Comparing the recommendations of two recently published national clinical practice guidelines for depression, this editorial highlights the concordance of advice concerning the selection and sequencing of therapies. Lifestyle and psychological interventions feature prominently and there is broad agreement regarding medication choice and optimisation strategies. The guidelines are therefore a useful resource.
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.
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Despite its prominent position in many international clinical practice guidelines, and a renewed interest from academic psychiatry, the use of lithium to treat Bipolar Disorder (BD) has steadily declined 1 .The reasons for this are threefold: First, as there is no 'patent' on lithium, it is not being marketed to physicians or patients, to the same extent or in the same manner as other agents that have similar indications; Second, compared to alternatives, lithium is generally regarded as more complicated to prescribe (necessitating regular
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.
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