Schizophrenia guidelines across the world: a selective review and comparison

Treatment guidelines provide evidence-based recommendations to assist practitioners in specific clinical situations. They are a major tool to assure and enhance treatment quality and to overcome existing disparities. However, guideline quality itself varies and needs to be considered. Based on a former review, schizophrenia guidelines with high methodological quality were identified and examined regarding updated versions. Five guidelines were selected, of which three updates have been newly evaluated with the AGREE instrument. In addition, clinical content regarding seven core topics in schizophrenia treatment decisions was compared. Guideline quality on average is good, with highest AGREE scores for the NICE guideline. Updating of the German guideline resulted in noticeable quality improvements. Regarding content, recommendations largely correspond in five areas across guidelines, whereas discrepancies or vagueness exist in two areas due to newly emerging (drug choice) or still restricted evidence (duration of antipsychotic treatment). There are increasing efforts to develop guidelines with improved quality. Also, there is a need to equalize and improve healthcare quality across countries. Since many formal and content-related issues are 'universal', development of trans-national guidelines seems indicated. Nevertheless, core guideline recommendations should be adapted to regional conditions using available tools for adaptation.     

Comparative evaluation of clinical practice guidelines for the treatment of schizophrenia

INTRODUCTION: Many clinical practice guidelines (CPG) have been published in reply to the development of the concept of "evidence-based medicine" (EBM) and as a solution to the difficulty of synthesizing and selecting relevant medical literature. Taking into account the expansion of new CPG, the question of choice arises: which CPG to consider in a given clinical situation? It is of primary importance to evaluate the quality of the CPG, but until recently, there has been no standardized tool of evaluation or comparison of the quality of the CPG. An instrument of evaluation of the quality of the CPG, called "AGREE" for appraisal of guidelines for research and evaluation was validated in 2002. AIM OF THE STUDY: The six principal CPG concerning the treatment of schizophrenia are compared with the help of the "AGREE" instrument: (1) "the Agence nationale pour le développement de l'évaluation médicale (ANDEM) recommendations"; (2) "The American Psychiatric Association (APA) practice guideline for the treatment of patients with schizophrenia"; (3) "The quick reference guide of APA practice guideline for the treatment of patients with schizophrenia"; (4) "The schizophrenia patient outcomes research team (PORT) treatment recommendations"; (5) "The Texas medication algorithm project (T-MAP)" and (6) "The expert consensus guideline for the treatment of schizophrenia". RESULTS: The results of our study were then compared with those of a similar investigation published in 2005, structured on 24 CPG tackling the treatment of schizophrenia. The "AGREE" tool was also used by two investigators in their study. In general, the scores of the two studies differed little and the two global evaluations of the CPG converged; however, each of the six CPG is perfectible. DISCUSSION: The rigour of elaboration of the six CPG was in general average. The consideration of the opinion of potential users was incomplete, and an effort made in the presentation of the recommendations would facilitate their clinical use. Moreover, there was little consideration by the authors regarding the applicability of the recommendations. CONCLUSION: Globally, two CPG are considered as strongly recommended: "the quick reference guide of the APA practice guideline for the treatment of patients with schizophrenia" and "the T-MAP".     

Korean Clinical Practice Guideline for the Diagnosis and Treatment of Insomnia in Adults

Objective We aim to present a clinical guideline for the diagnosis and treatment of insomnia in adults by reviewing and integrating existing clinical guidelines. The purpose of this guideline is to assist clinicians who perform evidence-based insomnia treatment. Methods We selected literature that may be appropriate for use in guideline development from evidence-based practice guidelines that have been issued by an academic or governmental institution within the last five years. The core question of this guideline was made in sentence form including Patient/Problem, Intervention, Comparison, Outcome (PICO) elements. After searching PubMed, EMBASE, and medical guideline issuing agencies, three guidelines were judged to be the most appropriately reviewed, up-to-date, and from trusted sources. Results The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate the quality of the three clinical guidelines. The final outcome of the guideline development process is a total of 15 recommendations that report the strength of the recommendation, the quality of evidence, a summary of content, and considerations in applying the recommendation. Conclusion It is vital for clinical guidelines for insomnia to be developed and continually updated in order to provide more accurate evidence-based treatments to patients.     

