Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: major depression summary

Based on the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders,1 Malhi and colleagues have produced guideline summaries for major depression2 and bipolar disorder.3

The major depression summary is likely to be used as a stand-alone guideline by primary care physicians treating depression.2 Bipolar disorder often presents as recurrent depression.1,3 It is therefore worrying that the major depression summary omits discussion of bipolar disorder. Identifying bipolar disorder is important because the treatment is different from that required for other types of depression.2,3

The bipolar disorder summary looks to the early detection of mania, as bipolar depression cannot be reliably distinguished from major depression.3 However, there are clues to a bipolar diagnosis during the preceding depressions. Bipolar disorder might be suspected in a pervasive depressive episode which does not make sense psychologically.4,5 A family history may also be suggestive.1

Bipolar disorder should be fully integrated into the management of major depression. After diagnosing major depression, ask routinely: “Could this be an episode of bipolar disorder?”. While the question cannot be answered definitively, it most definitely warrants the asking. Suspecting bipolar disorder can provide the patient and family with some explanation and can involve them in decisions about treatment.

Suspecting bipolar disorder earlier could lead to a better outcome. It may allow earlier bipolar treatment and avoid exacerbating the condition with antidepressant or psychotherapy monotherapy. At least, we could warn patients of the risk of inducing mania or cycling with antidepressants.1,3 Omitting bipolar disorder from the guidelines for major depression means that such a warning may not be considered.

The major depression summary2 recommends lithium, atypical antipsychotics and electroconvulsive therapy for treatment-resistant depression. Some psychiatrists believe that these are only effective in treating melancholic depression. For the more common treatment-resistant non-melancholic depression, stronger psychotherapies such as dialectical behaviour therapy and acceptance and commitment therapy may be more efficacious than stronger biological therapies.