The RANZCP 2020 guideline summaries and the need for standardised guideline development

The bipolar disorder and major depression summaries of the 2020 Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for mood disorders, published in the December 2020 issue of Bipolar Disorders, provide accessible and condensed overviews of current recommendations for diagnosis and management.1, 2 The 2020 guidelines3 replace the 2015 versions, and include some notable differences, most obviously in the language used to characterise approaches to treatment. In both summaries, treatment steps are now listed as ‘actions’, ‘choices’ and ‘alternatives’, replacing (but not directly corresponding to) steps 0–4 in previous versions. The new categorisations are both logical and intuitive, and we welcome the clarity and user-friendliness of this initiative; nevertheless, their novelty highlights the presence of wider discrepancies between the many published treatment guidelines for mood disorders. While there is a global variation in treatment approval, availability and acceptability, for which multiple mood disorder treatment guidelines are useful if they fulfil a unique need, guideline development processes are not standardised. Of particular concern is the impact on guideline quality. The AGREE II tool facilitates the assessment of treatment guideline quality by evaluating 23 items across six quality domains.4 This useful tool was recently applied to 19 treatment guidelines for unipolar depression and revealed considerable variation in quality. Worryingly, variation in the quality of guidelines also corresponded to some of the discrepancies between recommendations.5 The new RANZCP treatment steps include a combination of evidence-based and consensus-based recommendations, in line with other mood disorder treatment guidelines. Evidence-based recommendations are clearly preferable, but consensus-based guidance is necessitated by gaps in the research literature and inevitably limits the transparency of the guideline development process. However, several AGREE II domains on which unipolar depression guidelines scored poorly in our recent review5 could be used to ensure maximum transparency, and facilitate comparison between treatment guidelines. First, transparency in guideline funding and development group member affiliations is vital to ensure that the content (particularly consensus-based recommendations) has not been unduly influenced. This is assessed by the Editorial Independence domain of the AGREE II. The 2020 RANZCP guidelines were self-funded and do detail development group members' conflicts of interest, but published guidelines could perhaps go even further and explicitly discuss how potential conflicting interests may have impacted guideline development, and how this was mitigated. Second, clarity regarding guideline updates is needed, which falls under the ‘Rigour of Development’ domain of the AGREE II. Regular guideline updates ensure that recommendations are reflective of the most current research literature, minimise the need for consensus-based recommendations, and facilitate guideline comparability by limiting discrepancies due to variation in publication date.5 RANZCP regularly update their mood disorder guidelines, but this process might further benefit from advance publication of future update plans. The third (but by no means final) AGREE II domain on which unipolar treatment guidelines do not score highly is consideration of guideline applicability and context.5 The applicability domain of the AGREE II refers to the likely barriers and facilitators to implementation and resource implications. National guidelines such as RANZCP may be the most appropriate choice in this regard, as for example the National Institute for Health and Care Excellence (NICE) guidance in the UK reflects specific treatment pathways and availability within the United Kingdom National Health Service. But such national guidelines may not be available in every country and may not be of high quality. Therefore, all treatment guidelines should explicitly discuss their intended context of use, and how applicability considerations influenced their content. Retrospective application of the AGREE II is useful, but far greater benefit would be derived from the prospective implementation of a guideline development framework in psychiatry similar to the International Committee of Medical Journal Editors’ Vancouver Recommendations11 ICMJE. ICMJE | Recommendations. Published 2019. Accessed April 23, 2020. http://www.icmje.org/recommendations/. , or the Consolidated Standards of Reporting Trials statement for RCTs22 Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340(mar23 1):c332-c332. https://doi.org/10.1136/bmj.c332. . This would guarantee that guidelines are of good quality and help to ensure that differences between publications (and versions) are soundly based and the reasons underlying any differences clear. The new categorisation of management strategies employed by the 2020 RANZCP guidelines and guideline summaries are clinically useful as they distinguish between non-pharmacological ‘actions’ which are recommended for all cases, and pharmacological ‘choices’ or ‘alternatives’, which should be implemented where the ‘actions’ prove insufficient. The RANZCP guidelines make the rationale behind these new categorisations explicit, facilitating their potential consideration or adoption by future guideline publications. We suggest that the development and implementation of an internationally accepted guideline development framework, based on the domains of the AGREE II, would support the important work of preparing and updating these and other guideline, thus improving and standardising the provision of context appropriate evidence-based care for mood disorders. A.J.C. has in the last three years received honoraria for educational activities from Lundbeck and Janssen; honoraria for consulting from Allergan and Janssen; sponsorship for conference attendance from Janssen; and research grant support from Protexin Probiotics International Ltd. R.W.T. has no conflicts to declare.

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