By Jean Balchin 07/02/2018

According to the authors of a guideline summary on major depression published in the Medical Journal of Australia, doctors should take a broader approach to the management of depression in their patients, with treatments

“tailored to depressive subtypes and administered with clear steps in mind.”

The summary, written by a large group of authors representing the Royal Australian and New Zealand College of Psychiatrists (RANZCP), was led by Professor Gin Malhi, from the Northern Clinical School at the University of Sydney and the CADE Clinic at Royal North Shore Hospital. It includes guideline summaries on major depression and on bipolar disorder, published online by the MJA.

Both summaries are abridged versions of the RANZCP’s 2015 clinical guidelines, directed “broadly at primary care physicians”.

Guidelines for Depression

Depression, as defined by the Ministry of Health, is a mental illness where you feel sad and miserable most of the time and your mood is persistently very low.

According to the depression guidelines, which emphasise a “biopsychosocial lifestyle approach”, the following recommendations are advised:

  • In addition to, or before prescribing any form of treatment, consideration should be given to strategies that can manage stress, ensure appropriate sleep hygiene and enable uptake of healthy lifestyle changes.
  • Psychological management alone is an appropriate first line treatment for mild to moderate depression, especially early in the course of illness. Ideally, this psychological management should be in conjunction with psychosocial interventions.

These guidelines

“highlight the importance of tailoring care to the individual and creating a collaborative therapeutic relationship, while outlining key considerations for long term treatment strategies”, the authors wrote.

Guidelines for Bipolar Disorder

According to the National Institute for Mental Health, bipolar disorder, also known as manic-depressive illness,

is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely “up,” elated, and energised behaviour (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

The guideline summary for bipolar disorder provides the following specific recommendations:

  • For mania, all physicians should be able to detect early signs so that treatment can be initiated swiftly. From the outset, physicians should taper and cease medications with mood-elevating properties and institute measures to reduce stimulation, and transfer the patient to specialist care.
  • For 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.
  • For long term management, physicians should adjust treatment to prevent the recurrence of manic and/or depressive symptoms and optimise functional recovery. Physicians should also closely monitor the efficacy of pharmacological and psychological treatments, adverse effects and compliance.

For bipolar disorder, lithium as first line therapy

“remains the most effective medication for the prevention of relapse and potential suicide, but requires nuanced management from both general practitioners and specialists,” Malhi and colleagues wrote. “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.”

The summary on major depressive disorder may be read here, and the summary on bipolar disorder may be read here.