Statement of Principles concerning BIPOLAR DISORDER (Balance of Probabilities) (No. 54 of 2018) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986. Dated 22 June 2018 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Nicholas Saunders AO Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions 1 Name This is the Statement of Principles concerning bipolar disorder (Balance of Probabilities) (No. 54 of 2018). 2 Commencement This instrument commences on 23 July 2018. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning bipolar disorder No. 28 of 2009 (Federal Register of Legislation No. F2009L01595) made under subsection 196B(3) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about bipolar disorder and death from bipolar disorder. Meaning of bipolar disorder (2) For the purposes of this Statement of Principles, bipolar disorder: (a) means a group of disorders of mental health which are manifested by one or more periods of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy; and (b) includes: (i) bipolar and related disorder due to another medical condition; (ii) bipolar I disorder; (iii) bipolar II disorder; (iv) cyclothymic disorder; (v) major depressive episode with mixed features; (vi) other specified bipolar and related disorder and unspecified bipolar and related disorder; and (vii) substance/medication-induced bipolar and related disorder. Note 1: bipolar and related disorder due to another medical condition, bipolar I disorder, bipolar II disorder, cyclothymic disorder, major depressive episode with mixed features, other specified bipolar and related disorder and unspecified bipolar and related disorder and substance/medication-induced bipolar and related disorder are defined in the Schedule 1 – Dictionary. Note 2: The definition for each of the conditions included herein are derived from DSM-5. Note 3: DSM-5 is defined in the Schedule 1 – Dictionary. Death from bipolar disorder (3) For the purposes of this Statement of Principles, 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. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 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 under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 9 Factors that must exist At least one of the following factors 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: (1) for bipolar I disorder, bipolar II disorder, cyclothymic disorder, major depressive episode with mixed features, other specified bipolar and related disorder and unspecified bipolar and related disorder only: Note: bipolar I disorder, bipolar II disorder, cyclothymic disorder, major depressive episode with mixed features and other specified bipolar and related disorder and unspecified bipolar and related disorder are defined in the Schedule 1 – Dictionary. (a) experiencing a category 1A stressor within the six months before the clinical onset of bipolar disorder; Note: category 1A stressor is defined in the Schedule 1 - Dictionary. (b) experiencing a category 1B stressor within the six months before the clinical onset of bipolar disorder; Note: category 1B stressor is defined in the Schedule 1 - Dictionary. (c) experiencing a category 2 stressor within the six months before the clinical onset of bipolar disorder; Note: category 2 stressor is defined in the Schedule 1 - Dictionary. (d) experiencing the death of a significant other within the six months before the clinical onset of bipolar disorder; Note: significant other is defined in the Schedule 1 - Dictionary. (e) being within 90 days postpartum at the time of the clinical onset of bipolar disorder; (f) having alcohol use disorder or substance use disorder at the time of the clinical onset of bipolar disorder; or (g) having a disorder of mental health from Specified List 1 of clinically significant disorders of mental health within the five years before the clinical onset of bipolar disorder; Note: Specified List 1 of clinically significant disorders of mental health is defined in the Schedule 1 - Dictionary. (2) for substance/medication-induced bipolar and related disorder only: Note: substance/medication-induced bipolar and related disorder is defined in the Schedule 1 – Dictionary. (a) taking a drug, or a drug from a class of drugs, from the specified list of drugs, within the 14 days before the clinical onset of bipolar disorder; Note: specified list of drugs is defined in the Schedule 1 - Dictionary. (b) taking a drug which is associated in the individual with the development of symptoms of bipolar disorder while taking the drug, and the cessation or significant reduction of the symptoms of bipolar disorder within days or weeks of discontinuing the drug, where taking the drug continued for at least the two days before the clinical onset of bipolar disorder; (c) having ceased or reduced antidepressant drug therapy or antiepileptic drug therapy within the 30 days before the clinical onset of bipolar disorder; or (d) having alcohol use disorder or substance use disorder at the time of the clinical onset of bipolar disorder; (3) for bipolar and related disorder due to another medical condition only, having an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the medical condition is a direct physiological cause of the mood symptoms at the time of the clinical onset of bipolar disorder; Note: bipolar and related disorder due to another medical condition and medical condition is a direct physiological cause of the mood symptoms are defined in the Schedule 1 - Dictionary. (4) experiencing a category 1A stressor within the six months before the clinical worsening of bipolar disorder; Note: category 1A stressor is defined in the Schedule 1 - Dictionary. (5) experiencing a category 1B stressor within the six months before the clinical worsening of bipolar disorder; Note: category 1B stressor is defined in the Schedule 1 - Dictionary. (6) experiencing a category 2 stressor within the six months before the clinical worsening of bipolar