Introduction to the Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Series

Abstract

Clinical practice guidelines (CPGs) are defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [1]. Effective guidelines must: have utility for both clinicians and patients; be developed systematically; be specifically used to assist (not dictate) clinical decision making; and be applied on a case by case basis.

Six CPGs have been developed as part of the RANZCP Clinical Practice Guideline Project to guide management of schizophrenia, bipolar disorder, depression, panic and agoraphobia, anorexia nervosa and deliberate self-harm. A parallel set of guidelines has been prepared for patients and carers (see http://www.ranzcp.org/publicarea/cpg.asp). The guidelines have been developed on the assumption that the clinician has been fully trained to:

take a history incorporating present symptoms, a full developmental and interpersonal history and assessment of current psychosocial functioning and relationships;

conduct a detailed mental state examination; and

formulate the patient's problem from a biopsychosocial perspective.

The guidelines are intended to support evidencebased practice by psychiatrists and other mental health professionals, in the context of an individualized care plan. This plan should be based on a thorough assessment and informed discussion of treatment options with the patient (who will have read the patient/carer guidelines) and, where appropriate and with consent, the carer.

Developing the guidelines

The guidelines have been developed in the framework of the relevant National Health and Medical Research Council (NHMRC) process [2–5] (Table 1) under the direction of a steering and implementation committee. Guideline teams were selected by competitive tender. The process involved thorough literature review and wide consultation in early and final draft phases. Patients were members of each guideline group and together with carers were included in the consultation process. We regret that consultation with relevant indigenous people was less extensive. It was not possible to adhere completely to the NHMRC process in terms of the extent of the consultation or economic analysis; more detail about this is provided in the introduction to the CPG summaries (see Australasian Psychiatry [6]).

Table 1.

Features of the National Health and Medical Research Council process

The most crucial aspect of guideline development is its effective implementation. This will be informed by a review of mechanisms for disseminating and implementing mental health CPGs [7] and guided by the Quality Improvement Committee of the College. We examined the transparency and effectiveness of the guideline development process and identified specific strategies in professional colleges, health systems and consumer organizations in Australia and New Zealand.

Key quality features of the RANZCP guideline series

Classification of evidence

Systematic reviews are necessary to develop evidence-based resources. These summarize randomized controlled trials (RCTs) of predefined quality into meta-analyses. Where RCTs are unavailable, other forms of evidence such as observational and case control studies and expert opinion are considered. This allows the evidence to ‘speak for itself’. The pros and cons of CPGs are discussed elsewhere [8–10], including the risks of over-reliance on them. These guidelines are attempts to distil the evidence about specialist management of specific uncomplicated conditions.

In all six guidelines, evaluation of the literature and expert opinion utilized the NHMRC recommended process (Table 2). Evidence was considered in a hierarchical manner, with greatest weight being given to level 1. Consensus processes were used in each guideline team to interpret this evidence to develop draft recommendations. The strength of evidence depends on an overall assessment of its level, quality and statistical precision. The guidelines state where there is ‘strong’, ‘reasonable’, ‘equivocal’ or ‘no’ evidence of benefit or harm of treatment.

Table 2.

Levels of evidence

Limitations of evidence

Much of the evidence underlying CPGs comes from clinical trials of uncomplicated disorders. Therein lies their strength and weakness. Routine practice is more complex and ‘practice-based’ evidence is not available to guide treatment for all possible combinations of comorbidity and psychosocial complications.

Good clinical practice requires integration of clinical judgement, knowledge of research evidence relevant to a given person and patients’ own preferences. However, they should always be offered an evidence-based treatment as part of a dialogue about treatment choices.

The guidelines highlight gaps in evidence. These do not equate to evidence that a particular treatment is not effective; that is, ‘absence of evidence is not evidence of absence’.

CPGs do not deal with the nuances of the clinicianpatient relationship, where experience and skill are paramount. Treatment involves both science and art. Guidelines are a means to summarize the science but do not dictate practice and cannot prescribe the art.

Numbers needed to treat and absolute risk reduction analyses

Statistics used in evidence-based medicine are the number needed to treat (NNT) and absolute risk reduction (ARR) (and 95% confidence intervals). The former indicates the number of people who would need to receive treatment in order to have one additional person relieved of symptoms by the selected treatment compared to the comparison treatment. A low NNT (e.g. ‘3’) indicates a relatively more effective treatment, such as the comparison between an effective antidepressant and a placebo. The ARR is the percentage difference in treatment response rate between the selected treatment and the comparator (i.e. placebo or another treatment). The more effective the treatment, the greater the ARR. The NNT is the inverse of the ARR.

