Abstract
The publication of guidelines has become a major undertaking for many medical organizations. They have been inspired by the headlong rush into evidence-based medicine, the need to justify treatments to health insurance companies and also to avoid involvement in the ever-increasing field of medical negligence litigation.
They may serve also to satisfy the needs of intelligent and curious patients and to provide comfort as the distillation of current wisdom for an upcoming generation of trainees. Their primary goal, however, is to improve the practice of many clinicians and thus to enhance patient care and clinical outcome.
In a recent thoughtful overview of evidence-based medicine [1], it was stated that the RANZCP was the first medical specialty group to develop clinical practice guidelines. It went on to say that ‘psychiatry now has a substantial evidence base and the proportion of treatment decisions in psychiatry which are based on randomised controlled trial evidence is similar to that in general medicine’. Hence there is a firm foundation for guidelines in our specialty.
Nonetheless, the genre of clinical guidelines is not without its critics, and not least in psychiatry. It is claimed that they are unduly restrictive of clinical choice. It is feared that they will leave many clinicians prey to legal challenge. It is also held by many doctors that the guidelines of today will become the implacable dogma of tomorrow.
These important concerns are partly dealt with in the APA Statement of Intent. This offers the partial disclaimer that ‘guidelines are not intended to be construed or to serve as the standard of medical care. [These]… are determined on the basis of all clinical data available for an individual case…’ This statement is likely to mollify few who are critical of the power inherent in guideline publications.
By way of solace, the APA statement goes on: ‘some medical specialities that have been developing guidelines over the past two decades report that guidelines seem to have had the positive effect of fewer claims, and, for at least one specialty, lower malpractice insurance premiums’. They go on to say that monitoring by the APA since 1993 has failed to elicit ‘any trends suggesting an increase in the number or severity of malpractice claims…’
The crux of the concern that many clinicians have about guidelines derived from evidence-based medicine and their application to everyday practice was well expressed in an editorial recently [2]. This focused upon these differences stating ‘… it is therefore important to address unavoidable departures from ideal conditions and to design robust interventions that will remain effective in practice settings’.
These guidelines, the APA states are ‘to help practising psychiatrists determine what is known today about how best to help their patients’. Having emphasized the contemporary nature of the advice given, it is surprising that none of the 10 guidelines offered in this compendium provide a specific publication date, despite two being published as second editions.
The organization of each of the 10 guidelines in this volume is similar. Each starts with a summary of recommendations, followed by a description of the illness concerned, treatment principles and formulation of a treatment plan. Then follows a discussion of clinical and environmental features influencing treatment, research directions and a list of contributors. Each guideline then finishes with a huge number of references, usually several hundred long! Despite this awesome list, every reference is nonetheless coded according to the nature of the evidence provided by the paper concerned (e.g. review, randomised trial, case report, etc.).
The text includes guidelines for: psychiatric evaluation of adults; treatments for delirium; Alzheimers and other dementias of late life; substance-use disorders (alcohol, cocaine and opioids); nicotine dependence; schizophrenia; major depressive disorder; bipolar disorder; panic disorder and eating disorders.
The more important omissions include the personality disorders, generalized anxiety, phobias, obsessive– compulsive disorder and childhood disorders.
The overall product is of course similar to a textbook of general psychiatry, albeit incomplete. The layout, which is unrelentingly repeated for each chapter is unusually dull, being totally unrelieved by illustrations or even flow diagrams. There is also some inevitable repetition owing to the juxtaposition in this volume of closely related disorders, for example major depression and bipolar illness.
There are relatively few points of specific criticism of the treatments offered. The length of treatment for recurrent major depression is mentioned as only 2 to 3 years. The claimed equality of efficacy for both behaviour therapy and for medication in panic disorders is open to challenge. The increasingly recognized problems of obesity, diabetes and cardiac dysfunction with some of the atypical antipsychotics go unmentioned. It is questionable that a psychiatric publication should devoteover 10% of its space to the management of nicotine dependence, when this scourge is almost entirely dealt with at a general practice level.
Overall, this bargain-priced volume provides the active clinician with a major resource for many of the more common psychiatric disorders. Despite some shortcomings, it offers an enormous amount of carefully refined knowledge together with vast bibliographies unlikely to be found elsewhere.
These features, combined with the fact that the guidelines are the official pronouncement of the world's largest psychiatric body, make this text a force majeur. It is a compendium that is likely to enjoy a wide circulation and to have much influence.