The Importance of Guidelines

Every era of psychiatry has been defined by its prevailing model of mental illness. What we call a diagnosis today would once have been dismissed as a distraction from the real work of interpretation. In the psychoanalytic era, efforts to classify illness or use categorical diagnoses were often resisted. Symptoms were understood as downstream manifestations of unconscious psychic conflict, and the task of the analyst was not to label but to uncover hidden causes. By contrast, modern psychiatry has leaned heavily on categorical systems of diagnosis, crystallized most visibly in DSM-5. Although our field is evolving toward a more spectrum-based understanding of psychopathology, the value of structured classification remains paramount to the field. DSM-5’s power is not philosophical but practical: It allows clinicians across different health care systems, institutions, and cultural contexts to describe phenomena in reproducible ways. This consistency is essential for rigorous research, communication across teams, and structured approaches to treatment.

Psychiatric treatment guidelines build on the structured diagnostic model and provide a universal treatment approach. Guidelines are not about replacing expertise but rather ensuring reproducibility. Treatment of first-episode psychosis illustrates the persistent gap between evidence-based standards and real-world practice. Although coordinated specialty care, including integrating psychosocial supports and interventions alongside pharmacologic treatment, is widely recognized as the standard of care, claims-based data demonstrate that clinical practice often fails to align with this model.¹

One of the most powerful demonstrations of the value of structured, reproducible care comes not from psychiatry but from critical care medicine. In the early 2000s, Peter Pronovost and colleagues at Johns Hopkins University in Baltimore, Maryland, introduced a simple central line–associated bloodstream infection (CLABSI) checklist designed to ensure that intensivists followed each evidence-based step during catheter insertion. What made the project transformative was not only the checklist itself but also the cultural changes surrounding its implementation. For the first time, nurses were empowered to stop a procedure if the checklist was not followed, an unprecedented shift in authority that directly challenged entrenched medical hierarchies.² The intervention also pushed back against the dogma that highly trained physicians did not need to be reminded of basic steps. By introducing an algorithmic, standardized approach, the team reframed the checklist not as a threat to expertise but as a tool to guarantee that expertise was consistently translated into safe practice. The results were striking. At Johns Hopkins, catheter-related infection rates dropped dramatically, nearly reaching zero. When the intervention was scaled statewide in Michigan in 2003, the findings were replicated: CLABSI rates again plummeted, an estimated 2000 lives were saved, and $200 million in health care costs were avoided each year.³ This success story has since become a landmark example of how guidelines and checklists can transform outcomes, not by replacing clinical judgment but by ensuring consistency.

Dr Asbach is a psychiatric physician associate and serves as associate director of interventional psychiatry at DENT Neurologic Institute in Amherst, New York. Dr Roque is a clinical associate professor in the Hahn School of Nursing and Health Science at the University of San Diego in California.

References

1. Reist C, Valdes E, Ren Y, et al. Using claims data to assess treatment quality of first-episode psychosis. Psychiatr Serv. 2021;72(3):247-253.

2. Albrecht B. The checklist’s beginnings: how Peter Pronovost’s team at Johns Hopkins cut infections—and saved lives. Cleveland.com. January 13, 2020. Accessed September 3, 2025. https://www.cleveland.com/news/2020/01/the-checklists-beginnings.html

3. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.