Grace Morris

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

Modeling suicide in bipolar disorders

Suicide is a multicausal human behavior, with devastating and immensely distressing consequences. Its prevalence is estimated to be 20–30 times greater in patients with bipolar disorders than in the general population. The burden of suicide and its high prevalence in bipolar disorders make it imperative that our current understanding be improved to facilitate prediction of suicide and its prevention. In this review, we provide a new perspective on the process of suicide in bipolar disorder, in the form of a novel integrated model that is derived from extant knowledge and recent evidence.

The ideal mood stabiliser: A quest for nirvana?

Detailed critiques of the term mood stabiliser were published a decade ago (Goodwin and Malhi, 2007; Malhi and Goodwin, 2007). The aim of these articles was, firstly, to point out that stabilising mood has many components; for example: conferring acute antidepressant and acute anti-manic effects, the long-term maintenance of mood stability and, perhaps the most critical of all, the prevention of future illness (prophylaxis); specifically warding off the recurrence of both depressive and manic episodes. It was emphasised that this ability to ensure the longterm wellness of an individual (i.e. maximising functional recovery and minimising side effects) was the most important ingredient for successfully managing a chronic and debilitating illness, such as bipolar disorder. The second point was to highlight that, thus far, only lithium has demonstrable efficacy across all of these facets, although its efficacy on acute depressive symptoms is relatively modest and slow, and possibly differs depending upon whether the depressive symptoms constitute a unipolar illness or are part of a bipolar presentation. It is noteworthy however, that in the treatment of recurrent unipolar depression, only lithium has the ability to augment the effects of any antidepressant from any class. Although lithium’s acute antidepressant effect may be relatively meagre, its ability to facilitate the antidepressant effect of another agent is quite potent (Malhi et al., 2015). Furthermore, in the longer-term management of bipolar disorder, lithium is the most efficacious medication for prophylaxis, albeit in a subset of patients that approximate closely to manic-depressive illness. Research since then (e.g., the seminal BALANCE Study, Geddes et al., 2010) has borne this out and shifted the field in favour of lithium use. Hence lithium’s pole position in guidelines has been retained, and its advantage over other agents has been palpably enhanced. Contemporaneously, whether mood should define bipolar disorder and be given primacy to the extent that it is, has attracted increasing scrutiny. The importance of considering additional domains such as activity and cognition, and assigning these equal salience has spawned the concept of a multidimensional definition of bipolar illness that is not solely reliant on mood as the primary axis of change (Malhi et al., 2016). This richer and deeper perspective allows for a more nuanced and accurate description of mixed states, which have hitherto lacked a secure home within the mood disorders spectrum. The flavouring of mood episodes with mixed features specifiers as advised by DSM-5 fails to provide a reliable and meaningful depiction of real-world mixed states. But such additional refinement and sophistication comes at a price. It conspicuously complicates the definition of mood disorders and makes bespoke treatment a far more ambitious goal. But ultimately, these seeming impediments to gaining clarity about diagnosis and management are psychopathological advances that will usher in deeper understanding of the nature of these illnesses. In clinical practice, changes in symptoms and signs that reside on these additional axes can be accurately described and measured just as we measure fluctuations in mood, and can be used alongside our existing parameters to define illness and its response to successful treatment. In other words, the narrow definition of a mood stabiliser that focuses solely on mood per se needs to be broadened to encompass stability of activity and resumption of normal thought processing. An examination of pharmacotherapeutic and psychological interventions along these various domains would allow a more complete understanding of the illness and the potential side-effects of treatments that often limit their use and thereby diminish their effectiveness. This more elaborate approach would also afford the development of more refined and tailored therapies that could provide a more practical rationale for combinations of treatments. For example, agents with actions predominantly on one axis or domain The ideal mood stabiliser: A quest for nirvana?

Is “early intervention” in bipolar disorder what it claims to be?

The notion of early intervention is understandably appealing for conditions such as bipolar disorder (BD), a chronic life‐long illness that increases risk of suicide and diminishes quality of life. It is purported that intervening early in the course of the illness with suitable interventions could substantially alter the trajectory of BD and improve outcomes. However, while there are obvious benefits to the prompt commencement of treatment, it is important to consider the gaps in our understanding regarding the aetiopathogenesis of bipolar disorder—upon which the paradigm of early intervention is predicated.