Patient and carer guidelines

Providing understandable information to patients and/ or carers allows a more informed discussion about treatment preferences and will lead to a better outcome [11]. Availability of guidelines for patients and carers encourages clinicians to make regular use of the College CPGs [4, 7]. Clinicians are encouraged to provide a copy of the latter to patients and carers to assist them to engage in the treatment process and facilitate informed consent. We developed the patient/carer series by:

appointment of patient writers/reviewers by each CPG team;

commencing with consumers’/carers’ priority questions;

application of research evidence on patients’ expectations of mental health information, including a review of Australian mental health brochures [12];

ensuring that drafts met CPG criteria by appraising them against available quality appraisal instruments [4, 13];

applying epidemiology and treatment evidence from the practitioner versions and summarizing it into the patient/carer versions; and

ensuring that patients and carers wrote, oversaw the development of, or had substantial input into the preparation of their version.

Applying the evidence

The guidelines are an adjunct to good practice, not prescriptive stand-alone statements to be applied in all circumstances. Good practice requires sound assessment followed by a discussion with the patient to identify treatment options, including those evidence-based treatment options relevant for the patient. The CPGs are a resource for this discussion. The treatment chosen should reflect the discussion, informed patient preference, clinical experience and constraints on using a particular treatment. Guidelines thus inform treatment decisions, not dictate them.

As shown in Figs 1 and 2 [8], these guidelines may also be part of a self-audit quality improvement process and inform service initiatives, for example, development of clinical pathways, protocols [14–16] and standards [7], at local, state or national levels. They can also be used to guide media messages and public education about mental disorders and their effective treatments.

Figure 1.

Applying guidelines in clincial practice

Figure 2.

System application of nationally developed clinical practice guidelines

Conclusion

Clinical practice guidelines are accessible summaries of evidence for use in daily practice. Implementation requires not only a range of national, state and local mechanisms but also a commitment by clinicians to deploy these valuable resources effectively to ensure that those with mental disorders receive consistently high quality care. Carpe diem!

Footnotes

Acknowledgements

The RANZCP CPG Program was funded to develop the CPGs for use by all specialist mental health professionals by the National Mental Health Strategy, with contributions also from the NZ Ministry for Health.

References

Field

M J

Lohr

K N

. Guidelines for clinical practice: from development to use, Field

M J

Lohr

K N

. National Academy Press, Washington, DC 1992.

National Health and Medical Research Council . A guide to the development, implementation and evaluation of clinical practice guidelines. Handbook series on preparing clinical practice guidelines. National Health and Medical Research Council, Canberra 1999.

National Health and Medical Research Council . How do you put the evidence into practice: implementation and dissemination strategies. Handbook series on preparing clinical practice guidelines. National Health and Medical Research Council, Canberra 2000.

National Health Medical Research Council . How to present the evidence for consumers: preparation of consumer publications. Handbook series on preparing clinical practice guidelines. National Health and Medical Research Council, Canberra 2000.

National Health and Medical Research Council . How to review the evidence: systematic identification and review of the scientific literature. Handbook series on preparing clinical practice guidelines. National Health and Medical Research Council, Canberra 2000.

Boyce

Ellis

Penrose-Wall

Australian and New Zealand clinical practice guidelines for specialist adult mental health care: an introduction

Australasian Psychiatry 2003 11: 21–25.

Penrose-Wall

Truman

Boyce

. Considered consumer, responsive practitioner. A bi-national strategic framework for disseminating and implementing clinical practice guidelines in the mental health field. RANZCP, Sydney September, 2001, http://www.ranzcp.org/publicarea/ .

Boyce

Harris

Penrose-Wall

From good foundations. The role of treatment guidelines for psychiatrists –an overview of the RANZCP CPG Project

Australasian Psychiatry September, 2001 9: 67–75.

Pincus

H A

Zarin

D A

Evidence-based psychiatry in the United States

Australasian Psychiatry 1998 6: 119–122.

10.

Sackett

D L

Rosenberg

W MC

Gray

J AM

Haynes

R B

Richardson

W S

Evidence-based medicine: what it is and what it isn't

British Medical Journal 1996 312: 71–72.

11.

Say

R E

Thomson

The importance of patient preferences in treatment decisions –challenges for doctors

British Medical Journal 2003 327: 542–545.

12.

Evans Research . Report on the review of mental health information brochures produced under the Community Awareness Program (CAP). Commonwealth Department of Health and Aged Care, Canberra 1999.

13.

Shepperd

. The DISCERN handbook and the DISCERN instrument for judging the quality of written consumer health information on treatment choices. Oxford University Press, Oxford 1997.

14.

Baker

Morhr

J W

Nish

Tomaszewski

. Clinical pathways starter kit. Health Sciences Centre, London 1996.

15.

Holt

Wilson

Ward

. Clinical practice guidelines and critical pathways. A status report on national and New South Wales development and implementation activity. New South Wales Department of Health, June, Sydney 1996.

16.

Yellowlees

Emmerson

Denton

Wentworth

Dart

. Discussion paper: clinical pathways in mental health. Report to the Royal Australian and New Zealand College of Psychiatrists. University of Queensland, Brisbane July, 2002.