Clinical Practice Guidelines in Clinical Psychology and Psychotherapy

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Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 10, 337–351 (2003) Clinical Practice Guidelines in Clinical Psychology and Psychotherapy Glenys Parry,1* John Cape2 and Steve Pilling2,3 1 University of Shefﬁeld School of Health and Related Research, Shefﬁeld, UK 2 Camden and Islington Mental Health and Social Care Trust, St Pancras Hospital, London, UK 3 British Psychological Society Centre for Outcomes Research and Effective- ness, Department of Clinical Health Psychology, University College London, London, UK

Evidence-based clinical practice guidelines have proliferated over the past two decades. Few are limited to psychological therapies or are targeted at clinical psychologists and psychotherapists – the UK guideline Treatment Choice in Psychotherapy and Counselling is a major exception. However, psychological therapies will increasingly be considered alongside medical treatments in diagnosis-specific guidelines. There has been interest and debate about the place of guidelines in the psychological therapies, with views ranging from scepticism to enthusiasm. This paper defines clinical practice guidelines, describes major guideline programmes internationally, examines guidelines of specific interest to psychologists and psychotherapists, explores issues in their implementation, reviews evidence for their effectiveness in changing practice and improving therapy outcomes and draws out implications for practice. Guidelines are only one aspect of informing psychologists and psychotherapists about best practice. They need to be supplemented by other clinical support methods and with methods of monitoring what is actually done in practice. Copyright © 2003 John Wiley & Sons, Ltd.

INTRODUCTION Psychologists and psychotherapists have often used the term ‘guidelines’ when describing recom- Health care professionals are living in the age mendations based on clinical experience or unsys- of evidence-based guidance. There has been a tematic reviews. Examples include Horvath (1993) remarkable proliferation of clinical practice guide- on enhancing motivation in therapy of addictive lines over the last two decades. Citrome (1998) behaviour; King, Heyne, Gullone and Molloy reported over 1800 catalogued guidelines and (2001) on using emotive imagery in treatment of Cluzeau, Littlejohns, Grimshaw and Feder (1997) childhood phobias; Kovitz (1998) advising novices identified 472 guidelines in just five clinical areas – on conducting psychodynamic therapy; Kramer coronary heart disease, asthma, breast cancer, lung (1986) on terminating open-ended psychodynamic cancer and depression. therapy; Leibenluft and Goldberg (1987) on short term inpatient psychotherapy; Lipsius (1991) on combining individual and group psychotherapy; and Poey (1985) on conducting brief psychody- * Correspondence to: Professor G. Parry, University of Sheffield School of Health & Related Research, Regent Street, namic group therapy. Sheffield, S1 4DA, UK. This type of clinically-based guideline gives pro- E-mail: g.d.parry@sheffield.ac.uk cedural advice for psychological therapies rather

Copyright © 2003 John Wiley & Sons, Ltd. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.381 338 G. Parry, J. Cape and S. Pilling than disorder-specific recommendations. Whilst DEFINITIONS, DEVELOPMENT AND they tend to address important clinical dilemmas TYPES OF GUIDELINES and have value in clinical training and practice, they rarely meet criteria for systematically devel- Clinical practice guidelines (Department of Health, oped clinical practice guidelines based on research 1996a; Woolf, Grol, Hutchinson, Eccles, & evidence. Grimshaw, 1999) are classically defined as ‘sys- Guidelines also exist, targeted at psychologists tematically developed statements to assist practi- and psychotherapists, which claim to be based on tioner and patient decisions about appropriate evidence, but which have not been systematically health care for specific clinical circumstances’ developed. Many of these can be found on Inter- (Field & Lohr, 1990, p. 38). These guidelines set out net websites, and should be used with caution. the specific clinical processes that are expected to In contrast, very few systematically developed lead to optimal outcomes for the specific circum- research-based guidelines have been targeted at stances and patients under consideration. Most clinical psychologists and psychotherapists or deal common in both physical and mental health with psychological treatments. Amajor exception to settings have been disease- or condition-based this is the UK guideline on treatment choice in psy- guidelines (e.g. the assessment and management of chological therapies and counselling (Department depression in primary care; Agency for Health of Health, 2001a). However, medically oriented Care Policy Research, 1993) and problem-based guidelines increasingly include psychological guidelines (e.g. the management of violence in treatments. Examples include eating disorders clinical settings; Royal College of Psychiatrists, (American Psychiatric Association Work Group on 1998). In contrast, intervention guidelines (e.g. Eating Disorders, 2000), schizophrenia (American smoking cessation guidelines; Wetter et al., 1998; Psychiatric Association, 1997) and bipolar disorder treatment choice in the psychological therapies; (Kahn, Carpenter, Docherty, & Frances, 1996). Department of Health, 2001a) have been less Despite the lack of research-based psychological common. therapy guidelines, there has been extensive inter- Clinical practice guidelines differ from standard est and concern among psychologists and psy- literature reviews, chapters and textbooks in the chotherapists both about the guidance provided to manner of