not being able to get out of bed
~ Loss of interest in things that previously gave pleasure
~ Lack of motivation
~ Lowered self esteem, lack of self worth, feelings of general hopelessness
~ Poor concentration and short term memory loss
~ Inability to make decisions
~ Physical illnesses such as chronic pain and
~ if Depression is left to run its course, thoughts of suicide.

Conversely, during the high or Manic Stage, symptoms are the polar opposite.

Symptoms of a Manic stage may include:

~ Decreased need for sleep, not wanting to sleep
~ Having boundless levels of energy
~ Supreme levels of self confidence, able to solve the problems of the world
~ Over talkative and rapid speech
~ Flight of ideas, where there may be many projects on the go at once, without the ability to complete any of them
~ Severe irritability, often associated with anger management problems
~ Loss of inhibitions, this can be in the form of overspending, infidelity and consequent long term relationship breakdown
~ A special connectivity or spiritual meaning to all that is going on
~ In the extreme case, Psychosis occurs, delusions (visual, auditory and sensory) and paranoia.

With both the Depressive and Manic stages, hospitalization may be required: During the Depressive stage someone who is suicidal and generally feels “unable to cope”, often requires hospitalization for their own safety. For the Manic patient, hospitalization may be used so the sufferer doesn’t harm themselves or those around them.

The good news is, Bipolar Disorder can be managed and those living with the illness can live symptom free, provided they:

~ Recognise early warning signs by educating themselves
~ Avoid trigger factors that may cause them to spiral to either Mania/Depression
~ Learn coping mechanisms so they can remain well.


What causes Bipolar Disorder?

The cause of Bipolar Disorder is not fully understood. However it is known to be due to a combination of a number of factors.
1.    Genetic or biological causes
2.    Abnormal levels of certain brain chemicals
3.    Environmental or outside factors.

Genetic Causes

Bipolar Disorder is most often inherited. The genetic factors account for 80% of the cause of the disorder. In fact if one parent has Bipolar the chances of the offspring developing the illness is 10%. If both parents have Bipolar, the chances increase to 40%.

It is important to note, just because one family member may have the illness, it doesn’t mean other family members will develop Bipolar.

Involvement of the following factors must also occur.

Brain Chemicals

People with Bipolar Disorder exhibit differing brain chemistry. One theory suggests there is an abnormal level of Serotonin, a brain chemical that can have serious effects on someone’s mood.

It’s thought that other brain chemicals may play a role as well.

Environmental Factors

The most obvious external factor that can bring on Bipolar Disorder is stress. Stress itself is unlikely to bring on Bipolar, but when combined with a genetic predisposition, the likelihood increases dramatically.

Managing Bipolar Disorder involves minimizing the amount of stress in your life. Emotional pressure caused by different stressors can often bring on a relapse of the illness.

Other Possible Causes of Bipolar Disorder

Medical conditions themselves are not normally a cause of Bipolar, however some medications and conditions can produce symptoms that can be confused with Bipolar Disorder.

Some illicit drugs can also cause manic or hypomanic type symptoms.

Pregnancy unfortunately can induce an episode of Bipolar Disorder in a mother who may be predisposed to Bipolar Disorder by genetics.


What are the symptoms of Bipolar Disorder?

Manic symptoms include:

~ Elevation of mood
~ Racing thoughts
~ Inflated self esteem
~ Loud, rapid speech
~ Increased physical energy
~ Decreased need for sleep
~ Reckless and risky behaviour
~ Delusions of grandeur

Depressive symptoms include:
~ Loss of interest or pleasure
~ Inability to concentrate
~ Lack of energy, tiredness and fatigue
~ Sense of worthlessness or guilt
~ Changes in appetite
~ Changes in sleep patterns
~ Suicidal thoughts


How common is Bipolar Disorder?

Statistics indicate that Bipolar Disorder affects 3% of the population.  There is equal prevalence between male and female. However actual recorded cases may be much higher than these figures suggest, as many people’s illnesses go undetected or misdiagnosed.

Mood disorders such as Bipolar Disorder are more common in males in the 35-44 age group, while the 25-34 year age group is more common for women.

Interestingly, women are 5% more likely to report mood disorders than men.


What medications are available to treat Bipolar Disorder?

