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.

2020 年澳大利亚和新西兰皇家精神病学院 (RANZCP) 情绪障碍临床实践指南的双相情感障碍和重度抑郁总结，发表于 2020 年 12 月期的双相情感障碍，提供了当前诊断和管理建议的可访问和浓缩概述. ^{1, 2} 2020 年指南³取代了 2015 年版本，并包括一些显着差异，最明显的是用于描述治疗方法的语言。在这两个摘要中，治疗步骤现在列为“行动”、“选择”和“替代方案”，取代（但不直接对应）以前版本中的步骤 0-4。

新的分类既合乎逻辑又直观，我们欢迎这一举措的清晰性和用户友好性；尽管如此，它们的新颖性突出了许多已发布的情绪障碍治疗指南之间存在更大差异。虽然在治疗批准、可用性和可接受性方面存在全球差异，如果多种情绪障碍治疗指南满足独特的需求，则它们是有用的，但指南制定过​​程并未标准化。特别值得关注的是对指南质量的影响。AGREE II 工具通过评估六个质量领域的 23 个项目来促进治疗指南质量的评估。⁴这个有用的工具最近被应用于 19 份单相抑郁症治疗指南，并揭示了质量上的相当大的差异。令人担忧的是，指南质量的差异也与推荐之间的一些差异相对应。⁵

新的 RANZCP 治疗步骤包括基于证据和基于共识的建议的组合，符合其他情绪障碍治疗指南。基于证据的推荐显然更可取，但基于共识的指导因研究文献中的空白而必不可少，并且不可避免地限制了指南制定过​​程的透明度。然而，在我们最近的评论中，单相抑郁指南在几个 AGREE II 领域中得分很低⁵可用于确保最大的透明度，并促进治疗指南之间的比较。首先，指南资助和制定小组成员隶属关系的透明度对于确保内容（特别是基于共识的推荐）没有受到不当影响至关重要。这是由 AGREE II 的编辑独立性领域评估的。2020 RANZCP 指南是自筹资金，并详细说明了制定小组成员的利益冲突，但已发布的指南或许可以更进一步，明确讨论潜在的利益冲突如何影响指南制定，以及如何减轻这种冲突。

其次，需要明确指南更新，这属于 AGREE II 的“发展严谨性”领域。定期更新指南可确保推荐反映最新的研究文献，最大限度地减少对基于共识的推荐的需求，并通过限制因出版日期变化而导致的差异来促进指南的可比性。⁵ RANZCP 定期更新他们的情绪障碍指南，但这个过程可能会进一步受益于未来更新计划的提前发布。

单极治疗指南得分不高的第三个（但绝不是最终的）AGREE II 领域是考虑指南的适用性和背景。⁵AGREE II 的适用领域是指实施和资源影响可能存在的障碍和促进因素。在这方面，诸如 RANZCP 之类的国家指南可能是最合适的选择，例如，英国的国家健康与护理卓越研究所 (NICE) 指南反映了英国国家卫生服务机构内的特定治疗途径和可用性。但此类国家指南可能并非在每个国家都可用，而且质量可能不高。因此，所有治疗指南都应明确讨论其预期使用环境，以及适用性考虑如何影响其内容。

AGREE II 的回顾性应用是有用的，但从精神病学指南制定框架的前瞻性实施中获得更大的好处，类似于国际医学期刊编辑委员会的温哥华建议11 ICMJE。ICMJE | 建议。2019 年出版。2020 年 4 月 23 日访问。http://www.icmje.org/recommendations/。 , 或 RCTs2 的综合报告试验报告标准2 Schulz KF、Altman DG、Moher D，来自 CONSORT 集团。CONSORT 2010 声明：更新的平行组随机试验报告指南。英国医学杂志。2010;340(mar23 1):c332-c332。https://doi.org/10.1136/bmj.c332。. 这将保证指南的质量良好，并有助于确保出版物（和版本）之间的差异有充分的基础，并且任何差异背后的原因都清楚。2020 RANZCP 指南和指南摘要采用的新管理策略分类在临床上是有用的，因为它们区分了推荐用于所有病例的非药理学“行动”，以及应在以下情况下实施的药理学“选择”或“替代方案” “行动”证明是不够的。RANZCP 指南明确了这些新分类背后的基本原理，促进了未来指南出版物的潜在考虑或采用。我们建议制定和实施国际公认的指南制定框架，