disorder; Note: category 2 stressor is defined in the Schedule 1 - Dictionary. (7) experiencing the death of a significant other within the six months before the clinical worsening of bipolar disorder; Note: significant other is defined in the Schedule 1 - Dictionary. (8) being within 90 days postpartum at the time of the clinical worsening of bipolar disorder; (9) having a disorder of mental health from Specified List 2 of clinically significant disorders of mental health at the time of the clinical worsening of bipolar disorder; Note: Specified List 2 of clinically significant disorders of mental health is defined in the Schedule 1 - Dictionary. (10) taking a drug, or a drug from a class of drugs, from the specified list of drugs, within the 14 days before the clinical worsening of bipolar disorder; Note: specified list of drugs is defined in the Schedule 1 - Dictionary. (11) taking a drug which is associated in the individual with the worsening of symptoms of bipolar disorder while taking the drug, and the cessation or significant reduction of the symptoms of bipolar disorder within days or weeks of discontinuing the drug, where taking the drug continued for at least the two days before the clinical worsening of bipolar disorder; (12) having ceased or reduced antidepressant drug therapy or antiepileptic drug therapy within the 30 days before the clinical worsening of bipolar disorder; (13) having a medical condition as specified at the time of the clinical worsening of bipolar disorder; Note: medical condition as specified is defined in the Schedule 1 - Dictionary. (14) experiencing severe childhood abuse before the clinical worsening of bipolar disorder; Note: severe childhood abuse is defined in the Schedule 1 - Dictionary. (15) being deprived of at least one whole night's sleep within the two days before the clinical worsening of bipolar disorder; (16) having electroconvulsive therapy within the 14 days before the clinical worsening of bipolar disorder; (17) having a course of bright light therapy within the 14 days before the clinical worsening of bipolar disorder; (18) having deep brain stimulation for Parkinson's disease within the 48 hours before the clinical worsening of bipolar disorder; (19) having vagus nerve stimulation within the 48 hours before the clinical worsening of bipolar disorder; (20) inability to obtain appropriate clinical management for bipolar disorder. 10 Relationship to service (1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 9(4) to 9(20) 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 did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time. Schedule 1 - Dictionary Note: See Section 6 1 Definitions In this instrument: bipolar and related disorder due to another medical condition means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5): 1. A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. 2. There is evidence from the history, physical examination or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. 3. The disturbance is not better explained by another mental disorder. 4. The disturbance does not occur exclusively during the course of a delirium. 5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalisation to prevent harm to self or others or there are psychotic features. Note: DSM-5 is also defined in the Schedule 1 - Dictionary. bipolar disorder—see subsection 7(2). bipolar I disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5): 1. Criteria have been met for at least one manic episode (criteria A-D under manic episode). 2. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. Note 1: For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. Note 2: DSM-5, hypomanic episode, manic episode and major depressive episode are also defined in the Schedule 1 - Dictionary. bipolar II disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5): 1. Criteria have been met for at least one hypomanic episode (criteria A-F under hypomanic episode) and at least one major depressive episode (criteria A-C under major depressive episode). 2. There has never been a manic episode. 3. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 4. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Note 1: For a diagnosis of bipolar II disorder, it is necessary to meet the criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode. Note 2: DSM-5, hypomanic episode and major depressive episode are also defined in the Schedule 1 - Dictionary. category 1A stressor means one 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. category 1B stressor means one of the following severe traumatic events: (a) killing or maiming a person; (b) being an eyewitness to a person being killed or critically injured; (c) being an eyewitness to atrocities inflicted on another person; (d) participating in the clearance of a corpse or a critically injured casualty; or (e) viewing a corpse or a critically injured casualty as an eyewitness. Note: corpse and eyewitness are also defined in the Schedule 1 - Dictionary. category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing 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 ongoing 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 workloads, or experiencing bullying in the workplace or school environment; (d) experiencing serious legal issues including being detained or held in custody, ongoing 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. Note: significant other is also defined in the Schedule 1 - Dictionary. corpse means the human remains or body parts of one or more persons who have met a violent or horrific death. Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents. Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition. cyclothymic disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5): 1. For at least two years (at least one year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. 