For the first time, the American Psychological Association has launched an initiative to develop evidence-based clinical treatment guidelines. The Council of Representatives approved the move at its February 2010 meeting. Since then, a nine-member steering committee has been formed that chose depression and obesity as the first topics to take on.
“The APA has been talking about treatment guidelines for quite a few years,” says Jeffrey Magnavita, Ph.D., ABPP, of Glastonbury, Conn., the only full-time practitioner on the steering committee. “APA realized if we’re not the ones leading the movement, other groups would do it without the same level of empirical veracity.”
APA draws a distinction between practice guidelines, which “address the conduct of clinical practice with particular populations or in particular settings” (APA Practice Update; July 14, 2011) and treatment guidelines, which are specific recommendations around clinical interventions for different disorders based on a survey of the available literature.
“What good treatment guidelines do is synthesize the research literature to make it usable for clinicians and to help them integrate new knowledge into what they already know,” says Lynn Bufka, Ph.D., of the APA’s Practice Directorate.
While APA guidelines are expected to become the standard for psychological practice, the organization is not embarking on the effort in isolation. A process for developing clinical guidelines has been developed by the Institute of Medicine that starts with an independent “systematic review” of the thousands of relevant research articles and APA intends to mirror that process to end up with credible guidelines that are acceptable to the field, Bufka says.
Nor is APA averse to exploring potential partnering opportunities. The federal Agency for Healthcare Research and Quality (AHRQ) conducts systematic reviews for providers, payers and the public and APA could piggyback on its results. The International Society for Traumatic Stress Studies has developed PTSD guidelines. Other organizations that relate to behavioral health have pursued guidelines in their specialties and APA will look into formal or informal collaborations, Bufka says. APA has even had conversations with the American Psychiatric Association where the two organizations’ interests converge.
Each guideline is expected to take 18 to 24 months to develop and could cost $200,000, Bufka says. APA has made an initial three-year funding commitment to develop three guidelines. APA will use multiple channels for getting the guidelines into the hand of users, including a dedicated Web site [www.apa.org/about/offices/directorates/guidelines/clinical-treatment.aspx], American Psychologist magazine and even smartphone apps. Planners expect the launch of the first guideline to create momentum.
Given the time and expense involved, steering committee members deliberated over which conditions to tackle first. They developed a rating scale that looked at prevalence, societal burden, available research, what other treatment guidelines had to offer and so on. Depression offers an opportunity to provide an alternative to the American Psychiatric Association’s medication-oriented guideline and the comorbidities associated with both depression and obesity cut across many psychological diagnostic categories and will be addressed in the APA guidelines, Magnavita says.
Jennifer Lish, Ph.D., director of the Worcester (Mass.) Center for Cognitive Behavioral Therapy, welcomes the development of science-based guidelines because the psychoanalytic techniques she learned while getting her doctorate in the 1980s didn’t help her patients. She turned from clinical work to research, which gave her unique insight into which new therapies worked and she re-trained as a cognitive behavioral therapist.
“I think it’s shameful that people in our profession continue to practice outmoded treatments instead of doing evidence-based psychotherapy, for instance, for kids with OCD, playing cards and board games instead of doing Exposure and Response Prevention,” Lish says. “It will be considered malpractice in 10 years.”
Mark Hegel, Ph.D., co-director of adult outpatient services and psychiatry at Dartmouth-Hitchcock Medical Center, helped the Foundation for Informed Medical Decision Making develop the depression decision-aid tool. He says treatment guidelines will enhance clinicians’ and consumers’ ability to make sound decisions.
“There’s so much research out there that we’re almost shooting ourselves in the foot not to put out guidelines to say these are the things we know that work,” Hegel says.
In addition to private practices, Hegel says guidelines have a place in medical organizations to help design service-delivery systems that deploy limited resources most effectively. He uses evidence-based standards in evaluating the quality of care his staff therapists deliver to patients. Guidelines can enlighten an organization’s primary care physicians, he adds.
“Over the years, PCPs have come to know which therapists are providing evidence-based treatments, which helps them be more specific about where to refer patients,” Hegel says. “I know from experience they greatly appreciate the ability to do that.”
APA officials understand that guidelines might not be universally embraced. Some controversy stems from the fear that guidelines could constrain how therapists practice or be misperceived as “manualized” treatment.
“Guidelines should not be so rigid to say, `here’s what you must do for every patient,’ but rather to provide a framework to point a clinician or patient in the right direction based on what the research shows,” Bufka says.
Others worry that guidelines could provide ammunition for insurance gatekeepers to deny payment, particularly considering that guidelines will likely be incorporated into electronic health records. There is concern that guidelines could be biased toward treatments that have attracted the most research.
Such concern is why the systematic reviews will be conducted to the highest professional standards and why psychologists should be watching for opportunities to participate in guideline development, planners say.
“Email us,” Bufka says. “We check our mailbox every day.”
By Nan Shnitzler