The APA Board of Trustees voted at its meeting in Washington, D.C., last month to approve two new practice guidelines, one on treatment of patients with schizophrenia, the other on treatment of patients with Alzheimer's disease and related dementias.

The schedule calls for the new guidelines to be published in March and April. A new set of guidelines on treating patients with panic disorder and related anxiety disorders is scheduled for a vote by the Board at its June meeting, with publication slated for October.

Recognition of the utility of practice guidelines has grown over the years, according to APA Medical Director Melvin Sabshin, M.D. "I was pleased that the amount of support and understanding of the fact that the guidelines are helpful was much greater at this meeting than ever before," he commented.

Past president John McIntyre, M.D., is chair of APA's Steering Committee on Practice Guidelines.

With the addition of the new guidelines, APA has practice guidelines describing the care of patients in eight major areas of psychiatric illness, said McIntyre. "We now have a body of guidelines that is of enormous help to psychiatrists in day-to-day care of patients. It has formed a consensus for the field as a whole."

Compared with earlier drafts, the final version of the Alzheimer's treatment guidelines gives increased attention to the burden on families caring for patients with Alzheimer's and related dementias, he noted. "The reality is that having a close relative with Alzheimer's significantly increases the risk of the caregiver developing a psychiatric illness that warrants treatment," said McIntyre.

The final draft of the schizophrenia guidelines incorporated breaking developments in the psychopharmacological treatment of the disease, McIntyre said. The guidelines include data on newly marketed antipsychotic drugs, such as olanzapine, and on other drugs likely to be available soon to clinicians.

An important new part of the schizophrenia guidelines was inclusion of an algorithm to help clinicians make decisions on how best to treat patients. The algorithm is basically a "decision tree," McIntyre explained. This is the first time such a decision-making aid has been part of any APA guideline. "The algorithm we put in deals specifically with use of antipsychotic medications," he pointed out.

APA practice guidelines are not intended to set a "standard of practice," observed McIntyre. There are three levels of "practice parameters," he explained, ranging from "standards" to "options."

A standard is "a course of treatment that should, with few exceptions, be followed in all cases," he noted. When not used, the physician "has to have extensive and careful documentation justifying the decision" to deviate from the standard.

In a "guideline," however, "exceptions are not rare, and when they occur, the clinician needs to have some justification, but it's more minimal and need not be as extensive," as when he or she deviates from a standard of practice. In general, guidelines are followed in at least 80 percent of the cases, he added.

The third level is "options," where there is no preference between one course and another. An option may be used when standards are not yet established or when standard practice or guidelines have failed to produce the desired result.

"We explicitly chose the term 'guideline' because we are making recommendations that are to be followed in a majority of cases but that may be deviated from with less documentation than those involving 'standards,' " he stressed.

Summary of APA Guidelines

(Psychiatric News, January 17, 1997)