Guidelines for psychosocial interventions in dementia care: a European survey and comparison

Objective

The effectiveness of psychosocial interventions in treating people with dementia and their carers is increasingly emphasised in the literature. Dementia guidelines should summarise the scientific evidence and best practice that is currently available, therefore, it should include recommendations for psychosocial interventions. The aims of our study were (1) to collate dementia guidelines from countries across Europe and to check whether they included sections about psychosocial interventions, and (2) to compare the methodological quality and the recommendations for specific psychosocial interventions in these guidelines.

Methods

The European dementia guidelines were inventoried. The methodological quality of the guideline sections for psychosocial interventions was assessed with the (AGREE) Appraisal of Guidelines Research and Evaluation instrument. The recommendations for specific psychosocial interventions were extracted from each of these guidelines and compared.

Results

Guidelines for psychosocial interventions were found in five of 12 countries. Guideline developers, methodological quality and appreciation of available evidence influenced the inclusion of psychosocial interventions in dementia guidelines from Germany, Italy, the Netherlands, Spain and the UK. The UK NICE SCIE guideline had the best methodological quality and included the most recommendations for psychosocial interventions. Physical activity and carer interventions were recommended the most across all guidelines.

Conclusion

The inclusion of psychosocial interventions in dementia guidelines is limited across Europe. High‐quality guidelines that include psychosocial interventions and are kept up to date with the emerging evidence are needed. Throughout Europe, special attention to the implementation of evidence‐based psychosocial care is needed in the next few years. Copyright © 2011 John Wiley & Sons, Ltd.     

Reducing variation in the pharmacologic treatment of schizophrenia: Defining acceptable standards of treatment

Clinicians are exhorted to improve the quality of care for patients with schizophrenia by applying evidence-based medication treatment guidelines. Unfortunately, although there are many guidelines, they are all more or less out of date, and their recommendations often are inconsistent, leaving clinicians uncertain about the definition of acceptable standards of care. This paper reviews existing guideline recommendations and recently published research related to two parameters of care: 1) first-line treatment of multiepisode psychosis and 2) the care of treatment-resistant patients. Its purpose is to help clinicians understand the implications of the latest research for the content of schizophrenia guidelines and for the clinical practice they are supposed to inform.     

A systematic review of clinical guidelines on choice,dose, and duration of antipsychotics treatment in first- and multi-episode schizophrenia

Abstract

Clinical guidelines provide evidence-based recommendations to regulate pharmacological treatment of psychotic disorders. However, the quality of evidence, country of origin, and publication dates of such guidelines vary, which leads to discrepancies between recommendations. This systematic review aimed to examine consensus and disparities between clinical recommendations on the choice, dose, and duration of antipsychotic treatment for first- and multi-episode schizophrenia patients. A literature search through The Cochrane Library, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Sciences, and relevant bibliographies revealed 24 guidelines that met the inclusion criteria. The guidelines indicated mostly consistent recommendations regarding the optimal dose range of antipsychotics, while guidance with regards to the choice and duration of treatment remains somewhat controversial. Current trends in guidelines emphasize that there is simply no ‘one-size-fits-all’ method to manage schizophrenia patients. Further research is needed not only to address discrepancies between guidelines, but also to justify the gap between theory and practice.     