Wouldn’t it be nice if there was just one medication to take to treat Bipolar Disorder? Or better still if we had the technology so that medication wasn’t required at all? One day this may happen with further research into genetics.  In the mean time we have to use the best that’s available to us. Don’t be alarmed however, there is quite an array of medications available that can be tailored to suit the specific needs of each patient.

There are basically three main types of medication used to treat Bipolar Disorder. Usually only one type of medication is not enough. Often there needs to be a mixture of more than one type.

Medications are classified into –
1.  Mood stabilizer medications
2.  Anti Psychotic medications
3.  Anti Depressant medications

Mood Stabilizer Medications

These are the first line medications used to treat Bipolar Disorder. Since Bipolar is an illness where people suffer from oscillating extremes of moods, being major depression in the low form and mania or hypomania in the high form, it is essential to try and flatten out these extreme peaks and troughs. That is exactly what a Mood Stabilizer does. It has a stabilizing effect on the level of mood.

By flattening out the peaks and troughs, the person with Bipolar has less mood swings and can live a much more fulfilled and meaningful life.

In the early days of Bipolar treatment, Mood Stabilizers were the sole form of treatment. Unfortunately, despite bringing about vast improvement for sufferers, there was still room for improvement. Luckily, with further research, new developments occurred and treatment improved (see later in this topic).

The original Mood Stabilizer medication was Lithium. It still remains the “gold standard treatment” for Bipolar and is often the first medication of choice. More recently, Anti Epileptic medications have been found to exhibit Mood Stabilizer activity. These include:

Epilim – (Sodium Valproate)
Tegretol – (Carbamazepam)
Lamictal- (Lamotrogine)

It is possible to be taking one of this class but not unusual to be taking Lithium and one of the others concurrently.

Anti Psychotic Medications

For most people faced with the proposition of having to take medication for life, the name of this class of medication can be frightening. When you break the name down, it becomes less scary.

As part of mania, at the top end of the scale, psychosis is a real possibility. This is a scenario where the person can experience delusions and hallucinations. These experiences seem very real to the person but in actual fact are not.

It stands to reason, then, to correct this psychotic behavior, Anti Psychotic medications have to be used.

Anti Psychotic medications are primarily used in the treatment of acute mania. They’re action can reverse the symptoms of mania and are used widely in this phase of the illness.

As well as being useful in the treatment of mania, they also play a role as a Mood Stabilizing medication and even have some Anti Depressant activity.

Here we see an example of where one medication can have a variety of indications and can work in well by augmenting other classes of medication.

Anti Psychotic medications can be divided in two groups.

Typical and Atypical Anti Psychotics

1.Typical Anti Psychotics
These are the traditional or older forms of this medication. Examples include

Largactil – (Chlorpromazine)
Neulactil – (Pericyazine)
Stelazine – (Trifluperazine)

This class of medications work very effectively as Anti Psychotics, however they are associated with Parkinson’s Disease type side effects. This includes the patient suffering rigidity and tremors.

As a result a new generation of Anti Psychotics has been developed. These include the following

2. Atypical Anti Psychotics
These are just as effective as their older cousins but have less side effects. Examples include

Zyprexa – (Olanzapine)
Seroquel – (Quietapine)
Saphris – (Asenapine)
Clozaril – (Clozapine)
Invega – (Paliperidone)
Risperdal – (Risperidone)
Abilify – (Aripiprazole)

There are different ways of administering these medications, ranging from a tablet, to wafers dissolved on the tongue, to an injection.

The side effect profile of this new generation of Anti Psychotic medications is very encouraging. The most significant problem is weight gain. It’s important to understand the mechanism behind this and then weight gain can be less of a problem.

The medications themselves don’t cause weight gain. Instead they affect an area of the brain called the “satiety centre”. This area, normally, let’s the brain know when the patient has eaten sufficient or when they are full (satisfied).Because the medication affects this process, the signal the brain normally receives to tell it that’s enough, is lacking. As a result, over eating can occur and this is what puts on weight.

Knowing this, there are strategies that can be developed to overcome this problem.
1.    Limiting portion size
2.    Using a smaller plate
3.    Not lining up for a second helping
4.    Leave the table at the finish of the meal
5.    Cleaning teeth immediately after eating
6.    EXERCISE

Anti Depressant Medications

Since Depression plays such a large role in Bipolar Disorder, it is very common to have Anti Depressants included in the medication treatment plan.

