American Psychiatric Association Practice Guideline Research Articles

Practice Assessment Tool for the Care of Patients With Eating Disorders.

Eating disorders are characterized by significant disturbances in eating patterns associated with negative attitudes toward one's body, weight, and shape. They are associated with an increased risk of mortality and morbidity as well as significant health, economic, and psychosocial burdens. Additionally, individuals with eating disorders often hesitate to seek treatment and symptoms may be difficult to ascertain without structured assessment. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders aims to enhance knowledge and increase the appropriate use of interventions for eating disorders, including anorexia nervosa, bulimia nervosa, and binge-eating disorder, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with eating disorders. This practice assessment activity can also be used in fulfillment of Continuing Medical Education and ABPN Continuing Certification, Improvement in Medical Practice.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders.

APA Releases Updated Guideline for Treating Eating Disorders

Back to table of contents Next article Clinical & ResearchFull AccessAPA Releases Updated Guideline for Treating Eating DisordersNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:25 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.8AbstractThe new practice guideline focuses on evidence-based pharmacological, psychotherapeutic, and other nonpharmacological treatments for eating disorders in adolescents and adults.APA has released an updated practice guideline on how to treat patients with eating disorders— the first full update since 2006.There have been many clinical advances and diagnostic changes related to eating disorders in the past 17 years, noted Laura Fochtmann, M.D., M.B.I., a professor of psychiatry, pharmacological sciences and biomedical informatics at Stony Brook University School of Medicine and the medical editor for APA’s practice guidelines. Fochtmann was also the vice-chair of the writing group for this newest practice guideline.Notably, the publication of DSM-5 in 2013 and DSM-5-TR in 2022 resulted in broader diagnostic criteria for both anorexia nervosa and bulimia nervosa as well as the additions of binge-eating disorder and avoidant/restrictive food intake disorder (ARFID) categories. Binge-eating and avoidant/restrictive food intake disorders are both referenced in the updated guideline: There is a comprehensive section on assessing and treating binge-eating disorder, and there is also information on assessing patients with ARFID, Fochtmann noted. (Due to limited clinical data, there are no specific recommendations for how to treat patients with ARFID.)The fourth edition of APA’s practice guideline for eating disorders includes 16 clinical recommendations or suggestions, depending on the level of scientific evidence. Here are some of the recommendations:Screening for the presence of an eating disorder as part of an initial psychiatric evaluation.Conducting comprehensive patient evaluations, including laboratory tests such as electrocardiograms.Ensuring the treatment plan is patient-centered and culturally sensitive.Setting individualized weight goals for patients with anorexia.Treating patients with anorexia, bulimia, and binge-eating disorders with eating disorder–focused psychotherapy.Including family-based therapy as part of a treatment plan for adolescents with anorexia or bulimia.In addition to the guideline, APA has developed supplemental materials to help both health professionals and patients and families, such as a clinician pocket guide and educational slides. The centerpiece of these resources is an online tool that offers a step-by-step guide on how to assess symptoms and screen patients for a potential eating disorder. This clinical decision tool will be customized for different professionals (for example, psychiatrists, psychologists, and pediatricians) to match their skillsets and the symptoms they might expect when encountering someone with an eating disorder.The development of the online toolkit and other supporting resources was made possible through a grant from the Council of Medical Specialty Societies.The release of this new practice guideline comes at an important juncture for people with eating disorders (“Special Report: Youth With Eating Disorders—Time Is of the Essence in Achieving Remission”). Studies have reported upticks in individuals developing symptoms of and requiring hospitalization for disordered eating since the start of the COVID-19 pandemic in 2020. As noted in the guideline, maintaining a structured plan for meals and snacks is an important component of treatment, and the pandemic disrupted normal routines and increased stress and anxiety.“Early identification and treatment of an eating disorder is critical for achieving positive long-term outcomes,” said Joel Yager, M.D., a professor emeritus of psychiatry at the University of Colorado School of Medicine and the chair of the writing group for all three previous editions of the eating disorder practice guideline. “We hope that this tool will help anyone make an informed diagnosis regardless of their previous experience with eating disorders.” ■“The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders, Fourth Edition”Practice Guideline for Treatment of Patients with Eating Disorders. ISSUES NewArchived

Stewardship applied to antipsychotics: Development of an antipsychotic stewardship program in inpatient settings for monitoring and optimizing outcomes.

