The RANZCP mood disorders guidelines: An easy step-by-step toolbox for daily practice

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recently provided new guidelines for the management of mood disorders (Malhi et al., 2015). These RANZCP guidelines are based on scientific evidence but also benefited from input from numerous external experts and feedback from public consultation thus providing consensus-based recommendations. Thanks to this robust consultative methodology, the management of clinical situations usually not covered in the scientific literature is addressed, such as the management of psychiatric comorbidities (addictions, anxiety disorders, sleep and rhythms abnormalities, cognitive dysfunctions), mood disorders in special subgroups of patients (elderly, pregnancy, etc.) and contentious clinical matters often the focus of debate such as antidepressant use across all phases of bipolar disorders (BD). Another important issue is the consideration of both major depressive disorders (MDD) and BD together, as a spectrum, while providing practical approaches to distinguish MDD from BD. In regards to this, a lot of basic aspects such as the sub-typing of depression and a dimensional way approach to thinking of MDD and BD are detailed and summarized in easy to use tables. These guidelines also describe numerous specifiers that should be applied where possible as they help the development of personalized approaches both for acute phases of mood disorders and follow-up. Among others, one example of a rapidly evolving area is that considered in these guidelines, namely, seasonal patterns in mood disorders that respond to specific treatments such as bright light during winter depression. Indeed, this specifier is very rarely considered in treatment guidelines despite their high frequency (15% of mania and 25% of depressive bipolar episodes) and their putative association with poor outcome (Geoffroy et al., 2014). Taken as a whole, this extensive and compelling work, that reflects real-world practice, is likely to reduce the gap between theoretical guidelines and clinical practice.

Indeed, the most notable success of these guidelines is to be very accessible, with easy references and steps to follow in daily practice. The authors developed summaries in the form of figures proposing step-wise management of phases of illness such as MDD (Figure 6), mania (Figure 11) and bipolar depression (Figure 13). These digests are likely to help clinicians in their everyday clinical management as well as junior doctors in training. Additional innovations are the attempts to help clinicians better characterize the response to treatments (Figure 7), to provide strategies to address medication non-response (Figure 9), but also to propose recommendations for psychotherapies and for switching medications (Figure 10).

Whereas most guidelines focus on monotherapies, less than 10% of patients with BD receive monotherapy during mania, suggesting that, in routine practice, monotherapy is not appropriate in most cases to obtain a significant improvement and to effectively prevent relapse (Wolfsperger et al., 2007). In that regard, RANZCP guidelines also offer guidance for managing combination therapies (Figures 15 and 16). The proposition of different treatments for the different phases appears also very useful as the efficacy for the acute phase does not necessarily predict efficacy for the maintenance phase. Moreover, the risk/benefit ratio for the acute and maintenance phases are very different and changes for the maintenance phase should be considered for patients with side effects. To achieve these complex treatment optimizations, the RANZCP guidelines propose summaries for the clinical utility of medications used for maintenance therapy according to their efficacy of preventing mania and/or depression, but also in relation to their tolerability (Figures 15 and 17). These guidelines also provide guidance for physical examination and investigation of patients presenting with mood disorders (Table 9) surpassing the traditional and outdated somatic/psychiatric dichotomy (Amad et al., 2016). Finally, as patients with high risk of poor adherence should be detected to avoid poor outcomes, the RANZCP guidelines promote specific interventions on adherence such as cognitive-behavioural therapy and/or psychoeducation.

Progress in the management of patients with mood disorders needs the development of standardized approaches. The availability of up-to-date and easy to handle guidelines is a key issue to achieve these developments. The RANZCP guidelines belong to these next-generation guidelines and we strongly believe that they will promote improvement in everyday management of patients with affective disorders and in junior psychiatrist training. Our only wish is the development in the future of an electronic version of these RANZCP mood disorders guidelines that would sublimate this easy step-by-step toolbox for daily practice.

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