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Feature Section

Clinical Practice Guidelines for Psychiatrists in Canada

Praful Chandarana, MD, FRCPC

Chair, CPA Special Committee on Clinical Practice Guidelines; Associate Professor, Department of Psychiatry, The University of Western Ontario, London, Ontario.

Philip Beck, MD, FRCPC

Chair, CPA Standing Committee on Professional Standards and Practice; Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec.

Clinical practice guidelines (CPGs) are defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (1). They synthesize current information to help physicians and patients evaluate treatment options for effective care. It is suggested that “good guidelines start with a specific clinical question, articulate relevant issues, seek and synthesize sound evidence, assign values to outcomes, generate recommendations and try to influence what clinicians do in the hope that reduced practice variation, lower costs and improved health outcomes will result” (2). The primary purpose of CPGs is to bridge the gap between producers and consumers of health care research (2). To help standardize the development of CPGs in Canada, the Canadian Medical Association has developed Guidelines for Canadian Clinical Practice Guidelines (3). These guidelines emphasize ethical considerations and make recommendations for the development, implementation, and evaluation of CPGs.

The geographic isolation of treatment centres in Canada and the variable availability of resources highlight the urgent need for a coordinated effort to introduce effective CPGs. Also, rapid changes have occurred in the treatment of most psychiatric disorders. For example, selective serotonin reuptake inhibitors have virtually replaced first- generation antidepressants, and novel antipsychotics are increasingly used instead of the traditional neuroleptics. Further, traditional analytic psychotherapies are being challenged by empirically validated treatments such as cognitive-behaviour therapy and interpersonal therapy. Despite rapid innovation, the gap between research findings and clinical practice has continued to widen. CPGs may help to narrow this gap and potentially improve care through consistent application of evidence-based approaches.

The introduction of Canadian Clinical Practice Guidelines for the Treatment of Schizophrenia (4) marks the first major step by the Canadian Psychiatric Association (CPA) to update the treatment of this disorder. These guidelines were written by a select group of experts from across the country and vetted by several consultants prior to approval by the CPA Special Committee on Clinical Practice Guidelines and then by the CPA Board of Directors. Now, following dissemination of these guidelines, important steps must be taken to ensure their general adoption. To effect changes in practice, a combination of educational approaches is intended to bring this information to physicians and other mental health care providers. This effort will require the involvement of patients, their families, practitioners, institutions, government, and private industry. Outcome measurements will be required as objective proof of change in clinical practice. Further, periodic revisions will be required to keep pace with new advances.

If successfully adopted, CPGs, such as the recent guidelines for schizophrenia, should be beneficial in several ways. They will help upgrade individual practices, improve the quality of care in existing programs, provide vital information to patients with which they can make better informed decisions, make providers accountable, enhance continuing medical education, reduce treatment variation, diminish the cost of inappropriate care, and facilitate teamwork among health professionals (5).

Despite these obvious advantages, physicians in Canada seem reluctant to integrate guideline recommendations into their practices (6). Consequently, studies have failed to show clear evidence that using CPGs improves patient outcomes (7). This could be because of the lack of appropriate resources, concerns that guidelines curb creative effort, or apprehension that they may be misconstrued as standards that are unrealistic because of various factors beyond the control of the practitioner. There may also be concern that authors or their sponsors would come under scrutiny if the guidelines were to result in harm to the patient. Finally, some practitioners are concerned that lawyers may mount litigation against individuals who choose not to follow guidelines exactly.

The primary aim of guidelines is to upgrade standards of practice and improve quality of care. Their potential benefits far outweigh the risks. Hence, implementation will be an essential step once future guidelines are approved by the CPA. This will require the support of CPA members and coordination with medical schools and provincial organizations.

References

1. Field MJ, Lohr KN, editors. Clinical practice guidelines: directions for a new program. Institute of Medicine. Washington (DC): National Academy Press; 1990.

2. Hayward RSA. Clinical practice guidelines on trial. Can Med Assoc J 1997;156:1725–7.

3. Guidelines for Canadian clinical practice guidelines. 1994 Canadian Medical Association.

4. Working Group for the Canadian Psychiatric Association and the Canadian Alliance for Research on Schizophrenia. Canadian clinical practice guidelines for the treatment of schizophrenia. Revised. Can J Psychiatry 1998;43 Suppl 2:25S–40S.

5. Canadian Health Care Association and the Canadian Medical Association. Integrating clinical practice guidelines into Canadian health care facilities. 1996; 7–8.