儿童病毒性脑炎药物治疗循证指南的系统评价

目的系统评价儿童病毒性脑炎的相关指南,为临床循证用药提供参考。方法计算机检索Pub Med、EMbase、CBM、万方、CNKI、维普等数据库;以及NGC、GIN、TRIP等指南数据库和各大医学行业机构网站如CDC、IDSA、AAP、WHO、中国卫生和计划生育委员会、中国临床指南文库和中国临床指南协作网。检索时限从建库或建网至2014年10月。2位研究者依纳入与排除标准独立筛选文献,采用指南研究与评价的评审工具Ⅱ(AGREEⅡ)评价指南质量,使用组内相关系数(ICC)进行一致性检验。结果最终纳入3部指南,均为近5年发布,分别来自英国、美国和欧洲。指南最终推荐均为B级,在AGREEⅡ6个领域中"范围和目的 "得分最高,平均68.54%。得分较低的是"应用性"和"编辑的独立性"。对疑似患儿应尽早经验予阿昔洛韦治疗。确诊为单纯疱疹和水痘带状疱疹病毒性脑炎,亦推荐使用阿昔洛韦。但推荐级别不同,前者为强推荐,后者推荐强度降低。此外,单纯疱疹病毒性脑炎患儿暂不推荐使用糖皮质激素;而水痘带状疱疹,可使用激素作为备选治疗,但证据尚不充分。对于巨细胞病毒脑炎推荐更昔洛韦联合膦甲酸,不建议使用西多福韦;肠病毒脑炎可以使用普拉康纳利。结论各指南推荐的治疗病毒性脑炎的药物基本一致,但制定循证指南在编辑的独立性以及应用性上要进一步加强。     

Service user involvement in clinical guideline development and implementation: Learning from mental health service users in the UK

Abstract

The participation of service users and the public in the development of clinical guidelines is increasingly valued in international guideline programmes. This paper extends the findings of Harding et al.'s (2010) exploration of the views of service users who participated in developing NICE mental health guidelines. This analysis considered the relative value of personal versus professional knowledge and experience, the barriers to service users contributing effectively in guideline development, the unspoken ‘rules’ concerning decision making, and issues of power and group dynamics. We combine these insights with observations from research in guideline development and with advances in the recovery movement and in the shared decision-making clinical model to suggest areas of improvement in guideline development, notably: translating evidence to recommendations, optimizing the acceptability of treatment recommendations to service users, and reconciling different types of knowledge.     

Recommendations for post-stroke aphasia rehabilitation: an updated systematic review and evaluation of clinical practice guidelines

Background: Clinical practice guidelines (CPGs) have been shown to improve patient care and outcomes. For speech pathologists working with people with post-stroke aphasia, there is currently no single high-quality guideline that summarises all of the available research knowledge into recommendations to guide decision-making. While multiple stroke and aphasia guidelines exist, some are of low methodological quality, are out of date, or do not provide recommendations that specifically guide aphasia management. As such, it may be difficult for clinicians to choose one particular guideline to follow.

Aim: To identify, extract, and evaluate recommendations from high-quality CPGs to inform the management of post-stroke aphasia by speech pathologists.

Methods & Procedures: An updated systematic review of stroke and speech pathology-specific clinical guidelines was conducted in January 2015. The search included multiple databases (MEDLINE, Embase, CINAHL), guideline and stroke websites, and other sources. The quality of included guidelines was assessed using the Appraisal of Guidelines and Research and Evaluation (AGREE) II tool. Guidelines that obtained a high AGREE II “Rigour of Development” score were retained and the aphasia-relevant recommendations from these guidelines were extracted for further analysis. Recommendations were evaluated according to their applicability to aphasia and the clarity of linkages between the recommendations and underlying evidence.

Outcomes & Results: Five new guidelines were identified. Their AGREE II ratings ranged from 31.3 to 71.9, and one met the cut-off of 66.67 for further analysis. One hundred and eleven recommendations from four guidelines were extracted and evaluated. From these, 76 recommendations met the inclusion criteria, 25 of which were specifically targeted at aphasia management, the remainder being general rehabilitation principles that may apply to aphasia. Thirty-four recommendations were directly linked to evidence, and 42 were based on consensus. Research gaps were noted for goal-setting, counselling, patient and carer support, and discharge planning, indicating possible areas for future research. There were challenges in comparing recommendations from different CPGs, determining whether evidence was applicable to people with aphasia, and in identifying clear links between the evidence and some recommendations.

