https://doi.org/10.1177/0004867419863163 Australian & New Zealand Journal of Psychiatry 2019, Vol. 53(7) 595–596 DOI: 10.1177/0004867419863163 © The Royal Australian and New Zealand College of Psychiatrists 2019 Article reuse guidelines: sagepub.com/journals-permissions journals.sagepub.com/home/anp Australian & New Zealand Journal of Psychiatry, 53(7) It is becoming clearer that mood dis- orders and indeed most psychiatric disorders represent not only a distur- bance of brain function (as reflected by changes of mentation) but also a com- plex disturbance of multiple systems body wide. These then interact with psychological factors in a highly com- plex manner. One example of such complexity is the role of circadian sys- tems with, as pointed out in the edito- rial by Murray (this issue), virtually every cell in the body containing core clock machinery. Murray explains the importance of disturbances to the cir- cadian rhythm in mood disorders in a wonderfully clear and concise account of our current knowledge in this field. He suggests that ‘high resolution, time series measurement is fundamental to cir- cadian science’ and that the evolution of actigraphy adds an important tool to this endeavour. He also points out that complex psychological states vary according to the circadian rhythm, illustrating one of the many interac- tions between psychological and bio- logical factors in mood disorders. This editorial complements the article by Slyepchenko et al. (this issue), in which actigraphy is used to produce time series measurement. The study employs a combination of subjectively reported data alongside objective measures gleaned from actigraphy, which not only yields data on sleep and activity but also measures light exposure. Intriguingly, both subjective and objective measures reveal evi- dence of abnormalities in bipolar and unipolar mood disorders. Also of note is the finding that aspects of abnormal- ity in circadian rhythm are related to general functioning. Circadian rhythm disturbances have been shown to be linked to inflamma- tion and cardiovascular disease (Scheer et al., 2009). Life expectancy in bipolar disorder is reduced by 8–12 years with the major factor being cardiovascular disease. Coello et al. (this issue) investigated the 30-year cardiovascular risk scores in newly diagnosed bipolar disorder (most diagnosed in the previous 2 years), finding risk scores to be 98.5% higher than in matched con- trol subjects. Furthermore, risk was also higher among first-degree relatives of the patients with bipolar disorder. Coello et al. suggest that this argues for strategies to reduce cardiovascular risk at an early stage of the illness. Continuing the theme of linkages and adding further complexity still – increased levels of inflammatory markers are found to be linked to car- diovascular disease and to bipolar dis- order (Rosenblat and McIntyre, 2015). In an interesting case report, Chen et al. (this issue) describe a case of mania following bariatric surgery, in which the symptoms appeared to cor- relate with levels of the inflammatory marker C-reactive protein (CRP). They suggest that the inflammation may provide the link between the sur- gery the patient underwent and the episode of mania, citing a previous case report in the journal of resolu- tion of symptoms of mania following the administration of activated char- coal in a case which also followed bariatric surgery. Of course the rela- tionship between the gut microbiome, inflammation and mood disorder is increasingly being recognised and has been reviewed extensively recently in the journal (Morris et al., 2018). The complexities of treatment are such that even after over 100 pages of journal text, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines for the treatment of mood disorders were still unable to cover in detail the various treatments available for mood disorder. It is welcome therefore that this month’s issue includes guidelines for the practice of electroconvulsive therapy (ECT) (Weiss et al., this issue), a treatment which is often seen as being controversial (see McLaren, this issue) but which has seen significant advances in practice over the past dec- ade. Despite there being significant debate regarding aspects of ECT tech- nique in the past year (Loo et al., 2018; Rosenman, 2018), the authors have been able to reach a wide consensus which will likely serve as a guide for ECT practice in Australia and New Zealand. The guidelines note that they attempt to strike a ‘balance between promoting best evidence based practise and acknowledging that electro- convulsive therapy is a continually evolv- ing practice’. Given the complexities of brain function and especially dys- function, and the added complexity of ECT treatment, such evolution can sometimes occur only through the study of previous experiences such as The complexities of biological psychiatry Richard J Porter Department of Psychological Medicine, University of Otago–Christchurch, Christchurch, New Zealand Corresponding author: Richard J Porter, Department of Psychological Medicine, University of Otago–Christchurch, PO Box 4345, Christchurch 8140, New Zealand. Email: richard.porter@otago.ac.nz 863163ANP ANZJP This MonthPorter ANZJP This Month