Over the past decade, APA has published 14 practice guidelines using an
evidence-based process. After some initial concerns about "cookbook
medicine" and the possibility of increased malpractice actions, neither
of which have materialized, psychiatrists have increasingly accepted the
guidelines as an aid in making clinical decisions.
There have been three major challenges in the project: (1) developing a
reliable and effective process that incorporates the relevant evidence in a
usable form, (2) disseminating the guidelines and having them used in
day-to-day clinical work, and (3) keeping the guidelines current.
Development process: The process we developed for producing practice
guidelines is based on an Institute of Medicine report and criteria developed
by the American Medical Association. The process includes development by
expert work groups, a systematic review of evidence and the development of
evidence tables, broad review and iterative revisions, and approval by the APA
Assembly and Board of Trustees.
The Assembly and the Board have been very attentive to guidelines and have
made many substantive contributions to the content of individual guidelines
and to the process. Under the guidance of the devoted Steering Committee on
Practice Guidelines and a very effective APA project staff, the development
process has become almost automatic, with high acceptance from APA leaders and
other members. A challenging aspect of this work has been struggling with the
nature of evidence and how to develop recommendations in areas where the
evidence, at least as represented by randomized controlled trials (RCTs), is
spotty or nonexistent. A humorous article in the December 2003 British
Medical Journal pointed out the fallacy of relying exclusively on RCTs by
noting that there has not been an RCT on the effectiveness of parachutes in
saving lives. Waiting for such a study before using parachutes does not seem
like a good idea!
Dissemination: Throughout medicine, effective dissemination of
guidelines has been a major challenge. Many well-developed guidelines are
available, but their use by physicians in practice remains low. Each APA
guideline is published in the American Journal of Psychiatry. In
addition, each guideline is posted on the APA Web site at<www.psych.org>,
and a summary of the guideline is included in the federal Agency for Health
Care Research and Quality's guideline clearinghouse site, with a link to the
APA site. Also, every two years, a compendium of all APA practice guidelines,
including the most recent revisions, is published by APPI. Actually, the
iterative development process and the reality that about 800 members have
reviewed various drafts of each guideline helps significantly with
Quick-reference guides have been published that present the recommendations
in algorhythmic and bulleted format, and these guides will soon be available
for handheld PDAs. Pocket cards are also being developed. Continuing medical
education courses focusing on the guidelines are available, and increasingly
the guidelines are being incorporated into residency training programs.
Questions from the guidelines are included in PRITE examinations, and the
guidelines are a major source for ABPN certification and recertification
Keeping guidelines current: As the explosion of new knowledge in our
field continues, it is essential that practice guidelines be kept current. The
APA guideline process aims to revise each guideline within five years of
publication. To date, four guidelines have been revised, and revisions of four
others are in the pipeline.
An article in the September American Journal of Psychiatry
suggested that recent evidence would lead to a recommendation different from
that identified in the APA Practice Guideline on Bipolar Disorder, published
in 2002. To deal with such issues between major revisions of the guidelines,
the Steering Committee on Practice Guidelines recently agreed on a solution:"
Guideline Watches." Watches are brief updates that identify new
findings that should be considered when using a guideline. The watches are
written by experts associated with the development of the particular guideline
and are approved by the executive committee of the project but not by the
Assembly or Board. Hence they are not APA policy statements. Watches have been
published for Alzheimer's disease, psychiatric evaluation, and delirium, and
four more are in development—for major depressive disorder, panic
disorder, borderline personality disorder, and bipolar disorder. Each watch is
published online at the APA Web site and will be included in each two-year
compendium. We are also exploring other means of disseminating the watches.
For example, the watch on major depressive disorder is expected to be included
in the next issue of Focus, APA's continuing education journal.
Practice guidelines can be an aid to psychiatrists in their clinical work
with patients. However, for that to occur, the process of the guideline
development must be thoughtful and rigorous, and the recommendations must
reflect current evidence and clinical consensus. The Guideline Watches should
be helpful in meeting that challenge. ▪