Conclusions: The collated 76 (34 evidence-based, 42 consensus-based) recommendations can be used by speech pathologists to guide aphasia rehabilitation. Aphasia-specific research is required in areas such as goal-setting, counselling, patient and carer support, and discharge planning.     

A comparison of UK and US guidelines for drug treatment in borderline personality disorder

Abstract

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with ‘affective dysregulation’, ‘impulsive behaviour dyscontrol’ and ‘cognitive–perceptual’ symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.     

A systematic review and evaluation of post-stroke depression clinical practice guidelines

ObjectivePost-stroke depression is a depressive mood disorder that follows a cerebrovascular accident and is a burden on stroke patients. Its management is included in clinical practice guidelines focused on stroke, and the recommended treatment is selective serotonin reuptake inhibitors in conjunction with psychotherapy. Clinical practice guidelines are recommendations used to standardize best medical practice, but there is no current evaluation of guidelines containing post stroke depression recommendations. Thus, the objective is to appraise the selected guidelines manner of development and quality.Materials and MethodsA systematic literature review across three databases and a manual google search was performed to collect guidelines that included recommendations on the management of post-stroke depression. 1236 guidelines were screened, and 27 were considered for inclusion. Considered guidelines were manually reviewed by the authors, and ultimately, 7 met inclusion criteria. The appraisal of guidelines for research and evaluation was used to evaluate these guidelines’ recommendations around post-stroke depression.ResultsThree guidelines met the threshold considered “High”, with all of them having five or more quality domains eclipse the cutoff score of 70%. Across all guidelines, the highest scoring domains were “Scope and Purpose”, “Clarity of Presentation”, and “Editorial Independence” with scores of 76.98%, 73.81%, and 91.36% respectively. The lowest scoring domains were “Applicability”, “Rigor of Development”, and “Stakeholder Involvement” with respective scores of 58.73%, 54.02%, and 43.90%.ConclusionsThe domains “Applicability”, “Rigor of Development,” and “Stakeholder Involvement” were the lowest scoring domains. These specific domains represent areas in which future guidelines could be more developed.     

Texas Medication Algorithm Project: development and feasibility testing of a treatment algorithm for patients with bipolar disorder

BACKGROUND: Use of treatment guidelines for treatment of major psychiatric illnesses has increased in recent years. The Texas Medication Algorithm Project (TMAP) was developed to study the feasibility and process of developing and implementing guidelines for bipolar disorder, major depressive disorder, and schizophrenia in the public mental health system of Texas. This article describes the consensus process used to develop the first set of TMAP algorithms for the Bipolar Disorder Module (Phase 1) and the trial testing the feasibility of their implementation in inpatient and outpatient psychiatric settings across Texas (Phase 2). METHOD: The feasibility trial answered core questions regarding implementation of treatment guidelines for bipolar disorder. A total of 69 patients were treated with the original algorithms for bipolar disorder developed in Phase 1 of TMAP. RESULTS: Results support that physicians accepted the guidelines, followed recommendations to see patients at certain intervals, and utilized sequenced treatment steps differentially over the course of treatment. While improvements in clinical symptoms (24-item Brief Psychiatric Rating Scale) were observed over the course of enrollment in the trial, these conclusions are limited by the fact that physician volunteers were utilized for both treatment and ratings. and there was no control group. CONCLUSION: Results from Phases 1 and 2 indicate that it is possible to develop and implement a treatment guideline for patients with a history of mania in public mental health clinics in Texas. TMAP Phase 3, a recently completed larger and controlled trial assessing the clinical and economic impact of treatment guidelines and patient and family education in the public mental health system of Texas, improves upon this methodology.     

Reducing the Risk of Withdrawal Symptoms and Relapse Following Clozapine Discontinuation—Is It Feasible to Develop Evidence-Based Guidelines?

