A Randomized Controlled Clinical Trial Comparing “Guideline Exposed” and “Guideline Naive” Physicians in Respect to Dosage Selection and Treatment Outcome with Doxepin in Depressive Disorders

Impact of the WHO depression guideline on patient care by psychiatrists: A randomized controlled trial

Background

Scientific literature reviews aim to summarize the state of knowledge and published empirical evidence. In contrast, medical guidelines are intervention tools that aim to improve physician behaviour and patient outcome. They can have positive effects, but they can also have negative effects. Their effects must be tested by research.

Methods

In a randomized controlled trial, 103 psychiatrists in private practice were either provided with the WHO depression guideline only (information group), or provided with the WHO depression guideline and trained for one day in this guideline (intervention group), or left uninformed (control group). They then treated a total of 497 patients according to individual clinical considerations and the needs of the patients. Observation of routine treatment lasted 12 weeks. Physicians and patients documented the course of illness and treatment, including the patient–physician interaction.

Results

Psychiatrists in the intervention group saw more psychosocial stressors in their patients, prescribed higher dosages of medication, had fewer drop-outs, and rated treatment outcome as better. The ratings of patient–physician interactions indicated more strain in their relationships.

Conclusions

The results show both positive and negative effects of guideline exposure, but only in the training group and not in the information group. Guidelines should be empirically tested before being called “evidence based”. Every guideline should also explain how it can or must be implemented in order to become effective.

The effect of Clinical Practice Guidelines on prescribing practice in mental health: A systematic review

Clinical Practice Guidelines are succinct evidence-based recommendations and in psychiatry, exist to advise on psychotropic prescribing to effectively treat mental health conditions whilst minimising medication adverse effects. Implementation of psychiatric guidelines have, in the past, demonstrated little and transient impact on clinical practice. How effective prescribing guidelines are in aligning practice with evidence currently is unknown and this systematic review aimed to investigate said efficacy. Literature searches were performed on MEDLINE, EMBASE, and CINAHL up to September 2019 and articles were selected by two reviewers independently with discrepancies resolved by a third reviewer. The review identified 18 eligible articles pertaining to the following conditions: depressive disorders, psychotic disorders, post-traumatic stress disorder, anxiety disorders, bipolar affective disorder, attention deficit/hyperactivity disorder, borderline personality disorder, and opiate addiction with depression guidelines being the most frequently evaluated. Seven studies revealed guidelines effected no change in psychotropic prescribing. The remaining studies illustrated that even when practice was changed, the effect was generally small, emphasising the need to change guideline development and implementation, taking into account obstacles or opportunities specific to psychotropic pharmacotherapy.

The effects of a clinical care pathway for schizophrenia: a before and after study in 114 patients

BACKGROUND

The implementation of clinical guidelines in care pathways is being promoted for quality assurance in psychiatry and psychotherapy, as in other medical fields. The achievable benefits are disputed and are generally thought to be small. There have been hardly any studies of the effect of clinical care pathways on the costly inpatient treatment of schizophrenic psychoses.

METHODS

We conducted a prospective, controlled, before and after study in 114 patients with schizophrenia to determine whether the implementation of a pathway would improve diagnosis and treatment in conformity with published guidelines, and whether there would be any associated improvement in outcome. The patients' course was extensively documented with a number of structural, process-related, and outcome-related variables in the years before and after pathway implementation. Moreover, two different intensive methods of pathway implementation were tested. Data were collected from 2003 to 2005. The primary indicators of outcome quality included pharmacotherapy-related variables and assessments of treatment efficacy by the physicians, the nurses, and the patients themselves.

RESULTS

After pathway implementation, some diagnostic tests that had been performed only rarely beforehand were performed much more often. The percentage of over- or undermedicated patients, as defined by the treatment pathway, declined markedly. Surprisingly, however, the patients' multidimensionally documented psychopathological course and their subjective judgments of their condition were worse after pathway implementation than before on all four scales that were used to assess these variables.

CONCLUSION

The implementation of a treatment pathway brought about a robust change in process-related variables. The findings of this study furnish no explanation for the observed decline in treatment efficacy.

Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: a systematic review

PURPOSE AND SETTING

This review aimed to evaluate the effectiveness of strategies to implement clinical guidelines for chronic disease management in primary care in EU Member States.

METHODS

We conducted a systematic review of interventional studies assessing the implementation of clinical guidelines. We searched five databases (EMBASE, MEDLINE, CENTRAL, Eppi-Centre and Clinicaltrials.gov) following a strict Cochrane methodology. We included studies focusing on the management of chronic diseases in adults in primary care.

