Schizophrenia guidelines across the world: A selective review and comparison

Abstract

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.     

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。     

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.     

The CARE-AAT Guideline: Development and testing of a consensus-based guideline for case reports in anthroposophic art therapy

ABSTRACT

Anthroposophic art therapists (AATs) report individual cases in narratives of poor scientific quality. Good quality case reports are an important factor in the development of evidence-based practice. A guideline for scientific case reports could contribute to this. However, the recently published guideline for medical case reports (the CARE Guidelines, covering diagnosis, treatment and outcomes) is not completely suitable for AAT. This study aimed at the development of a guideline for AAT case reports. The CARE Guidelines were adjusted following the recommended steps for health reporting guidelines. The proposed adjustments are based on AAT literature and expert opinions. The face validity of the new CARE-AAT Guideline was judged by an international group of 35 AATs and 3 experts on case study methodology. Seven items of the CARE Guidelines needed specification or addition. One item (Treatment Objectives and Plan) had to be added and six items could be used without change. The face validity of the new guideline is good. The CARE-AAT Guideline is suitable for scientific case reporting of AAT practice. It is assumed to be suitable for art therapy case reporting as well. Future use of the guideline will show whether further optimisation of the guideline is needed.     

A review and commentary on a sample of 15 UK guidelines for the drug treatment of Alzheimer's disease.

BACKGROUND: There has been widespread development of clinical guidelines for the treatment of Alzheimer's disease since the introduction of donepezil in the UK in 1997. These have been developed nationally, regionally, locally and by independent groups. An independent review of guidelines available in the public domain was commissioned to provide an overview of the range and variability in the recommendations being made. METHODS: Fifteen sets of guidelines obtained from a variety of sources were reviewed in a standardized way to extract the recommendations being made in the following areas: diagnosis; investigations; the evidence base of the recommendations: initiation of drug treatment; monitoring and dose adjustment; and decision-making on maintenance or discontinuation of treatment. RESULTS: None of the documents fulfilled criteria for high-quality evidence-based guidelines. Substantial variability was evident in all areas of recommendation. All of the guidelines appeared to be based upon consensus opinion. Only one incorporated a statement of potential conflicts of interest affecting the working group who developed the guideline. CONCLUSIONS: The lack of consistency found in this sample of guidelines would inevitably lead to inequalities in the health care delivered in different areas. A national initiative is needed to encourage true evidence-based guideline development, not only on drug treatment but also on the wider issues raised such as diagnosis, investigations and the best treatment setting for delivering drug and other therapies.     

The role of group decision making processes in the creation of clinical guidelines

Abstract

Guideline development groups are an integral part of evidence-based healthcare and will remain so for the foreseeable future. There is a need for the efficient production of high-quality guidelines both to ensure high standards of care and to conserve resources. Social psychological research on group processes provides valuable information that can be applied to studying the functioning of guideline development groups, including the methods they use to develop recommendations. This article describes four key concepts in the group process literature: information sharing, systematic processing, group development, and group potential productivity. We evaluate their importance for guideline development groups and conclude with methodological suggestions for the study of these complex processes.     

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.     

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea,insomnia and sleep quality in cardiac patients: a meta-analysis

BackgroundA number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.ObjectiveTo identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.MethodsWe systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).ResultsOf the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45–0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87–0.96) but poor specificity at standard cut-off criteria.ConclusionThere are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.     

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.     

Manejo del ictus agudo. Tratamientos y cuidados específicos de enfermería en la Unidad de Ictus

ObjectiveThis study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres’ internal protocols, serving as a reference for nursing care.MethodsWe review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification.ResultsThe study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital.ConclusionsThese guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.     

Implementation of Evidence-Based Tobacco Use Cessation Guidelines in Managed Care Organizations

Background: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings.Purpose: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented.Methods: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation.Results: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined.Conclusions: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination. This research was supported by grants from the Tobacco-Related Disease Research Program (Taylor) and from the Robert Wood Johnson Foundation (Taylor and Curry).     

Problems in development and use of guidelines for clinical practice]

According to the Agency for Healthcare Research and Quality in the USA, the characteristics to be fulfilled by clinical guidelines are validity, reproducibility, reliability, clinical flexibility, clarity and scheduled review. However, most clinical guidelines do not necessarily fully satisfy these factors. I have been engaged in the development of evidence-based guidelines for the management of stroke in Japan. Problems in development of guidelines are as follows. The first is the lack of high level evidence such as randomized controlled trials, which influences recommendation grade. In the case of clinical guidelines for treatment of cerebral hemorrhage in the acute stage, the recommendation grade (C1, C2), which means a lack of sufficient scientific evidence, covered 86% of all recommendation items. The second is ease of clinical application. Evidence based clinical guidelines are not likely to be easy to use if sufficient high-level scientific evidence is not available. It must be realized that guidelines can only be applied to 60 to 95% of patients. Depending on the patient, setting, and other factors, guidelines can and should be tailored to fit individual needs. Deviations from guidelines will be fairly common and can be justified by differences in individual circumstances.     

