Key Words: clinical practice guidelines, CPGs, comparison, schizophrenia, stable phase
Clinical practice guidelines (CPGs) have been developed to bridge the gap between existing clinical practice and current evidence derived from research. CPGs may be advantageous for several reasons (1,2). Firstly, published guidelines organize large amounts of information and allow broader dissemination of this knowledge to interested parties. CPGs can increase awareness of current practice trends among clinicians. Second, guidelines can be used for guiding the delivery of quality health care. For example, third-party payers may use CPGs to determine “approved” or “recommended” treatments. Researchers, too, may be interested in using guidelines for outcome research. Finally, CPGs may be helpful in identifying areas of weakness or confusion and lead to new avenues for research for specific illnesses. Due to gaps in existing knowledge, CPGs are thus not intended to be exhaustive; in cases of limited evidence, consensus may still be achieved by polling experts in the field. Ultimately, the overriding goal of CPGs remains unchanged; that is, to synthesize current evidence and to assist practitioners to evaluate effective treatment options for patients.
While CPGs have multiple benefits, they also may be fraught with problems (4). For instance, many health care financing organizations may adhere too rigidly to CPGs and thus prevent patients and clinicians from deviating from the “approved” practice. In addition, CPGs may be biased toward promoting 1 narrow aspect of a complex issue. Third-party payers are often cited as an example of this approach (3). In addition, the quality of CPGs may vary, which therefore may lead to difficulties for the clinician applying them. Liability concerns also may be raised if clinicians do not adhere to the guidelines. This issue has been further compounded for organizations that attempt to keep guidelines current in the face of rapidly changing clinical and research information.
Many CPGs for the management of several psychiatric disorders have been published in the past decade. Several professional bodies and research groups have focused on schizophrenia and have developed CPGs for the management of this serious and disabling condition (5–10). Interest in the up-to-date management of this illness has been led by developments over the past decade in the areas of diagnosis, early intervention, and effective treatments, both pharmacologic and psychotherapeutic. Along with preparation and dissemination of guidelines for effective and appropriate management of schizophrenia, several groups have attempted to study clinicians’ adherence to these guidelines (4,11). While this study may be a useful and appropriate step in the evaluation process, it does not account for discrepancies that may exist among the various guidelines. These discrepancies are noteworthy, since CPGs are designed to reduce variations in practice patterns, yet disagreement may exist among the various experts.
Our objective was to systematically evaluate the guidelines as they pertained to the management of schizophrenia during the stable phase. We chose this phase for comparison purposes for several reasons. The stable phase is often the longest phase of the illness for many of patients. The stable phase is also desirable from a clinician’s perspective: it becomes an important period for management, wherein rehabilitation efforts, medication adjustment, and psychosocial treatments can take place. A comparison of CPGs would hopefully demonstrate areas of strength and weakness among the various guidelines. A similar broad comparison of clinical guidelines was last published in 1998, in which 2 published and 1 unpublished series of guidelines were reviewed (3). The emphasis was on American guidelines, and the international literature was not evaluated. In addition, one of the series of CPGs evaluated at the time has undergone subsequent revision (6). Therefore, our objective was to be comprehensive when evaluating the available guidelines while focusing on a specific phase of the disorder.
We conducted literature searches using the Medline and PsycInfo databases from January 1, 1990, to December 31, 2000. Further, we used the Google search engine as part of the Internet search strategy on the same topic. Key words used in the searches included schizophrenia, practice guidelines, and clinical algorithms. Practice guidelines published prior to 1990 were not evaluated because of developments that have occurred in the field over the past decade. Since community outpatient management of schizophrenia was our area of interest, we chose not to examine the treatment guidelines published for the child and adolescent population or for the forensic population.
Six published series of CPGs for the management of schizophrenia were obtained (5–10). Of these, 2 series of guidelines were derived from an expert consensus in the field of schizophrenia research and practice (6,10). One group comprised primarily of North American experts (6) (with the guidelines having undergone revision since their first publication in 1996), while the second group of experts was based in France (10). The other 4 series were derived from a rigorous review of the literature and had undergone varying stages of expert input (5, 7–10). The American Psychiatric Association (APA) had published its CPGs in 1997 (8), and the review of the evidence published by this group was used to varying extents by other groups such as the one from Canada (5) and the one from Texas (9). The Schizophrenia Patient Outcomes Research Team (PORT) involved several experts who provided recommendations to the committee doing the literature review (7). The goals of these organizations differed in that they aimed to reflect local practices as well as provide increased specificity to the guidelines. For example, the Texas Medication Algorithm Project (TMAP) developed stepwise algorithms for drug therapy recommendations.