The Royal Australian and New Zealand College of Psychiatrists clinical guidelines for mood disorders: Kudos and quarrels

Sometime, size matters. The recently published Royal Australian and New Zealand College of Psychiatrists (RANZCP) Mood Disorders Guidelines (Malhi et al., 2015) is enormous—130 pages, approximately 1000 references, 26 tables, 18 figures and 16 recommendation boxes. In many ways, it is a textbook of mood disorders. In contrast to most other Practice Guidelines, its scope is all mood disorders, not just bipolar disorder or unipolar depression. Its breadth includes diagnostic issues, appropriate laboratory tests, first line as well as experimental treatments. It provides a balanced perspective on virtually all topics it covers, befitting its iterative process with multiple authors, expert reviewers and even public consultation, with meetings of the core group over 2.5 years. Having been one of the authors of the last American Psychiatric Association’s Bipolar Practice Guidelines, I can attest to the remarkable amount of work such a process requires. The RANZCP Guidelines addresses broad-based conceptual issues as well as everyday practical concerns, such as advantages and disadvantages of the three strategies for switching from one antidepressant to another.

Another strength of the document is the Guidelines’ a priori vision of using both evidence-based recommendations (EBRs) and consensus-based recommendations (CBRs) in areas where insufficient evidence exists. This last point is critical since psychiatry cannot provide optimal clinical recommendations currently purely on the basis of evidence since we have far too little of the latter in far too many areas of clinical importance. For EBRs, one needs a great deal of evidence (E), which we simply do not have. Adding to the Guidelines’ strength is the stated focus on patient preference as a core part of clinical decision making since, in many if not most instances, there are a few—not just one—‘right’ strategies (and, of course, a larger group of ‘wrong’ strategies). Engaging patients in which of the right strategies should be implemented will inevitably lead to better treatment adherence and a firmer sense of doctor and patient as therapeutic allies, not enemies.

Cultural differences across countries and regions make some recommendations more local than universal. As examples, the RANZCP Guidelines repeatedly refer to what primary care physicians vs specialists should be consulted for. Because the relationship between these two physician types differs across countries—such as in the United States compared to Australia and New Zealand, with primary care physicians playing less of a role in treating a variety of psychiatric disorders in the former—these recommendations were not helpful to me. I also wish the authors had more explicitly addressed economic issues in treatment choices such as in the consideration of transcranial magnetic stimulation (TMS) for depression or in choosing psychotherapy (which is far more expensive) than pharmacotherapy for treating simple major depression. Although economic decisions on health care are made by a society’s leaders, as physicians, we are obliged to be thoughtful about costs since bottomless funds for health care are not and never will be available.

Of course, it is unimaginable that a document like this would satisfy every reader (including this one) in every conclusion. In reviewing the clinical research literature leading to treatment recommendations, there are a few quarrels/disagreements. It was surprising to read (p. 1147) that valproate has ‘modest efficacy’ in acute mania when multiple double blind studies have demonstrated its robust efficacy that is equivalent to lithium (Bowden et al., 1994). In the section on comorbid depressions, medications are described as ‘having limited benefits in the management of borderline personality disorder with atypical antipsychotics having the best efficacy’ (p. 1161) when meta-analyses suggest more robust efficacy with anticonvulsants showing the greatest drug/placebo difference with effect sizes of 0.42–1.51 across different domains (Ingenhoven et al., 2010). In discussing the complex issues of pregnancy in bipolar disorder, the Guidelines states categorically that ‘breastfeeding is contraindicated with lithium’ (p. 1167). Although I agree with the statement, there is controversy around this question, with a number of scholars recommending that, in some cases, the benefits of breastfeeding outweigh the risks of lithium secreted in breast milk (Altshuler and Kiriakos, 2006). In the same section, the authors equate the risk during pregnancy for lamotrigine with that of carbamazepine, despite the far greater evidence of both teratogenicity and development abnormalities for the latter (Dolk et al., 2016).

A final comment reflects the controversy about bipolar depression, especially the use of antidepressants. Although there is no greater area of disagreement among experts in our field, some of the statements lack the nuance required in complex situations. As an example, the Guidelines states that antidepressants should be avoided in bipolar patients with a history of rapid cycling or mixed features during depression. These clinical features do indeed predict a higher likelihood of treatment-emergent mania and/or increased cycling but a blanket warning—‘should be avoided’—might be softened to ‘should be used with caution’ since we all have rapid cycling patients who need antidepressants (along with their mood stabilizers) for optimal long-term management.

As noted, however, these are minor quarrels among friends. Professor Malhi and his colleagues are to be congratulated for a remarkably comprehensive and wise set of Practice Guidelines.