6. Hayward RSA, Guyatt GH, Moore KA, McKibbon KA, Carter AO. Canadian physicians’ attitudes about and preferences regarding clinical practice guidelines. Can Med Assoc J 1997;156;1715–23.

7. Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc J 1997;156;1705–12.

Lignes directrices de la pratique clinique destinées aux psychiatres du Canada

Praful Chandanara, MD, FRCPC

Président du Comité spécial des lignes directrices de la pratique clinique de l’APC; professeur agrégé, Département de psychiatrie, University of Western Ontario, London (Ontario).

Philip Beck, MD, FRCPC

Président du Comité des normes professionnelles et de la pratique de l’APC; professeur agrégé, Département de psychiatrie, Université McGill, Montréal (Québec).

On définit les lignes directrices de la pratique clinique (LDPC) comme étant des énoncés élaborés systématiquement dans le but d’aider le praticien et le patient à décider des soins de santé les plus appropriés dans des circonstances cliniques précises (1). Elles résument l’information actuelle afin d’aider médecins et patients à évaluer les choix de traitement pour des soins efficaces. Selon ce qui est suggéré, « les bonnes lignes directrices commencent par une question clinique précise, énoncent les questions connexes pertinentes, cherchent et résument des études rigoureuses, attribuent des valeurs aux résultats, produisent des recommandations et tentent d’influencer les gestes des cliniciens dans l’espoir d’obtenir une variation réduite de la pratique, des coûts inférieurs et une meilleure santé » (2). Le but premier des LDPC consiste à réduire l’écart entre les producteurs et les consommateurs de la recherche sur les soins de santé (2). Pour contribuer à normaliser l’élaboration des LDPC au Canada, l’Association médicale canadienne (AMC) a rédigé les Principes directeurs concernant les guides de pratique clinique au Canada (3). Ces principes mettent l’accent sur les considérations d’ordre éthique et offrent des recommandations sur l’élaboration, la mise en oeuvre et l’évaluation des LDPC.

L’isolement géographique de certains centres de traitement au Canada et la variation de la disponibilité des ressources mettent en lumière le besoin pressant d’un effort de coordination en vue d’instaurer des LDPC efficaces. En outre, des changements brusques se sont produits dans le traitement de la plupart des troubles psychiatriques. Par exemple, les inhibiteurs spécifiques du recaptage de la sérotonine ont à toutes fins utiles remplacé la première génération d’antidépresseurs, et l’on recourt de plus en plus aux nouveaux antipsychotiques plutôt qu’aux neuroleptiques classiques. De même, les psychothérapies analytiques traditionnelles sont mises au défi par des traitements éprouvés par l’expérience, comme le modèle cognitiviste ou la thérapie interpersonnelle. Malgré l’innovation accélérée, l’écart entre les découvertes de la recherche et la pratique clinique est de plus en plus prononcé. Les LDPC peuvent contribuer à réduire cet écart et éventuellement, à améliorer les soins grâce à l’application cohérente de méthodes éprouvées.

La publication des Lignes directrices de la pratique clinique canadienne sur le traitement de la schizophrénie (4) marque la première grande étape pour l’APC en vue de mettre à jour le traitement de cette maladie. Ces lignes directrices ont été rédigées par un groupe choisi d’experts des quatre coins du pays et examinées par plusieurs consultants avant de recevoir l’approbation du Comité spécial des LDPC, puis celle du conseil d’administration de l’APC. Suite à la diffusion de ces lignes directrices, d’importantes mesures devront être prises en vue de les faire adopter par tous. Une importante campagne de sensibilisation est présentement organisée pour faire en sorte que ces connaissances nouvellement acquises modifient la pratique des médecins. Cet effort exigera la participation des patients, de leurs familles, des médecins, des établissements, du gouvernement et du secteur privé. Il faudra mesurer les résultats pour obtenir une preuve tangible du changement de la pratique clinique. En outre, des révisions périodiques seront nécessaires pour suivre les progrès récents.