Pharmacological interventions for the treatment of insomnia: quantitative comparison of drug efficacy

PurposeAlthough different forms of pharmacological intervention are often prescribed for insomnia disorder, the comparative efficacies among various drugs remain unclear. We therefore conducted this study to quantitatively compare the efficacy of various pharmacotherapies for insomnia by modeling.MethodsWe searched PubMed, EMBASE and Cochrane Library databases for randomized placebo-controlled trials of insomnia medications that were conducted within a designated time period (from the inception dates to May 16, 2019). Pharmacodynamic models were established to describe the time course of changes from baseline in selected sleep parameters. Sleep quality and dropout rates were also compared by a single-arm meta-analysis.ResultsIn sum, 43 studies covering 44 trials (14,535 patients) were included in the analysis. The drugs evaluated included flurazepam, quazepam, temazepam, triazolam, eszopiclone, zaleplon, zolpidem, extended-release zolpidem, suvorexant, ramelteon and doxepin. The established models revealed eszopiclone had the highest efficacy in terms of sleep latency (SL), total sleep time (TST), and sleep quality, and was also associated with the lowest dropout rates. The effect of suvorexant on the parameter ‘wake after sleep onset’ (WASO) was significantly higher than that of the other drugs analyzed.ConclusionsEach drug has its own characteristics in the treatment of insomnia, and this needs to be taken into consideration to meet individual clinical needs. These results serve as a quantitative supplement for clinical practice by reflecting the difference in efficacy of various drugs in the treatment of insomnia.     

Evidence-based guidelines: response to professor Gordon Parker's critique

OBJECTIVE: To clarify the development of the 'Australian and New Zealand clinical practice guidelines for the treatment of depression' and to discuss the critique of these guidelines. METHOD: Consideration of international practice in evidence-based medicine and rebuttal of criticisms. RESULTS: We agree with Professor Gordon Parker on fundamental issues in the treatment of depression. His main criticisms reflect his concerns about the classification of depression. We consider that many of his detailed criticisms reflect a difference of opinion on how data should be evaluated or interpreted. CONCLUSIONS: The guideline for the treatment of depression makes sound recommendations, in agreement with comparable guidelines from the US and the UK.     

《中国失眠障碍诊断和治疗指南》解读

2016年6月,中国睡眠研究会组织编制的《中国失眠障碍诊断和治疗指南》正式出版,旨在为失眠障碍的诊断与治疗提供规范化的临床参考依据。指南采用循证医学标准,基于最新的睡眠障碍国际分类第3版,强调认知行为疗法在治疗中的地位,且增加和丰富对特殊人群的评价和干预。本文拟对指南编制过程和重点内容进行详细解释和补充说明,以为临床医师更好地理解和运用指南提供必要的帮助和指导。     

The role of antiplatelet therapy in the management of ischemic stroke: implementation of guidelines in current practice

Abstract

Objective: To review and discuss evidence-based guideline recommendations for the use of antiplatelet agents for secondary prevention in patients with ischemic stroke or TIA.

Methods: A literature search was conducted on PubMed through August 2007 using combinations of the following search terms: aspirin, clopidogrel, dipyridamole plus aspirin, transient ischemic attack, secondary prevention, stroke and guidelines.

Results: Modification of risk factors such as hypertension, diabetes, hypercholesterolemia, cigarette smoking and obesity are fundamental to stroke management. Antiplatelet therapy is highly effective in reducing the risk of recurrent vascular events and is recommended over oral anticoagulants for non-cardioembolic stroke. Evidence from head-to-head comparative clinical trials versus aspirin monotherapy has shown that clopidogrel and the combination of aspirin plus dipyridamole are safe and effective therapeutic options.

Discussion: Despite the availability of evidence-based guidelines, recommended interventions are largely underutilized. Quality improvement initiatives such as the ASA's Get with the Guidelines – Stroke and the UCLA stroke PROTECT Program have demonstrated effectiveness in increasing adherence to recommended therapies and thereby improving patient outcomes.     

Implementing the revised American Psychiatric Association practice guideline for the treatment of patients with eating disorder.

Practice guidelines aspire to be authoritative statements regarding the state of the art in quality care for various clinical problems. The American Medical Association Partnership has set forth stringent parameters for guideline development by professional organizations, and these have been followed by the American Psychiatric Association in creating its practice guidelines for the treatment of patients with eating disorders. The revised edition, published in January 2000, benefitted from extensive input from a wide array of psychiatrists, psychologists, pediatricians, and other recognized experts who blended together available evidence-based practice with a considerable amount of clinical experience and consensus. These guidelines are useful for practitioners, students, and health-resource managers. Future research will continue to lead to constant upgrades.     

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2012 on the long-term treatment of bipolar disorder

Abstract

Objectives. These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults. Methods. Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A–F) and different grades of recommendation to ensure practicability were assigned. Results. Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios. Conclusions. Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.     

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.     

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.