their construction. Their development is others about psychological therapies and about systematic and explicit, usually involving a repre- the potential applicability of such guidance to the sentative guideline development group and a practice of psychological therapists themselves. systematic approach to identifying, evaluating Psychologists have criticized psychiatric guide- and incorporating evidence in the guideline. Both lines for understating the case for empirically sup- evidence from research, taken from existing or ported psychological therapy (Craske & Zucker, specially commissioned systematic reviews and 2001; Hollon and Shelton, 2001), overstating the evidence of clinical opinion obtained from struc- case for medication (Persons, Thase, & Crits- tured consensus methods are used in developing Christoph, 1996) and neglecting the importance of the guideline recommendations, with guidelines patient preference in choosing one type of treat- varying in how research and clinical opinion are ment over another (Munoz, Hollon, McGrath, weighted and combined. A key factor of clinical Rehm, & VandenBos, 1994). guidelines is that the evidence base (research and Guidelines attract a wide range of responses structured clinical opinion) for each recommenda- from psychological therapists, from outright scep- tion is clearly indicated, so users of the guideline ticism to enthusiasm – even seeing them as a way can evaluate this. of defending and preserving psychotherapeutic In length, guidelines may vary from a single page interventions in public health care systems (Shaner, to a short book and often brief and longer versions 2002). are produced. In addition, versions for patients are This paper defines clinical guidelines, describes increasingly common. For example, the UK Depart- their development and evaluation, gives an over- ment of Health Treatment Choice in Psychological view of major guideline programmes, examines Therapies and Counselling clinical guideline has a guidelines of specific interest to psychologists and main 62-page version and an accessible practitioner psychotherapists and explores issues in their 8-page version (Department of Health, 2001a). In implementation. Finally, we review evidence for addition a related advice booklet for patients incor- the effectiveness of guidelines and draw out prac- porated material from the evidence-based guide- tice implications. line (Department of Health, 2002).

Clinical guidelines may be developed by local development of clinical guidelines preferring to groups of clinicians, national bodies or agencies produce criteria on their evaluation and appropri- (both professional and governmental) and spon- ate use (APA, 2002). sored by these groups or by commercial organiza- The development of psychological treatment tions (especially pharmaceutical companies). In the guidelines has tended follow a pattern for guide- past, most guidelines have been developed locally. lines more generally. That is, they were often For example, in the UK in 1997, Cluzeau et al. originally the product of specialist societies or found that only 21 of 472 guidelines in five clinical special interest groups. However, increasing areas of national priority were national. They concern has been expressed about the quality, reli- argued for national guideline coordination. The ability and independence of such guidelines same group advised local clinicians not to develop (Audet, Greenfield, & Field, 1990; Grilli, Magrine, guidelines but to concentrate on effective dissemi- Penna, Mura, & Liberati, 2000). Grilli et al. under- nation and implementation strategies (Littlejohns took a systematic review of ‘specialty guidelines’ et al., 1999). In the UK, such arguments have led to which focused on three areas; those of professional the development of a national body, the National and stakeholder involvement; identification of Institute of Clinical Excellence (NICE) with sys- primary evidence; and appropriate grading of rec- tematic and formal processes for health technology ommendations. Of 431 guidelines only 5% were assessments, cost-effectiveness review and guide- rated adequate in these three areas. They argued line commissioning. for a more multi-disciplinary approach with The main target audience for national guideline explicit and transparent methods and programmes programmes has been generalists – general based on international standards of good practice, medical practitioners, family practice and inter- such as are set out by Lohr (1998). nists. The role of these practitioners requires them The focus on methodological development is to make clinical decisions over widely differing exemplified in the development of the Appraisal domains and they accordingly have the greatest Guideline Research and Evaluation Collaboration need for easily accessible sources of guidance. (AGREE) an international research collaboration Also, their numbers are such that modest improve- aimed at the harmonization of guideline devel- ments in practice have potential to translate into opment methods (www.agreecollaboration.org). significant population benefit. The clinical deci- AGREE’s membership comprises many of the sions they have to make are, however, often differ- prominent national guideline development groups ent from those of specialists. In this respect clinical and methodologists. In a recent systematic review guidance that is useful for generalists (e.g. on from the AGREE group, Burgers, Grol, Klazingha, whether a patient might be suitable for referral for Maleka and Zaat (2003) provided evidence for psychological therapy) is often less useful to spe- increasing commonalty of guideline develop- cialists, who may need guidance on how most ment method and appraisal. Examples of the effectively to provide the psychological therapy. common approach to methods can