When it comes to treatment guidelines, APA is late to the party, but I am glad we have finally arrived. Evidence-based guidelines (EBG) have been around for a long time in the larger health-care arena. In the 1970s, medicine woke up to the fact that the "art of medicine" or "clinical judgment" did not necessarily result in positive patient health outcomes. The literature of the time was replete with examples of physician errors in medical reasoning and failure to follow the consensus standards of their own experts. The explosion in the scientific literature made it impossible for any practicing physician to keep up. Medicine was shocked to learn that only 15 percent of medical practice was based on solid clinical research.
In response, beginning in the 1980s, several medical groups worked to create guidelines. In 1981, the American College of Physicians began its Clinical Efficacy Assessment Project to write literature reviews; by 1985, they were publishing them as guidelines. In 1987, the Council of Medical Specialty Societies convened a national meeting to promote the idea of guidelines. Soon after, the American Medical Association (AMA) brought together a large number of professional societies to help coordinate EBGs. In 1989, the U.S. Preventive Services Task Force was convened to evaluate the research and issue guidelines for preventive health services. In 1993, the Agency for Healthcare Research and Quality (AHRQ) launched a program to create EBGs and the Cochrane Collaboration created a 13-country network to provide recommendations based on systematic reviews. In the 1990s, the AMA, AHRQ and the American Association of Health Plans (now American's Health Insurance Plans) created the National Guideline Clearinghouse.1
By the end of the 1990s, it was widely accepted in medicine that guidelines should be based on evidence and that consensus-based methods were appropriate only in the absence of evidence. In this context, many specialty societies, disease-based associations and managed-care organizations built guideline programs.1 By 2011, the Guidelines International Network database had 3,700 guidelines and the National Guidelines Clearinghouse had 2,700.2
But consumers of these guidelines often had no good way to determine which were based on solid evidence and which were not. In response, in 2008, Congress asked the Institute of Medicine to determine the best methods for developing guidelines. This effort resulted in eight standards for developing rigorous, trustworthy guidelines: establishing transparency; managing conflict of interest; selecting a multidisciplinary guideline-development group with patient and public input; articulating the link between guideline development and systematic review of the literature; establishing evidence foundations for and rating the strength of recommendations; articulating recommendations; conducting external reviews of the guidelines; and updating the guidelines.2 It was heartening to review APA's Criteria for Evaluating Treatment Guidelines, published in 2002, which are entirely consistent with these standards.3
In my view, it is important that APA join the EBG movement if it is to be an effective player in the larger health-care arena. EBGs are already a central part of medical care and will be part of the integrated-care delivery systems of the future. Psychologists have important scientific expertise to offer and can play a critical role in assuring that psychological interventions are part of the EBG movement; patients should have access to effective psychological interventions and not be limited to drugs or other biologic interventions.
I applaud the work of APA's Clinical Treatment Guideline Steering Committee and encourage you to learn more.
1 Eddy, D. Health Affairs 2005: 24:9–17.
2 IOM. Clinical Practice Guidelines We Can Trust. 2011, http://iom.edu/~/media/Files/Report%20Files/2011/Clinical-Practice-Guidelines-We-Can-Trust/Clinical%20Practice%20Guidelines%202011%20Report%20Brief.pdf
3 APA. American Psychologist 2002: 57: 1052–1059
Letters to the Editor
- Send us a letter