Anti Depressants can only be prescribed if a Mood Stabilizer is also in use. If an Anti Depressant is used in isolation, the patient can quickly cycle into mania, as there is no Mood Stabilizer present to halt this from occurring. Having an Anti Psychotic as well, can add further to the Mood Stabilizer effect, assisting with prevention of mania and depression.

By now, you will notice how all three classes of medication work together to provide the optimum effect.

There are a number of different classes of Anti Depressants available. These include
1.    Selective Serotonin Reuptake Inhibitors (SSRI’s)
2.    Selective Serotonin and NorAdrenaline Reuptake Inhibitors (SNRI’s)
3.    Tricyclic AntiDepressants
4.    Mono Amine Oxidase Inhibitors (MAOI’s)
5.    Tetra Cyclic Anti Depressants
6.    Others
7.    Natural Substances and Strategies

SSRI’s

Without doubt, these are the most commonly prescribed of all the Anti Depressants. The reason for this is they have the least amount of side effects. Their mechanism of action is to increase the amount of Serotonin in the brain. Serotonin is a brain chemical that appears to be lacking in someone with Bipolar Disorder or Depression. When the levels are increased, there is a corresponding rise in mood of the patient.

Examples include –
Prozac – (Fluoxetine)
Cipramil – (Citalopram)
Aropax – (Paroxetine)
Lexotan – (Escitalopram)
Zoloft – (Sertraline)
Luvox – (Fluvoxamine)

SNRI’s

Also very commonly prescribed, this class improves the levels of both Serotonin and NorAdrenaline in the brain. There is also a corresponding increase in level of mood when this occurs.

Examples include –
Efexor – (Venlafaxine)
Pristiq – (Desvenlafaxine)
Cymbalta – (Duloxetine)

Tri Cyclic Anti Depressants

This group of Anti Depressants were the first to be developed. They are just as effective as an Anti Depressant as the other classes. The problem is they can affect not only Serotonin and Nor Adrenaline, but have a wide ranging effect on other chemicals in the brain. They can make the patient drowsy, which can be an advantage if difficulty sleeping is an issue. They are still very widely used and are very safe.

Examples include –
Dothep – (Dothiepin)
Allegron – (Nortryptiline)
Endep – (Amitryptyline)
Deptran – (Doxepin)
Tofranil – (Imipramine)
Anafranil – (Clomipramine)

Tetracyclic Anti Depressants

This group of Anti Depressants works on improving the levels of Serotonin, Nor Adrenaline and Dopamine. All these brain chemicals, when at sufficient levels, improve the mood. This class of medications cause drowsiness and can stimulate the appetite. This is particularly useful if the patient is having difficulty sleeping and is suffering from decreased appetite whilst battling Depression.

Examples  include-
Avanza – (Mirtazapine)
Brintellix – (Vortioextine)

Others

A relatively new medication available is called Valdoxan (Agomelatine). It works by regulating the body’s stores of Melatonin. Melatonin is a chemical produced by our body when it becomes dark, to assist with sleep.
This medication is used when sleep is an issue and if there is associated Anxiety and Depression.

Natural Substances and Strategies

The supplement, St John’s Wart (Hypericum) is available over the counter in Pharmacies. It is a useful Anti Depressant in mild cases. Caution must be taken however, as it has the ability to interact with a number of Prescription medications including other Anti Depressants. Please consult with your Pharmacist prior to taking this supplement.

The first form of treatment for Depression should always be exercise. Exercise releases the body’s natural “feel good” hormones, endorphins. These are powerful Anti Depressants and as such should always be a part of your treatment plan. Everybody can exercise. Whether it be a Gym membership, jogging, water aerobics, yoga, pilates or simply walking.

For more information about Exercise, read about it in the section on the website, Spoke definitions.

Quite often patients get confused with medication side effects and the symptoms of the illness. Unfortunately, we tend to spend too much time on the negative aspects of medication, ie side effects, and not enough time on the “good effects”.