Antipsychotic (AP) medications are prescribed for various psychiatric diagnoses that require routine monitoring to ensure optimal use, effectiveness, adherence, and for potentially severe adverse effects. There is currently no comprehensive protocol for institutional supervision of prescribing and monitoring AP. Antibiotics (ABX) are commonly associated with stewardship programs aimed at optimizing use and mitigating harm. These programs have proven to result in positive outcomes in both safety and efficacy parameters for numerous institutions. Given that AP are also associated with significant adverse effects and often misused, the concept of stewardship can be applied to this class of agents to optimize their use and improve overall patient outcomes. The objective of this paper is to provide guidance for the implementation of antipsychotic stewardship programs (APSP) in the inpatient setting. The development of this APSP was designed based on ABX stewardship programs and the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, and the American Psychiatric Association practice guidelines on the treatment of patients with schizophrenia. In conclusion, APSPs have the potential to enhance and standardize institutional supervision of prescribing and monitoring practices of AP, leading to improved clinical outcomes and the reduction of adverse effects. APSP teams should be multidisciplinary, consisting of clinicians and administrators, working in conjunction with patients and patient advocates to design individualized recovery plans that consider the individual patient's history and desired outcomes. Monitoring, stewardship interventions, and outcomes should be documented on both an individual and deidentified institutional basis, analyzed, and summarized periodically as measures for quality improvement.

Letter to the Editor: Rethinking The Cost Of Antipsychotic Treatment: The Average Cost Of The Drugs Used In Turkey In 2020.

Letter to the Editor: Rethinking The Cost Of Antipsychotic Treatment: The Average Cost Of The Drugs Used In Turkey In 2020.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia.

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

Evaluating the Impact of Pharmacists on Clinical Outcomes and Adherence in Patients with Mental Illness: A Literature Review

Purpose: The purpose of this literature review is to investigate the role of pharmacists in improving clinical outcomes and adherence to psychotropic medications in patients with mental illness. The majority of patients tend to stop taking their medications due to the delayed effects or adverse events. It has been established that pharmacists have a positive effect on patients’ clinical outcomes in different chronic disease states other than mental illness. There is also a stigma associated with how comfortable pharmacists are on counseling patients about psychotropic medications. This literature review will evaluate the level of pharmacists’ involvement in treating patients with mental illness as well as strategies used to achieve persistence and compliance with therapy. Methods: A PubMed search was conducted to identify articles related to mental illness and pharmacists. MeSH terms included “antidepressants”, “adherence”, “pharmacists”, and “bipolar disorder”. A free-text search was conducted using the same terms and to search for the most updated American Psychiatric Association practice guidelines. The National Institute of Mental Health database was searched for current mental health statistics in the United States. Collectively, 62 results returned for the MeSh search. This review included studies on adults with mental disorders who were evaluated by pharmacists for adherence and clinical outcomes between the years of 1995-2019. The results of five clinical trials assessing the role of pharmacists in adherence to psychotropic medications will be discussed in this literature review. Results: The clinical trials included in this review showed a statistically significant increase in adherence to psychotropic medications associated with pharmacists’ interventions. The results were not statistically significant for the clinical outcomes in most studies but presented positive improvements in the inpatient and outpatient settings. Canales et al. results showed that patients receiving pharmacists’ interventions in the inpatient setting had >30% improved clinical outcomes measured by different rating scales. The results of Valenstein et al. study conducted at Veteran Affairs clinics were statistically significant for adherence improvement presented by a 25% increase in medication possession ratio. Aljumah et al. clinical trial had a 18% increase in adherence associated with pharmacist interventions. The EMDADER-TAB trial resulted in a statistically significant decrease in ER visits, significant improvement of the depression symptoms, and overall improvement of severity of symptoms. Conclusion: Mental illness should be treated as any other medical condition that requires interventions whenever clinical outcomes are not optimal. Pharmacists have the skills to evaluate clinical symptoms of different psychiatric disorders as well as the knowledge on therapeutic treatments necessary for the optimization of medication use.