be seen in Unfortunately the evidence base for intervention the publications of the Scottish Intercollegiate guidelines is invariably less secure. Guidelines Network (SIGN 2000) of a guideline developer’s handbook (SIGN, Publication No. 50, www.sign.ac.uk), the guidance from the National MAJOR GUIDELINE PROGRAMMES Health and Medical Research Council (NHMRC, 1999) of Australia and the recent guidance from The 1990s saw a significant increase in the number NICE (NICE, 2001). of guidelines generally, with an increasing number Burgers et al. (2003) also described some differ- focusing also on psychological treatment. In many ences in the programmes, where, perhaps not sur- cases these were led by professional organizations, prisingly, the approach taken to dissemination and for example, the American Psychiatric Association implementation reflected the different structures which in the 1990s produced guidelines on a range of the health care systems in which they were of disorders including depression (a common developed. Many European countries and other starting point for many psychological treatment countries such as Australia have favoured the guideline programmes) and specialty groups, for development of nationally coordinated or sup- example the International Traumatic Stress Society ported programmes of guideline development (see (Foa, Keane, & Friedman, 2000). In contrast, the Burgers et al. (2003) for a list of many of these pro- American Psychological Association eschewed the grammes). However, in the United States the posi-

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) 340 G. Parry, J. Cape and S. Pilling tion is more complex and reflects the demands of professional approach, extensive patient involve- the health care system, including the role of third ment and an explicit requirement to examine cost party insurers in developing their own treatment effectiveness. This focus on cost effectiveness is guidelines alongside professional organizations, often a characteristic of nationally funded pro- specialty groups and government organizations. grammes and is also an explicit requirement of, for This has led to very considerable duplication of example, the government-funded programmes of guidelines often covering the same area. For France (Agence Nationale d’Accrediation et d’E- example, a search on the National Guidelines valuation en Sante) and Sweden (Swedish Council Clearing House Website (see below) identifies 170 on Technology Assessment in Health Care). guidelines concerned with some aspect of the treat- Government-sponsored bodies explicitly set up for ment and management of depression. Following the purpose of guideline development often have the problems faced by the Agency for Health Care strong links with professional organizations. For Policy Research in the United States, the solution example, SIGN is a government supported inter- adopted by its successor organization, the Agency professional alliance and NICE develops its guide- for Health Research and Quality, has been to stop lines through links with the professional bodies. development of clinical practice guidelines at a The second broad group of nationally co- national governmental level. Instead they have ordinated guideline programmes is those located established (in conjunction with the American within professional organizations, for example, the Medical Association and American Association of Association of the Scientific Medical Societies in Health Plans) the National Guideline Clearing- Germany. These tend to place less emphasis on cost houseTM which provides a comprehensive database effectiveness but it would be wrong to see this as of evidence-based clinical practice guidelines and a simple and categorical distinction. For example, related documents. This provides health care pro- the Finnish Medical Society Duodecim, a profes- fessionals and others with ‘an accessible mecha- sional organization, lists cost effectiveness as a key nism for obtaining objective, detailed information reason for guideline development. on clinical practice guidelines and to further Whatever the particular location of the guideline their dissemination, implementation and use.’ development programme many programmes seek (www.guideline.gov). The Agency has also drawn to develop strong links with professional organi- attention to the problem of guidelines becoming zations in order to facilitate implementation. In out of date and hence invalid, when the evidence some cases this approach is well developed; for on which they were based is superseded. Ortiz, example, the general practice mental health Eccles, Grimshaw and Woolf (2002) studied 17 guideline implementation programme developed AHRQ guidelines and found only three were suf- in Australia (Penrose-Wall & Harris, 2000). In time ficiently valid to be retained. Their guideline on the development of patient-specific guidance Depression in Primary Care was one of the seven drawn from the original clinical practice guideline, that were found so obsolete as to warrant with- may also become an important driver in support of drawal. implementation. Where nationally co-ordinated programmes exist In addition to methodological developments, for guideline development they tend to fall into two there has been an increasing tendency to focus broad groupings. The first group, as exemplified on multi-modal approaches to treatment within by NICE in England or the NHMRC in a single guideline. Such guidelines are usually Australia are governmental organizations with problem or disorder focused and the psychological strong professional support or underpinning. For treatment is embedded in a broad-based approach example, in the case of NICE, six professionally-led to assessment, treatment and management. This is collaborating centres have been established. Each the approach