a comparison of guidelines for the treatment of schizophrenia

7/27/2019 A Comparison of Guidelines for the Treatment of Schizophrenia

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PSYCHIATRIC SERVICESo

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July 2002 Vol. 53 No. 7888

Although the clinical and admin-istrative rationales for the use ofguidelines in the treatment ofschizophrenia are convincing,meaningful implementation hasbeen slow. Guideline characteris-tics themselves influence whetherimplementation occurs. The au-thors examine three widely dis-tributed guidelines and one set ofalgorithms to compare character-istics that are likely to influenceimplementation, including theirdegree of scientific rigor, com-prehensiveness, and clinical ap-plicability (ease of use, timeliness,specificity, and ease of opera-tionalizing). The three guidelinesare the Expert Consensus Guide-line Series Treatment of Schizo-phrenia; the American Psychi-

atric Associations PracticeGuideline for the Treatment ofPatients With Schizophrenia; andthe Schizophrenia Patient Out-comes Research Team (PORT)treatment recommendations. Thealgorithms are those of the TexasMedication Algorithm Project(TMAP). The authors outline thestrengths of each and suggest howa future guideline might build onthese strengths. (Psychiatric Ser-

vices 53:888890, 2002)

In the past decade, practice guide-lines have been developed for thetreatment of many chronic illnesses, in-cluding schizophrenia. Guidelines aredesigned to assist practitioners in mak-ing appropriate health care decisionsby synthesizing the treatment litera-ture into a usable form and facilitatingthe transfer of research into practice.Guidelines have also been used to con-trol practice variation, to lower costs,and to evaluate care processes (1,2).

Despite the tremendous promise oftreatment guidelines, however, im-plementation has been difficult toachieve (3). Guideline characteristics,such as clarity, complexity of treat-ment recommendations, perceivedcredibility, and organizational spon-sorship, have been shown to affect cli-nicians acceptance of guidelines (3

5). The Institute of Medicine taskforce described a good guideline asone that has validity, reliability, repro-ducibility, applicability, clarity, sched-uled review, good documentation,and multidisciplinary input (6).

Comparison of guidelinesTo compare characteristics that arelikely to affect implementation, we ex-amined three nationally prominentpractice guidelines and one set of algo-rithms: the Expert Consensus Guide-

line Series Treatment of Schizo-phrenia (7), the American PsychiatricAssociations (APA) Practice Guide-line for the Treatment of Patients WithSchizophrenia (8), the SchizophreniaPatient Outcomes Research Team(PORT) treatment recommendations(9), and the Texas Medication Algo-rithm Project (TMAP) algorithms(10). We compared them on degree ofscientific rigor, comprehensiveness,and clinical applicability.

We believe this comparison will as-sist the decision-making process forpractitioners and health care organi-zations that are considering the im-plementation of guidelines and willinform the development of futureguidelines.

Scientific rigor

Guidelines developed with a high de-gree of scientific rigor are likely to bevalid, reliable, and reproducible. Ideal-ly, guideline developers should specifytreatment questions, conduct an exten-sive structured literature search, assessthe quality of the studies identified inthe search, report how the studies syn-thesized the scientific evidence, makekey data available for readers, and labelthe strength of the evidence for eachtreatment recommendation.

The guidelines produced by APAand by PORT are the most scientifical-ly rigorous of those we examined. Thedevelopers of these guidelines con-ducted extensive structured literaturereviews and considered study designand quality in making their recom-mendations. They also coded each rec-ommendation to indicate the strengthof the supporting evidence and includ-ed a list of references. However, nei-ther set of developers published for-mal evidence tables, and only PORT

specified how expert review was incor-porated into the final guideline.

The developers of the Expert Con-sensus guideline and of the TMAP al-gorithms conducted limited literaturesearches and did not code recom-mendations to indicate the level ofsupporting evidence. Indeed, the Ex-pert Consensus guideline was devel-oped specifically to provide assistanceto clinicians in areas in which scientif-ic evidence was weak or lacking.

A Comparison of Guidelines forthe Treatment of SchizophreniaKaren K. Milner, M.D.

Marcia Valenstein, M.D., M.S.

The authors are clinical assistant profes-sors in the department of psychiatry of theUniversity of Michigan Health System,B1D102, UH, University of MichiganHealth System, 1500 East Medical CenterDrive, Ann Arbor, Michigan 48109-0020(e-mail, [email protected]). Dr. Valen-

stein is also affiliated with the Ann ArborVeterans Affairs Health Services Researchand Development Center for Excellence.