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults: Guideline V. Assessment of Cultural Factors.

(Excerpted from "The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition." Copyright © 2016, American Psychiatric Association. Reprinted with permission.).

Whatever Happened to Couples and Family Therapy in Psychiatry?

Whatever Happened to Couples and Family Therapy in Psychiatry?

Treating schizophrenia: the quality of evidence behind treatment recommendations and how it can improve

ObjectiveTo assess the methodological and reporting quality of systematic reviews that comprise the American Psychiatric Association (APA) Practice Guideline for the Treatment ofPatientswith Schizophrenia and to determine the extent to...

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

(Reprinted with permission from Am J Psychiatry 2018; 175:86-90).

Clinical guidelines for the management of schizophrenia (ΙΙ): Community service-level interventions and the role of Primary Care

Schizophrenia is one of the most disabling disorders globally, with a significant impact on the professional, social and personal functioning of those affected. Mortality rates are estimated to be 2-2.5 times greater than in the general population attributable to not only suicide but also physical illnesses, such as cardiovascular, metabolic and infectious diseases. Patients with schizophrenia have increased needs for health services which vary according to the stage of the illness and the way the disorder affects the patient. A significant part of the costs of treating patients with schizophrenia is attributed to the health service costs, both to address the disorder itself and its wider effects. In 2015 the National Clinical Guidelines for the management of schizophrenia were formulated by a Working Group that was set up by the Greek Ministry of Health. In this article, a summary of the recommendations (as included in the National Clinical Guidelines) is presented, describing the role of primary care and community mental health services in the management of schizophrenia. The NICE Guideline (National Institute of Clinical Excellence, 2010, 2014) for the management of Psychosis & Schizophrenia was utilized as the main guide to develop the Greek National Guidelines . In addition the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Schizophrenia (APA, 2004), the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders (Royal Australian and New Zealand College of Psychiatrists, 2005), as well as other relevant sources were also used. The Working Group also took into consideration the available Greek bibliography as well as the external evaluations of the Greek psychiatric reform programs. Special effort was made to adapt the international experience to the current Greek landscape with its constraints resulting from the uneven dispersion of mental health services, the lack of coordination between services, the incomplete sectorization of mental health services provided as part of the National Health System, the still underdeveloped Primary Care Health Service, and last but not least the difficult economic situation in Greece. The proposals aim to contribute to the efficient implementation of the provision of community mental health services for patients suffering from psychotic disorders, focusing in particular on: (a) the role of primary health care services and the role of family physician in the treatment of schizophrenia; (b) the cooperation and coordination between mental health services and primary care services in order to ensure continuity of care (c) designing services that deliver evidence-based interventions,thus ensuring that a larger proportion of the population receives interventions with documented effectiveness in the treatment of schizophrenia, in the least restrictive environment. A particular emphasis is placed on services that are expected to reduce the need for hospitalization, such as crisis intervention services, community interventions aimed at maintaining and continuing the treatment of difficult patients who tend to be lost to follow up from services and early intervention services in psychosis.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder.

Clinical guidelines for the management of schizophrenia:Aims and limitations (Ι)

