In the mood

This bumper issue of the ANZJP features the second guideline in the RANZCP’s series of new Clinical Practice Guidelines (CPGs). Many of you, not unreasonably, are probably thinking, ‘Why do we need more guidelines filled with research evidence that seems to have little relevance to my clinical practice?’ or perhaps, ‘Has that much changed since the last iteration of the CPGs?’

Well, this guideline is different; indeed it is unique. It is the first guideline to address all the mood disorders from major depressive disorders to bipolar disorders together in one document. It does this because many of the key elements of mood disorders are shared. For example, the symptoms of depression are essentially the same in both major depression and bipolar disorder and both sets of disorders most often initially present with depression. But the management of depression varies considerably depending upon whether it arises in the context of a depressive or bipolar illness and this necessitates sophisticated understanding of both sets of disorders and their treatments. By considering the mood disorders as a whole, this guideline is able to provide advice and recommendations that have real-world applicability. And I’m not just saying this because I have served as a member of the Mood Disorders Committee charged with the task of creating these CPGs!

The Mood Disorders CPG draws heavily on DSM-5 classification and addresses phenotypes within both ‘Bipolar and Related Disorders’ and ‘Depressive Disorders’. Members of the Mood Disorders Committee (MDC), adopted DSM-5 taxonomy because it provides a useful framework that is widely recognized. However, DSM-5’s diagnostic limitations are acknowledged and, where necessary, the MDC has drawn on alternative descriptive models – such as the biopsychosocial and lifestyle (BPSL) model, which provides an aetiological perspective.

The BPSL is an important feature of this guideline. It attaches particular importance to taking a comprehensive approach to the assessment of patients with a mood disorder. Such an approach requires clinicians to take a careful history that allows understanding of the context of the patient’s mood disorder and then making a comprehensive formulation of the patient. The formulation takes into account predisposing, precipitating and perpetuating factors, and is then used to guide treatment. In other words, management is not driven solely by the diagnosis. In this manner, the evidence synthesised in this guideline can be considered alongside the clinician’s experience and the patient’s circumstances and preferences to develop and implement appropriate management strategies.

There are, of course, limitations to the evidence derived from clinical trials, which needs to be couched within empirical knowledge. For example, while we are familiar with the limitations of antidepressant trials, particularly the high placebo response that could lead to the conclusion that antidepressants are ineffective – this has to be interpreted within a clinical context and moderated by our practical experience – which informs us that antidepressants are effective when used appropriately for suitable patients. Therefore, the limitations of antidepressant clinical trials and psychotherapy trials in depression and bipolar disorder are all discussed within the guideline, along with necessary clinical considerations – drawing on expertise and experience in equal measure. Thus, the MDC did not simply and uncritically regurgitate published evidence, but instead endeavoured to balance and couch the evidence within clinical experience when formulating the recommendations.

Recognising these limitations, the guideline also provides a series of consensus-based recommendations that have come from careful deliberation involving members of the MDC. These recommendations point out the importance of having an integrated care team in managing patients with mood disorders, with collaboration between primary care, community mental health care, psychologists and support agencies.

In secondary care, we will often see patients who do not have a full response to first line treatments and, in this guideline, guidance is provided about what strategy to use; to increase the dose, augment, switch to another antidepressant or re-evaluate the clinical presentation. These are very practical points that will be of great relevance to all clinicians. There is also detailed discussion about the management of patients after the acute phase of illness in both depressive disorders and bipolar disorder (especially the necessary monitoring strategies that should be followed).

The CPG also addresses some interesting aspects of mood disorders. For example, the complexities of managing bipolar depression are considered in depth (e.g. monotherapy vs combination therapy and psychological treatments), acknowledging that this is one of the more challenging mood disorders to treat. The CPG provides a number of useful strategies to treat bipolar depression, along with a practical set of figures, and a careful reading of this section in the guideline will be of great assistance to clinicians. Similarly, the relatively new DSM mixed features specifiers are discussed along with suggestions on treatment strategies, recognising that there is little evidence as yet to inform optimal treatment. There is also some discussion of the vexed (but important) issue of differentiating Bipolar II disorder from borderline personality disorder – with clinical clues as to how to achieve better separation.

The CPG also provides succinct advice regarding management of specific populations of patients with mood disorders and specific issues related to Māori and to Aboriginal and Torres Straight Islander peoples.

In sum, although the length of the Mood Disorders Clinical Practice Guideline may appear daunting, it is well worth delving into to aid in the management of patients with all of the mood disorders. The text is supplemented by a series of tables that summarize data (for example, key facts on depression), diagrams that illustrate in a clear form what has been described in the text, and recommendation boxes that provide more focused advice. These are all supplemented by figures that illustrate and summarise treatment options and provide information on efficacy and tolerability of medications.

There will be something for everyone in the guideline, for trainee psychiatrists as well as experienced clinicians that want an update. We hope that reading through this guideline or simply sampling it from time to time will assist you in managing your mood disorder patients.

This issue also includes two research papers and a series of letters concerning mood disorders, covering topics that build on elements touched on by the guidelines. Nierenberg et al. (this issue) outline an approach in helping bipolar patients achieve wellness using the concept of ‘marginal gains’. This is a concept successfully used by the coach of the British cycling team to improve the team’s performance. In essence, this involved the cyclists achieving marginal gains in a number of domains (diet, sleep) that have an aggregated positive effect. Nierenberg et al. suggest that this approach can be used to help patients with bipolar disorder. It involves engaging patients to make small gains in a number of domains (thinking patterns, diet, healthy sleep/wake cycle, using peer support) using well-recognised psychosocial treatments (CBT, IPSRT, Motivational Interviewing) as well as wellness phone apps. The authors argue that the small gains achieved will together be amplified and lead to a better outcome or recovery.

Glue and Herbison (this issue) used a network meta-analysis to examine the effectiveness of combined mood stabilizers and antipsychotics vs monotherapy in the treatment of mania. Unsurprisingly (at least to many clinicians working in an acute setting), they found that the combination of a mood stabilizer and an antipsychotic was more effective than monotherapy. What might surprise some is treating a manic episode using activated charcoal. Hamdani et al (this issue) report the case of a woman who became manic following a subtotal gastrectomy. They suspected that the mania could have been induced by altered gut microbiota (on the basis that she had raised inflammatory markers) and that activated charcoal, an absorbent of inflammatory cytokines, would be able to treat her mania. This approach was successful and as her mania settled the inflammatory cytokine levels fell and she did not require any psychotropic medication.

Finally, we have two debate articles that are sure to excite some interest and perhaps even put you ‘in the mood’. Wand (this issue) discusses the merits of a recovery approach in mental health care, with its undoubted merits in focusing on an individual’s strengths, self-empowerment and achieving ‘recovery’. In doing so he also provides a critique of the ‘biomedical’ model, pointing out the limitations of categorical diagnoses, the lack of biomarkers for psychiatric diagnoses, that psychotropic medications have limited efficacy and carry considerable harms, and a focus on ‘risk’ rather than resilience. Murray (this issue) takes a more considered approach emphasising that ‘personal recovery’ and ‘clinical recovery’ are complementary concepts. He argues that we need to aim for both and that the recovery model can sit alongside the biomedical model, and that, while our diagnoses may be problematic, they serve an important purpose. This is an important debate and worth reading and deliberating further.