Saturday, May 14, 2016.
APA Meeting, Atlanta GA.

The American Psychiatric Association (APA) released the third edition of the Practice Guidelines for the Psychiatric Evaluation of Adults.

 While this latest edition represents the first full practice guideline published by APA in five years, these guidelines are seminal in that they represent the first APA guidance developed using a new process that addresses standards set forth in a 2011 Institute of Medicine (IOM) report titled “Clinical Practice Guidelines We Can Trust.”

“There had been a perception that practice guidelines across health disciplines were inconsistent in their rigor and associated with potential conflicts of interest,” said Laura Fochtmann, M.D., a professor of psychiatry at Stony Brook University School of Medicine and the medical editor for APA’s practice guidelines.

“This new process was designed to meet high standards of transparency, management of conflicts of interest, composition of guideline writing groups, and synthesis of evidence.”

It is only fitting that the first practice guidelines using this new development process would involve the psychiatric evaluation of a patient, said Joel Silverman, M.D., chair of psychiatry at Virginia Commonwealth University and chair of the APA Work Group on Psychiatric Evaluation—the group behind these guidelines.

“The nature of the initial psychiatric evaluation helps form the doctor-patient relationship, which is critical to the entire treatment process,” he told Psychiatric News. “And when done properly, it gathers the data necessary to arrive at the correct diagnosis.”

In line with some of the IOM recommendations, the most noticeable change in the third edition of thePractice Guidelines for the Psychiatric Evaluation of Adults is the framework. Rather than resembling a manual, these new guidelines are divided into nine separate guideline “modules” that are connected by the overarching theme of psychiatric evaluation. These are the nine guidelines:

  • Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History

  • Substance Use Assessment

  • Suicide Risk Assessment

  • Assessment of Risk for Aggressive Behaviors

  • Assessment of Cultural Factors

  • Assessment of Medical Health

  • Quantitative Assessment

  • Involvement of the Patient in Treatment Decisions

  • Documentation of the Psychiatric Evaluation

“This new format offers two important advantages,” Fochtmann said. “Having discrete chunks of information related to a particular topic enables psychiatrists to readily access what they need. It also allows us to update individual modules when needed as they become outdated.”

Given the personal nature of a patient evaluation, as well as ethical considerations, Silverman noted that the guidance within these practice guidelines is based on consensus of professionals as opposed to evidence, but that does not make them any less reliable or useful.

“It is a fact that throughout medicine doctors must make important decisions that may not be informed by concrete evidence,” he said. “In the case of the initial evaluation, there are questions you cannot easily answer with a double-blind study.

“However, to ensure that the guidelines are as strong as possible, we made sure to include large group of external experts in the informative process in addition to our extensive review of the literature.”

Around 800 experts contributed, in fact, as part of a process envisioned by Joel Yager, M.D., a member of the Systematic Review Group for these practice guidelines. Known as a “snowball survey,” psychiatrists regarded as experts on psychiatric evaluation were approached to provide input on evaluation strategies that would improve patient outcomes and were asked to nominate other experts they knew.

“We found that the responses were tremendously uniform,” Silverman said. “It tells us there is consensus in the field.”

In situations with less expert consensus, the guidelines offered “suggestions” instead of recommendations. When writing out the recommendations, care was taken to avoid nebulous words like “consider” which can be hard to implement and may vary in interpretation.

Fochtmann did note that even given the strength of these recommendations, each of the modules has a section on implementation that discusses barriers to carrying out the recommendations and adjustments for patient preferences. “The guidance is not set in stone by any means,” she said.

As new science informs the evaluation process, the iterative design of the practice guidelines will allow them to be reviewed and updated expeditiously.

“This is a big step forward to improving the clinical care for patients and their families,” Silverman said. “And it is not just limited to psychiatric evaluation, as we now have a better understanding of the review and development process that will drive future APA guidelines.”

In addition to Silverman, the APA Work Group on Psychiatric Evaluation was composed of Marc Galanter, M.D., Maga Jackson-Triche, M.D., Douglas Jacobs, M.D., James Lomax II, M.D., Michelle Riba, M.D., Lowell Tong, M.D., and Katherine Watkins, M.D.