Si l’on réussit à les faire adopter, les LDPC semblables aux lignes directrices récentes sur la schizophrénie devraient être avantageuses à maints égards. Elles contribueront à mettre à jour les pratiques individuelles, à améliorer la qualité des soins des programmes existants, à fournir l’information essentielle aux patients en vue de décisions éclairées, à responsabiliser les fournisseurs, à améliorer la formation médicale continue, à réduire la variation des traitements, à diminuer le coût des soins inadéquats et à favoriser le travail d’équipe chez les professionnels de la santé (5). Malgré ces avantages évidents, les médecins du Canada hésitent à intégrer les recommandations de ces lignes directrices à leur pratique (6). Les études n’ont donc pas réussi à démontrer clairement que le recours aux LDPC améliore l’état des patients (7), ce qui est peut-être attribuable au manque de ressources appropriées, aux préoccupations du fait que les lignes directrices peuvent entraver l’effort créateur ou à la crainte qu’elles ne soient interprétées comme des normes irréalistes en raison de nombre de facteurs indépendants de la volonté du praticien. On s’inquiète peut-être aussi de ce que les auteurs et leurs commanditaires pourraient faire l’objet d’un examen très strict si les lignes directrices devaient causer du tort au patient. Enfin, certains praticiens craignent que des avocats ne s’en prennent aux personnes qui choisissent de ne pas suivre à la lettre les lignes directrices.

Le but premier des lignes directrices consiste à mettre à jour les normes de la pratique et à améliorer la qualité des soins. Leurs avantages éventuels excèdent nettement les risques. La mise en oeuvre sera donc une étape essentielle, une fois que les futures lignes directrices seront approuvées par l’APC. Elle nécessitera le soutien de tous les membres de l’APC ainsi que la coordination avec les facultés de médecine et les organisations provinciales.

Références

Implementing Clinical Practice Guidelines: Educational Issues

Ivan Silver, MD, MEd, FRCPC

Chair, CPA Continuing Professional Development Committee; Associate Professor, Faculty of Medicine, University of Toronto, Toronto, Ontario.

Dave Davis, MD, FRCPC

Associate Dean, Continuing Medical Education, Faculty of Medicine, University of Toronto, Toronto, Ontario.

John Leverette, MD, FRCPC

Chair, CPA Standing Committee on Education; Associate Professor, Faculty of Medicine, Queen’s University, Kingston, Ontario.

Clinical practice guidelines (CPGs) have proliferated in the past 15 years, partly in response to the growing importance of evidence-based medicine (1). They are educational tools intended to help health practitioners stay current after they have completed their professional training. When implemented effectively, CPGs can be powerful agents for maintaining professional competence. Although there is considerable evidence that CPGs do improve clinical practice, their impact on practitioner behaviour is extremely variable (2).

Various factors affect the adoption of guidelines (1). This paper examines some of the educational and training issues, especially as they relate to continuing education, that must be considered if guidelines are to be effectively adopted.

Medical Student Education

CPGs tend to be very evidence-based and more rigorously scrutinized by the profession than other psychiatric source material. They offer medical students a glimpse into the complexities of psychiatric diagnosis and treatment (3). They may be adapted for medical students and may include algorithms to indicate the point at which primary care physicians should consider referring the patient to a specialist. Guidelines can be incorporated into problem-based learning cases in the preclerkship and into patient-centred sessions during the relationship. Licencing examinations should also reflect CPG recommendations.

Resident Education

CPGs most often provide up-to-date, well-referenced literature reviews and clinical decision algorithms that can be easily incorporated into residency training. They may serve as starting points for clinical decision-making in case-based learning, seminars, and tutorials and as study guides for residents (3). Guidelines also are suitable for incorporation into written and oral examinations of the Royal College of Physicians and Surgeons of Canada.

Continuing Education

A needs assessment of practicing clinicians is an essential element in any CPG implementation program (4). The needs of the targeted learners should be determined before the guidelines are written. CPG planners need to ask the following questions: What objective evidence is there that guidelines are needed to improve patient care? If objective learning needs are demonstrated, do they coincide with the perceived needs of the targeted learners, that is, psychiatrists? The latter is particularly important because it is more difficult to implement CPGs if the learners do not perceive the need to change their clinical practice. If CPG developers know beforehand that psychiatrists do not recognize a need for change, they can choose their educational strategy to overcome this resistance. For instance, opinion leaders (influential psychiatrists who are respected by their peers) as teachers may help to deal with such resistance to change.

