American Psychiatric Association Practice Research Articles

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.

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).

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

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).

Beyond Psychopharmacology: Emerging Psychosocial Interventions for Core Symptoms of Schizophrenia

Psychiatrists who work with patients with severe mental illness often are more focused on diagnosis, medical management, and psychopharmacology than on psychosocial treatments. Furthermore, many psychosocial interventions that show great promise may not be available locally, making it harder for psychiatrists to recognize emerging trends. Finally, there has not been an update in the American Psychiatric Association's Practice Guideline for the Treatment of Schizophrenia for many years, and the most recent Patient Outcomes Research Team (PORT) review of evidence-based psychosocial treatments for schizophrenia was published eight years ago. This article reviews a selection of psychosocial interventions that have shown success in treating some of the more vexing and persistent core schizophrenia symptoms that often continue despite optimal pharmacologic treatment; formerly these had been considered too risky or out of reach for psychosocial intervention. The interventions reviewed include cognitive-behavioral therapy for psychosis (CBTp), which aims to reduce distress and disability from psychotic symptoms; CBT and other behavioral interventions focused for comorbid posttraumatic stress syndrome; cognitive training (remediation) interventions that use computerized training programs to reduce the severity and consequence of cognitive impairment associated with schizophrenia; clubhouse and peer support models that address the social alienation and social defeat endemic to persons with severe mental illness; and supported employment interventions that are effective in helping patients get back to work in a competitive job environment. The interventions are reviewed with the needs of the prescribing mental health clinician in mind. Each intervention's strengths and weaknesses are described, as well as their role in recovery-oriented treatment services.

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults.

These Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association’s Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for theDevelopment of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research andQuality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines’ systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http:// www.psychiatry.org/File%20Library/Practice/APA-GuidelineDevelopment-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.

Who’s Your Expert? Use of an Expert Opinion Survey to Inform Development of American Psychiatric Association Practice Guidelines

For many clinical questions in psychiatry, high-quality evidence is lacking. Credible practice guidelines for such questions depend on transparent, reproducible, and valid methods for assessing expert opinion. The objective of this study was to develop and demonstrate the feasibility of a method for assessing expert opinion to aid in the development of practice guidelines by the American Psychiatric Association (APA). A "snowball" process initially soliciting nominees from three sets of professional leaders was used to identify experts on a guideline topic (psychiatric evaluation). In a Web-based survey, the experts were asked to rate their level of agreement that specific assessments improve specific outcomes when they are included in an initial psychiatric evaluation. The experts were also asked about their own practice patterns with respect to the doing of the assessments. The main outcome measures are the following: number of nominated experts, number of experts who participated in the survey, and number and nature of quantitative and qualitative responses. The snowball process identified 1,738 experts, 784 (45 %) of whom participated in the opinion survey. Participants generally, but not always, agreed or strongly agreed that the assessments asked about would improve specified outcomes. Participants wrote 716 comments explaining why they might not typically include some assessments in an initial evaluation and 1,590 comments concerning other aspects of the topics under consideration. The snowball process based on initial solicitation of Psychiatry's leaders produced a large expert panel. The Web-based survey systematically assessed the opinions of these experts on the utility of specific psychiatric assessments, providing useful information to substantiate opinion-based practice guidelines on how to conduct a psychiatric evaluation. The considerable engagement of respondents shows promise for using this methodology in developing future APA practice guidelines.