taken by national guideline develop- focuses on a specialty area but is funded nationally ment programmes and is likely to be increasingly and using a common nationally agreed method the case. It contrasts social, organizational, psy- (NICE, 2001). The National Collaborating Centre chological and pharmacological approaches to for Mental Health is the unit primarily charged treatment and management more sharply than with development of mental health guidelines for previous approaches. It also goes beyond the rela- England and is jointly led by the clinical effective- tive effectiveness (both clinical and cost) of differ- ness units of the Royal College of Psychiatrists ent interventions to highlight patient preference, and the British Psychological Society. The NICE the value placed on different outcomes, the avail- programme has a strong emphasis on multi- ability of appropriate levels of evidence and the

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) Clinical Practice Guidelines 341 capacity of services to deliver the range of inter- future direction may be obtained from a compari- ventions recommended. This approach requires son of American Psychiatric Association guideline guideline developers to consider carefully com- on schizophrenia produced in 1997 (APA, 1997) bined or stepped approaches to care, which and that produced by NICE in 2003 (Kendall et al., demand complex judgements to be made about the 2003). In part the difference between them reflects relative benefits to be obtained from individual differences in methodological approaches and the treatments. dates of their publication (and as a consequence the A major advantage of such an approach is that it available evidence). This is perhaps best indicated enables climical guidelines to relate more closely to by the differing recommendations for the use of the experience of patients as they enter and move CBT in schizophrenia. Whereas the APA guideline through a health care system. The guideline aims did not recommend the routine use of CBT for to provide a common reference point to guide schizophrenia the NICE guideline does, probably treatment choice on the basis of the best available reflecting the increasing evidence available since evidence. It may also help to support implementa- the literature review was conducted for the APA tion at a local level, providing recommendations guideline (completed in 1993). However, on social about the relative benefits of treatment that would skills training the reverse is true with the APA otherwise be difficult to collate locally. guideline recommending the use of social skills However, the multi-modal approach also brings training, an approach which is not supported by a number of problems. It is particularly important the NICE guideline. In contrast to the position with to ensure wide ownership from a range of profes- CBT, this however does not reflect a changing evi- sional and stakeholder groups and that the most dence base but rather a different interpretation robust and transparent of methods of evidence of the available evidence. Provisional evidence identification and synthesis are used. Where this is suggests that psychological interventions will not the case problems can arise; this can be seen for continue to have a significant role in multi-modal example, in the response of psychologists (see for treatment for mental health disorders and perhaps example, Hollon & Shelton, 2001) to the American an increasingly important role in multi-modal Psychiatric Association guideline on the treatment guidelines for physical health disorders. Again this of depression (APA, 2000a,b). This was developed will have major implications for the demand for by a uni-professional group with an emphasis on effective psychological interventions. consensus methods and a number of psychologists questioned the process and conclusions, suggest- GUIDELINES FOR PSYCHOLOGISTS ing that psychological treatments were rated less AND PSYCHOTHERAPISTS effective as they might have been. The focus on specific disorders or diagnoses can also be prob- The precursor to UK guidelines for psychologists lematic as many people do not present with prob- and psychotherapists was a strategic review of lems that easily fit the guideline. This problem is policy on psychotherapy services published by the found with both multi-modal and single treatment Department of Health in 1996b. This review and approaches. Roth, Fonagy and Parry (1996) proposed the same In most national guideline development pro- model of evidence-based psychotherapy, which grammes depression, anxiety and schizophrenia emphasizes collaboration between researchers, feature in the list of guidelines undertaken with clinicians and those commissioning services. This depression the most common. (For example, approach can be briefly summarized as follows. depression scored 170 ‘hits’ on the National Guideline Clearinghouse website, compared to 138 • Psychological therapists develop new for anxiety and only 14 for schizophrenia.) approaches, building on existing theory, knowl- However, many of the guidelines were concerned edge and practice. with the treatment and management of anxiety or • Promising new therapies are formally depression in the context of another disorder, for researched to establish efficacy, but also field- example cardiac rehabilitation or chronic pain. tested in large samples in natural service Given the different methods adopted in the systems. development of these guidelines it is difficult to • Both research evidence and clinical consensus predict the impact of multi-modal guidelines on inform clinical practice guidelines, in order to the types of recommendations that emerge on psy- clarify where general statements can (or cannot) chological treatment. A possible indication of the be made about best practice.

