Usefulness and limitations of treatment guidelines in psychiatry.

The second half of the 20th century witnessed great advances in our understanding of the epidemiology and etiologies of mental illnesses. Much has also been learned about the efficacy and effectiveness of various treatments - somatic, psychotherapeutic and social. A significant challenge for psychiatry, as for all of medicine, is the incorporation of this new knowledge into the daily work of clinicians. One approach to increase the use of evidence-based treatments is the development and implementation of practice guidelines. Practice guidelines may be defined as strategies for the care of patients developed to assist clinicians in their decision making. Guidelines for the care of patients have existed for centuries. However, the recommendations in these guidelines were generally not supported by evidence, the process used in their development was not documented and there was no formal review or revision process identified. Over the last two decades, there has been an explosion in the number of practice guidelines developed in medicine. Guidelines have been developed by professional associations, by government agencies, by insurance companies and other third party payors, and by providers of care. The processes used in developing these guidelines vary widely. Some are evidencebased, some reflect a consensus of experts, while others are the opinions of one or more authors. In 1990, the Institute of Medicine published a monograph describing the elements of 'good' guidelines (1). In 1988, the American Medical Association organized a Practice Guideline Partnership comprised of 14 specialty organizations including the American Psychiatric Association (APA). This partnership also defined 'good' guidelines and identified 5 criteria that such guidelines possess. They: a) are developed by physicians in active clinical practice; b) integrate relevant research and clinical expertise; c) describe specific treatment approaches, including indicators, efficacy, safety and alternative treatment strategies; d) are reviewed and revised at regular intervals not longer than 5 years; e) after approval, are widely disseminated. In psychiatry, one of the first developers of the new style of guidelines was the Royal College of Psychiatrists of Australia and New Zealand (2). The APA began developing practice guidelines in 1990 (3). At first there was considerable concern about the project and some resistance by psychiatrists who anticipated that the use of guidelines would contribute to a culture of 'cookbook medicine'. There was also concern that the publication of guidelines would lead to increased professional liability for practitioners. However, as the project continued and clinically sound guidelines were produced by an iterative process involving a large number of members, there was a gradual increasing acceptance of the guidelines (4). The APA has now published 12 guidelines. Each guideline has been published in the American Journal of Psychiatry and is also available on the APA web site. Three of these guidelines are revisions of earlier guidelines and the Association is committed to revising the guidelines regularly, with intervals not exceeding 5 years.