Understanding the attributes of the learner is important in planning an educational strategy. Not everyone embraces CPGs at the same rate. Greer describes the characteristics of learners’ responses to new innovations (5). He suggests 5 categories of learner behaviour: innovators, early adopters, an early majority, a late majority, and late adopters. The first 2 categories are highly influenced by evidence-based medicine. This group often includes opinion leaders and may not require educational intervention beyond disseminating the guidelines. The early and late majority, which comprise most of the population, require varied continuing education interventions to change their behaviour. The late adopters require special interventions, which might include the direct involvement of opinion leaders, one-on-one teaching, and incentives to change clinical practice (6).

CPGs need to be adapted to the local needs of psychiatrists and other physicians. Guidelines written for psychiatrists will need to be adapted for family doctors and other providers of psychiatric care. There is considerable evidence that adapting CPGs to local needs, especially to small groups of physicians in specific communities, positively affects behavioural change in these physicians and, ultimately, patient outcome (5,7).

After CPGs are disseminated, usually through publication in monographs or clinical journals, the real work of educational implementation begins. The impact of guidelines on clinical practice will always be disappointing as long as implementation strategies are not carefully planned as part of CPG development. Three kinds of educational interventions have been described: traditional continuing medical education (CME) methods, community-based interventions, and practice-based interventions (1). What is the evidence that they are effective?

Traditional CME

Educational materials (journal articles and monographs) can increase awareness of the existence of the CPGs but are insufficient by themselves to change physician behaviour (4). Most physicians associate CME with formal conferences including courses, symposia, lectures, and small-group workshops. Several studies, however, have failed to demonstrate any change in physician behaviour as a result of lecture-based seminars in small groups (8–10). Small-group learning that is longitudinal and that encourages dialogue between the learners may be more effective (11,12).

Community-Based Interventions

Academic detailing has been found to be a powerful community intervention for inducing behavioural change (13,14). In this case, a pharmacist or other health professional visits the practitioner in his or her office and focuses on the appropriate way to prescribe specific medications. Opinion leaders also have been shown to be effective in implementing CPGs among community practitioners (15). Their influence is most effective in a small-group context or in the community, where learners can observe and model their behaviour (1).

Practice-Based Interventions

Educating patients has been shown to be an effective way to change their behaviour. Educational materials might include newsletters, reminder systems, and public awareness campaigns. Katon and others describe the use of patient-centred educational materials on depression, based on CPGs targeted at family physicians (7). The number of patient visits to physicians and patient compliance with medications both increased.

Auditing physicians’ practices and providing appropriate feedback, especially when this is conducted with peers or opinion leaders, has been shown to be an effective agent for behaviour change, but the results of some studies are mixed (16,17). Using this method, clinicians review clinical syndromes and then audit their patient charts with colleagues to understand how they can improve their clinical skills. Lastly, reminders such as posters and pocket-sized laminated cards have been found to be effective in changing behaviour (18–20).

Comments

There is considerable evidence that multiple complementary educational strategies used simultaneously have a greater impact on physician behaviour and patient outcome than does a single intervention (3,8). The working group for the implementation of the new Canadian Clinical Practice Guidelines for the Treatment of Schizophrenia recently published by the Canadian Psychiatric Association is considering as part of its strategy regional workshops using small-group, case-based teaching led by opinion leaders; Internet-based discussion groups; and self- assessment questionnaires (21).

Following dissemination of CPGs, it will be important for the CPA to evaluate the impact of our educational interventions on psychiatrist behaviour and patient outcome. More specifically, it will be important to assess the extent to which psychiatrists are aware of the guidelines, whether they agree with them, the extent to which they actually follow them and, ultimately, whether patient outcomes improve (3). Although considerable evidence supports the efficacy of specific educational strategies with physicians, there are no random, controlled trials targeted to psychiatrists (4). The CPA’s commitment to the creation of several user-friendly, practical CPGs over the next few years is an opportunity to conduct random, controlled trials of different educational interventions and thus contribute to the literature on how psychiatrists learn best.

The CPA Special Committee on Clinical Practice Guidelines invites dialogue with members about the merits and validity of guidelines. The CPA web site, CPAnet, will provide opportunities for this dialogue in the near future.

References

1. Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J 1997;157:408–16.

2. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317–22.

3. Yager J, Zarin DA, Pincus HA, Mcintyre JS. Practice guidelines and psychiatric education: potential implications. Acad Psych 1997;21:226–33.

4. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700–705.

5. Greer A. The state of the art versus the state of the science: the diffusion of new medical technologies into practice. Int J Technol Assess Health Care 1988;4:5–26.