• Standards derived from research-based guide- simply lists ‘validated’ treatments. This was partly lines are set and clinical audit is used to check on the grounds that it is a misleading use of they are achieved. research evidence. This approach fails to take • Skills deficits revealed by audit are addressed by account of strong evidence that although therapy training. types and specific techniques have an influence on • Outcome benchmarking has a role to play in outcome, they do not account for much of the improving patient care. variance in outcome, and that all successful psychotherapies share many common factors In addition to proposing this model, the Depart- (Norcross, 2002). However, for some, evidence- ment of Health review recommended that those based psychotherapy implies that each separate responsible for commissioning psychological psychotherapy type, with its theoretical base and therapies should not fund services or procedures set of specific techniques, is treated as if it were a where there is clear empirical evidence that they drug. Like a pharmacological substance, each are ineffective. It suggested that a commissioning therapy would be tested against placebo or the strategy should drive forward the agenda of standard treatment in a randomized clinical trial, evidence-based practice by moving investment in order to have its safety and efficacy established. towards those psychology, counselling and psy- The temptation to move in this direction remains chotherapy services which meet five standards: strong, despite strong empirical evidence for (1) They have adopted clinical guidelines for common factors across psychotherapies and the standard practice. comprehensive attack on the drug metaphor in (2) The guidelines are informed by the findings of psychotherapy research mounted by Stiles and research and service evaluation. Shapiro (1994). (3) They specify the patient groups for which the The British guideline Treatment choice in psycho- service is appropriate. logical therapies and counselling (Department of (4) They monitor outcomes for innovative Health, 2001a) was commissioned because of con- treatments. cerns that in routine general practice, referral deci- (5) They audit key elements of standard practice. sions were not commonly made on the basis of research evidence or even expert clinical opinion. More recently, the Eastern development centre of Hence the type of psychological therapy received the National Institute for Mental Health in England may be inappropriate, leading to less effective care (NIMHE) has published a set of standards for good and wasted resources, in a situation where demand practice in delivery of psychological therapies exceeds supply and waiting lists are long. (2002). These are based on 10 principles derived The scope of the guideline was extremely broad, from an informally developed consensus, rather including evidence on any psychological therapy than a research base or a formal consensus- including counselling, for a range of common generating methodology. One of these principles mental health problems and four common physi- emphasizes the use of evidence-based approaches cal problems with psychological components. This to provision of psychological therapies and recom- includes depression, anxiety, social anxiety and mends that therapies lacking an evidence base phobias, post traumatic disorders, eating disor- should only be provided in the context of a formal ders, obsessive-compulsive disorders, personality research study. disorders, chronic pain, chronic fatigue, gastroin- Developments in the United States place a testinal disorders and gynaecological problems. It greater emphasis on ‘empirically supported treat- excluded a number of other disorders for which ments’, where criteria are set for which forms of psychological therapies may be helpful – mental psychotherapy have good evidence of efficacy health problems in childhood and adolescence, (Chambless, 1993). This initiative was contentious psychoses including schizophrenia, mania and (Elliott, 1998). Although it was supported by many bipolar disorder, alcohol and other drug addic- researchers (Barlow, 1996; Crits-Christoph, 1996), tions, sexual dysfunction and paraphilias and others were highly critical (Garfield, 1996; Henry, organic brain syndromes. 1998; Shapiro, 1996a) on both scientific and prag- The guideline recommendations were developed matic grounds. over a 2-year period by a multidisciplinary group It is important to note that the Department of under the auspices of the British Psychological Health in England (1996b) explicitly eschewed Society. They were based on three sources of evi- a model of evidence-based psychotherapy that dence: a systematic review of existing reviews and

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) Clinical Practice Guidelines 343 meta-analyses, supplementary review of research internal validity (Shapiro, 1996b). This leaves the evidence appearing more recently than those guideline developer and user of a guideline uncer- reviews and structured expert consensus. The tain as to the extent to which the research is guideline incorporated service user feedback, was generalizable to patients who might have been subject to independent peer review and was excluded from a typical efficacy trial because of formally appraised against criteria for guideline multiple co-morbidities (Aveline, Shapiro, Parry, & quality. About half the recommendations are Freeman, 1995). A fuller picture emerges when general considerations, for example, on recom- results of efficacy trials are supplemented by mended length of therapy, the impact of patient effectiveness studies using representative clinical and therapist characteristics and the importance of populations (e.g. Guthrie et al., 1999; Shadish, the therapeutic alliance irrespective of therapy Malt, Navarro, & Phillips, 2000) and practice-based type. The other recommendations are for first-line evidence gathered through Practice Research therapies for specific conditions, and some con- Networks (Audin et al., 2001). traindications. Although closer to the concept of ‘empirically supported treatments’ than the 1996b Department of Health policy statement, the guide- Condition-based Versus line explicitly warns against assuming that absence Intervention Guidelines of evidence implies evidence of ineffectiveness, particularly in a field where very few studies Most clinical practice guidelines in medicine are demonstrate relative rather than absolute efficacy. disease- or condition-based guidelines of the form ‘What are the most effective treatments/interventions for condition X?’ The American Psychologi- ISSUES FOR GUIDELINES IN cal Association Empirically Supported Treatment PSYCHOLOGY AND PSYCHOTHERAPY guidelines (Chambless, 1993) are of this form (the most appropriate treatment for specified DSM IV Research Base defined conditions) as are approximately half of Evidence-based clinical practice guidelines depend the recommendations in the UK Treatment Choice on there being a body of research that can be used in Psychological Therapies and Counselling to assist clinical decisions. The psychological Guideline (Department of Health, 2001a). therapies, for a type of intervention that does not Condition-based guidelines are appropriate to benefit from development and evaluation funding the practice of medicine where practice decisions from industry (pharmaceutical companies) or are primarily about choice of intervention (e.g. usually from dedicated research charities, is type of drug to prescribe and/or type of therapy to blessed with an extensive research literature. refer to) and the practitioner does not have respon- However, there are significant gaps in the research sibility for quality control of the intervention itself. evidence and some have questioned whether It is the pharmaceutical company that is respon- results from randomized trails can be used to assist sible for the quality of the drug prescribed and practice decisions (Aveline, 1997). the therapist referred to (whether physical thera- Most research has been conducted on short-term pist or psychotherapist) who is responsible for and structured forms of psychotherapy (Roth & the therapy provided. The physician’s decision Fonagy, 1996), with gaps in the research evidence is limited to choice of the most appropriate for many types of therapy, especially longer ones. intervention. The most significant gap is in eclectic and integra- Psychological therapists, in common with physi- tive therapies, where the therapist uses a range of cal therapists and surgeons, as well as deciding on techniques and procedures in response to individ- type of intervention (type of operation or therapy), ual patient need. Such approaches are not often are responsible for the quality of the intervention researched because of the difficulty of specifying delivered. Effectiveness to the patient depends as and standardizing the intervention, yet may be the much or more, on the skilful undertaking of the most common forms of therapy practised (Milan, intervention by the practitioner over time as in Montgomery, & Rogers, 1994; Zook & Walton, choice of the most appropriate intervention/pro- 1989). cedure. In the UK, the public enquiry into the Research on the effectiveness of psychotherapy Bristol paediatric cardiac surgery deaths that led to has most commonly been carried out on relatively major changes in health quality regulation (Depart- tightly defined populations in order to maximize ment of Health, 2001b) were not the result of sur-

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) 344 G. Parry, J. Cape and S. Pilling geons choosing the wrong operation, but from professionals. However, the issues that concern inadequate technique. In another example from patients and are important for patients to be surgery, the development of keyhole surgery and reflected in guidelines, may well be different from evidence for its effectiveness led to an increase in those of professionals (Bussing & Gary, 2001; Teno, surgical complications as a result of surgeons Casey, Welch, & Edgman Levitan, 2001). Patients, starting to practise the new techniques without for example, have very different views from having acquired sufficient skill (Rogers, Elstein, & medical professionals on the relative merits of anti- Bordage, 2001). depressant medication and counselling and psy- Intervention guidelines define the steps required chological therapies (Priest, Vize, Roberts, Roberts, in the skilful practice of an intervention over time. & Tylee, 1996). This has been suggested as one Treatment manuals used in successful trials of reason why treatment of depression by general psychological therapies, although drawn up for a medical practitioners is often at variance to guide- different purpose, are a form of clinical practice line recommendations (Kendrick, 2000), while guidelines for carrying out that intervention. Such giving patients information and choice about treat- manuals are now available for a wide variety of ment may improve guideline adherence (Dwight- psychotherapies (Addis, 1997; Najavits, Weiss, Johnson, Unutzer, Sherbourne, Tang, & Wells, Shaw, & Dierberger, 2000; Wilson, 1998) and teach- 2001). ing programmes based on these manuals are Involvement of patients and users in guideline increasingly delivered (Calhoun, Moras, Pilkonis, development groups is now much more extensive & Rehm, 1998). (NICE, 2001) and where the influence of patient Formal measures of therapist competence groups is considerable they are likely to alter (Chevron & Rounsaville, 1983) are another poten- the scope and emphasis of the guideline. Where tial source of intervention guidance. Methods patients and user representatives were the major- include the assessment of case formulations or ity in a guideline development group, for the psychodynamic interpretations (Crits-Christoph, patient information booklet based on the UK Cooper, & Luborsky, 1988; Silberschatz, Fretter, & Department of Health Treatment Choice in Psy- Curtis, 1986) and of whole sessions using formal chological Therapies Guidelines (Department of rating scales (Barber & Crits-Christoph, 1996; Health, 2002), they wished to focus on a range of Bennett & Parry, 2003; Vallis, Shaw, & Dobson, areas not reflected in the practitioner guideline 1986; J.E. Young & A.T. Beck, unpublished data). (Department of Health, 2001a). For example, they The use of these rating scales in practice is not dis- placed much more emphasis on minimizing harm similar to process guidance; therapeutic skills and from therapist incompetence