Unsolicited treatment guidelines keep landing on the desk of Daniel J. Abrahamson, PhD. The managed-care companies he works with all have their own guidelines for treating patients with depression, for example. Various professional societies he belongs to use different guidelines. And the Medicare carrier in Connecticut has its own suggestions about the way to treat patients.
"Guidelines are proliferating faster than dandelions on a spring lawn," says Abrahamson, administrative director at the Traumatic Stress Institute in South Windsor, Conn. "And it's not just the sheer volume but the inconsistencies. Trying to cull what's useful in them can be mind-numbing."
Driven by converging trends toward evidence-based medicine and cost-containment, guidelines recommending specific treatment strategies are becoming ubiquitous. Government agencies, professional societies, managed-care organizations and even actuarial firms are all producing guidelines whose quality, scope and length vary widely.
Although APA has chosen not to add to the deluge, the association is working to help practitioners evaluate any guidelines they receive. And psychologists around the country are getting involved in other organizations' guideline development projects, ensuring that psychology has a voice at the table.
Meanwhile, a key question remains: Are these guidelines really useful?
The push to produce clinical guidelines began over a decade ago, explains Christopher J. McLaughlin, director of professional development in APA's Practice Directorate. Concerned about variations in practice, the health-care community hoped to improve patient care and reduce costs by reviewing the empirical evidence, developing protocols and persuading practitioners to voluntarily adopt the suggested practices. In the early 1990s, for instance, a federal agency called the Agency for Health Care Policy and Research (AHCPR) developed a series of treatment guidelines for various conditions.
Coupled with this interest in evidence-based medicine has been a growing national concern with reducing health-care costs.
"In some cases," says McLaughlin, "guidelines are being used to justify treatment decisions based on economic reasoning rather than clinical reasoning or scientific evidence."
Fears about conflated clinical and cost considerations have kept APA from joining the Practice Guidelines Coalition, a group that has brought together representatives from managed-care associations, professional organizations, consumers and the government to develop guidelines that attempt to meet the needs of all involved. The coalition has produced a guideline on panic disorder, with one on chronic pain in the works.
"Our position has been that the development of guidelines should be conducted independently of health-system cost issues," says Geoffrey Reed, PhD, assistant director for professional development at APA. "We have some concerns about those issues being blended in the process the coalition is using."
But just because guidelines are proliferating doesn't mean psychologists and other health-care professionals are using them.
In a recent article in the Journal of the American Medical Association (Vol. 282, No. 15), for instance, psychologist Cynthia S. Rand, PhD, and colleagues at the Johns Hopkins University identified several barriers that have kept physicians from using guidelines. Problems range from lack of awareness to frustration with confusing or cumbersome guidelines to disagreement with the suggested practices. Psychologists face the same kinds of barriers, says Rand, an associate professor of medicine in the School of Medicine.
For these and other reasons, AHCPR--now known as the Agency for Healthcare Research and Quality--has made a shift in strategy. With support from the American Medical Association and the American Association of Health Plans, the agency now sponsors an online clearinghouse of guidelines (www.guideline.gov) designed to let interested practitioners know about guidelines already out there. The agency also funds evidence-based practice centers charged with compiling evidence to be made available to organizations developing guidelines.
And although the National Committee for Quality Assurance---a managed-care industry association that accredits managed-care organizations--now requires managed behavioral health organizations to have guidelines, the requirement hasn't had much impact. For some organizations, says Reed, fulfilling the requirement has simply meant distributing the American Psychiatric Association's guidelines to practitioners.
In addition to being unclear about guidelines' utility, APA has concerns about the difficulty of applying guidelines to psychology in the first place. As Reed points out, psychologists are leery of anything that seems to restrict their own judgment. The cases they face rarely conform to the clear-cut diagnostic categories implicit in guidelines. And there's much less consensus on the best methods for treating patients with psychological rather than physical disorders, since there may be several effective alternative treatments for the same disorder. Some psychologists reject even the premise of evidence-based medicine.
"It's much easier to establish for pediatric immunizations than for the treatment of PTSD," says Reed.