Brief Reports


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Comprehensiveness

Comprehensive guidelines for thetreatment of schizophrenia addressmore phases of the illness, discuss awider variety of treatment modalities,and make greater numbers of specific

recommendations. They also havegreater depth, with recommendationsreflecting previous treatment trialsand responses. Ideally, costs and re-source allocation are also considered.

Literature review. The APA

guideline has the most comprehen-sive literature review, with an exten-sive text summary of the treatmentliterature and an exhaustive list of ref-erences. The PORT guideline refer-ences detailed review articles, where-



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Table 1

Comparison of the American Psychiatric Associations Practice Guideline for the Treatment of Patients With Schizophre-nia, the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations, the Expert ConsensusGuideline Series Treatment of Schizophrenia, and the Texas Medication Algorithm Project (TMAP) algorithms

Characteristic APA guideline PORT recommendations Expert Consensus guideline TMAP algorithms

Scientific rigorStructured literature Yes Yes Noused existing guide- No

review with specific lines and limited searchinclusion and exclu- to identify areas in which

sion criteria evidence is lackingSpecified criteria for No Yes No No

assessing quality ofstudies

Specified how evidence Yesexpert opin- No Yesused a quantitative Nowas synthesized ion was used to method to synthesize

synthesize evidence expert opinionRated level of support- Yesa Yesb No Noing evidence for eachrecommendation

ComprehensivenessNumber of recom- 79c 30 More than 300d 30 to 40

mendationsRecommendations con- Several recommen- Few recommendations Many recommendations All recommendations

tingent on patients dations take his- take history into take history into account take history into

history tory into account account accountExtensive literature Extensive literature Extensive literature re- No literature review included No literature reviewreview review and refer- view but referenced included

ences included in onlythe guideline itself

Phases of illness Acute and main- Acute and maintenance Acute and maintenance Acutetenance

Variety of treatment Extensive summaries Many treatment modal- Extensive summaries of Pharmacotherapy onlymodalities of treatment mo- ities addressed, in- treatment modalities

dalities cluding vocationalrehabilitation, phar-macotherapy, psycho-social, and family in-terventions

Comorbid conditions Extensive Minimal Moderate MinimalCost and resource con- No No No No

siderationsClinical applicability

Format Literature review Numbered recommen- Tables Algorithmsdations

Easy to use No Yes Yes YesDate of scheduled Scheduled every None scheduled Reviewed in 1999 after Updated as new anti-

review three to five years three years psychotics drugs areintroduced

Concise and easily No Yes No Yesoperationalized

a Three rating levels: recommended with substantial clinical confidence; recommended with moderate clinical confidence; and options that can be rec-ommended on the basis of individual circumstances

b Three rating levels: good research-based evidence, with some expert opinion, to support the recommendation; fair research-based evidence, with sub-

stantial expert opinion, to support the recommendation; and recommendation based primarily on expert opinion, with minimal research-based evi-dence but significant clinical experience

c A number of less formal recommendations are included in the APA guidelines literature review.d The Expert Consensus guideline includes first-, second-, and third-line treatment options, totaling more than 300 recommendations.


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as the Expert Consensus guidelineand the TMAP algorithms includeonly limited literature reviews and se-lected references.

Number and depth of recom-mendations. The APA and ExpertConsensus guidelines make the mostspecific treatment recommendations,and PORT makes the fewest. Only aminority of the APA and PORT rec-

ommendations are contingent on apatients treatment history. In con-trast, the recommendations listed inthe TMAP algorithms are based ex-clusively on the patients treatmentand response history.

Phases of the illness. The APA,PORT, and Expert Consensus guide-lines include specific recommenda-tions about treatment of the acuteand maintenance phases of schizo-phrenia. TMAP indicates that its al-gorithms are suitable for any patientbeginning medication treatment ortaking a medication without a satis-factory response.

Content. The APA guideline in-cludes several recommendationsabout pharmacological management,group and individual therapy, voca-tional rehabilitation, and specific psy-chosocial interventions. The PORTrecommendations focus mainly onpharmacotherapy, but recommenda-tions are also made for family inter-

ventions, psychological interventions,vocational rehabilitation, and casemanagement. The Expert Consensusguideline addresses both pharmaco-logical and psychosocial interventionsand offers recommendations aboutthe intensity or location of nonphar-macological services. In contrast, theTMAP algorithms address only thepharmacological management ofschizophrenia.