Conflicts of interest and the quality of recommendations in clinical guidelines

There is increasing concern that conflicts of interest affect the development process of clinical practice guidelines. We evaluated The American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder to determine the existence of financial and intellectual conflicts of interest and examine their possible effects. We selected this guideline because of its influence on clinical practice and because this guideline recommends pharmacotherapy for all levels of depression, despite controversies over the evidence base. We determined the number and type of financial conflicts of interest for members of the guideline development group as well as for the independent panel charged with mitigating any effect of these conflicts. We also quantified the potential for intellectual conflicts of interest. We examined the quality of references used to support recommendations, as well as the degree of congruence between the research results and the recommendations. Fewer than half (44.4%) of the studies supporting the recommendations met criteria for high quality. Over one-third (34.2%) of the cited research did not study outpatients with major depressive disorder, and 17.2% did not measure clinically relevant results. One-fifth (19.7%) of the references were not congruent with the recommendations. Financial ties to industry were disclosed by all members (100%) of the guideline development committee with members reporting a mean 20.5 relationships (range 9-33). The majority of the committee participated on pharmaceutical companies' speakers' bureaus. Members of the independent panel that reviewed the guidelines for bias had undeclared financial relationships. As a marker of intellectual conflict of interest, 9.1% of all cited research and 13% of references supporting the recommendations were co-authored by the six guideline developers. The prevalence of conflicts of interest among panel members was high. The quality of the evidence cited raises questions about the validity of the recommendations. Attention to the quality of cited studies and to the risk of bias resulting from conflicts of interest should be a priority for guideline development groups.

Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Data from the 2006 National Ambulatory Medical Care Survey were examined for differences in the diagnosis and treatment of depressive and anxiety disorders in rural and nonrural primary care settings. A sample of 11,658 patient visits to primary care providers was examined. ICD-9-CM codes were used to identify prevalence rates of depressive and anxiety disorder diagnoses. Treatments also were examined with criteria from American Psychiatric Association practice guidelines. No rural-nonrural differences were found in diagnosis rates for depression (about 3%) or anxiety disorders (about 1.5%). Approximately 67% of individuals with a depressive disorder and 36% of those with an anxiety disorder received a recommended treatment during the visit, with no rural-nonrural differences. Although few differences were found between rural and nonrural primary care visits, these data support the notion that anxiety and depression are underdiagnosed in primary care. Moreover, recognition and diagnosis often do not translate into adequate treatment in both rural and nonrural primary care settings.

Clinical Manual for Diagnosis and Treatment of Psychotic Depression

Back to table of contents Previous article Next article Book ReviewFull AccessClinical Manual for Diagnosis and Treatment of Psychotic DepressionDavid B. Roat D.O.David B. Roat D.O.Search for more papers by this authorPublished Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.8.1144aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Examples of psychotic depression are in the media all too often: the mother who inexplicably drowns her children in a bathtub and the quiet graduate student who kills his teacher and classmates, then turns the gun on himself. These are unfortunate examples of psychotic depression—a serious, life-threatening illness that, while treatable, is often overlooked or mismanaged by mental health professionals, with tragic results.Dr. Rothschild states in his preface that he wrote this book to help clinicians better recognize and treat psychotic depression. He believes that it is frequently missed as a diagnosis, often being mistaken as simple depression or as paranoid schizophrenia. Being incomplete, both diagnoses lead to treatment errors and bad outcomes. He believes that the general lack of clarity about the illness results from too few clinicians' having specialized in its treatment, a misperception that its incidence is rare, and almost no relevant research studies. Dr. Rothschild cites research indicating that from 16% to 54% of patients diagnosed as having major depression may instead have psychotic depression. The author backs up his allegations about psychotic depression's being an "orphaned disorder" with the sobering facts that from 1983 to 2003 the National Institute of Mental Health did not fund one study of medication treatment for the disorder and that no treatments of the disorder have been approved by the Food and Drug Administration. He also points out that the second edition of the American Psychiatric Association's Practice Guidelines for the treatment of patients with major depressive disorder, published in 2000, dedicates only one paragraph to the treatment of psychotic depression.Dr. Rothschild is the perfect champion for bringing his concerns to the psychiatric community; he has spent 25 years in both the clinical and research settings diagnosing, studying, and treating patients who have psychotic depression. He is a professor of psychiatry at the University of Massachusetts Medical School. His book is an attempt to summarize his vast experience into an evidenced-based, approachable, pragmatic manual. The guide has utility for the clinical psychiatrist in practice as well as for those in training, clinical researchers, general practitioners, neurologists, psychiatric nurses, and others in the mental health professions.The book is a thorough overview of the disorder and is organized into chapters that cover epidemiology, family studies and genetics, biology, diagnosis, treatment, and special populations. The book also includes a chapter on the nursing care of psychotic depression, written by Judith Shindul Rothschild, Ph.D., R.N., C.S. Of particular interest is a somatic algorithm for the treatment of psychotic depression and a helpful overview of electroconvulsive therapy. Each of the chapters concludes with a bulleted list of clinical pearls as well as cited references and recommended readings for further study. The book is concise, well written, and easily referenced.In summary, this manual goes a long way toward filling the gaps in our understanding of psychotic depression while giving strong clinical guidelines for improving the treatment of those with the disorder. It is a welcome addition to any mental health professional's library.The reviewer reports no competing interests.Dr. Roat is acting medical director and chief of psychiatric services at Ancora Psychiatric Hospital, Hammonton, New Jersey. FiguresReferencesCited byDetailsCited ByScientific Reports, Vol. 7, No. 1 Volume 60Issue 8 August, 2009Pages 1144-1145PSYCHIATRIC SERVICES August 2009 Volume 60 Number 8 Metrics PDF download History Published online 13 January 2015 Published in print 1 August 2009