6. Grol R. Implementing guidelines in general practice care. Quality Health Care 1992;1:184–91.

7. Katon W, Von Korff M, Lin E, Walker F, Simon GF, Bush T, and others. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273:1026–31.

8. Lewis S. Paradox, process and perception: the role of organizations in clinical practice guidelines development. Can Med Assoc J 1995;153:1073–7.

9. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 1995;153:1423–31.

10. Karuza J, Calkins E, Feather J, Hershey CO, Katz L, Majeroni B. Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guidelines using a small-group consensus process. Arch Intern Med 1995;155:625–32.

11. Premi JN, Shannon S, Hartwick K, Lamb S, Wakefield J, Williams J. Practice-based small group CME. Acad Med 1994;69:800–802.

12. Mittman BS. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. Quality Review Bulletin 1992;18:413–22.

13. Nardella A, Pechet L, Snyder LM. Continuous improvement, quality control, and cost containment in clinical laboratory testing. Effect of establishing and implementing guidelines for preoperative tests. Arch Pathol Lab Med 1995;119:518–22.

14. Desantis G, Harvey KJ, Howard D, Mashford ML, Moulds RF. Improving the quality of antibiotic prescription patterns in general practice. The role of educational intervention. Med J Aust 1994;160:502–5.

15. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. The effect of a consensus statement on the practice of physicians. N Engl J Med 1989;321:1306–11.

16. Robinson MB. Evaluation of medical audit. J Epidemiol Community Health 1994;48435–40.

17. Johnson CC, Martin M. Effectiveness of a physician education programme in reducing consumption of hospital resources in elective total hip replacement. South Med J 1996;89:282–9.

18. Emslie C, Grimshaw J, Templeton A. Do clinical guidelines improve general practice management and referral of infertile couples? BMJ 1993;306:1728–31.

19. Bouhaddou O, Frucci L, Cofrin K. Implementation of practice guidelines in a clinical setting using a computerized knowledge base (Iliad). Proceedings. The Annual Symposium on Computer Applications in Medical Care 1993:258–62.

20. Pestotnik JI, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and finical outcomes. Ann Intern Med 1996;124:884–90.

21. Working Group for the Canadian Psychiatric Association and the Canadian Alliance for Research of Schizophrenia. Canadian clinical practice guidelines for the treatment of schizophrenia. Revised. Can J Psychiatry 1998;43 Suppl 2:25S–40S.

Guidelines on Guidelines

Sidney H Kennedy, MD, FRCPC

Head, Mood and Anxiety Disorders, Centre for Addiction and Mental Health; Professor, Mood and Anxiety Disorders, University of Toronto, Toronto, Ontario.

Sagar V Parikh, MD, FRCPC

Head, Bipolar Clinic, Centre for Addiction and Mental Health; Director of Continuing Education, Centre for Addiction and Mental Health; Assistant Professor, University of Toronto, Toronto, Ontario.

Developing clinical practice guidelines has gradually evolved from an art form into a scientific process with its own set of guidelines (1). Most physicians view the development and dissemination of practice guidelines as part of the promotion process for evidence-based medicine. A majority of respondents to a recent survey of 3000 Canadian physicians endorsed the motivation both to improve quality of care and to control health care costs. However, a minority felt that guidelines were too rigid to apply to individual patients, were a threat to physician autonomy, or represented an oversimplified approach to complex medical problems (2). Of greatest concern to those who are involved in the development or funding of guidelines is that there is no strong evidence that clinicians alter their practice patterns in a way that either improves quality of care or controls health costs (3,4).

In planning the development of clinical practice guidelines, 2 parallel scientific processes need to be initiated—one for their creation and the other for their dissemination—both employing evidence-based methodology. Content and process issues must be addressed in both areas. Most guidelines that have been developed in Canada since 1994 reflect the principles addressed in the Canadian Medical Association’s Guidelines for Canadian Clinical Practice Guidelines (1). This document provides valuable guidance about the development and dissemination aspects of CPGs.

The Development Process

1. The first step involves identifying a need and the availability of a credible expert panel motivated to address the need. The expert panel may be invited by a professional body such as the Canadian Psychiatric Association. Conversely, a professional body (such as the Canadian Network for Mood and Anxiety Disorders) may identify appropriate clinical issues.

2. It is important to address funding issues from the outset, since the amount of money available clearly will influence the scope of the process and the input that can be obtained. The role of government, the pharmaceutical industry, or other parties potentially having a vested interest in the field must be carefully considered with respect to the subsequent credibility of the document. Autonomous, well-funded government agencies have successfully developed guidelines in the United States without external funding sources (5), while multiple pharmaceutical company support (6) and government-only support (7) methods have also been used in Canada.