Clozapine is the only antipsychotic that is effective in treatment-resistant schizophrenia. However, in certain clinical situations, such as the emergence of serious adverse effects, it is necessary to discontinue clozapine. Stopping clozapine treatment poses a particular challenge due to the risk of psychotic relapse, as well as the development of withdrawal symptoms. Despite these challenges for the clinician, there is currently no formal guidance on how to safely to discontinue clozapine. We assessed the feasibility of developing evidence-based recommendations for (1) minimizing the risk of withdrawal symptoms, (2) managing withdrawal phenomena, and (3) commencing alternatives treatment when clozapine is discontinued. We then evaluated the recommendations against the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. We produced 19 recommendations. The majority of these recommendation were evidence-based, although the strength of some recommendations was limited by a reliance of studies of medium to low quality. We discuss next steps in the refinement and validation of an evidence-based guideline for stopping clozapine and identify key outstanding questions.     

Using state administrative and pharmacy data bases to develop a clinical decision support tool for schizophrenia guidelines

Administrative and pharmacy data bases represent a largely untapped resource for clinical decision support and quality improvement. In this study, we examined the feasibility of using New York State Office of Mental Health (NYSOMH) data bases to develop an automated clinical report to support implementation of schizophrenia guidelines. First we reviewed the structure of existing data bases for capacity and limitations in supporting guideline implementation. Second, we identified schizophrenia guideline recommendations and adherence measures that would be the focus of our implementation. Third, a preliminary report was programmed, based on operational definitions of the guideline recommendations. Finally, we developed user groups to define content and format of new reports, through an iterative process of field testing, feedback, and revision. Our experience suggests that administrative and pharmacy data bases, despite their limitations, can be used to develop guideline-based clinical decision support tools for schizophrenia with high physician acceptability.     

Quality Assessment of Physical Activity Recommendations Within Clinical Practice Guidelines for the Prevention and Treatment of Cardio-metabolic Risk Factors in People With Schizophrenia

The aim of this review was to assess the quality of physical activity recommendations within clinical practice guidelines for the prevention and treatment of the cardio-metabolic risk factors in schizophrenia. Several databases were searched from their inception through July 2010. The Appraisal of Guidelines for Research and Evaluation instrument was used for the quality assessment. Twelve recommendations met all the in- and exclusion criteria. The overall agreement of the quality assessment using the intraclass correlation coefficient was 0.90. Comparison identified considerable variation in the quality of the content. Based on quality assurance standards, only one of 12 guidelines was recommended. Differences on in-depth analysis suggest a lack of consistency in relation to information about the potential role of physical activity in reducing cardiometabolic risks in schizophrenia. High quality recommendations are highly needed along with specific practical advice for persons with schizophrenia, family members and health care professionals.     

Improving outpatient treatment in schizophrenia: effects of computerized guideline implementation—results of a multicenter-study within the German Research Network on Schizophrenia

Schizophrenia clinical practice guidelines are developed to provide expert- and evidence-based advice to practicing psychiatrists in order to improve the management of this disorder. However, the application of these guidelines in everyday health care can still be described as nonsatisfying. Within the project “Guideline-supported quality management in outpatient treatment”, we investigated whether guideline adherence and quality of outcome can be improved by implementing a computer-based, guideline-oriented decision-support system. Therefore, a disease-specific decision-support system was developed interactively presenting guidelines to support the physicians decision-making process during the treatment of schizophrenia patients. We evaluated the system in a control group design: An experimental group consisting of 15 psychiatrists in private practice used the decision-support system, thus documenting the treatment of schizophrenic patients. Guideline-based algorithms were interactively and case specifically displayed on the PC-screen as soon as predefined triggers were met. A first control group in Munich provided treatment-as-usual, documenting the treatment via paper–pencil. Two further physician groups served as additional comparison groups: one also documented electronically using the decision-support system, however without receiving electronic guideline support, the second group carried out traditional quality circles while also using the paper–pencil approach. As a result of the intervention, we observed a strong initial but time-limited improvement with respect to the core aspects of outpatient treatment in schizophrenia in the experimental group. The findings suggest that decision-support systems, despite their limitations, can be used to enhance treatment outcome in schizophrenia outpatient care.     