or abuse. tasks are derived from professional consensus (in some cases, using structured methods) and speci- Misuse of Guidelines fied with clarity and precision in a way that can be rated reliably. Where these measures have been Guidelines may be misused by practitioners, by found to predict clinical outcome (Crits-Christoph managers and funders of services, and by patients. et al., 1988; Shaw et al., 1999) there is an evidence Each may insist on following a guideline recom- base for their use. Evidence related to measures of mendation when an alternative course of action the therapeutic alliance (Martin, Garske, & Davis, would be more clinically appropriate. Guidelines 2000; Safran & Muran, 1996) can be similarly are designed to assist practitioners and patients incorporated. in making complex clinical judgements and not Systematic appraisal of these sorts of evidence in to replace the judgement process (Baker, 2001; the future will allow therapy process intervention Haynes, Devereaux, & Guyatt, 2002). Clinicians guidelines to be developed that go beyond shared retain both clinical freedom to do something dif- clinical wisdom. The source and quality of evi- ferent and responsibility for their judgements. This dence (whether research or consensual) for each point is strongly made by advocates of evidence- recommendation in an intervention guideline based medicine (Sackett, Rosenberg, Gray, & needs to be explicit as in other guidelines. Haynes, 1996). Practitioners and patients need to decide if the circumstances of the patient and point of therapy are such that the guideline recom- Patient Views mendations are appropriate. Slavish adherence to The scope and content of clinical practice guide- guideline recommendations (i.e. 100% adherence) lines has generally been determined by health is as likely to reflect poor clinical practice as

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) Clinical Practice Guidelines 345 clinical decisions never being in accordance with and recognition of depression than on more guidelines. complex areas of psychological intervention. The Only including evidence of costs and effective- very few study reports which have included an ness in guideline development may make their attempt to assess uptake of primary care depres- application more problematic. Berg, Meulen and sion guideline recommendations on psychological van den Burg (2001), based on a study for the Royal therapies (Baker, Reddish, Robertson, Hearnshaw, Dutch Medical Association, argue that explicit & Jones, 2001; Brown et al., 2000; Wells et al., 2000) attention should also be given to ethical and only mention this in passing, with too few details political considerations. They used an exploratory to allow adequate evaluation. We have been unable qualitative method to explicate clinicians’ nor- to find any studies that have evaluated the impact mative considerations. Similarly, Boyce, Harris of clinical practice guidelines on the practice of and Penrose (2002), describing the RANZCP pro- psychological therapists. gramme of guidelines development, assert that Passive dissemination of guidelines alone (e.g. guidelines must reflect a fit between clinician by post) has little or no effect (Freemantle et al., aspirations, the evidence, and consumer expecta- 2000; Lomas, 1991). Even well-resourced, national tions if they are to be adopted into routine service guidelines, published in multiple media, can fail delivery. to reach, let alone impact, their target audience (Feldman et al., 1998; Rix et al., 1999). In the field of mental health, Bauer’s (2002) review of 41 EVIDENCE FOR EFFECTIVENESS quantitative studies of adherence to guidelines OF GUIDELINES suggested that guideline adherence is not high without specific intervention, and that those inter- There is evidence now from a number of system- ventions that improve adherence are typically mul- atic reviews that clinical practice guidelines can tifaceted and resource-intensive ones. He found both influence practice and result in better health mixed results of the impacts of adherence on outcomes for patients (Bauer, 2002; Effective clinical outcomes and noted that adherence tends Health Care, 1994; Grimshaw & Russell, 1993). The to return to pre-intervention levels over time. review of Bauer (2002) is specifically on guidelines The disappointing results of passive implemen- in mental health. tation of depression guidelines has led to calls Studies of the effectiveness of guidelines in for a range of approaches including provider mental health have most commonly been on education, dedicated resources, structured care depression in primary care, in particular on the programmes and systematic follow-up of patients’ AHCPR (1993) depression guideline. There is an treatment adherence and clinical outcomes (Simon, issue of how applicable to a primary care setting 2002). In the broader guidelines field, a substantial are guidelines developed from research in sec- literature has developed on strategies that facili- ondary or tertiary care. This has been highlighted tate the uptake of guidelines by clinicians (Effec- by Schulberg et al. (1995) who found in a study of tive Health Care, 1994, 1999; Grimshaw & Russell, guideline implementation that although the appli- 1994; Moulding, Silagy, & Weller, 1999; Wensing, cation of the guideline was feasible, it was van der Weijden, & Grol, 1998). Two of the more complex, with only 33% of primary care depressed effective strategies identified from these reviews patients assigned to receive antidepressant med- are educational outreach with individual practi- ication completing the full regimen recommended tioners (termed ‘academic detailing’ in the US lit- by the AHCPR guidelines. erature; Soumerai, 1998; Thomson O’Brien et al., Although this and similar depression guidelines 2002) and patient-specific reminders to use the (American Psychiatric Association, 2000 a,b) guideline (e.g. computer prompt or note on the include reference to psychological therapies, the patient’s file; Cannon & Allen, 2000). aspects of guideline adherence usually examined In mental health more specifically, Rollman, in studies of guideline effectiveness are recognition Gilbert, Lowe, Kapoor and Schulberg (1999) of depression and medication management. As describe an example of an electronic medical there is evidence that adherence to guideline rec- record (EMR) to disseminate the AHCPR depres- ommendations is generally lower for recommen- sion guideline to primary care doctors. Educational dations that are more complex (Grilli & Lomas, outreach in particular has been used in a number 1994), it is likely that it will be easier to show of studies showing impact on GP antidepressant impact of guidelines on medication management prescribing (Brown et al., 2000; Freemantle et al.,

