Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines for Mood disorders: A Review.

Vol 2 #9

Alan Eppel MB, FRCPC

The strength of these guidelines released in 2015, is their easy readability and fluent written style coupled with numerous helpful tables and diagrams illustrating key processes.

The guidelines were developed by a Mood Disorders Committee under the auspices of the Royal Australian and New Zealand College of Psychiatrists.

The goal was for the production of evidence-based, clinically relevant, real-world recommendations. Members of the committee included many clinically based as well as academic psychiatrists and psychologists. The committee produced both evidence-based and consensus-based recommendations.

Comments were invited from outside experts on draft guidelines and  a public consultation was carried out.

It is stated that the development of the guidelines was funded by the College and also relied on volunteer  commitments. Nevertheless it should be noted that in the conflicts of interest section only 2 of the 12 members of the mood disorders committee were free of conflicts of interest with many members listing multiple roles with pharmaceutical companies.

The guidelines cover depressive and bipolar disorders. Specific groups including children and adolescents and aboriginal populations are addressed.

The guidelines illustrate a clear approach to the classification of mood disorders and arrange  interventions in relation to acute and maintenance strategies.

Psychotherapeutic approaches are considered in detail with a review of the literature for CBT, IPT, behavioural activation, short-term psychodynamic psychotherapy, mindfulness-based cognitive therapy, problem-solving therapy and others.

Evidence for adjunctive complementary supplements was reviewed and provided support for the use of omega-3 fatty acids, folate, zinc and S-adenosyl methionine in the treatment of depression.

First line pharmacological treatment for depression contain the conventional  list of first-line agents which includes SSRIs, mirtazapine and bupropion.  Less typically is the inclusion of reboxetine, agomelatine, and mianserin.

Second line agents include SNRIs venlafaxine, desvenlafaxine, duloxetine, milnacipran and tricyclic antidepressants. MAO inhibitors are third line.

There is good coverage of augmentation strategies including lithium .

ECT and rTMS are also carefully reviewed.

When it comes to the controversial area of the treatment of bipolar depression, recommendations are fairly conventional:  quetiapine, lurasidone, lamotrigine, olanzapine, lithium and valproate for monotherapy. The guidelines do identify that the side effect burden with antipsychotics is a very serious consideration.

The guidelines  include a very useful table on the many methodological flaws in bipolar disorder trials:

• many patients for are recruited on existing medications
• many patients experience withdrawal from medication. Withdrawal symptoms may respond to the trial medications particularly antipsychotics which have sedative and anticholinergic  This can give a false positive signal.
• The percentage of patients with rapid cycling included in trials is often not identified.
• Selection biases and high dropouts after acute phase of treatment.

Regarding the deeply polarized debate on the use of anti-depressants in bipolar depression the guideline authors steer a diplomatic course between the Scylla and Charybidis  of the opposing factions rather than biting the bullet and acknowledging the absence of evidence for the benefit of antidepressants in bipolar disorder and the serious hazards in the form of cycle acceleration, mixed mood states and increased levels of suicide.

It is a pity they did not seize this opportunity to improve the management of patients with bipolar disorder.

References

https://www.ranzcp.org/Publications/Guidelines-and-resources-for-practice.aspx

Australian and New Zealand Journal of Psychiatry 2015, 49, 12. 1087 – 1206.