Remember, every situation in our lives is a “risk benefit” situation. Although it is useful to read information about the medication we take, you will notice that very little space is allocated to the “good effects” whilst there’s always a multitude of “bad effects” listed. Reminds us of the old adage, “good news never made a paper sell”, doesn’t it?

As a Pharmacist, I see it time and time again. People blaming their medications for the way they feel, when it’s actually the effects of their illness that they’re experiencing.

One example of this is, feeling flat, a change in personality from the once vibrant you, unable to get out of bed, overwhelming tiredness, loss of motivation. These are all symptoms of Depression, not side effects from the medication. You have to realize your brain has undergone a major traumatic event and it takes time to recover. Perhaps if you liken it to a total knee reconstruction. Think about how long the affected area is out of action, how you have to have physio and rehab to eventually get it back to it’s former self. Often we aren’t patient enough when it comes to medication, we want the problem fixed now. Maybe it’s because there no outward signs. Be kind to yourself  and let the healing process take its course.

Knowing this can be of great benefit. Understanding where your medication fits in and the different classifications of each and how all of this relates to the Peterz Weel.

Are you managing your medication? Or would you prefer your Pharmacist to provide you with your medications packed on a weekly basis ?


What is recovery?

Recovery in Mental Health doesn’t necessarily mean a complete recovery from a mental health problem, unlike what you might expect from most physical illnesses.

The concept of recovery is all about staying in control of your life despite experiencing a mental illness. This is done by building resilience (see What is Resilience ?) not just treating or managing symptoms.

Recovery in Mental Health is an ongoing journey. It is a belief that someone is able to regain a meaningful life despite having a mental illness. That journey is aided by the guiding principle of hope. People have the hope that they can manage their illness whilst on their ongoing journey of recovery.

Nowadays, most education and support groups are based on the Recovery Model of Care. This gives everyone the hope that they can reach their goal of recovery, despite it being an ongoing process.

To do this, the process provides a holistic view of mental health, focusing on the person, not the illness. It calls for optimism and commitment from all concerned and requires a well organized system of support from family, friends and mental health services.

When all this is in place, the Recovery Model allows people to look beyond just merely surviving and encourages moving forward, setting new goals and developing relationships that give their life new meaning.

Peterz Weel is an example of a Wellness Recovery Plan. When you have all the spokes and they’re all playing a role, recovery is possible.


What is resilience?

Resilience is the term given to the ability to adapt positively to stress and adversity.  Stress and adversity can come in the shape of family or relationship problems, health problems, or workplace and financial worries, among others.

Everyone has the ability to be resilient, however it is not evident in everyone. It has to be learned and developed. It can be thought of as a process, rather than a characteristic that exists in us all.  People who have built up resilience easily navigate their way around moments of crisis by utilizing coping skills that they have developed along their journey. There is a distinct ability to balance negative and positive emotions.

With regard to mental health, resilience is a person’s ability to bounce back from a negative experience. This can be participating in life with hope and humour despite having endured devastating losses.  Not only is resilience about emerging from the other side of a stressful situation, but coming through with competent functioning and becoming a strengthened and more resourceful person.

Some useful tips to help build resilience include-
1.    Maintaining a good support network with family and friends
2.    Avoid seeing crises as being stress events. Instead, view them as opportunities that can be overcome to help build resilience.
3.    Accept that there are some things you can’t change.
4.    Have realistic goals, ones that are sometimes only small, and work towards them
5.    Be decisive and assertive in adverse situations
6.    Look for opportunities to discover yourself after a loss
7.    Develop self confidence. Don’t be afraid of some self praise.
8.    Always keep a long-term view on life and consider any stressful event in a broader context
9.    Maintain an optimistic outlook. That way you expect good things to happen and actually visualize what is wished.
10.  Practise self care. Paying attention to your mind and body by exercising regularly and having a healthy and nutritious diet.

Building resilience allows us to have the necessary equipment to combat and notice our early warning signs of becoming unwell. Resilience is the coping mechanisms we have learnt to engage to avoid relapse.


What can family and friends do?

When faced with the situation of a loved one developing a mental illness, the situation can become quite frightening. Coming to terms with the fact can often be difficult. Often there is a feeling of guilt amongst the other family members that it may have been something they’ve done to cause the illness.