The initiative for the development of national treatment guidelines, dates back to the '90s. In Greece, however, National Clinical Guidelines for the management of schizophrenia were first formulated in 2014 when a Working Group was set up for this purpose by the Greek Ministry of Health. The objective of this Working Group was to provide evidence-based recommendations covering the pharmacological and psychosocial treatment of schizophrenia as well as the development of appropriate treatment services. The Working Group utilized the NICE Guideline (National Institute of Clinical Excellence, 2010, 2014) for the management of Psychosis & Schizophrenia as the main guide to develop the Greek National Guidelines , and in addition the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Schizophrenia (APA 2004), the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders (Royal Australian and New Zealand College of Psychiatrists 2005) , as well as other relevant sources. The Working Group also took into consideration the available Greek bibliography as well as the external evaluations of the Greek psychiatric reform programs. A special effort was made to adapt the international experience to the current Greek landscape with the constraints resulting from the uneven dispersion of mental health services, the lack of coordination between services, the incomplete sectorization of mental health services provided as part of the National Health System, the still underdeveloped Primary Care Health Service, and last but not least the difficult economic situation in Greece. After the preparation of the draft guidelines, a thorough consultation followed with the relevant stakeholders, including mental health professionals, user associations and representatives of the Greek Ombudsman. Additionally, the Hellenic Psychiatric Association established an Expert Committee in Spring 2016, that contributed with its observations to the final exercise. This article will be followed by two further publications (incorporating the Hellenic Psychiatric Association comments) which include: (1) the summary recommendations regarding the pharmacological, psychological and psychosocial interventions in the treatment of schizophrenia, and (2) the summary recommendations regarding: (a) the role of primary health care service and the role of the family physician in the treatment of schizophrenia (b) the summary recommendations regarding continuity of care and c) the summary recommendations regarding community interventions with documented effectiveness in the treatment of schizophrenia.

Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum and Other Psychotic Disorders.

The objective of this article is to identify best practices in the diagnosis and assessment of patients with schizophrenia spectrum and other psychotic disorders. The diagnosis and assessment may occur in a range of situations from the emergency room to the outpatient clinic and at different stages of the disorder. The focus may be on acute exacerbations of illness, residual symptoms, levels of function, or changes in the response to treatment. A systematic search was conducted for guidelines published in the last 5 years for schizophrenia and schizophrenia spectrum disorders. The guidelines were rated by at least 2 raters, and recommendations adopted on the diagnosis and assessment were primarily drawn from the American Psychiatric Association practice guidelines for the psychiatric evaluation of adults and the National Institute for Health and Care Excellence guideline on psychosis and schizophrenia in adults. A number of de novo recommendations were also developed. Eleven recommendations were identified that cover a range of assessment situations from diagnosis to the involvement of families in assessments. An accurate assessment establishes the baseline for treatment planning based on clinical decision making for both pharmacotherapy and psychosocial treatments.

Are patients with emotionally unstable personality disorder overmedicated?

Emotionally Unstable Personality Disorder (EUPD) is often considered as treatment resistant clinical challenge. While effectiveness of psychological therapies for EUPD is widely acknowledged, there is less supportive evidence for pharmacotherapy use and patients with EUPD are perceived as overmedicated.Objectives and aimsThe purpose of the study was to review prescribing guidelines and clinical practices for EUPD.MethodsMEDLINE and PsycINFO were searched for all English-language articles published 2000-2016 and containing the keywords “emotionally unstable personality disorder”, “borderline personality disorder”, “pharmacotherapy”, “drug treatment” and “treatment guidelines”.ResultsNICE guidelines (2009) recommend pharmacotherapy should not be used for EUPD but for comorbid conditions only. In line with the American Psychiatric Association practice guideline, the Dutch and German guidelines recommend antipsychotics for cognitive-perceptual symptoms. However, in contrary to mood stabilisers they question the efficacy of antidepressants on impulsivity and affective dysregulation.Studies on clinical practice showed 68% of borderline patients without comorbid disorder in UK were using antidepressants, 59% antipsychotics, 59% sedatives and 23% mood stabilizers. Similar results reported Paolini et al with polypharmacy in 83.5% of cases.ConclusionsAll international guidelines recommend psychological therapies as the first-choice in EUPD treatment but diverge with respect to pharmacotherapy use. NICE and Australian guidelines abstain from psychotropics what may prevent to some degree counterproductive polypharmacy, but also can refrain from temporary pharmacological support when needed. More RCTs for pharmacotherapy use in EUPD are needed but meanwhile using pharmacotherapeutic algorithms for specific symptom domains might be the way forward.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia.

(Reprinted with permission from American Journal of Psychiatry 2016; 173:543-546).

Ethical Challenges in Geriatric Psychiatry.

Ethical Challenges in Geriatric Psychiatry.