The 2020 mood disorders clinical practice guidelines: Dazzlingly bedazzling!

The recently published College mood disorders clinical practice guidelines (Malhi et al., 2021) are dazzling in their breadth, comprehensiveness and erudition. They intelligently criticise the concepts of depression and bipolar illnesses. (Rosenman, 2021)

Akin to a William Morris tapestry, Dr Stephen Rosenman explicates the ACE (activity, cognition and emotion) Model described in the recent mood disorder clinical practice guidelines (CPGs) and extrudes the analogy through his mental loom, so as to create a marvellous image of the material of mood disorders.

We concur entirely with the view that ‘careful discriminations of phenomena ground practice in psychiatry’ and that ‘there is no obvious limit to the fineness of those discriminations’ and furthermore, that ‘good practice means making relevant discriminations up to the limits of our time, our language and our experience’.

We also share his critical view of the current approach to taxonomy that entails the generation of categorical diagnoses, many of which lack validity (e.g. disruptive mood dysregulation disorder [DMDD], Bipolar II disorder) (Malhi and Bell, 2019a, 2019b). To this end, his suggestion of supplanting the concept of bipolar disorder with the ACE model is intriguing and perhaps this is precisely the kind of avant-garde thinking that is needed. Interestingly, the shift away from the traditional subtyping of bipolar disorder to a more dimensional approach that better accommodates mixed presentations has been widely welcomed.

Similarly, the introduction of new paradigms such as channelling response has been greeted with enthusiasm. These are important ‘inventions’ as they provide new perspectives on clinical challenges and practice. But as Rosenman states, they remain ‘imaginative hypotheses’ and as such, they require vigorous interrogation and robust testing. For example, our Windows of Antidepressant Response Paradigm (WARP) may be useful in devising future clinical trials, especially where agents purported to have rapid actions are investigated. This would also test the utility of the paradigm and allow it to be further refined, if found to be useful. Similarly, our Channelling Response Paradigm (CRP) can perhaps provide a framework for naturalistic treatment studies conducted in real-world populations, in a similar vein to landmark studies such as STAR*D (Rush et al., 2004).

Dr Rosenman’s description of the guidelines as ‘intellectually dazzling’ is balanced by his well-founded concern that psychiatric diagnoses of disorders and paradigms for psychiatric management need to constantly evolve and strive harder to better capture reality. While we share his, and arguably mainstream psychiatry’s, belief that the current binary diagnoses do not adequately capture the descriptive landscape of mental health (which has prominent dimensional components like A, C and E), we have had to be pragmatic and construct a guideline on the available evidence which derives principally from a taxonomy based on binary diagnoses.

We thus extend an invitation to everyone to assist us in further bedazzling future iterations of the guidelines and help us escape the confines of our thinking.