2. During the above two-year period (one year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than two months at a time. 3. Criteria for a major depressive, manic or hypomanic episode have never been met. 4. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 5. The symptoms are not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication) or another medical condition (for example, hyperthyroidism). 6. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Note: DSM-5 is also defined in the Schedule 1 - Dictionary. DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. eyewitness means a person who experiences an incident first hand and can give direct evidence of it. This excludes persons exposed only to public broadcasting or mass media coverage of the incident. hypomanic episode meets the following diagnostic criteria (derived from DSM-5): 1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day. 2. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behaviour, and have been present to a significant degree: (i) inflated self-esteem or grandiosity; (ii) decreased need for sleep (for example, feels rested after only three hours of sleep); (iii) more talkative than usual or pressure to keep talking; (iv) flight of ideas or subjective experience that thoughts are racing; (v) distractibility (that is, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed; (vi) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation; or (vii) excessive involvement in activities that have a high potential for painful consequences (for example, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication, other treatment) or another medical condition. The episode is not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication, other treatment) or another medical condition. Note 1: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note 2: bipolar I disorder and DSM-5 are also defined in the Schedule 1 - Dictionary. major depressive episode meets the following diagnostic criteria (derived from DSM-5): 1. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (i) depressed mood or (ii) loss of interest or pleasure: Note: Do not include symptoms that are clearly attributable to another medical condition. (i) depressed mood most of the day, nearly every day, as indicated by either subjective report (for example, feels sad, empty, or hopeless) or observation made by others (for example, appears tearful); Note: In children and adolescents, can be irritable mood. (ii) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation); (iii) significant weight loss when not dieting or weight gain (for example, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day; Note: In children, consider failure to make expected weight gain. (iv) insomnia or hypersomnia nearly every day; (v) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down); (vi) fatigue or loss of energy nearly every day; (vii) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick); (viii) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others); or (ix) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note 1: Criteria A–C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note 2: bipolar I disorder and DSM-5 are also defined in the Schedule 1 - Dictionary. major depressive episode with mixed features meets the following diagnostic criteria (derived from DSM-5): 1. At least three of the following manic/hypomanic symptoms are present during the majority of days of a major depressive episode: (i) elevated, expansive mood; (ii) inflated self-esteem or grandiosity; (iii) more talkative than usual or pressure to keep talking; (iv) flight of ideas or subjective experience that thoughts are racing; (v) increase in energy or goal-directed activity (either socially, at work or school, or sexually); (vi) increased or excessive involvement in activities that have a high potential for painful consequences (for example, engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments); or (vii) decreased need for sleep (feeling rested despite sleeping less than usual, to be contrasted with insomnia). B. Mixed symptoms are observable by others and represent a change from the person's usual behaviour. C. For individuals whose symptoms meet full criteria for either mania or hypomania, the diagnosis should be bipolar I or bipolar II disorder. D. The mixed symptoms are not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication or other treatment). Note: DSM-5 and major depressive episode are also defined in the Schedule 1 - Dictionary. manic episode meets the following diagnostic criteria (derived from DSM‑5): 1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalisation is necessary). 2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour: (i) inflated self-esteem or grandiosity; (ii) decreased need for sleep (for example, feels rested after only three hours of sleep); (iii) more talkative than usual or pressure to keep talking; (iv) flight of ideas or subjective experience that thoughts are racing; (v) distractibility (that is, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed; (vi) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (that is, purposeless non-goal-directed activity); or (vii) excessive involvement in activities that have a high potential for painful consequences (for example, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication, other treatment) or another medical condition. Note 1: A full manic episode that emerges during antidepressant treatment (for example, medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note 2: Criteria A–D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder. Note 3: bipolar I disorder and DSM-5 are also defined in the Schedule 1 - Dictionary. 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. Note: Examples of these medical conditions include: (a) adrenal insufficiency; (b) Alzheimer-type dementia; (c) cerebral trauma; (d) cerebrovascular accident; (e) Cushing syndrome; (f) epilepsy; (g) Graves' disease; (h) human immunodeficiency virus; (i) hypothyroidism; (j) multiple sclerosis; (k) Parkinson's disease; or (l) toxoplasmosis. 