Many guidelines exist worldwide on how best to manage psychiatric illnesses, but we never see two guidelines that agree with each other; because there are so many gaps in the evidence, said Professor Victor Reus, University of California at San Francisco School of Medicine, CA, and Chair of the Practice Guideline Writing Group for the APA, at APA 2019. Such lack of agreement highlights what we do not know rather than what we do know.
Teams of APA experts aim to produce the best possible guidelines for psychiatric illnesses based on the available evidence to:
- enhance evidence-based practice
- decrease variations in clinical practice
- guide against inappropriate treatment
- improve safety
The interactive APA guideline process
Systematically developed statements to assist practitioner and patient decisions
Guideline processes used worldwide include expert consensus and more formalized evidence-based approaches, such as the process used by the APA.
The APA aligns its approach with that advocated by the Institute of Medicine (IOM) in Clinical Practice Guidelines, Directions for a New Program published in 1990, explained Professor Laura Fochtmann, Stony Brook University, New York, USA and Medical Editor of the APA Clinical Practice Guidelines. The IOM defined practice guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”
In 2011, the IOM, now renamed as the National Academy of Medicine, refined its recommendations for compiling clinical practice guidelines, highlighting that a systematic review of the literature for each clinical question to be addressed is essential. In addition, guidelines should be assembled in a non-biased manner, and an interactive external review of the proposed guideline should involve broad groups of stakeholders.
Rigorous systematic reviews of the evidence are now incorporated into the APA guideline process and may be carried out by Agency for Healthcare Research and Quality (AHRQ), APA staff, or Doctor Evidence (DRE, a software company that applies deep domain knowledge and artificial intelligence technology to rapidly find and analyze medical literature), Professor Fochtmann said.
New APA guidelines on schizophrenia and bipolar disorder
The process and current progress of new APA guidelines on schizophrenia and bipolar disorder were described to highlight the interactive nature of the APA guideline process and the challenges faced when carrying out a systematic review when there is a lack of good-quality evidence.
The chair of the APA Guidelines for the Treatment of Schizophrenia, Professor George Keepers, Oregon Health and Science University, Oregon, USA presented the draft guideline statements, which have been based on an AHRQ review of the literature, existing guidelines from the APA and other organizations, and additional relevant literature suggested by members of the writing group. These statements are now available for public comment and revision before final approval by the APA Assembly.
The process for developing the APA Practice Guideline on the Treatment of Patients with Bipolar Disorder, has however, proved more challenging, explained Professor Reus. The rigorous 2-year AHRQ systematic excluded many important studies, because they did not meet criteria for inclusion in the review. This meant that for one valuable and widely used medication, only four studies were included in the review despite hundreds of articles demonstrating efficacy. Insufficient data were also available for other well-used and valuable therapies. As a result, the systematic review has not proved helpful and the guideline committee is re-evaluating the evidence and has needed to spend more time than expected to formulate the draft statements.
The future for APA guidelines
The lack of staging of psychiatric illness has proved challenging
In closing the session, Professor Daniel Anzia, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA and chair of the APA Guideline Committee, noted that changing views on psychiatric illnesses, for example anxiety, will produce further challenges for systematic reviews of the evidence. He also commented that clinicians are now requesting guidelines on how to manage patients with major depressive disorder, who exhibit suicidal behavior to take into account new data.
An understanding of the treatment trajectory and where a patient is on that trajectory is necessary to make the best-informed treatment decisions
The lack of staging of psychiatric illness has also proved challenging when formulating the guidelines, he said. An understanding of the treatment trajectory and where a patient is on that trajectory is necessary to make the best-informed treatment decisions.
Finally, he invited everyone to take part in the APA guideline process and to review and comment on the draft statements to ensure the guidelines meet their goals to enhance evidence-based practice and provide the best possible treatment for each patient.