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

The promise of digital mood tracking technologies: are we heading on the right track?

The growing understanding that mood disorders are dynamic in nature and fluctuate over variable epochs of time has compelled researchers to develop innovative methods of monitoring mood. Technological advancement now allows for the detection of minute-to-minute changes while also capturing a longitudinal perspective of an individual’s illness. Traditionally, assessments of mood have been conducted by means of clinical interviews and paper surveys. However, these methods are often inaccurate due to recall bias and compliance issues, and are limited in their capacity to collect and process data over long periods of time. The increased capability, availability and affordability of digital technologies in recent decades has offered a novel, non-invasive alternative to monitoring mood and emotion in daily life. This paper reviews the emerging literature addressing the use of digital mood tracking technologies, primarily focusing on the strengths and inherent limitations of using these new methods including electronic self-report, behavioural data collection and wearable physiological biosensors. This developing field holds great promise in generating novel insights into the mechanistic processes of mood disorders and improving personalised clinical care. However, further research is needed to validate many of these novel approaches to ensure that these devices are indeed achieving their purpose of capturing changes in mood.

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

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.

Defining a mood stabiliser: novel framework for research and clinical practice

Summary The term ‘mood stabiliser’ is ill-defined and lacks clinical utility. We propose a framework to evaluate medications and effectively communicate their mood stabilising properties – their acute and prophylactic efficacy across the domains of mania and depression. The standardised framework provides a common definition to facilitate research and clinical practice. Declaration of interest The Treatment Algorithm Group (TAG) was supported logistically by Servier who provided financial assistance with travel and accommodation for those TAG members travelling interstate or overseas to attend the meeting in Sydney (held on 18 November 2017). None of the committee were paid to participate in this project and Servier have not had any input into the content, format or outputs from this project.

The limitations of using randomised controlled trials as a basis for developing treatment guidelines

Randomised controlled trials (RCTs) are considered the ‘gold standard’ by which novel psychotropic medications and psychological interventions are evaluated and consequently adopted into widespread clinical practice. However, there are some limitations to using RCTs as the basis for developing treatment guidelines. While RCTs allow researchers to determine whether a given medication or intervention is effective in a specific patient sample, for practicing clinicians it is more important to know whether it will work for their particular patient in their particular setting. This information cannot be garnered from an RCT. These inherent limitations are exacerbated by biases in design, recruitment, sample populations and data analysis that are inevitable in real-world studies. While trial registration and CONSORT have been implemented to correct and improve these issues, it is worrying that many trials fail to achieve such standards and yet their findings are used to inform clinical decision making. This perspective piece questions the assumptions of RCTs and highlights the widespread distortion of findings that currently undermine the credibility of this powerful design. It is recommended that the clinical guidelines include advice as to what should be considered good and relevant evidence and that external bodies continue to monitor RCTs to ensure that the outcomes published indeed reflect reality.

Is atypical depression simply a typical depression with unusual symptoms

The term ‘atypical depression’ (AD) was first used by West and Dally in 1959 to describe depressed patients who failed to respond to tricyclic antidepressants (TCAs) but responded to the monoamine oxidase inhibitor (MAOI), iproniazid. Subsequently, Klein and Davis described a condition they labelled hysteroid dysphoria consisting of a subgroup of depressed female patients who demonstrated ‘an extreme response to admiration, approval and personal rejection’ and who also had symptoms of hypersomnia and hyperphagia (for a review of the history, see Davidson, 2007; Parker et al., 2002). Much later, it was recognised that these patients were further characterised by the symptoms of mood reactivity, weight gain, reverse diurnal mood variation and profound energy loss – captured in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as ‘feeling heavy, leaden, or weighted down, usually in the arms or legs; this is generally present for at least an hour a day but often lasts for many hours at a time’ and described as ‘leaden paralysis’. These clinical features have come to be known as ‘atypical’, contrasting them from the ‘typical’ features of appetite loss, weight loss, decreased sleep and morning worsening over-represented in melancholic depression. ‘Rejection sensitivity’ was subsequently included as a clinical feature of atypical depression. DSM-5 classifies atypical features as a specifier for depressive disorder, with the diagnostic criteria primarily of mood reactivity with two or more of the following: significant weight gain or increased appetite, hypersomnia, leaden paralysis and a long-standing pattern of interpersonal rejection Is atypical depression simply a typical depression with unusual symptoms?