The RANZCP guidelines: Managing mood disorders in the real world

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines for mood disorders is the first to address the management of major depressive disorder (MDD) and bipolar disorder (BD) presentations in a single guideline (Malhi et al., 2015). It is founded on robust methodology and integrates the classification and clinical management of mood disorders. The guideline also examines specific populations, including subtypes of mood disorders manifesting throughout the life cycle (children, elderly, etc.). The clinical relevance of the guidelines by Malhi and colleagues is enhanced by the fact that it considers real-world clinical populations – similar to those found in most hospital systems and community mental health centres worldwide. The guidelines are particularly timely post-publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) providing a didactic summary of the DSM-5 mood disorders section, accommodating BD type I to premenstrual dysphoric disorder, along with personality disorders in the one guideline.

Despite compelling evidence establishing the efficacy of medications for mood disorders, many recommendations in guidelines actually fails because they rely on categorical diagnoses, and these do not capture the full complexity of individuals. In addition to a granular analysis of what the patient is presenting with, the integrative approach of the RANZCP guidelines extends beyond the diagnosis and contextualizes this in terms of the patient’s history/narrative.

Most treatment guidelines report antidepressant efficacy in patients with moderate to severe MDD but, for milder forms of depression, some guidelines suggest that antidepressants as a first-line treatment should be avoided, because of uncertainty with regard to their benefits. In practice, there is equally insufficient evidence for the many seemingly effective alternatives, and this may hinder psychiatrists’ prescribing choice and result in the seemingly indiscriminate use of antidepressants.

The section on maintenance pharmacological treatment, including residual symptoms – showing decision points along a trajectory of functional recovery through successive phases of treatment (Figure 14) with practical clinical examples is noteworthy because it could facilitate the use of guidelines by clinicians. This is a good example of where the authors have summarized a huge amount of data, organizing all the necessary information in clear figures indicating step-wise management of mood phases (Figures 11 and 13) and treatment response (Figures 7 and 9).

Despite limited research evidence, the guideline provides a strong clinical consensus indicating that the highly impairing depressive phase of BD should be managed in a comprehensive biopsychosocial-lifestyle (BPSL) manner. The recommendation of psychotherapy interventions is richly described in the guideline with useful inputs across the mood spectrum (Table 21).

There is robust evidence for causal (often bidirectional) links between sleep and mood dysregulation in mood disorders. The RANZCP guidelines have addressed this and provide a comprehensive approach to lifestyle in the maintenance phase of MDD and BD, by including assessments and behavioural interventions for sleep improvement. As with diet and exercise prescription, clinicians may not require specialized skills in lifestyle behavioural interventions. Rather, providing psychoeducation to follow good sleep habits for achieving adequate sleep are likely sufficient.

The guideline was developed through a multidisciplinary professional group with academic and non-academic representation, and service users and caregivers’ representatives assuring credibility of knowledge and providing greater flexibility in terms of the practical delivery of the intervention that could facilitate guideline implementation. By involving clinical practitioners directly in the process and allocating resources into existing clinical contexts, the guideline gets close to what happens clinically in the real world in the absence of evidence. Rather than leaving blanks and stating ‘there is no evidence’, the guidelines provide a useful consensus-based recommendation where possible.

Mood episodes (depression or manic) are clinically heterogeneous, of varying length with diverse responsivity to treatment (Henry et al., 2007). Additionally, in patients who rapidly cycle between mania and depression, the benefits or adverse effects on mood of any treatment (pharmacological or psychological) can be difficult to assess. The use of mobile technologies to track affective instability and behavioural changes in a continuous manner might give us better information to improve guidelines as well as promote self-monitoring and patient autonomy. The implementation of an electronic, portable version of the guidelines devoted to patients with mood disorders may also encourage active patient involvement in decision-making.

The RANZCP guidelines are comprehensive and tackle issues thatare often not considered in other guidelines such as BPSL interventions, service delivery and personalized medicine in mood disorders. However, the development of guidelines alone will not change practice, and, to this end, clinical management approaches need to be standardized and local barriers to implementation need to be addressed in dailyclinical practice. Integrating clinical expertise alongside evidence-based medicine is clearly a more relevant way of developing guidelines inpsychiatry and providing practicable recommendations.