2002; Goldberg et al., 1998; van Eijk, Avorn, It is plausible that different ways of facilitating Porsius, & de Boer, 2001; Worrall, Angel, Chaulk, implementation of guidelines and different combi- Clarke, & Robbins, 1999). By contrast, standard nations may be more effective depending on the education and training workshops in mental particular practitioner and practice circumstances. health skills have not generally been found effec- In a study of guidelines for management of depres- tive (Lin et al., 1997; Tompson et al., 2000). Audit sion in general medical practice, Baker et al. (2001) and feedback to clinicians as to their adherence to found that tailoring methods to overcome obsta- guideline recommendations, although found to be cles to change identified for individual general effective outside mental health (Palmer et al., 1996), practitioners was more effective in changing prac- has been less frequently studied in mental health tice than blanket dissemination methods and was and with mixed results (Simon, Von Korff, Rutter, associated with reduced depression in patients & Wagner, 2000). Continuous quality improvement treated. There are now a number of theoretical failed in two studies relating to implementation analyses, often based on psychological theories of of guidelines on depression and hypertension change, as to how guideline implementation strate- (Brown et al., 2000; Goldberg et al., 1998). gies might be tailored to specific practitioner Reviews of strategies to facilitate the uptake of and practice circumstances (Firth-Cozens, 1997; guidelines by clinicians commonly conclude that Limbert & Lamb, 2002; Marteau, Sowden, & Arm- multifaceted approaches are more effective than strong, 1998; Moulding et al., 1999; Robertson, single strategies (Bero et al., 1998; Effective Health Baker, & Hearnshaw, 1996). Care, 1999; Greco & Eisenberg, 1993; Oxman, Thomson, Davis, & Haynes, 1995; Wensing et al., 1998). These approaches incorporate more than CONCLUSIONS one strategy (educational outreach, reminders, audit and feedback) and thus target different obsta- It is important to recognize that clinical guidelines cles to change. The few experimental studies in are only one aspect of informing psychologists and mental health where strategies to improve adher- psychotherapists what might be best to do. Guide- ence to guidelines have also had an impact on clin- lines, even when supported by the best implemen- ical outcome have used multifaceted approaches tation practices, need to be supplemented by other (Katon et al., 1995, 1996, 2001; Katzelnick et al., clinical support methods and with methods of 2000; Wells et al., 2000). However, since these mul- monitoring what is actually done in practice and tifaceted approaches also involve organizational its response on the patient (Cape & Barkham, 2002; changes to practice and additional resources (e.g. Roth et al., 1996). For example, Whipple et al., patient self-help materials, nurse case managers, (2003) described the use of feedback regarding psychiatric consultation and brief psychological client progress and clinical support tools (CSTs) in therapy), it is unclear whether the improved clini- psychological therapy in routine practice, finding cal outcomes were mediated through guideline that patients stayed in therapy longer and had adherence or through enhanced therapeutic input superior outcomes when these problem-solving of other kinds. methods were used. Results from naturalistic studies on the relation- Having said this, the impact on practitioners of ship between receiving guideline-adherent mental research-based clinical guidelines is likely to health treatment and clinical outcomes are mixed. increase in the future. In the UK this is well under Some studies showed improved outcomes for way with the dissemination of the Treatment patients receiving guideline-adherent treatment Choice in Psychological Therapies and Coun- (Fortney, Rost, Zhang, & Pyne, 2001; Melfi et al., selling guideline (Department of Health, 2001a) 1998; Revicki, Simon, Chan, Katon, & Heiligen- and the current development of a suite of NICE stein, 1998; Rost, Williams, Wherry, & Smith, 1995), mental health guidelines each incorporating others show no difference in outcomes (Druss & recommendations on psychological therapies Rosenhack, 1997; Rost et al., 1998; Schulberg et al., (www.nice.org.uk). 1997). Where studies do find an association with In the UK, we see a danger that health service outcome, there are other possible explanations, managers, required by policy makers to implement such as that patients who are amenable to and NICE guidelines, might take a simplistic approach capable of complying with their care may be more to ensuring compliance. For example, the recom- likely anyway to achieve better outcomes (Bauer, mendation that people with positive symptoms in 2002). schizophrenia should have access to cognitive

Copyright © 2003 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 10, 337–351 (2003) Clinical Practice Guidelines 347 behaviour therapy presents a difficulty when depressive disorder (revision). American Journal of there are insufficient practitioners with the skills Psychiatry, 157 (Suppl.), 1–45. required to implement the methods to the stan- American Psychiatric Association Work Group on Eating Disorders. (2000). Practice guideline for the treatment dards that were found effective in the original of patients with eating disorders (revision). American research. Such an apparently simple recommenda- Journal of Psychiatry, 157, (Suppl.), 1–39. tion in fact has implications for many parts of the American Psychological Association. (2002). Criteria for complex mental health care system. Changes are evaluating treatment guidelines. 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