Costs. None of these guidelines in-clude specific considerations about

costs and resource allocation in theirrecommendations, although the APAguideline notes that the advantages ofthe newer antipsychotic medicationsshould be balanced against theircosts, the PORT recommendationsrefer to the costs of assertive commu-nity treatment and clozapine, and theExpert Consensus guideline includesa policy section that recommends in-terventions to increase the cost-effec-tiveness of mental health services.

Clinical applicability

Ease of use. The algorithmic formatemployed by TMAP makes it the eas-iest to use. The Expert Consensusguideline, designed to be user-friend-ly, lists recommendations in tabularform. The numbered PORT recom-mendations are quickly assimilated.The APA guideline, written in theform of a literature review, is more

difficult to assimilate and use.Timely review. The APA guideline,

published in 1997, was based on re-views of the scientific literature up to1995. Revisions are scheduled atthree- to five-year intervals. ThePORT was based on literature reviewsup to 1993, and no revisions are sched-uled. The Expert Consensus guidelinewas originally published in 1996 andwas updated in 1999. TMAP revisionsare made available at the TMAP Website as new antipsychotic agents are in-troduced; the latest revision occurredin December 1999.

Specificity or ease of opera-tionalizing. Guidelines that are spe-cific and can be operationalized asrate-based monitors lend themselvesto benchmarking and the establish-ment of best-practice parameters.Both the TMAP algorithms and thePORT recommendations are explicit,specific, and easily operationalized.The Expert Consensus guidelines are

more general, and the APA guidelinesare almost didactic in format, makingthem more difficult to operationalize.

DiscussionAn ideal guideline for the treatment ofschizophrenia would combine the bestfeatures of each of these efforts. Itwould be derived from a comprehen-sive literature review and would ex-plicitly assess the quality of supportingresearch studies and the methods usedfor synthesizing evidence. Evidence

tables would be constructed and pub-lished. Although both evidence-basedand expert opinion would be incorpo-rated, there would be a clear delin-eation between the two.

The ideal guideline would make rec-ommendations not only for the phar-macological management of schizo-phrenia but also for assessment andpsychosocial interventions during boththe acute and the maintenance phasesof the illness. Treatment recommen-

dations would take into account im-portant demographic, clinical, andpsychosocial issues. Cost considera-tions would be included. Recommen-dations would be summarized in aconcise, user-friendly format, and sug-gestions would be made about how theguidelines might be operationalized asquality monitors. Guidelines would berevised at three-year intervals.

Guidelines that address the factorsdescribed in this review may be moreeffective in changing practices. How-ever, even excellent guidelines willrequire additional support, such asacademic detailing and provider re-minders, if best practices are to bewidely disseminated. o

References

1. Margolis CZ: Solving clinical problems usingclinical algorithms, in Implementing ClinicalPractice Guidelines. Edited by Margolis CZ,

Cretin S. Chicago, American Hospital Asso-ciation Press, 1999

2. Smith TE, Docherty JP: Standards of careand clinical algorithms for treating schizo-phrenia. Psychiatric Clinics of North Ameri-ca 21:203220, 1998

3. Davis DA, Taylor-Vaisey A: Translatingguidelines into practice: a systematic reviewof theoretic concepts, practical experience,and research evidence in the adoption ofclinical practice guidelines. Canadian Med-ical Association Journal 157:408416, 1997

4. Solbert LI, Brekke ML, Fazio CJ, et al:Lessons from experienced guidelines imple-menters: attend to many factors and use mul-

tiple strategies. Joint Commission Journal onQuality Improvement 26:171188, 2000

5. Hayward RS: Clinical practice guidelines ontrial. Canadian Medical Association Journal156:17251727, 1997

6. Field MY, Lohr KN (eds): Clinical PracticeGuidelines: Directions for a New Agency.

Washington, DC, Institute of Medicine, Na-tional Academy Press, 1990

7. McEvoy JP, Scheifler PL, Frances A: TheExpert Consensus Guidelines Series: treat-ment of schizophrenia. Journal of ClinicalPsychiatry 60(suppl 11):180, 1999

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al: American Psychiatric Association practiceguideline for the treatment of patients withschizophrenia. American Journal of Psychia-try 154 (suppl 4)163, 1997

9. Lehman AF, Steinwachs DM, and the co-in-vestigators of the PORT project: Translatingresearch into practice: the Schizophrenia Pa-tient Outcomes Research Team (PORT)treatment recommendations. SchizophreniaBulletin 24:110, 1998

10. Miller AL, Chiles JA, Chiles JK, et al: TheTexas Medication Algorithm Project(TMAP) schizophrenia algorithms. Journalof Clinical Psychiatry 60:649657, 1999



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a comparison of guidelines for the treatment of schizophrenia

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