Clinical guideline confusion

Questions asked by those working with them.

A group of psychotherapy researchers from across the UK, Europe, Canada and the USA, and from different theoretical orientations, met in Oxford this autumn. Our discussions were prompted by new guidelines for depression in development in Sweden and those developed by NICE that are due to be published shortly. We share three broad concerns:

  • Different guidelines reviewing the same evidence base for the same conditions are arriving at different recommendations (Moriana et al. 2017).
  • There is a marked discrepancy between the evidence reviewed for clinical guidelines and the evidence from therapies delivered on the ground (Pybis et al., 2017).
  • After over a decade of implementing NICE’s influential clinical guidelines for depression, for example, we have yet to fully understand the variations in outcomes that we see.

We do know some things. Where NICE recommends several therapies, we know patients want to choose the one they feel works best for them (Williams et al., 2016). We know they want us to aim for recovery and not be curtailed by arbitrary limits (Royal College of Psychiatrists, 2011, 2013). We know too about unintended harms. GPs continue to over-prescribe medication (McManus et al., 2016; Spence et al., 2014). But increasing the access targets to therapy without the capacity is toxic to staff wellbeing (British Psychological Society/New Savoy Partnership annual staff wellbeing surveys 2014/15/16). Whilst we did not expect clinical guidelines to reduce the burden of depression on their own, getting the right balance between ‘command and control’ and listening to voices from the NHS frontline is far from a ‘job done’.

It was famously said that ‘people in this country have had enough of experts … telling us what’s best…and getting it wrong’ (this from Michael Gove shortly before the UK voted to leave Europe). This was aimed at economic experts. In order to pre-empt disillusion with experts in psychotherapy we believe it is important to address the concerns above. Our intention in the coming months is to seek to work collaboratively with key decision-makers, and across the discipline. Starting with the questions being asked by those who use clinical guidelines, we aim to follow where the evidence needed leads us and, with luck, come up with useful answers.

Jeremy Clarke CBE, London School of Economics and Political Science
Lynne Angus, York University, Ontario, Canada
Michael Barkham, University of Sheffield, England, UK
Robert Elliott, University of Strathclyde, Scotland, UK & University of Toledo, USA
Gillian Hardy, University of Sheffield, England, UK
Aarno Laitila, University of Jyvaskyla, Finland
John McLeod, University of Abertay, Scotland, UK & & University of Oslo, Norway
Naomi Moller, BACP & Open University, UK
Glenys Parry, University of Sheffield, England, UK
Bjorn Philips, Stockholm University, Sweden
Stig Poulson, University of Copenhagen, Denmark
Jan Ivar Rossberg, University of Oslo, Norway
Henning Schauenburg, University of Heidelberg, Germany
Bruce Wampold, Modum Bad Psychiatric Center, Norway & University of Wisconsin-Madison, USA

References

  1. British Psychological Society & New Savoy Partnership annual staff wellbeing survey, New Savoy Conference 2015, 16 & 17
  2. McManus S, Bebbington P, Jenkins R, & Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.
  3. Moriana, J. A., Galvez-Lara, M., & Corpas, J. (2017). Psychological treatments for mental disorders in adults: a review of the evidence of leading international organizations. Clinical Psychology Review, 54, 29–43.
  4. Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and counselling in the treatment of depression: evidence from the 2nd UK national audit of psychological therapies. BMC Psychiatry, 17, 215.
  5. Royal College of Psychiatrists, 2011, Report of the 1st Round of the National Audit of Psychological Therapies, 2011; Royal College of Psychiatrists, 2013, Report of the 2nd Round of the National Audit of Psychological Therapies, 2013.
  6. Spence, R., Roberts, A., Ariti, C., & Bardsley, M. (2014) QualityWatch: Focus on Antidepressant prescribing – Trends in the prescribing of antidepressants in primary care. The Health Foundation Nnuffield Trust
  7. Williams, R., Farquharson, L., Palmer, L., Bassett, P., Clarke, J., Clark, D. M., & Crawford, M. J. (2016). Patient preference in psychological treatment and associations with self-reported outcome: national cross- sectional survey in England and Wales. BMC Psychiatry, 16, 4.

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