To the Editor: We are delighted at the attention which the editorial by Hickie and Blashki1 has drawn to our clinical update on the management of bipolar disorder in general practice.2 However, we are bemused by a number of the sentiments, criticisms and statements of fact included in that robustly expressed editorial.

We will focus only on a few of the major issues raised. Hickie and Blashki argue that there are too many “worthy” guidelines promulgated to general practitioners by “specialist colleagues” across the range of medical conditions, and that extrapolation from specialist centre studies “may particularly annoy GPs”. On the other hand, they bemoan the fact that “few [guidelines] have targeted general practice”. We are surprised by this insinuation that such issues pertain to our clinical update.

Three of the authors of our article are GPs in either clinical or academic practice, and the document has been formally endorsed by the Royal Australian College of General Practitioners. Our article focuses on the practical issues concerning the role of the GP in the management of patients with bipolar disorder, and deals frankly with the respective contributions of the GP, psychiatrist, and psychologist. It is our experience that GPs are enthusiastic in enhancing their skills in the management of mental illnesses such as bipolar disorder in the primary care setting. Therefore, we have little doubt that updates such as ours will be viewed as helpful aids for GPs, who are often the main “port of call” for people with this condition. We strongly contend the statement that we ignore practice-based issues and thereby risk “an overall negative rating from the target audience”.

Hickie and Blashki state that “the most useful mental health guidelines tackle the tough issues”, such as sources of self-help, self-monitoring, detailed illness descriptions, family education, quality e-health resources, and guidance when patients become a danger to themselves and others. We fail to understand the implication that our update does not address such issues, as these very practical matters are clearly highlighted in detail in our article.

Finally, we are surprised at the negative tone concerning guidance for the management of mental illness in general practice by authors who have argued strongly for the value of evidence-based guidelines in specialist psychiatric practice.3 Although (as we clearly acknowledge) there is currently a limited evidence base for managing such conditions in primary care, there is still a major need for practical guidance for the practitioner in this setting.

To the Editor: Hickie and Blashki are to be commended for their view that clinical practice guidelines in mental health should be relevant to a primary care setting.1 Unfortunately, such guidelines have little effect on clinical outcomes, as most general practitioners have not been taught how to use them to their best advantage.2 There is also little known about the best way to implement guidelines in mental health, let alone in primary care mental health settings.3 As a result, more guidelines, even those more attuned to the primary care environment, will be of little benefit to our community.

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is actively promoting the use of clinical practice guidelines4 as a quality improvement tool that will allow mental health practitioners (including GPs) to assess their practice more carefully and measure and analyse variance. The next step is to fund research into how best to implement mental health guidelines at the coalface.

It is only through practice-based research that the barriers to successful implementation of evidence-based practice can be identified and overcome. Such research could be funded via a National Health and Medical Research Council (NHMRC) or Australian Research Council (ARC) grant program and coordinated by groups such as the RANZCP or the National Mental Health Working Group Safety and Quality Partnership Group. Mental health has already been identified as a grant funding priority by the ARC.5 Once this has been achieved, then training and mentoring to help practitioners review their practice as part of a quality improvement framework is required, rather than more guidelines per se.

Providing well researched, up-to-date and accessible information for GPs on “self-help, self-monitoring, [and] detailed illness descriptions”, as suggested by Hickie and Blashki, is commendable, but is not what is required for guidelines to truly improve the safety and quality of mental health care in Australia.