Are Patients With Depression at Heightened Risk of Suicide as They Begin to Recover?

Are Patients With Depression at Heightened Risk of Suicide as They Begin to Recover?

Are Patients With Depression at Heightened Risk of Suicide as They Begin to Recover?

It has long been taught and believed that patients with depression and suicidal tendencies are at heightened risk of suicide as they begin to recover and their energy and motivation return. What are the data behind this enduring belief? More than a century ago, eminent clinicians noted that some patients with depression committed suicide just as their depression seemed to be improving. The clinicians went on to warn that early recovery carries a high risk of suicide. Although no studies have tracked suicide along with symptomatic change in depression, recent large-scale studies of suicide and phase of treatment do not indicate that suicide is more likely to occur early in recovery than at other times. Our forebears helpfully pointed out that patients with depression may commit suicide as they are beginning to recover. But the idea that these patients are at particular risk of suicide at this time, intuitively plausible as it is, remains to be substantiated.

The Search for Knowledge: Developing the American Psychiatric Association's Practice Guideline for Major Depressive Disorder

Article AbstractBecause this piece has no abstract, we have provided for your benefit the first 3 sentences of the full text.Working in Boston in the late 1980s, I received a telephonecall from Byram Karasu, M.D. Byram was to chair the workgroupwriting the American Psychiatric Association's (APA)first Practice Guideline for the Treatment of Patients WithMajor Depressive Disorder (MDD) and honored me with aninvitation to join. The first MDD Guideline was publishedin 1993. Byram chaired the workgroup that prepared the secondedition, which was published in 2000.†‹

Performance in Practice: Sample Tools for the Care of Patients with Major Depressive Disorder

To facilitate continued clinical competence, the American Board of Medical Specialties and the American Board of Psychiatry and Neurology are implementing multi-faceted Maintenance of Certification programs, which include requirements for self-assessments of practice. Because psychiatrists may want to gain experience with self-assessment, two sample performance-in-practice tools are presented that are based on recommendations of the American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder. One of these sample tools provides a traditional chart review approach to assessing care; the other sample tool presents a novel approach to real-time evaluation of practice. Both tools can be used as a foundation for subsequent performance improvement initiatives that are aimed at enhancing outcomes for patients with major depressive disorder.

Traitement pharmacologique de la schizophrénie : évaluation comparative de la qualité des recommandations de pratique clinique