3. The clinical content of the guidelines naturally will influence the constitution of the panel for their development, aiming to achieve healthy diversity rather than a narrow consensus or total stalemate. Round-table discussions and consultations with various stakeholders can facilitate and enhance the process. Evidence-based methods for guideline development are essential, often with superimposed expert opinion to maximize clinical utility. For example, clinical-trial evidence about effective monoamine oxidase inhibitor (MAOI) treatment for depression needs to be balanced against safety considerations if a practical recommendation for MAOI-use is to be made.

4. The next major issue for the panel is to decide what literature searches are required and how much source material, pertinent metaanalyses, and review papers have to be reviewed. For example, in producing Canadian guidelines for seasonal affective disorder (8), the working group could realistically review all published treatment trials that met minimum standards. However, in the development of schizophrenia or depression guidelines, more emphasis would be placed on reviewing metaanalyses, given the large number of relevant studies that already exist.

5. Where clinical equipoise exists, developers of guidelines should acknowledge treatment options but reserve the right to focus on the topic under review, leaving other treatments for subsequent review. Emphasizing flexibility and the importance of individual doctor–patient relationships will help to reduce the sceptic’s concerns about imposed rigidity.

The Dissemination Process

1. It is important to quickly establish a close working relationship with experts in continuing medical education and have them as members of the development committee or a parallel dissemination committee.

2. There is also a need to explore mechanisms to solicit input and provide feedback from target audiences for whom the document is intended (for example, family physicians or community psychiatrists). These target groups should also have input, as members of the dissemination committee or as consultants; field-testing the document is an important step before final dissemination. For example, bipolar guidelines were precirculated to more than 150 psychiatrists and family practitioners (9) before publication. Focus groups of end users can also be helpful in this process.

3. Key stakeholders (such as the Ministry of Health; patient, family, and other self-help groups; the pharmaceutical industry; or medical schools) should also be identified and solicited for input to implementation strategies and for funding of other tangible initiatives. Partnering with key professional bodies not only strengthens professional credibility but also should provide more effective dissemination and a platform from which to develop methods for outcome evaluation.

4. Finally, it is vital to recognize the importance of evaluation as the first step in planning revisions for subsequent editions of successful guidelines.

Many guideline documents have been developed that stand up to content analysis but fail miserably when the implementation process is evaluated. By recognizing and implementing the science of dissemination, patients and health providers together can achieve the best outcome.

References

1. Canadian Medical Association. Guidelines for Canadian clinical practice guidelines. Ottawa: Canadian Medical Association; 1994.

2. Hayward RSA, Guyatt GH, Moore KA, McKibbon KA, Carter AO. Canadian physicians’ attitudes about and preferences regarding clinical practice guidelines. Can Med Assoc J 1997;156:1715–23.

3. Arroll B, Jenkins S, North D, Kearns R. Management of hypertension and the core services guidelines: results from interviews with 100 Auckland general practitioners. N Z Med J 1995;108:55–7.

4. Rosser WW, Palmer WH. Dissemination of guidelines on cholesterol. Effect on patterns of practice of general practitioners and family physicians in Ontario. Ontario Task Force on the Use and Provision of Medical Services. Can Fam Physician 1993;39:280–4.

5. Depression Guidelines Panel. Depression in primary care. Volume 2. Treatment of major depression. Clinical practice guideline #5. Rockville (MD): US Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1993.

6. Working Group for the Canadian Psychiatric Association and the Canadian Alliance for Research on Schizophrenia. Canadian clinical practice guidelines for the treatment of schizophrenia. Revised. Can J Psychiatry 1998;43 Suppl 2:2S–40S.

7. Canadian Network for Mood and Anxiety Treatments, Depression Working Group. Guidelines for the diagnosis and pharmacological treatment of depression. CANMAT; 1999.

8. Lam RW, Levitt AJ, editors. Canadian consensus guidelines for the treatment of seasonal affective disorder: A summary report of the Canadian Consensus Group on SAD. The Canadian Journal of Diagnosis 1998;October Suppl:1–15.

9. Kusumakar V, Yatham LN, editors. The treatment of bipolar disorder: review of the literature, guidelines, and options. Can J Psychiatry 1997;42 Suppl 2:67S–100S.