As with the person who has the illness, the first step for family and friends is acceptance. This helps to understand the emotions often felt by the family ie anger, confusion, sense of loss or grief.

With family, often too much emphasis is put on the care of the person and not enough responsibility is left with the person with the mental illness.  It’s important to realize that the person with the mental illness will perform better if there is a balance of care between them and the family or care givers.

This balance can be achieved by
1.    Accepting the person has an illness and acknowledging the hope for recovery
2.    Encourage the person to keep their independence. Resist the temptation of providing too much care.
3.    Not devoting too much time to the person at the expense of other members of the family.
4.    Encourage the person to do as much as possible for themselves but not to be unrealistic about demands

Remember, knowledge is power. Family members should educate themselves as much as possible about the illness and methods of treatment. The different mental health services that are available should also be researched.

Here are some tips to assist in the care of someone in your family who may be suffering from a mental illness.

1.    Encourage open dialogue amongst the family. It’s best if everyone has the same understanding and position.
2.    Research any training that can be done by family members and join a support group so you can meet others in the same predicament
3.    Encourage the person with the illness to maintain their involvement with social groups they may have prior to diagnosis.
4.    Encourage the person to remain independent and responsible for themselves as much as possible.
5.    Look at the holistic aspect of the person. Not just the mental health but all the facets of physical health as well.

Suicide is a very real possibility with mental health. Take any thoughts or words of intent, or self-harm, very seriously. Speak with the treating doctor or psychiatrist as soon as possible. Have a plan devised in case the person becomes unwell. Always have the phone numbers of the nearest Psychiatric facility or Continuing Care Assessment Team, ready, in case of crisis.

Sometimes the care of the person can be lifelong for the parents. In this case it’s important to consider what happens when the parents are no longer able to provide the care required. Discussion with family members, health professionals, legal professionals and financial steps would all have to be undertaken to ensure continuity of care.

Caring for the person with the mental illness can extract a lot of energy form the carer. Caring for the carer then, becomes very important. Here are some tips to allow that to happen.

1.    Allow for regular time out. Respite care is when the person spends time in care to give the family a break. Use this service.
2.    Maintain your social life and remember to regularly do things you enjoy.
3.    Never internalize your feelings. Bottling up feelings can have disastrous consequences. Talk about your feelings, to other family members, the person and to your doctor.
4.    Don’t take on too much. Have a plan and watch for signs of  becoming stressed. It’s better to do a little less and still be of use.

Nowadays, most people have access to the internet. You will find many sources of support available. Here are a few.

1. Mental Illness Networks
ph 1800 985 944       www.minetworks.org.au

2. Centrelink
ph 10 10 21                www.centrelink.gov.au

3. Carers Australia
ph 1800 242 636     www.carersaustralia.com.au

4. Commonwealth Carelink
ph 1800 052 222      www.commcarelink.health.gov.au

5. Sane Helpline
ph 1800 187263     e- helpline@sane.org    www.sane.org

Supporting a family member with a mental illness can be an arduous task, however if you follow the advice given and use the resources available, it should be a a lot easier.

Is good physical health necessary for good mental health?

Being physically active and physically fit will help you cope better emotionally and mentally.  As mentioned elsewhere, regular exercise releases the body’s feel good hormones, or endorphins. These help to relieve any pain you may be experiencing as well as elevating your mood.  Being physically healthy is also about the food we eat and the lifestyle we live.  A lot of money can be saved by eating more healthily. Bad habits such as smoking, eating junk food, drinking fizzy drinks and alcohol to excess, all cost money.

To become more healthy physically, we must develop strategies to break these bad habits. Replacing these with good habits can be a challenge. A lot of us think it’s too hard to make the change as sometimes it can seem insurmountable.  To change effectively, it must be done in small steps. Eg if your first day of exercise is a 5km run, you’ll be so sore the next day, you’ll be turned off exercise. Whereas if you instead walked 3km, you will quickly learn to enjoy this as it’s much easier to repeat the exercise every day.

Inevitably during the process of change, relapse or failure will occur eg if you give up smoking and you’re out one night with friends and have a few cigarettes.  Don’t be hard on yourself. Think in terms of how long you’ve not smoked, don’t focus on the couple you had one night.  Becoming physically fit is initially about the change to get there, then it’s about maintaining that lifestyle and remaining in the zone.