Many clinical practice guidelines (CPG) have been published in reply to the development of the concept of "evidence-based medicine" (EBM) and as a solution to the difficulty of synthesizing and selecting relevant medical literature. Taking into account the expansion of new CPG, the question of choice arises: which CPG to consider in a given clinical situation? It is of primary importance to evaluate the quality of the CPG, but until recently, there has been no standardized tool of evaluation or comparison of the quality of the CPG. An instrument of evaluation of the quality of the CPG, called "AGREE" for appraisal of guidelines for research and evaluation was validated in 2002.The six principal CPG concerning the treatment of schizophrenia are compared with the help of the "AGREE" instrument: (1) "the Agence nationale pour le développement de l'évaluation médicale (ANDEM) recommendations"; (2) "The American Psychiatric Association (APA) practice guideline for the treatment of patients with schizophrenia"; (3) "The quick reference guide of APA practice guideline for the treatment of patients with schizophrenia"; (4) "The schizophrenia patient outcomes research team (PORT) treatment recommendations"; (5) "The Texas medication algorithm project (T-MAP)" and (6) "The expert consensus guideline for the treatment of schizophrenia".The results of our study were then compared with those of a similar investigation published in 2005, structured on 24 CPG tackling the treatment of schizophrenia. The "AGREE" tool was also used by two investigators in their study. In general, the scores of the two studies differed little and the two global evaluations of the CPG converged; however, each of the six CPG is perfectible.The rigour of elaboration of the six CPG was in general average. The consideration of the opinion of potential users was incomplete, and an effort made in the presentation of the recommendations would facilitate their clinical use. Moreover, there was little consideration by the authors regarding the applicability of the recommendations.Globally, two CPG are considered as strongly recommended: "the quick reference guide of the APA practice guideline for the treatment of patients with schizophrenia" and "the T-MAP".

Do Comorbid Personality Disorders Moderate Panic-Focused Psychotherapy?

The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome. Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005. Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity. Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects. ClinicalTrials.gov identifier NCT00128388.

Predicting Hospitalization Versus Discharge of Suicidal Patients Presenting to a Psychiatric Emergency Service

Predicting Hospitalization Versus Discharge of Suicidal Patients Presenting to a Psychiatric Emergency Service

Assessment, Treatment, and Prevention of Suicidal Behavioredited by Robert I. Yufit and David Lester; Somerset, New Jersey, John Wiley and Sons, 2005, 482 pages, $65

Back to table of contents Previous article Next article Book ReviewFull AccessAssessment, Treatment, and Prevention of Suicidal BehaviorDouglas Jacobs M.D.Douglas Jacobs M.D.Search for more papers by this authorPublished Online:1 Oct 2006https://doi.org/10.1176/ps.2006.57.10.1536AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Edited by two distinguished suicide scholars, Assessment, Treatment, and Prevention of Suicidal Behavior is a well-referenced and comprehensive book about the assessment of and psychotherapeutic approaches to the individual at risk for suicide. I found the title, though, to be somewhat misleading, because it is too broad for the book's content, which is focused on intervention and not prevention. Intervention is the domain of the clinician, and prevention is the domain of public health systems ( 1 ). In an era of psychopharmacology, it is certainly useful to have a book devoted to various psychotherapeutic approaches to the suicidal patient. As indicated by the American Psychiatric Association (APA) practice guideline on suicide ( 2 ), such interventions are a valuable component to a comprehensive treatment, having the potential to reduce the symptoms of psychiatric disorders that are often associated with suicidal behavior. For the clinician who wants to learn about various psychotherapeutic approaches, this book is useful. At the same time, it is important for clinicians to understand that recommendations come from case studies instead of controlled studies. Additionally, in terms of the treatment of suicidal behavior, it is important to acknowledge that combination treatment—psychotherapy and pharmacotherapy—is usually necessary. However, these issues should not detract from the usefulness of the approaches and vignettes referred to in the book, because psychotherapy is certainly one of the linchpins in the treatment of the suicidal person. The chapter on no-suicide contracts is particularly helpful because it places no-suicide contracts into a useful clinical perspective, including appropriate limitations on their use. The APA practice guideline on suicide does not recommend suicide scales for routine clinical use, because of the large number of false positives and the unacceptable number of false negatives. In addition, the APA guideline directly states that such scales "lack the predictive validity necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation" ( 2 ). However, clinicians should be familiar with suicide scales because they provide insight into a variety of questions that can be used when conducting a suicide inquiry. I recommend this book for therapists working with suicidal patients, but the buyer is advised to review the back jacket of the book as opposed to the title, which is more reflective of its contents.Dr. Jacobs is affiliated with the National Mental Illness Screening Project and the Department of Psychiatry, Harvard University, Boston.