Treatment of adult patients with schizophrenia and complex mental health needs – A national clinical guideline

Background and aim: The Danish Health and Medicines Authority assembled a group of experts to develop a national clinical guideline for patients with schizophrenia and complex mental health needs. Within this context, ten explicit review questions were formulated, covering several identified key issues. Methods: Systematic literature searches were performed stepwise for each review question to identify relevant guidelines, systematic reviews/meta-analyses, and randomized controlled trials. The quality of the body of evidence for each review question was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Clinical recommendations were developed on the basis of the evidence, assessment of the risk-benefit ratio, and perceived patient preferences. Results: Based on the identified evidence, a guideline development group (GDG) recommended that the following interventions should be offered routinely: antipsychotic maintenance therapy, family intervention and assertive community treatment. The following interventions should be considered: long-acting injectable antipsychotics, neurocognitive training, social cognitive training, cognitive behavioural therapy for persistent positive and/or negative symptoms, and the combination of cognitive behavioural therapy and motivational interviewing for cannabis and/or central stimulant abuse. SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously. Where no evidence was available, the GDG agreed on a good practice recommendation. Conclusions: The implementation of this guideline in daily clinical practice can facilitate good treatment outcomes within the population of patients with schizophrenia and complex mental health needs. The guideline does not cover all available interventions and should be used in conjunction with other relevant guidelines.     

急性缺血性卒中相关性肺炎的管理相关循证指南的AGREEⅡ质量评价

目的 评价预防急性缺血性卒中相关性肺炎相关指南的质量,为科学系统制定我国的临床指南提供参考.方法 按照纳入、排除标准纳入数据库及网站检索的国内外有关预防急性缺血性卒中相关性肺炎的临床指南,并按照国际公认的指南评价工具(Appraisal of Guidelines for Research and Evaluation...     

Employer Best Practice Guidelines for the Return to Work of Workers on Mental Disorder–Related Disability Leave: A Systematic Review

Objective:

There has been an increasing number of employer best practice guidelines (BPGs) for the return to work (RTW) from mental disorder–related disability leave. This systematic review addresses 2 questions: 1) What is the quality of the development and recommendations of these BPGs? and 2) What are the areas of agreement and discrepancy among the identified guidelines related to the RTW from mental illness–related disability leave?

Method:

A systematic literature search was performed using publically available grey literature and best practice portals. It focused on the RTW of workers with medically certified disability leave related to mental disorders. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) was used to assess the quality of the development and recommendations of these BPGs.

Results:

A total of 58 unique documents were identified for screening. After screening, 5 BPGs were appraised using AGREE II; 3 BPGs were included in the final set. There were no discrepancies among the 3, although they were from different countries. They all agreed there should be: 1) well-described organizational policies and procedures for the roles and responsibilities of all stakeholders, 2) a disability leave plan, and 3) work accommodations. In addition, one guideline suggested supervisor training and mental health literacy training for all staff.

Conclusion:

Although there were no discrepancies among the 3 BPGs, they emphasized different aspects of RTW and could be considered to be complementary. Together, they provide important guidance for those seeking to understand employer best practices for mental illness–related disability.     

Psychosocial skills training for schizophrenia: lessons from the laboratory

A large body of research supports the efficacy of psychosocial treatments for schizophrenia, particularly learning-based therapies. The Schizophrenia Patient Outcomes Research Team recommended that cognitive-behavioral therapies be used in schizophrenia, and skills training was included in the practice guideline for treating patients with schizophrenia published by the American Psychiatric Association. This article provides an updated review of empirical studies of psychosocial skills training, showing its value in treating patients with schizophrenia as well as its broader clinical effectiveness. Data supporting the efficacy of psychosocial skills training continue to accumulate. Such programs should continue to be included in best practices guidelines and treatment recommendations for schizophrenia. Future clinical service research could be directed toward integration of skills training with other psychosocial treatment methods.