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Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet].

Implementation of treatment guidelines in mental health care

This version published: 2014; Review content assessed as up-to-date: July 10, 2012.

Plain language summary

During the past few decades, a wide range of therapies and interventions for mental health have been developed that have been supported by research and randomised evidence. 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 employed in healthcare settings, including those providing treatment for schizophrenia. It remains unclear, however, 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).

This review is based on a search carried out in March 2012 and includes five studies. The review examines the effectiveness of guideline implementation strategies in improving healthcare services and outcomes for people with mental illness. However, with such a small number of studies, and with all main results graded by review authors as providing very low quality evidence, it is not possible to arrive at concrete and definite conclusions. Although single studies provided initial evidence that implementation of treatment guidelines may achieve small changes in mental health practice, a gap in knowledge still exists about how this 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.


Background: A huge gap exists between the production of evidence and its take‐up in clinical practice settings. To fill this gap, treatment guidelines, based on explicit assessments of the evidence base, are commonly employed in several fields of medicine, including schizophrenia and related psychotic disorders. It remains unclear, however, whether treatment guidelines have any 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 additionally explored which components of different guideline implementation strategies can influence process and patient outcomes.

Search methods: We searched the Cochrane Schizophrenia Group Register (March 2012), 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 882 studies; five individual studies met the inclusion criteria and were considered. As critical appraisal of the five included studies revealed substantial heterogeneity in terms of focus of the guideline, target of the intervention, implementation strategy and outcome measures, meta‐analysis was carried out for antipsychotic co‐prescribing only.

Main results: Of the five included studies, practitioner impact was assessed in three. The five studies were generally at unclear risk of bias, and all evidence in the 'Summary of findings' table was graded by review authors as of very low quality. Meta‐analysis of two studies revealed that a combination of several guideline dissemination and implementation strategies targeting healthcare professionals did not reduce antipsychotic co‐prescribing in schizophrenia outpatients (two studies, n = 1,082, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.99 to 1.23; corrected for cluster design: n = 310, RR 0.97, CI 0.75 to 1.25). One trial, which studied a nurse‐led intervention aimed at promoting cardiovascular disease screening, found a significant effect in terms of the proportion of people receiving screening (blood pressure: n = 96, RR 0.07, 95% CI 0.02 to 0.28; cholesterol: n = 103, RR 0.46, 95% CI 0.30 to 0.70; glucose: n = 103, RR 0.53, 95% CI 0.34 to 0.82; BMI: n = 99, RR 0.22, 95% CI 0.08 to 0.60; smoking status: n = 96, RR 0.28, 95% CI 0.12 to 0.64; 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 statistically significant for blood pressure and cholesterol only (blood pressure, corrected for cluster design: n = 33, RR 0.10, 95% CI 0.01 to 0.74; cholesterol, corrected for cluster design: n = 35, RR 0.49, 95% CI 0.24 to 0.99; glucose, corrected for cluster design: n = 35, RR 0.58, 95% CI 0.28 to 1.21; BMI, corrected for cluster design: n = 34, RR 0.18, 95% CI 0.02 to 1.37; smoking status, corrected for cluster design: n = 32, RR 0.25, 95% CI 0.06 to 1.03; Framingham score, corrected for cluster design: n = 38, RR 0.71, 95% CI 0.48 to 1.03; very low quality). Regarding participant outcomes, one trial assessed the efficacy of a shared decision‐making implementation strategy and found no impact in terms of psychopathology, satisfaction with care and drug attitude. Another single trial studied a multifaceted intervention to promote medication adherence and found no impact in terms of adherence rates.

Authors' conclusions: With only five studies meeting inclusion criteria, and with limited low or very low quality usable information, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that, although small changes in psychiatric practice have been demonstrated, uncertainty remains in terms of clinically meaningful and sustainable effects of treatment guidelines on patient outcomes and how best to implement such guidelines for maximal benefit.

Editorial Group: Cochrane Schizophrenia Group.

Publication status: New.

Citation: Barbui C, Girlanda F, Ay E, Cipriani A, Becker T, Koesters M. Implementation of treatment guidelines for specialist mental health care. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD009780. DOI: 10.1002/14651858.CD009780.pub2. Link to Cochrane Library. [PubMed: 24443146]

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

PMID: 24443146

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