One way to enhance the quality of our care of patients is to learn and implement expert practice guidelines. But there are some problems. First of all, there are so many guidelines out there that it is hard to know which ones to learn. A related issue is that some guidelines are funded by drug companies standing to benefit financially from the recommendations. This doesn’t necessarily mean the guidelines are biased, but it has caused quite a bit of controversy. For example, the widely disseminated Texas Medical Algorithm Project (TMAP), which publishes treatment algorithms for depression, bipolar disorder, and schizophrenia, and which is partly funded by drug companies, has come under fire in its home state. The Texas Attorney General accused Janssen of using TMAP as a marketing tool for Risperdal, and recently ordered that the use of the guidelines for children be halted in the state.
Aside from the confusing panoply of guidelines, there is the issue of whether they actually change our clinical practice. Apparently, they usually don’t. That’s the conclusion of a recent review of guideline implementation studies. Of 18 studies that measured whether psychiatrists actually changed their prescribing behaviors after being taught guidelines, most found either no effect, or a very modest effect (Weinmann S, et al., Acta Psychiatric Scand 2007; 115 (6): 420-433). Interestingly, one of the only successful guidelines in this review was the TMAP, which significantly altered prescription patterns (Miller AL, et al., Schizophr Bull 2004;30:627-647.) But whether the altered behavior was truly evidence-based, rather than marketing-based, remains in dispute.
The good news is that recently two articles have been published on the successful implementation of guidelines in psychiatry. We’ll review these studies below. The TMAP studies are older, but still worth reading, and the TMAP algorithms have been updated, and can be accessed freely at http://www.dshs.state.tx.us/ mhprograms/TMAPtoc.shtm. The APA treatment guidelines are also freely accessible at http://www.psych.org/ MainMenu/PsychiatricPractice/ PracticeGuidelines_1.aspx. These are long and not particularly practical documents, although shorter reference versions are available for purchase on the same site.
Guidelines for Inpatient Care of Schizophrenia
In one study conducted in Germany, researchers examined key indices of treatment of schizophrenia in inpatient settings both before and after the implementation of a prominent German treatment guideline (Weinmann S, et al., J Clin Psychiatry 2008;69:1299-1306). The German Schizophrenia guidelines initially received support from four drug companies, but members of German psychiatric associations protested so much that the entire sum was paid back to the companies, according to an email communication from the first author of this article.
In order to make the guidelines more likely to stick, researchers boiled the huge source document down to a small number of key treatment recommendations, mostly having to do with avoiding polypharmacy, avoiding unnecessarily high doses, and adequately treating EPS (see box). The guidelines were taught to all staff in four psychiatric hospitals by giving them copies of the guidelines, doing two 90 minute slide presentations, and hosting17 biweekly “quality circles,” which entailed 90 minute training meetings about specific guideline items.
Obviously, a lot of effort was put in to make sure the psychiatrists understood the guidelines. However, they were not forced to follow them and were allowed their own clinical discretion in making decisions for individual patients.
Did teaching the guidelines affect the care provided? It did. The rate of antipsychotic monotherapy at discharge increased from 39.5% to 67.6%, and the incidence of extrapyramidal side effects decreased from 26.3% to 7%. In addition, patients in the post-intervention group showed more symptomatic improvement on the PANSS score. Finally, patients treated in accordance with the guidelines were much more adherent to treatment. The proportion of patients who “cooperated actively” in taking medication jumped from 29.2% to 67.2%.
Guidelines for Outpatient Care of Depression
Another study from Europe, this one from Sweden, shows that a similar guideline implementation process can be successfully applied for the treatment of depression (Forsner T et al., BMC Psychiatry 2008;8:64).
Six psychiatric clinics in Stockholm volunteered to be part of this study. Four of the clinics were designated as intervention clinics, and two as control clinics. The staff of the intervention clinics were given copies of depression treatment guidelines (developed by the Stockholm Medical Advisory Board), along with seminars, regular feedback, and academic visits. The control clinics were simply given copies of the guidelines without training.
The guidelines focused on practices such as the use of standardized rating scales at each visit, a written treatment plan, documentation of antidepressant medication, structured suicide assessments, and documentation of the treatment outcome (see box).
Researchers reviewed charts to determine compliance with these guidelines at baseline, and then again six months after the guideline training was done. A total of 725 patient records were examined, 365 before implementation and 360 six months later. In the control clinics, they found essentially no improvement in practices over the course of the study. But in the intervention clinics, improvements were seen in all items, and some were dramatic. The proportion of clinicians using standardized rating instruments for depression, substance abuse and suicidality doubled or nearly doubled. A global compliance score increased by 51% in the intervention group, while it decreased by 4% in the control group.
The bottom line is that it is possible to improve your practice by paying attention to a basic checklist of good practices. Some of these practices are easy to implement (such as documenting symptoms and starting antidepressant treatment with depressed psychotic patients) while others are more challenging (such using standardized rating scales consistently). Guidelines are flexible; for example, many would substitute evidence-based psychotherapy for antidepressant medication. But simply taking a structured approach to treatment may, in itself, improve the consistency of your results.
TCPR VERDICT: Don’t just read guidelines – use them!