Given these concerns, APA has decided its role should be to help psychologists distinguish between good and bad guidelines.
In 1995, APA's Council of Representatives approved a "Template for Developing Guidelines: Interventions for Mental Disorders and Psychosocial Aspects of Physical Disorders." At council's request, a Template Implementation Work Group of the Board of Professional Affairs (BPA), Board of Scientific Affairs and the Committee for the Advancement of Professional Psychology is now revising that document. Chaired by Daniel J. Abrahamson, the work group hopes to present the new "Criteria for Evaluating Treatment Guidelines" to council in August.
The document presents a series of criteria for evaluating guidelines, focusing on such issues as the quality and scope of research reviewed, the effectiveness and feasibility of recommended approaches and the composition of the panel that produced the guideline. The document can help practitioners identify guidelines that cherry-pick data to support what are really thinly disguised utilization-review documents or suggest approaches that have never been proven to work in real-life clinical settings, for example.
In addition to helping practitioners decide which guidelines are most useful, the document will also provide them with ammunition for challenging guidelines they find objectionable.
"The document will give people a tool so they can say, 'We're not just accepting carte blanche any guidelines handed to us,'" says Abrahamson, adding that managed-care organizations are just beginning to link reimbursement with adherence to guidelines. "We're going to subject these guidelines to rigorous evaluation to ensure that what we're being asked to use stands up to good clinical practice and scientific methodology."
Work by other groups
APA members are also helping other organizations develop guidelines that affect psychological practice.
"Getting involved in these efforts represents an opportunity to ensure that other organizations know what psychology can do and to ensure that guidelines speak to what we believe as psychologists," says BPA member Ronald H. Rozensky, PhD, chair of the department of clinical and health psychology at the University of Florida in Gainesville.
David C. Mohr, PhD, assistant clinical professor of neurology at the University of California at San Francisco (UCSF), is a member of a multidisciplinary steering committee putting together guidelines on treating multiple sclerosis for the Paralyzed Veterans of America, for example. The committee oversees working groups that review the literature and produce guidelines for practitioners and versions for patients. As the only psychologist on the steering committee, Mohr has helped ensure that the guidelines address the psychological and behavioral aspects of such problems as fatigue and urinary dysfunction. His role will become even more important as the committee starts developing guidelines on topics like depression.
Professional societies often request psychologists' participation in guideline projects as well. Wendy L. Stone, PhD, associate professor of pediatrics at Vanderbilt University in Nashville, has worked with a multidisciplinary team brought together by the American Academy of Neurology to produce guidelines on the screening and diagnosis of autism. The outgrowth of a 1998 National Institutes of Health state-of-the-science meeting, the project brought representatives from different organizations together in a two-day working meeting. Stone and another psychologist tackled the section on psychology. The first part of the guidelines appeared in the Journal of Autism last December; the background section should be out by the end of this year.
"The project really fostered interdisciplinary collaboration and helped us transcend our own guild issues and work toward a common end--helping these kids," says Stone.
At the government level, Ricardo F. Muñoz, PhD, a professor of psychology in UCSF's department of psychiatry, served on a panel that produced an AHCPR report on pharmacological interventions for treating depression.
Muñoz first got involved when he published a critique of AHCPR's guideline on treating depression, citing the document's overemphasis on psychopharmacology despite a background section that clearly indicated psychotherapy's value. When the agency was contracted to produce an updated review of randomized trials on pharmacotherapies last year, he served as APA's representative.
"One of the nice things about doing these reviews is that you learn a tremendous amount," says Muñoz.
To BPA member Danny Wedding, PhD, MPH, efforts like these are crucial.
"Guidelines are sometimes referred to denigratingly as 'cookbook' medicine," says Wedding, who has helped develop guidelines for the Missouri Department of Mental Health in his role as director of the Missouri Institute of Mental Health. "But the fact is, for most of us, cookbooks work better than experimentation."
Still, APA continues to assert that guidelines should be an aid to clinical judgment, not take precedence over it.
Rebecca A. Clay is a writer in Washington, D.C.