A Presentation that promotes Evidence-Based Psychiatry and informed clinical decision making in the daily practice of Psychiatry. Prepared by Dr Yasser Amer and Dr Maged Elesely

3. Saudi Psychiatric Association

4. Saudi Psychiatric Association

5. Learning Objectives
1. Concepts and Definitions: EBM, CPGs
2. Why do we need CPGs ?
3. Who needs CPGs ?
4. How to find CPGs on the Web?
5. How do we react to CPGs?
CPGs Development, Adaptation, Dissemination
and Implementation

6. Concepts
&
Definitions

7. Two Different Approaches to
Evidence-Based Psychiatry Practice
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators

8. EBP definition
The integration of best research evidence
with clinical expertise and patient
values
Sackett et al 2000
EVIDENCE – BASED
PSYCHIATRY

9. EBM Method
Assess
Ask clinical
Questions
your patient
(PICO)
Acquire the
Appraise
best evidence
the evidence
Apply
evidence to
patient care

10. EBM Resources
• Cochrane library
http://www.cochrane.org/
A lot of ready appraised studies that answer
PICO questions (High quality SRs and
RCTs).
• Clinical Evidence - BMJ:
http://clinicalevidence.bmj.com/x/index.html

11. Clinical Practice Guidelines (CPGs)
Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (Institute of Medicine 1990).
Increasing international interest in the
development and implementation of CPGs.

12. CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for Developing
Trustworthy CPGs (IOM-AHRQ) 2011

14. Rationale for CPGs
• Worldwide concerns about:▫ Unexplained variations in clinical practice
▫ Rising health care costs
▫ Exponential growth of information ????
• Aim of CPGs:▫ To facilitate more consistent, effective and
efficient practice and improve health
outcomes for patients

15. Clinical
Care GAP
Best
Practice

17. • Doctors
• Nurses
• Decision makers
• Patients
• Public

18. How to Find CPGs?

19. Producers
Finders

20. • Specialized Psychiatry societies:• American Psychiatry Association
• American Academy of Child & Adolescent Psychiatry
• Canadian Network for Mood & Anxiety Treatments
• The Maudsley Hospital, NHS, UK
• National CPGs agencies:

NICE - UK
SIGN - UK

21. American Psychiatric Association

23. AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

25. 15 Current CPGs

28. The Maudsley Hospital

29. CPG Producers:
National Agencies
SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk
12 CPGs

30. CPG Producers:
National Agencies
NICE
National Institute for
Health & Clinical
Excellence
www.nice.org.uk

31. 132 CPGs

32. CPGs Finders
1- National Guidelines Clearinghouse (NGC)
2- Guidelines International Network (G-I-N)
3- DynaMed database
4- PubMed/MedLine
5- Google/ Google Scholar:

33. 408 CPGs
National Guideline Clearinghouse (NGC)
www.guidelines.gov

34. Guidelines International Network (G-I-N)
www.g-i-n.net
EBHC-KT Chair, King Saud University
Org. Member since 2009 (3rd Member from MENA Countries)

36. Shaikh Bahamdan’s Research Chair for
Evidence-Based Health Care & Knowledge
Translation
Member of G-I-N since Oct. 2009
Free access to International CPG Library of G-I-N

37. http://c.ksu.edu.sa/ebhc

38. http://ebhc.ksu.edu.sa/gin/index.html

42. DynaMed
https://dynamed.ebscohost.com/

43. PubMed
US National Library of
Medicine
National Institutes of
Health (NIH)

44. Some CPGs are only retrievable by
“Googling” them!

45. Extensive search for BAD CPGs
•
•
•
•
•
International (13) 2004-2011
USA (8) 2004-2011
UK (4) 2005-2013
Canadian (12) 2004-2013
Review articles (evidence) (28) 2007-2013

47. Adapt
Develop
Adopt
Read
CPGs ?

48. Strength/ Level
Evidence
Recomm.
EVIDENCE PYRAMID

49. I
SR
A
RCT
II
Cohort
Case control
B
III
Case series
Case report
IV
Expert opinion
C
Grades of Recommendations
Levels of Evidence
Evidence Pyramid

50. Topic
Team
Content
Search
FOUND
NOT FOUND
Appraise
Develop
Adopt or Adapt
Appraise
Dissemination - Implementation
Evaluate impact

52. Guideline Adaptation
• Is the systematic approach to the endorsement and/or
modification of a guideline(s) produced in one cultural
and organizational setting for application in a different
context. Adaptation may be used as an alternative to
de novo guideline development, e.g., for customizing
(an) existing guideline(s) to suit the local context.
• http://www.adapte.org/

53. ©Copyright ADAPTE 2007

54. CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions

55. How to assess of the quality of any CPG ?

56. Assess guideline
quality
ADAPTE TOOL 9
AGREE II Instrument
23 items in 6 domains
7 point response scale
Domain scores
Recommendations

57. 23 Items in 6 Domains
USER’S MANUAL page 7
No. of Items
DOMAINS
1
Scope & Purpose
3
2
Stakeholder Involvement
3
3
8
4
Rigour of Development
(Methodology)
Clarity & Presentation
5
Applicability
3
6
Editorial Independence
2
4

58. AGREE Enterprise website
http://www.agreetrust.org/

59. Implementing Guidelines
If CPGs are to have a
positive impact on patient
care outcomes they must
be implemented into daily
clinical practice

60. CPGs Are Not Rules
• Expect the vast majority of practice to fall within
CPGs (80 % - 90 % Rule)
• Deviation from CPGs is allowed for specific patients
with specific circumstances.
• When such deviation occurs an individual clinician
is expected to explain the rationale.
• Strong evidence (Level 1 & 2) are expected to be
followed.
• Weaker evidence (Level 3 & 4) can be handled
differently .

61. Clinical Scenario
An 82 year-old female with dementia is admitted to the
Black Lion Hospital for recurrent falls. She is found to have
Alzheimer’s dementia and she is on no medications. The patient
has never learned to read or write so a Mini Mental Status
Examination was not possible. The diagnosis was made on clinical
grounds with collateral from her family. However, she is agitated at
night. Her family is against antipsychotic medication and the team
has asked if there are any other classes of medication that are
helpful for agitation. She will return to her family in the
countryside once this problem is addressed and the family cannot
manage her otherwise. The treating team questions the role of
antidepressants in treating behavioural symptoms in dementia
patients and would like to know if there is support for a specific
antidepressant in this case?

62. Best Evidence
Evidence-Based
Psychiatry
Traditional
CPGs
Textbooks
(Recommendati
ons + Evidence)
Evidence
PIPOH
PICO
(CPG Websites)
(EBM Websites)
Journals
Experts

63. Best
evidence
Patient
values
My Clinical
Experience
Evidence-Based (Best Practice) Psychiatry

64. Acknowledgments
• Prof. Dr. Lubna Al-Ansary
Professor, Consultant, Family Medicine
Holder, Shaikh Bahamdan EBHC-KT Chair
Head, CPGs Committee, University Hospitals
King Saud University
Member, G-I-N Board of Trustees
Co-chair, G-I-N Adaptation Working Group
• Prof. Dr. Eman Abahussein
Professor, Consultant, Psychiatry
Head, Psychiatry CPGs Subcommittee
College of Medicine & King Khalid University Hospital
King Saud University
• Dr. Yasser S. Amer
Pediatrician - Healthcare Informatician
CPGs General Coordinator, QMD, CPGs Committee,
King Saud University Hospitals (KKUH/KAUH)
Member, G-I-N Adaptation Working Group/Steering Committee

65. Thank you for
Listening !
