Bill Lyndon

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Objectives: To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility. Methods: Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders. Results: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care. Conclusions: The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. Mood Disorders Committee: Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh. International expert advisors: Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O’Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham. Australian and New Zealand expert advisors: Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O’Connor, Dr Nick O’Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

A comparison of RUL ultrabrief pulse (0.3 ms) ECT and standard RUL ECT

An important goal in electroconvulsive therapy (ECT) research is to minimize associated cognitive side-effects while maintaining its high efficacy. This study explored the use of a novel approach, right unilateral (RUL) ECT with an ultrabrief pulsewidth (0.3 ms) (RUL-UB), in comparison with standard RUL ECT. Seventy-four depressed in-patients received RUL-UB ECT at six times seizure threshold, and 22 patients received standard RUL ECT (1.0 ms pulsewidth) at five times seizure threshold. Formal, prospective evaluations of mood and cognitive functioning over the treatment course were done by a rater blinded to treatment condition. Efficacy was maintained using the ultrabrief pulsewidth, with equivalent numbers of responders and remitters to the standard RUL ECT group, although the speed of response was slower. Cognitive outcomes were superior in the RUL-UB ECT group, particularly in the retention of verbal and visual information, as well as in retrograde autobiographical memory.

Predictors of response to ultrabrief right unilateral electroconvulsive therapy

BACKGROUND Recent trials have demonstrated clinically meaningful efficacy and minimal cognitive side effects with ultrabrief pulsewidth right unilateral (RUL) ECT. In many countries it is gradually being adopted into clinical practice and further information on predictors of response is needed. METHODS Data collected from 75 depressed patients who received ultrabrief RUL ECT in a prospective research trial were analysed for predictors of response. Mood improvement was assessed with the Montgomery-Asberg Depression Rating Scale. Improvement in unipolar versus bipolar depression was analysed. RESULTS Sixty-one percent of patients met the criteria for response and 36% met the criteria for remission. Logistic regression identified index episode duration ≥one year (OR=10.50, p=.006), fewer failed antidepressant treatments (OR=0.46, p=.003), previous ECT course (OR=7.33, p=.01), and absence of concurrent antidepressant (OR=0.09, p=.005) as predictors of response. Psychotic features (OR=7.18, p=.032) and baseline depression severity (OR=0.90, p=.017) were predictors of remission. There was a trend towards greater improvement in bipolar than unipolar depression in the first week of treatment (p=0.077). LIMITATIONS Data were obtained from a prospective but non-randomised clinical trial which was designed to evaluate efficacy rather than to examine predictors of response. Treatment decisions (concurrent medication, switching to other types of ECT) were made on clinical grounds. CONCLUSIONS This preliminary study suggests that predictors of response for ultrabrief RUL ECT are similar to those identified for other types of ECT previously studied.

A consensus statement for safety monitoring guidelines of treatments for major depressive disorder

Objective: This paper aims to present an overview of screening and safety considerations for the treatment of clinical depressive disorders and make recommendations for safety monitoring. Method: Data were sourced by a literature search using MEDLINE and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content. Results: Screening and monitoring can detect medical causes of depression. Specific adverse effects associated with antidepressant treatments may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment. Conclusion: The adoption of safety monitoring guidelines when treating clinical depression is likely to improve overall physical health status and treatment outcome. It is important to implement these guidelines in the routine management of clinical depression.

Depression in hepatolenticular degeneration (Wikon's disease)

Objective: To describe the course of depression in a patient with hepatolenticular degeneration (Wilsons disease). Clinical picture: A 21 -year-old male with hepatolenticular degeneration is described in whom depression was the earliest manifestation. Insomnia and psychomotor slowing were prominent. Treatment: The mood disturbance showed limited response to tricyclic antidepres-sants, mianserin, lithium augmentation and initial decoppering therapy. Introduction of the chelating agent tetrathiomolybdate was followed by normalisation of mood and improvement in non-psychiatric symptoms. Outcome: Three years after the disorder was first diagnosed the patient was euthymic and fully functional. Conclusions: Although hepatolenticular degeneration is rare, it commonly presents with psychiatric symptoms. It is important for psychiatrists to be aware of the condition and its psychiatric manifestations.

Lithium augmentation of venlafaxine in adolescent major depression

Objective: Studies on the pharmacotherapy of adolescent major depression are limited but suggest that the illness is often resistant to drug treatment. We aim to report the use of lithium augmentation of venlafaxine in two teenagers with major depression. Clinical picture: Two 16–year-olds with major depression are described. Treatment: In both patients, the treatment involved trials of a selective serotonin re-uptake inhibitor, venlafaxine, and psychotherapy preceded lithium augmentation of venlafaxine. The trial of venlafaxine alone had been short in one patient. Outcome: Combining lithium and venlafaxine was rapidly followed by marked improvement in mood and function. Conclusions: Augmentation of antidepressants should be considered in young depressed patients who fail to respond to adequate trials of new antidepressants alone.

