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

Malhi, Gin S; Outhred, Tim; Morris, Grace; Boyce, Philip M; Bryant, Richard; Fitzgerald, Paul B; Hopwood, Malcolm J; Lyndon, Bill; Mulder, Roger; Murray, Greg; Porter, Richard J; Singh, Ajeet B; Fritz, Kristina

doi:10.5694/mja17.00658

ARTICLE
AUTHORS
REFERENCES

Topics

Mental disorders

General medicine

Abstract

Introduction: In December 2015, the Royal Australian and New Zealand College of Psychiatrists published a comprehensive set of mood disorder clinical practice guidelines for psychiatrists, psychologists and mental health professionals. This guideline summary, directed broadly at primary care physicians, is an abridged version that focuses on bipolar disorder. It is intended as an aid to the management of this complex disorder for primary care physicians working in collaboration with psychiatrists to implement successful long term management.

Main recommendations: The guidelines address the main phases of bipolar disorder with a particular emphasis on long term management, and provide specific clinical recommendations.

Mania:

All physicians should be able to detect its early signs so that treatment can be initiated promptly.
At the outset, taper and cease medications with mood-elevating properties and institute measures to reduce stimulation, and transfer the patient to specialist care.

Bipolar depression:

Treatment is complicated and may require trialling treatment combinations.
Monotherapy with mood-stabilising agents or second generation antipsychotics has demonstrated efficacy but using combinations of these agents along with antidepressants is sometimes necessary to achieve remission. Commencing adjunctive structured psychosocial treatments in this phase is benign and likely effective.

Long term management:

Physicians should adjust treatment to prevent the recurrence of manic and/or depressive symptoms and optimise functional recovery.
Closely monitor the efficacy of pharmacological and psychological treatments, adverse effects and compliance.

Changes in management as a result of the guidelines: The guidelines position bipolar disorder as part of a spectrum of mood disorders and provide a longitudinal perspective for assessment and treatment. They provide new management algorithms for the maintenance phase of treatment that underscore the importance of ongoing monitoring to achieve prophylaxis. As a first line treatment, lithium remains the most effective medication for the prevention of relapse and potential suicide, but requires nuanced management from both general practitioners and specialists. The guidelines provide clarity and simplicity for the long term management of bipolar disorder, incorporating the use of new medications and therapies alongside established treatments.

1 CADE Clinic, Royal North Shore Hospital, Sydney, NSW
2 Northern Clinical School, University of Sydney, Sydney, NSW
3 Westmead Clinical School, University of Sydney, Sydney, NSW
4 UNSW Sydney, Sydney, NSW
5 Epworth Clinic, Epworth Healthcare, Melbourne, VIC
6 Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University, Melbourne, VIC
7 University of Melbourne, Melbourne, VIC
8 Mood Disorders Unit, Northside Clinic, Sydney, NSW
9 University of Otago, Christchurch, NZ
10 Swinburne University of Technology, Melbourne, VIC
11 Deakin University, Geelong, VIC

Correspondence: gin.malhi@sydney.edu.au

Acknowledgements:

The development of the clinical practice guidelines for mood disorders was supported and funded by the RANZCP.

Competing interests:

Gin Malhi has received grant or research support from Australian Rotary Health, the NHMRC, NSW Health, Ramsay Health, the University of Sydney, AstraZeneca, Eli Lilly, Organon, Pfizer, Servier and Wyeth; has been a speaker for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck, Pfizer, Ranbaxy, Servier and Wyeth; and has been a consultant for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck and Servier. Philip Boyce has received consultation fees, sponsorship and speaker fees from Servier; is a member of the advisory board for Lundbeck, Eli Lilly, AstraZeneca and Janssen; has received speaker fees from Lundbeck, AstraZeneca and Janssen; and has received funding for a clinical trial from Brain Resource Company. Richard Bryant has received an NHMRC Program Grant and Project Grant. Paul Fitzgerald is supported by an NHMRC Practitioner Fellowship Grant; and has received equipment for research from MagVenture A/S, Medtronic Ltd, Neuronetics and Brainsway Ltd, and funding for research from Neuronetics; he is on scientific advisory boards for Bionomics Ltd and LivaNova and is a founder of TMS Clinics Australia. Malcolm Hopwood has received a grant and personal fees from Servier, and personal fees from Lundbeck, Eli Lilly and AstraZeneca. Bill Lyndon has received personal fees from Lundbeck Australia, AstraZeneca and Eli Lilly Australia. Greg Murray has received an NHMRC Project Grant and personal fees from Servier and CSL Biotherapies. Ajeet Singh has received personal fees from Servier Australia and Lundbeck Australia; has received a grant from Pfizer Australia; has equity in ; is the founder and owner of website; and has a patent on the Antidepressant Pharmacogenetics Report.

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

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