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 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; or (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. Note: Examples of these medical conditions include: (a) adrenal insufficiency; (b) Alzheimer-type dementia; (c) cerebral trauma; (d) cerebrovascular accident; (e) Cushing syndrome; (f) epilepsy; (g) Graves' disease; (h) human immunodeficiency virus; (i) hypothyroidism; (j) multiple sclerosis; (k) Parkinson's disease; or (l) toxoplasmosis. MRCA means the Military Rehabilitation and Compensation Act 2004. other specified bipolar and related disorder and unspecified bipolar and related disorder are mental disorders (derived from DSM-5) in which symptoms characteristic of a bipolar and related disorder cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class. Note: DSM-5 is also defined in the Schedule 1 - Dictionary. relevant service means: (a) eligible war service (other than operational service) under the VEA; (b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or (c) peacetime service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. 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. 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. specified list of drugs means: (a) alpha-adrenoceptor agonists; (b) alprazolam; (c) amantadine; (d) amphetamines, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy); (e) anabolic-androgenic steroids; (f) angiotensin converting enzyme (ACE) inhibitors; (g) antidepressants; (h) antiepileptics, except valproate, lamotrigine and levetiracetam; (i) armodafinil; (j) atypical antipsychotics; (k) baclofen; (l) benzodiazepines; (m) cannabis; (n) centrally acting antihypertensives; (o) chloroquine; (p) clarithromycin; (q) cocaine; (r) corticosteroids, other than topical steroids; (s) depot medroxyprogesterone acetate; (t) dextromethorphan; (u) digoxin; (v) disulfiram; (w) dopaminergic anti-Parkinsonian drugs; (x) ephedrine; (y) eszopiclone; (z) fenfluramine; (aa) fluoroquinolones; (bb) fluphenazine; (cc) fluspirilene; (dd) gonadotropin releasing agents; (ee) hallucinogens; (ff) hydralazine; (gg) hydroxychloroquine; (hh) ifosfamide; (ii) interferons; (jj) interleukin-2; (kk) intravenous 5-flurouracil; (ll) iproniazid; (mm) isocarboxazid; (nn) isoetharine; (oo) isoniazid; (pp) levothyroxine; (qq) mefloquine; (rr) methylphenidate; (ss) modafinil; (tt) mycophenolate mofetil; (uu) opioids; (vv) oral contraceptive agents; (ww) phencyclidine; (xx) phentermine; (yy) phenylephrine; (zz) phenylpropanolamine; (aaa) pseudoephedrine; (bbb) quinagolide; (ccc) ramelteon; (ddd) reserpine; (eee) rimonabant; (fff) thiazide; (ggg) thyroxine; (hhh) varenicline; (iii) zaleplon; or (jjj) zolpidem. Specified List 1 of clinically significant disorders of mental health means one of the following conditions, which is of sufficient severity to warrant ongoing management: (a) acute stress disorder; (b) agoraphobia; (c) anxiety disorder; (d) obsessive-compulsive disorder; (e) panic disorder; (f) posttraumatic stress disorder; (g) social anxiety disorder; or (h) specific phobia. Note 1: "Management" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner. Note 2: To "warrant ongoing management" does not require that any actual management was received or given for the condition. Specified List 2 of clinically significant disorders of mental health means one of the following conditions, which is of sufficient severity to warrant ongoing management: (a) acute stress disorder; (b) agoraphobia; (c) alcohol use disorder; (d) anxiety disorder; (e) attention-deficit/hyperactivity disorder; (f) depressive disorder due to another medical condition; (g) disruptive impulse-control and conduct disorder; (h) eating disorder; (i) obsessive-compulsive disorder; (j) panic disorder; (k) personality disorder; (l) posttraumatic stress disorder; (m) premenstrual dysphoric disorder; (n) social anxiety disorder; (o) specific phobia; (p) substance use disorder; or (q) substance/medication-induced depressive disorder. Note 1: "Management" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner. Note 2: To "warrant ongoing management" does not require that any actual management was received or given for the condition. Note 3: Depressive disorder due to another medical condition, premenstrual dysphoric disorder and substance/medication-induced depressive disorder are types of depressive disorders. substance/medication-induced bipolar and related disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5): 1. A prominent and persistent disturbance in mood that 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. 2. There is evidence from the history, physical examination, or laboratory findings of both (i) and (ii): (i) the symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication; and (ii) the involved substance/medication is capable of producing the symptoms in Criterion A. C. The disturbance is not better explained by a bipolar or related disorder that is not substance/medication-induced. Such evidence of an independent bipolar or related disorder could include the following: (i) the symptoms precede the onset of the substance/medication use, the symptoms persist for a substantial period of time (for example, about one month) after the cessation of acute withdrawal or severe intoxication, or there is other evidence suggesting the existence of an independent non-substance/medication-induced bipolar and related disorder (for example, a history of recurrent non-substance/medication-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Note: DSM-5 is also defined in the Schedule 1 - Dictionary. terminal event means the proximate or ultimate cause of death and includes the following: (a) pneumonia; (b) respiratory failure; (c) cardiac arrest; (d) circulatory failure; or (e) cessation of brain function. VEA means the Veterans' Entitlements Act 1986.