Defining melancholia: A core mood disorder

Gordon Parker, Darryl Bassett, Tim Outhred, Grace Morris, Amber Hamilton, Pritha Das, Bernhard T Baune, Michael Berk, Philip Boyce, Bill Lyndon, Roger Mulder, Ajeet B Singh, Gin S Malhi

Unlocking the diagnosis of depression in primary care: Which key symptoms are GPs using to determine diagnosis and severity?:

Objective: Diagnosing depression in primary care settings is challenging. Patients are more likely to present with somatic symptoms, and typically with mild depression. Use of assessment scales is variable. In this context, it is uncertain how general practitioners (GPs) determine the severity of depressive illness in clinical practice. The aim of the current paper was to identify which symptoms are used by GPs when diagnosing depression and when determining severity. Method: A total of 1760 GPs participated in the RADAR Program, an educational program focusing on the diagnosis and management of clinical depression. GPs identified a maximum of four patients whom they diagnosed with depression and answered questions regarding their diagnostic decision-making process for each patient. Results: Overall, assessment of depression severity was influenced more by somatic symptoms collectively than emotional symptoms. Suicidal thoughts, risk of self-harm, lack of enjoyment and difficulty with activities were amongst the strongest predictors of a diagnosis of severe depression. Conclusions: The conclusions are threefold: (1) collectively, somatic symptoms are the most important predictors of determining depression severity in primary care; (2) GPs may equate risk of self-harm with suicidal intent; (3) educational initiatives need to focus on key depressive subtypes derived from emotional, somatic and associated symptoms.

Defining disorders with permeable borders: you say bipolar, I say borderline!

1Mood Assessment and Classification (MAC) Committee, Sydney, NSW, Australia 2Private Practice in Psychiatry and Division of Psychiatry, University of Western Australia, Perth, WA, Australia 3Department of Psychological Medicine, University of Otago – Christchurch, Christchurch, New Zealand 4Academic Department of Psychiatry, Northern Sydney Local Health District, St Leonards, NSW, Australia 5Sydney Medical School, Northern, University of Sydney, Sydney, NSW, Australia 6CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia 7School of Medicine, IMPACT Strategic Research Centre, Deakin University, Barwon Health, Geelong, Vic., Australia 8Department of Psychiatry, Orygen Research Centre, Florey Institute for Neuroscience and Mental Health, University of Melbourne, Melbourne, Vic., Australia 9Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia 10Discipline of Psychiatry, Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia 11Mood Disorders Unit, Northside Clinic, Greenwich, NSW, Australia 12ECT Services, Northside Group Hospitals, Greenwich, NSW, Australia 13School of Psychiatry, University of New South Wales, Sydney, NSW, Australia 14Black Dog Institute, Sydney, NSW, Australia

Severity alone should no longer determine therapeutic choice in the management of depression in primary care: Findings from a survey of general practitioners

BACKGROUND The treatment of depression in primary care remains suboptimal for reasons that are complex and multifactorial. Typically GPs have to make difficult decisions in limited time and therefore, the aim of this study was to examine the management of depression of varying severity and the factors associated with treatment choices. METHOD Nested within a primary care educational initiative we conducted a survey of 1760 GPs. The GPs each identified four patients with clinical depression whom they had treated recently and then answered questions regarding their diagnosis and management of each patient. RESULTS Comorbid anxiety, sadness and decreased concentration appeared to direct the management of depression toward psychological therapy, whereas comorbid pain and a patients overall functioning, such as the ability to do simple everyday activities, directed the initiation of pharmacological treatment. The use of antidepressants with a broader spectrum of actions (acting on multiple neurotransmitters) increased from mild to severe depression, whereas this did not occur with the more selective agents. SSRIs were prescribed more frequently compared with all other antidepressants, irrespective of depression severity. LIMITATIONS GPs chose the RADAR programme and therefore they were potentially more likely to have an interest in mental health compared to GPs who did not participate. CONCLUSIONS GPs do not appear to be determining pharmacological treatment based on depression subtype and specificity, but rather on the basis of the total number of symptoms and overall severity. While acknowledging important differences between primary care and specialist practice, it is suggested that guidelines to assist GPs in matching treatment to depression subtype may be of practical assistance in decision-making, and the delivery of more effective treatments.