Special Series Evaluating the American Psychiatric Association's Treatment Guidelines

The Spring 2001 edition of Behavior Therapy includes a Special Series which presents a behavioral perspective on the American Psychiatric Association's Practice Guidelines. All in all, ApA's published guidelines are pretty good. However, with a number of disorders they tend to overemphasize medication and underemphasize well-established cognitive-behavioral treatment approaches. Abstracts of the articles reviewing the treatment guidelines follow:

Practice Guidelines for Eating Disorders by G. Terence Wilson and W. Stewart Agras

The American Psychiatric Association's (2000) "Practice Guideline for the Treatment of Patients With Eating Disorders" (PGED) provides useful, practical advice on the clinical and medical management of eating disorders, and an informative summary of the evidence on their epidemiology, nature, and treatment. The main limitation is the methodological adequacy and application of the coding system used to establish level of clinical confidence in treatment recommendations. The PGED represents a mix of science and expert clinical judgment that results in an overinclusiveness and several questionable conclusions. The PGED provides a balanced analysis of pharmacological treatment of anorexia and bulimia nervosa but not binge-eating disorder. Although it notes that cognitive behavior therapy enjoys the most scientific support of any treatment for bulimia nervosa, the PGED misses an opportunity to promote dissemination of this approach. The guideline misleadingly characterizes core cognitive-behavioral treatment strategies as "nutritional rehabilitation."

Treatment Guidelines for Major Depressive Disorder by Steven D. Hollon and Richard C. Shelton

Treatment guidelines represent attempts to describe a set of best practices based on the available empirical evidence and current clinical consensus. The American Psychiatric Association has recently revised its guideline for the treatment of major depression. The revised guideline clearly improves upon the original in many respects and is more closely tied to the empirical literature. It provides an excellent overview of the nature of depression and its pharmacological treatment. It also does a better job than the original of differentiating between those psychosocial interventions that have done well in empirical trials (like the cognitive behavioral interventions and interpersonal psychotherapy) versus those that have not, like the more traditional dynamic interventions. Nonetheless, it still understates the case for the empirically supported psychosocial interventions, which compare favorably to drugs in the reduction of acute distress and may have broader and more enduring effects.

Consideration of the APA Practice Guideline for the Treatment of Patients With Panic Disorder: Strengths and Limitations for Behavior Therapy by Michelle G. Craske and Bonnie G. Zucker

The need to disseminate information about empirically supported treatments is becoming paramount in the current cost-minimizing health care climate. Cognitive-behavioral treatments are clearly effective for panic disorder, and yet the majority of persons suffering from panic disorder do not receive this treatment. Publications like the American Psychiatric Association's "Practice Guideline for the Treatment of Patients With Panic Disorder" (1998) potentially have a widespread influence on mental health - care practitioners, and therefore it is essential that the guideline be accurate and up-to-date. In this paper, we critique the guideline's presentation of cognitive-behavioral therapy (CBT) in terms of scientific basis, clinical practice, training of behavior therapists, and diversity issues. Although the guideline appropriately highlights CBT as a primary treatment for panic disorder, the discussions of its breadth, techniques, and utility are understated.

The American Psychiatric Association Practice Guidelines for Schizophrenia: Scientific Base and Relevance for Behavior Therapy by Alan S. Bellack, Robert W. Buchanan and James M. Gold

The American Psychiatric Association's practice guidelines for schizophrenia provide a general blueprint for treating people with the illness. They are primarily oriented toward psychiatrists and pharmacological management. However, the guidelines also discuss the importance of psychosocial treatments, including behavioral therapy techniques. We provide an overview of the treatment guidelines and their empirical base. The pharmacological recommendations are generally consonant with the literature, albeit they have become somewhat dated due to the rapid progress in studies of the effects of new generation antipsychotics. We next review recommendations concerning social skills training, cognitive therapy and rehabilitation, behavioral family therapy, and vocational rehabilitation. Overall, the guidelines are quite positive about the potential benefit of these interventions, but they are appropriately conservative in interpreting the literature. There are promising data to support the efficacy of each of these approaches, but effectiveness data are lacking and questions remain about their actual impact on community functioning. Schizophrenia has not received sufficient attention from behavior therapists since the early successes achieved by operant programs. The optimistic stance taken by the guidelines should, if anything, encourage students to pursue careers working with this very needy population.

American Psychiatric Association Practice Guideline for Substance Use Disorders by Barbara S. McCrady and Douglas Ziedonis,

The American Psychiatric Association has published a practice guideline for treatment of patients with substance use disorders. This review focuses on scientific and clinical strengths and limitations of the guideline, and the relevance of the guideline to behavior therapy. The guideline incorporated a thorough review of the scientific literature, presented substance use disorders as complex and multifaceted problems, recommended pharmacological and psychosocial interventions where appropriate, and noted the limits of scientific knowledge. The guideline focuses on the strong empirical support for a number of major behavioral and cognitive-behavioral interventions. Expansion of the guideline to consider less severe cases, expanded information about specific population subgroups, more careful attention to assessment and diagnosis, and more objective criteria for classifying studies that are applied more systematically would strengthen future editions.

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Conflict of Interest in Clinical Practice Guidelines, by found elsewhere and posted by Jim Pretzer, 02/06/02

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