The clinical practice guidelines

To the Editor

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. Nonetheless, they proceed to use those very concepts in their discussion of treatments. We remain in thrall to diagnoses such as Major Depressive Disorder, the misshapen product of the clinical–industrial complex of a powerful foreign culture.

The discussion of ACE (Activity, Cognition, Emotion) is a welcome disentangling of the threads of the poorly woven fabric of the over-arching Bipolar Disorder concept. You could scrap the Bipolar Disorder concept without any loss and focus simply on the ACE threads that would be better targets for clinical description and treatment. The ACE threads themselves will turn out to be spun from many different fibres. (Emotion, for example, includes despair, desire, fear and more. They are phenomena that do not obviously share a single process or move together.) Good practice should tease these fibres apart for description and management not lump them together as if one phenomenon.

Careful fine discriminations of phenomena ground practice in psychiatry. Good practice means making relevant discriminations up to the limits of our time, our language and our experience. Yet the guidelines propose that we will continue to use the ‘pragmatically useful’ categorical diagnoses we always have. These diagnoses have the pragmatic ‘usefulness’ of any categorising term like ‘geriatric’ or ‘indigenous’, terms that are dangerous to the well-being of the people to whom they are applied.

The guidelines are intellectually dazzling. But the guidelines are grounded on old generalisations that served a different place and time. Diagnoses are not things; they are imaginative hypotheses we use to organise and explain the phenomena of illness. They are pragmatically useful like the myths and humours by which the ancient Greeks explained and regulated their world. The phenomena of human experience and the understanding of it move on and we need to move on from our old diagnostic myths and not embed them more deeply with guidelines. These guidelines furnish, albeit luxuriously, the ‘epistemic prison’ ^{(Hyman, 2010)} of our current diagnostic practices.