Recent issues of Psychiatric Times had articles focusing on psychiatric practice guidelines and algorithms.1-4 Dr Michael Fauman examined the extent to which they are used, how they are used, and studies that have validated their usefulness compared with usual care. This article focuses more on why psychopharmacology guidelines and algorithms are not followed and proposes 7 clinical scenarios in which the recommendations should be followed more often than they are. Major guideline and algorithm projects are summarized in Table 1.
Standardized care driven by evidence-supported algorithms is a model that has attracted the attention of the hospital business community.5 Intermountain Health Care in Salt Lake City has been using standardized treatment for 2 dozen illnesses, such as pneumonia, diabetes, and heart disease in its 21 hospitals and 90 clinics for many years, with robust improvement in care quality and reduction of costs. The business case for their approach is impressive: operating margins are at the very top of the industry.5 Thus, it seems likely that many of us will someday find ourselves working in care systems in which algorithm adherence will be the expectation.
Why are guidelines and algorithms not used?
Fauman discussed the many reasons why physicians object to guidelines and algorithms.1,4 Curiously, physicians often agree with the recommendations when they are presented to them separately.6 Nonadherence may therefore be a problem caused more by a failure of the health care system to provide reminders of the recommendations at a timely moment in the physician's work flow than by disagreement with the recommendations themselves.7 Ideally, they should be in an abbreviated format, but with the option to access the full reasoning and supporting evidence as needed. Clearly, the appropriate vehicle for getting the algorithm advice to the physician is a computerized medical record and order-entry system.8 However, the standard for how best to incorporate the logic and recommendations of guidelines and algorithms into such systems does not exist yet.9
Another reason for differences between what guidelines and algorithms recommend and what physicians do is related to the way practicing physicians make treatment decisions.10 Experienced physicians do not usually think through every decision with a systematic and exhaustive comparison of alternatives: collecting all possible relevant data about the patient and then considering all the pertinent literature. This kind of evidence-based medicine practice is too time consuming to be practical. Instead, physicians do a limited review of the patient's history and mental status, prompted by certain symptoms or historical details. They rather quickly determine the important characteristics of the situation, after which a solution may just "fall into place."10 Such "rules of thumb" are less cumbersome to apply than the "rules" of algorithms that are based on more exhaustive analyses.7
Clinical experience validates these rules of thumb, and they are assumed to exemplify the "art" of medicine. Personal heuristics provide efficient and effective solutions at many decision points, which may be as good as the recommendations of the algorithms. Indeed, research may establish the superiority of some of these other approaches. Physicians tend to oppose recommended practices that are harder or take more time than what they do now. In these situations, the experience-based rules of thumb may fall short of optimal practice.7
When should guidelines/ algorithms be followed?
Most recommendations in guidelines and algorithms probably are followed.4 The following 7 recommended practices, which seem to differ from what many physicians do but may produce better results, are listed in Table 2 and are explained and discussed below. ("Better result" is defined as either a better clinical outcome or the same outcome with equivalent safety but with reduced cost.)
|Use clozapine(Drug information on clozapine) after 2 adequate monotherapy trials of other antipsychotics in schizophrenia.|
|Make 1 medication change at a time, with adequate dose and duration of therapy.|
|When there is no significant response to monotherapy, switch to a different agent rather than adding a second medication.|
|When initiating an SSRI, select an inexpensive generic for cost-effectiveness.|
|Check for potential drug-drug interactions before prescribing.|
|Use lithium(Drug information on lithium) in preference to valproate(Drug information on valproate) as first-line treatment for bipolar disorder.|
|Approach insomnia as a symptom that requires diagnosis and treatment specific to the diagnosis.|
Use clozapine after 2 adequate monotherapy trials of other antipsychotics in schizophrenia. Numerous lines of evidence support this recommendation, found in all schizophrenia algorithms including the International Psychopharmacology Algorithm Project (IPAP), the Texas Medication Algorithm Project (TMAP), and the Psychopharmacology Algorithm Project at the Harvard South Shore Department of Psychiatry (PAPHSSDP). The latest Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) data confirm this recommendation.11 Yet clinicians prefer to try many additional monotherapy trials, various combinations of antipsychotics, and other polytherapy.