RESULTS

A total of 21 studies were found. The implementation strategy was fully effective in only four (19%), partially effective in eight (38%), and not effective in nine (43%). The probability that an intervention would be effective was only slightly higher with multifaceted strategies, compared to single interventions. However, effect size varied across studies; therefore it was not possible to determine the most successful strategy. Only eight studies evaluated the impact on patients' health and only two of those showed significant improvement, while in five there was an improvement in the process of care which did not translate into an improvement in health outcomes. Only four studies reported any data on the cost of the implementation but none undertook a cost-effectiveness analysis. Only one study presented data on the barriers to the implementation of guidelines, noting a lack of awareness and agreement about clinical guidelines.

CONCLUSION

Our results reveal that there are only a few rigorous studies which assess the effectiveness of a strategy to implement clinical guidelines in Europe. Moreover, the results are not consistent in showing which strategy is the most appropriate to facilitate their implementation. Therefore, further research is needed to develop more rigorous studies to evaluate health outcomes associated with the implementation of clinical guidelines; to assess the cost-effectiveness of implementing clinical guidelines; and to investigate the perspective of service users and health service staff.

Is there a gap between recommended and 'real world' practice in the management of depression in young people? A medical file audit of practice

BACKGROUND

Literature has shown that dissemination of guidelines alone is insufficient to ensure that guideline recommendations are incorporated into every day clinical practice.

METHODS

We aimed to investigate the gaps between guideline recommendations and clinical practice in the management of young people with depression by undertaking an audit of medical files in a catchment area public mental health service for 15 to 25 year olds in Melbourne, Australia.

RESULTS

The results showed that the assessment and recording of depression severity to ensure appropriate treatment planning was not systematic nor consistent; that the majority of young people (74.5%) were prescribed an antidepressant before an adequate trial of psychotherapy was undertaken and that less than 50% were monitored for depression symptom improvement and antidepressant treatment emergent suicide related behaviours (35% and 30% respectively). Encouragingly 92% of first line prescriptions for those aged 18 years or under who were previously antidepressant-naïve was for fluoxetine as recommended.

CONCLUSIONS

This research has highlighted the need for targeted strategies to ensure effective implementation. These strategies might include practice system tools that allow for systematic monitoring of depression symptoms and adverse side effects, particularly suicide related behaviours. Additionally, youth specific psychotherapy that incorporates the most effective components for this age group, delivered in a youth friendly way would likely aid effective implementation of guideline recommendations for engagement in an adequate trial of psychotherapy before medication is initiated.

What do psychiatrists talk about with their depressed patients parallel to prescribing an antidepressant?

BACKGROUND

Treatment of depression includes pharmacotherapy as well as psychotherapy. Even if no specific psychotherapy is done, still, pharmacotherapy must be accompanied by patient education, reassurance and guidance. There is a lack of data available on the content of psychiatrist-patient interactions additional to prescribing an antidepressant.

METHOD

A total of 43 psychiatrists in ambulatory practice treated 200 depressed outpatients for 12 weeks with the antidepressant mirtazapine. Content of the patient-psychiatrist interaction was assessed by the pivotal topic method.

RESULTS

Patient-psychiatrist encounters lasted on average 17.5 min (SD = 6.9 min). Primary topics were at the beginning of treatment the therapeutic alliance, assessment of symptoms, patient education, and discussion of problems in life; after 2 weeks of medication compliance; after 8 weeks progress of illness and increase of activities; and after 12 weeks progress and relapse prevention. Limitations. Only patients who were treated with an antidepressant were included, so that results may be different in other cases.

CONCLUSION

The primary content of conversation is case management, supportive reassurance and alliance building while specific pychotherapeutic interventions are the exception. The content of psychiatrist-patient verbal interaction depends on time of treatment. The data describe "psychiatric counselling and psychotherapy" in routine care as opposed to "specific psychotherapy".

Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up

BACKGROUND

The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.

METHODS

Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.

RESULTS

The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.

CONCLUSIONS

Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.

Structural and organizational determinants of quality of care in patients with schizophrenia in Italy

Several reports have described the poor quality of care delivered to psychotic patients. However, the context in which care was delivered, including the structure, organization, and performance of the health care system, as a possible determinant of quality of care has received less attention. In this study we explored the relationship between conformance with guidelines and structural and organizational characteristics in 2 departments of Mental Health in Italy. Dosing of antipsychotic drugs in the maintenance phase was investigated in 125 patients. Higher than recommended doses could be explained by the high patient caseload per psychiatrist, leading to insufficient contacts with patients and their families and to excessive reliance upon drug treatment. The analysis of structural and organizational determinants of care at the local level may help to explain insufficient quality and to plan suitable interventions.