Implementation of treatment guidelines in mental health care

Background

During the past few decades, a wide range of therapies and interventions for mental health have been developed that have been supported by evidence from research. This includes research evidence on the effectiveness of pharmacological treatments (such as antipsychotic drugs) and psychological therapies (such as cognitive behavioural therapy, family therapy and psychoeducation). However, research evidence is not easily translated into practice and the everyday working of healthcare services. A huge gap exists between the production of research evidence (what is known) and its uptake in healthcare settings (what is done). Better uptake of research evidence can be achieved by increasing awareness that such evidence exists.

One method of encouraging better uptake is the use of treatment guidelines based on assessments of research evidence. Treatment guidelines are now commonly used in healthcare settings, including those providing treatment for schizophrenia. However, it remains unclear whether treatment guidelines have any positive impact on the performance of mental health services, or whether they improve outcomes for patients (such as better quality of life, improved mental state, employment, and fewer admissions to hospital).

Searches

This review is based on a search, carried out by the information specialist of the Cochrane Schizophrenia Group, in March 2012 and updated in August 2015.

Study characteristics

This review includes six studies that examine the effectiveness of guideline implementation strategies in improving healthcare services and outcomes for people with mental illness compared with the usual care provided.

Results

Although single studies provided initial evidence that implementation of treatment guidelines may achieve small changes in mental health practice, most results showed no effect.

Conclusions

With such a small number of studies, and with all main results graded by review authors as providing very low-quality evidence, it was not possible to arrive at concrete and definite conclusions. A gap in knowledge still exists about how implementation strategies might improve patient outcomes and health services. This leaves scant information for people with mental health problems, health professionals, and policy makers. More large-scale, well-designed and well-conducted studies are necessary to fill this gap in knowledge.

This plain language summary has been written by a consumer Ben Gray: Service User and Service User Expert, Rethink Mental Illness.

Authors' conclusions: 

Considering the available evidence, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that uncertainty remains about clinically meaningful and sustainable effects of treatment guidelines on patient outcomes and how best to implement such guidelines for maximal benefit.

Read the full abstract...
Background: 

A huge gap exists between the production of evidence and its uptake in clinical practice settings. To fill this gap, treatment guidelines, based on explicit assessments of the evidence base, are commonly used in several fields of psychiatry, including schizophrenia and related psychotic disorders. However, it remains unclear whether treatment guidelines have any material impact on provider performance and patient outcomes, and how implementation should be conducted to maximise benefit.

Objectives: 

The primary objective of this review was to examine the efficacy of guideline implementation strategies in improving process outcomes (performance of healthcare providers) and patient outcomes. We also explored which components of different guideline implementation strategies could influence them.

Search strategy: 

We searched the Cochrane Schizophrenia Group Register (March 2012 and August 2015), as well as references of included studies.

Selection criteria: 

Studies that examined schizophrenia-spectrum disorders to compare guideline implementation strategies with usual care or to assess the comparative efficacy of different guideline implementation strategies.

Data collection and analysis: 

Review authors worked independently and in duplicate to critically appraise records from 990 studies; six individual studies met the inclusion criteria. Among the six included studies, significant heterogeneity was found in the focus of the guideline, target of the intervention, implementation strategy, and outcome measures, so meta-analysis was carried out for antipsychotic co-prescribing only.

Main results: 

This review now includes six studies, with a total of 1727 participants. Of the six included studies, practitioner impact was assessed in four. Overall, risk of bias was rated as low or unclear, and all evidence in the 'Summary of findings' tables was graded as low or very low quality. Meta-analysis revealed that a combination of several guideline dissemination and implementation strategies targeting healthcare professionals did not reduce antipsychotic co-prescribing in schizophrenia outpatients (2 RCTs, N = 1082, RR 1.10 CI 0.99 to 1.23; corrected for cluster design: N = 310, RR 0.97, CI 0.75 to 1.25, very low-quality evidence). One trial, which studied a nurse-led intervention aimed at promoting cardiovascular disease screening, found a significant effect in the proportion of people receiving screening (Framingham score: N = 110, RR 0.69, 95% CI 0.55 to 0.87), although in the analysis corrected for cluster design, the effect was no longer statistically significant (N = 38, RR 0.71, 95% CI 0.48 to 1.03, very low-quality evidence).

One trial reported the patient outcomes of global state, satisfaction with care, treatment adherence, and drug attitude; no effect between treatments was seen. Quality of life was not reported by any of the studies.

One trial, which studied the use of re-written guideline text compared to original text, did not find a significant effect on staff receiving training (N = 68, RR 1.03, 95% CI 0.87 to 1.21, low-quality evidence), staff receiving supervision (N = 68, RR 0.86, 95% CI 0.64 to 1.17, low-quality evidence), or staff providing psychological interventions (N = 68, RR 0.86, 95% CI 0.62 to 1.18, low-quality evidence).

Regarding participant outcomes, only one trial assessed the efficacy of a shared decision-making implementation strategy and found no impact on psychopathology, satisfaction with care, or drug attitude. Another single trial studied a multifaceted intervention to promote medication adherence and found no effect on adherence rates.

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