APA moves forward on developing clinical treatment guidelines
By Howard S. Kurtzman, PhD, and Lynn Bufka, PhD
In 2010 the American Psychological Association (APA) initiated a process for the development of evidence-based clinical treatment guidelines. This long-term project, which involves psychologists from both the science and practice communities, was approved by the APA Council of Representatives at its February 2010 meeting and is being overseen by the Board of Directors, Board of Scientific Affairs, Board of Professional Affairs, and Committee for the Advancement of Professional Practice.
This is the first time that APA has sought to develop recommendations for treatments of particular disorders and conditions. The effort builds on previous APA policy statements on evidence-based practice and on the evaluation of treatment guidelines that are developed by other organizations. APA has also developed what it calls practice guidelines, which are distinct from treatment guidelines in that they address the conduct of clinical practice with particular populations or in particular settings but are not condition- or treatment-specific.
The decision to develop treatment guidelines was motivated in part by changes in recent years in how psychological services are delivered and compensated and by the growing emphasis across health care on assessing the comparative effectiveness of treatments (including the recent health care reform legislation). Also influencing the decision was the fact that many other health organizations are now developing guidelines for the purposes of synthesizing research and conveying what is known about the most effective approaches for treating and managing various disorders. Without strong guidelines from APA that represent psychology and psychological interventions, it is likely that guidelines established by other organizations would become the standards within health care for mental and behavioral conditions.
Steering Committee is Established
As a first step in APA’s development of treatment guidelines, a nine-member “advisory steering committee” was formed. The members of the steering committee, who were selected by the Board of Directors from among more than fifty nominations, are: Steven D. Hollon (Vanderbilt University), chair; Patricia A. Areán (University of California, San Francisco); Michelle G. Craske (University of California, Los Angeles); Kermit A. Crawford (Boston University School of Medicine); Daniel R. Kivlahan (Veterans Affairs Puget Sound Health Care System); Jeffrey J. Magnavita (Glastonbury Psychological Associates); Thomas H. Ollendick (Virginia Polytechnic Institute and State University); Thomas L. Sexton (Indiana University); and Bonnie Spring (Northwestern University). The members will serve for three-year terms and may be appointed to second terms. The work of the steering committee is supported by APA staff from both the Science and Practice Directorates.
The responsibilities of the advisory steering committee include: determining the scope and format of APA clinical treatment guidelines; selecting disorders and conditions for which treatment guidelines will be developed; recommending experts from a broad range of scientific and clinical perspectives to serve on panels that will write guidelines for the selected disorders and conditions; identifying and commissioning independent systematic reviews of relevant empirical literature that will underpin the guidelines; and advising APA governance and staff on the association’s policies and support for guidelines development.
Systematic reviews aim to identify, assess, and summarize all scientific literature related to a specific question in a methodical, non-biased fashion; they often involve meta-analytic techniques. Although the steering committee will not itself conduct systematic reviews or produce guidelines, it will oversee those processes with the aim of ensuring that they are rigorous, objective, and transparent.
The steering committee has met twice in person in Washington DC, in December 2010 and February 2011, as well as held regular conference calls and communicated via email and an intranet website. The next meeting in Washington is planned for August 2011.
Designing a Process
In its initial meetings, the steering committee examined the guidelines and guideline development processes of other professional organizations within medicine and behavioral health. It also reviewed two recent Institute of Medicine reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust. It studied as well the work of two international groups: the GRADE Working Group, which has published standards for evaluating the quality of evidence and strength of guideline recommendations, and the AGREE consortium, which has produced criteria for assessing the quality of the process by which guidelines are developed and presented. Further, psychologist Steve Pilling, who helps lead the development of mental health treatment guidelines for the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), attended a portion of the February meeting and discussed with committee members the process by which NICE conducts systematic reviews and develops guidelines.
Based on this consideration of the broader landscape of treatment guidelines development as well as of the particular characteristics and needs of psychologists and their clients, the steering committee has begun to draft a Manual of Procedures that describes in detail the guidelines development process that APA will follow. This Manual will include a statement of mission, vision, and principles; criteria for selecting particular disorders and conditions; criteria for the formulation of questions that will drive systematic reviews of the research literature; criteria for choosing members of the panels that will produce guidelines; and discussion of the specific roles and procedures of the steering committee, guidelines development panels, and consultants. Any guidelines produced through the process described in the Manual would have to be approved by the Council of Representatives in order to be adopted as APA policy.
When it is completed, the Manual will be posted on a public website. It is intended to be a living document that can be modified in future years as APA gains further experience in guidelines development and as thinking about guidelines evolves in other sectors of health care.
Other topics as well have come up in steering committee meetings. One line of ongoing discussion concerns the advantages and disadvantages of collaborating with other organizations in producing systematic reviews and developing guidelines. In addition, the committee is weighing whether it would be preferable for new systematic reviews to be conducted by an office that would be established within APA or to be contracted to outside organizations. Also under discussion is how most effectively to include patient advocates and experts from disciplines other than psychology in guidelines development.
Further, the committee has begun to address the costs and financing of guidelines development. The APA Board of Directors has approved an initial round of funding that will support the development of guidelines for a single disorder or condition. However, the committee is also investigating the possibilities for obtaining funding from outside organizations, including both federal agencies (e.g., the Agency for Healthcare Research and Quality and the National Institutes of Health) and private foundations. Based on other organizations’ experiences, it is estimated that development of guidelines for a single disorder/condition, including conduct of a systematic review, will take 18-24 months. With outside funding or collaboration with another organization, more than one set of guidelines could be developed during that timeframe.
In order to add specificity to its discussions, the steering committee has focused on a number of particular disorders/conditions, including depression (a large research domain for which youth and adults might be considered separately), obesity, oppositional defiant disorder, post-traumatic stress disorder, and somatic symptom disorders. Later in 2011, the committee is likely to select one or two of these to be the first for which guidelines will be developed.
Concerns have been raised by steering committee members and APA staff about terminology. APA’s usage of the terms “treatment guidelines” and “practice guidelines” does not comport with that of other organizations and therefore might produce confusion in the broader health care field. Outside of APA, both terms are commonly used to refer to what APA currently labels as “treatment guidelines.” One possible solution is for APA to switch to the term “professional guidelines” for what it currently calls “practice guidelines,” and to adopt “practice guidelines” for what it currently calls “treatment guidelines.” The Board of Professional Affairs will consider this proposal, consult with other governance groups, and decide whether to recommend its adoption by the Council of Representatives.
The steering committee has expressed its commitment to maintaining an open and transparent process. Its members will disclose any potential conflicts of interest related to treatment guidelines on an annual basis or whenever their situations change. Potential conflicts may involve financial interests; research, clinical, and training activities; organizational affiliations; and intellectual biases that could compromise objectivity. Potential conflicts and their implications will be discussed by the steering committee members and APA staff (including the Office of the General Counsel).
The committee will also work with APA staff to develop a public website and regular newsletter updates for broad sharing of documents and other information about the treatment guidelines development process. In addition, the committee members will provide reports to the memberships of other organizations with which they are associated about the APA effort.
Questions and comments can be directed to APA’s Clinical Treatment Guidelines electronic mailbox.
Howard Kurtzman, PhD, is deputy executive director for science (Science Directorate) and Lynn Bufka, PhD, is assistant executive director for practice research and policy (Practice Directorate) at the American Psychological Association. This article is appearing in both Psychological Science Agenda and Practice Update.
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