There will always be the possibility that bad habits can return. Here, we have to remind ourselves why we want to remain physically healthy.  Just like we do with our mental health, it’s essential we watch for early warning signs. The earlier we notice these signs, the greater the chance we’ve got of being able to prevent physical illness.

Regular physical checkups with your GP are the best means of checking for these signs. Having a mental health condition can often take centre stage in our lives and when we visit our GP there’s a tendency to neglect our physical health and just concentrate on our mental health.

The following tests should be checked at least yearly and often more so, if you have a mental illness:

1.    Total Cholesterol – this can be an indicator of heart disease
2.    Blood Glucose – this can be an indicator for diabetes
3.    Liver function – indicates liver function
4.    Electrolytes – indicates kidney function
5.    Pap smear – for early detection of cervical cancer
6.    Blood levels of certain drugs used for mental and physical illnesses eg Lithium, Epilim, Thyroxine
7.    Blood pressure – early detection prevents against eg stroke
8.    Body weight and height – used to calculate BMI (Body Mass Index), a figure used to establish a healthy weight to height ratio.
9.    Waist circumference – this is directly proportional to risk of eg diabetes
10.  Anything unusual eg a lump or growth that’s appeared suddenly
11.  Any recent changes eg weight gain/loss, an ache, tiredness
12.  Have regular dental checkups to maintain oral health
13.  Have regular eye checkups to maintain your vision

Maintaining good physical health is all about being aware of any health risks and recognizing the early warning signs. Do this by having regular checks with your doctor, making sure attention is paid to your physical health as well your mental health.

What happens when someone is suicidal ?

Suicide is a very real alternative when dealing with someone who has a mental illness. The ultimate symptom of depression can be to have suicidal thoughts which in turn can lead to suicide. At the time of the person having these thoughts, it appears to them to be the only solution to the terrible world they are finding themselves trapped in.

To quote a famous football coach and all round excellent role model :

“Suicide is a permanent solution to a temporary problem”

Analysing this, it’s fair to say depression, despite seeming to be a permanent condition, when you are experiencing it, is in fact temporary. In time and with the right strategies and skills, depression will pass. It is a horrible shame when a person decides to end their life, unaware of this.

If someone you know is thinking about suicide, the best thing is to try and talk to them about how they are feeling. Against popular opinion, talking about suicide to someone who is contemplating it, will not make them take action.

Let the person know you are concerned and that you are there to help. Ask them if they have made any plans for suicide. Asking these questions shows the person that you care about them. It will also serve for them to talk about their feelings and any plans if present. This is the first step towards getting help. You might notice the common theme with all mental health conditions, including suicide.
Acceptance is the first step towards recovery.

A person who is considering suicide should be encouraged very strongly to receive professional assistance. They will not get better without help and it’s not enough to think they will get help on their own.

Examples of how to help if someone is considering suicide are

1.    Make an appointment with a GP asap and accompany the person
2.    Make contact with a counsellor, employee assistance program, family member or friend
3.    Contact a specialist helpline for information and advice eg Lifeline, Beyond Blue, SANE Helpline, Black Dog Institute
4.    If the person has a plan, check if they are able to proceed, and remove any objects etc that are part of the plan
5.    If you feel the situation warrants, contact the Emergency Psychiatric Team at the local hospital with a Psychiatric ward and the police via 000
6.    Report to the authorities, the person is suicidal, has made a plan and you are very concerned for their safety.

Never discount the risk that someone who has depression may be considering suicide. Due to the stigma associated with mental illness and of course suicide, too often we hear in the news about the tragic deaths of young people. Often these people are good sportspeople or gifted academically. Because they are such high achievers, this creates a double problem. Firstly, they think they are invincible and aren’t prepared to accept they may have a problem. Secondly they may be a role model in society or amongst their peers and the pressure not to disclose feelings of suicide is very high.

Either way they are unable to express their feelings for fear of ridicule. Too often then, they make take their own life, which is a dreadful shame as they have so much still to offer.

Suicide not only affects the victim. Because it can be a sudden event, happening without warning, it can have devastating effects on family, friends and even society eg Robyn Williams.

Is someone you know acting differently to their normal self ?


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