Guidelines in mental health – National and international perspectives

High-quality clinical guidelines remain the most elaborate and well-developed expression of evidencebased medicine in clinical care, combining a systematic approach to reviewing the evidence with multi-professional and service user involvement, along with robust systems for consultation and review. This approach to clinical guideline development is a response to previous criticisms of clinical guidelines, for example, the limitations of the uni-professional guideline (Grilli et al., 2000) and the need for more robust methods for ensuring and evaluating quality in guideline production (Cluzeau et al., 1999). However, concerns about the quality and value of clinical guidelines continue to be expressed (Grol, 2010; Shaneyfelt & Centor, 2009). These concerns include the cost and speed of development, over-reliance on expert consensus, the misuse of guidelines as performance measures, the promotion or suppression of professional interests, and the considerable challenges of effective implementation. These concerns are important. Equally important, and in many ways more pressing, is the place that guidelines have in health and social care, and the purpose of these products. Essentially a distillation of what we can claim to know, guidelines are subject to all the imperfections that any knowledge brings: is it reliable, is it useable, is it focused on what is really important? Much of the work described in this special edition, which draws heavily on the work of the National Collaborating Centre for Mental Health (NCCMH), attempts to address these concerns. The fi rst three papers by Clark (pp. 318 – 327), Barnes & Paton (pp. 328 – 335) and Worrall (pp. 336 – 341) address the very important issue of implementation of clinical guidelines. Clark describes the development of the Improving Access to Psychological Therapies (IAPT) programme, an initiative of the Department of Health in England to train over 7,000 additional psychological therapists over a 6-year period. This programme of implementation takes as its starting point the recommendations provided by the National Institute for Health and Clinical Excellence (NICE) guidelines on the treatment of depression and anxiety disorders. It is the largest single implementation programme for any NICE guideline. By completion of the implementation phase of the IAPT programme (in 2015), it is expected that an additional 900,000 people will be in receipt of NICE recommended evidence-based psychological treatments. In his paper, Clark describes the main components of the IAPT programme including the range of interventions provided, the training programmes specifi cally designed to develop a new workforce based predominantly in primary care and skilled in the evidence-based psychological interventions needed to implement the NICE guidelines in common mental health problems, and the systems for service delivery and organization, including a stepped-care approach and routine outcome monitoring. The paper also reports some data from the early pilot programmes with recovery rates (with an aim of matching those achieved in RCTs) of over 50%, and an average of 42% for the fi rst year of the national roll out programme. Clark also highlights important remaining challenges for IAPT, including the provision of evidence-based interventions apart from CBT (the primary focus of the initial programme), and the integration of the IAPT services with other psychological treatment services. A second paper on the implementation of NICE guidelines by Barnes & Paton (pp. 328 – 335) describes the work of the Prescribing Observatory in Mental Health in the United Kingdom (POMH-UK). This highly innovative and successful initiative has employed a quality improvement approach focused on the quality of prescribing in mental health. Having developed a subscription network of healthcare organizations throughout the UK, POMH-UK established important benchmarks for prescribing a number of different drugs including antipsychotics, cognitive enhancers and lithium based upon standards derived from NICE guidelines. Barnes & Paton also identify areas where organizational barriers obstruct improving practice, such as in lithium prescribing. This systematic national network has made signifi cant changes in the prescribing of psychiatric drugs, including in highly topical areas such as the use of antipsychotics for people with dementia. International Review of Psychiatry, August 2011; 23: 314–317