Are the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders meeting the needs of clinicians?

Clinical guidelines originated in the United States in the early 1980s, initially as a cost-containment exercise. There are healthcare professionals who view clinical guidelines as the panacea for the delivery of quality health care, while others consider them to be sinister seeking to control and limit clinical decision making, enforcing ‘cook-book’ style medicine (Hopkins, 1995). Clinical guidelines are beneficial when they provide accessible knowledge of available treatment options and clear straightforward directives for clinical care. Standardised treatments can reduce variations in care and assist with identifying gaps that need to be addressed, thus encouraging clinical research and serving the needs of both clinicians and learners.

It has been 10 years since the publication of the previous mood disorder guidelines, and the release of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for mood disorders (Malhi et al., 2015) is timely post-publication of the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5; American Psychiatric Association, 2013). The structure and content of the guidelines are outstanding, with the inclusion of diagrams and reference to the DSM-5 enhancing the readability and utility of the guidelines. The combination of both evidence-based and consensus-based viewpoints has produced guidelines that have strong utility for clinical decision making, educational value and highlight the current gaps in research. The guidelines are inclusive being directed at a range of clinicians who provide care for individuals with mood disorders. Furthermore, they are tailored to an Australian and New Zealand population meaning that although they may not be broadly generalisable, they adhere to Australian and New Zealand regulatory issues, incorporating drugs and treatments that are locally available; as such, they are context specific.

For clinicians, evidence-based, pragmatic guidelines which are easy to follow and that address controversies are useful. Evidence-based medicine is the conscientious, explicit and judicious use of current evidence in making decisions about the care of individual patients (Sackett et al., 1996). The practice of evidence-based medicine is to integrate individual clinicians’ expertise with the best available external evidence from systematic reviews. In the absence of strong evidence from systematic reviews, consensus-based guidelines from a panel of eminent experts guiding clinical care are advantageous. Clinical care guidelines, however, are not rigid prescriptions of the process of care and are not meant to restrict clinical decision making nor are they meant to be a replacement for an extensive understanding of the disorders.

Clinical expertise in managing mood disorders involves an understanding of the efficacy, effectiveness and efficiency of the options, balanced with consideration of the patients’ clinical circumstances, their preferences and attitudes. The RANZCP mood disorder guidelines aim to support the implementation of evidence-based research findings into clinical practice by improving understanding, specifically providing an up-to-date summary of evidence regarding the benefits and risks of pharmacological interventions and highlighting current areas of uncertainty.

However, one may debate as to whether these are clinical guidelines as they purport to be. I would contend that these are not simply clinical guidelines but rather an amalgamation of clinical guidelines, clinical care pathways and clinical algorithms. They consist of decision points linked to represent the logic and flow of clinical practice. Additionally, they provide a systematic review of the pertinent evidence and recommendations for action that specify the necessary steps to assure consistent clinical decisions. Furthermore, they provide a standard of practice summarised in the form of an algorithm. Thus, these guidelines set the clinical standard for daily practice encouraging clinicians to advance and refine their care process.

Although the clinical mood disorder guidelines provide great directives for the clinical care of varied individuals with different mood disorders, challenges still remain. These guidelines primarily focus on the majority of the population in Australia. Although these guidelines provide some consideration of special, minority population segments, it should be recognised that more needs to be done. For example, Aboriginal and Torres Strait Islander peoples, in particular, have distinct presentations that are currently less well understood and require urgent detailed examination. Another major challenge pertains to how often the guidelines are updated with a plethora of new research emerging in the time period between the publications. Thus, there is scope for adopting an online version of dynamic guidelines that could be updated as research and clinical care findings change, accordingly providing the most informed and up-to-date care for individuals with mood disorders. The guidelines could also be further refined, for instance, by the inclusion of specifiers corresponding to the course of the illness – for example, the role of valproate in treating mania in bipolar disorder specified by early and later episodes of mania. Furthermore, in addition to the guidelines providing the recommended course of action, the guidelines could also seek to include what is not recommended.

In addition to the above challenges, the clinical guidelines could also address contemporary challenges, those specifically pertaining to bipolar disorder such as the role of antidepressants in bipolar disorder, when to withdraw antipsychotics in a manic episode and the complexity of comorbidity. Another contemporary challenge relates to cognition, specifically how to minimise and manage cognitive impairment. Although challenges remain, the RANZCP clinical practice guidelines are accessible, pragmatic and comprehensive, providing directives for the provision of care for individuals with varied mood disorders concomitantly meeting the needs of a range of clinicians.

See RANZCP Guideline by Malhi et al. 50(12): 1087–1206