Resources for Clinical Psychologists

While many definitions of CPGs exist, common features of CPGs include the development of specific recommendations for practice using a transparent process that incorporates the best available evidence and the involvement of relevant stakeholders (Beauchamp, Drapeau & Dionne, 2015). CPGs fulfill a range of purposes which include, but are not limited to: synthesizing the research in a given area in a way that supports clinical decision-making; helping to accelerate the translation of research findings into clinical practice; and informing both practitioners and consumers about what can reasonably be expected from a given intervention and highlighting potential challenges and risks associated with these.

CPGs are often conceptualized as the “tip” of the evidence pyramid (see image 1.1)

Image 1.1 Image By CFCF – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42857470.

CPGs have a number of potential benefits, including:

• Synthesizing research in a given area in a way that supports clinical decision-making
• Helping to accelerate the translation of research findings into clinical practice
• Informing both practitioners and consumers about what can reasonably be expected from a given intervention or service
• Highlighting potential challenges and risks

CPGs are frequently used by our colleagues in other professions and have been used by healthcare decision-makers to inform their choices around diverse topics, including accreditation, the allocation of resources and reimbursement of services. There are even cases where CPGs have been used in legal proceedings as a proxy for standards of practice. As CPGs become more ubiquitous in our healthcare environment, practicing psychologists need to be aware of the guidelines that may be relevant to their work.

The clinical section began looking at CPGs in 2014-2015, after this issue was highlighted in our review of past surveys of members and executive officers. In our section business meeting at the annual convention in 2015, we presented a proposal to use a portion of our budget surplus to develop a “hub” or “portal” to provide access to high-quality CPGs for psychologists. This proposal was supported and we formed a CPG working group to begin developing the site.

The first step in this process was to conduct an environmental scan, to ensure that a comparable resource did not already exist. This was completed in the summer of 2015. Our scan revealed that while there are several resources that psychologists may use to access CPGs (you can find the full scan here) there currently is no single location that compiles CPGs for psychology that is accessible, comprehensive, authoritative and easy to use.

Our next step was to conduct a needs assessment survey of our members, which we completed in the fall/winter of 2015. 198 individuals responded to the survey; 81% of this sample identified as members of the clinical section. 65% of our respondents indicated that they use CPGs at least some of the time, but several barriers to using CPGs were identified, including difficulties accessing CPGs, concerns about the relevance and appropriateness of CPGs to the practice environment and a preference to review the evidence firsthand (for more information about this survey, see our symposium presentation from the 2017 convention, here. However, one of the most prominent themes to emerge in the comments was concern about the quality of CPGs, and quality assessment emerged as a feature that psychologists would want to see in any CPG resource developed by the section.

Concern about the quality of CPGs is warranted. For example, a recent review of 70 CPGs in the area of child and adolescent mental health found that 69% of guidelines that were assessed were developed using methods that did not align with established criteria for guideline development and lacked key features like mandatory rigorous systematic reviews, the inclusion of appropriate stakeholders in the review committee and transparent conflict of interest policies (Bennett et. al, 2015). Similar findings have been found by other research teams (e.g, Beauchamp, Drapeau & Dionne, 2015).

Our original vision was to develop a “hub” or portal facilitating access to high-quality CPGs for psychology. 85% of survey respondents reported that they were somewhat or very likely to use a portal like this if this existed. What our review of this area so far has revealed, however, is that there is urgent work to be done related to the quality of CPGs, and that the scale of this work requires partnership and resources beyond what we currently have available.

In February, 2017, the clinical section put out a call for individuals with relevant expertise to submit proposals related to CPGs that build on the work we have done to date. We are currently developing partnerships to help carry on these activities.

CPGs for psychology are listed in many places; we suggest you start by looking at the table in our environmental scan (here) for an overview that includes additional details about features for each site we reviewed. Highly-rated accessible sites that met all or most of our criteria include:

• National Institutes of Clinical Excellence *met all criteria
  https://www.nice.org.uk/guidance?unlid=310756116201461222831
• Agency for Healthcare Research and Quality (AHRQ) Clearinghouse *met all criteria
  https://www.guideline.gov
• National Health and Medical Research Council
  http://www.nhmrc.gov.au/
• Substance Abuse and Mental Health Services Administration (SAMHSA) – National Registry of Evidence-Based Programs and Practices (NREPP)
  https://www.samhsa.gov/nrepp
• Veteran’s Health Administration
  http://www.healthquality.va.gov
• Cochrane Library
  http://www.cochranelibrary.com/Additional sites specific to psychology include:
• American Psychological Association (APA) Guidelines for Practitioners
  http://www.apa.org/practice/guidelines/index.aspx
• American Group Psychotherapy Association – Practice Guidelines for Group Psychotherapy
  http://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
• Australian Psychological Society – Evidence-based and Quality Information for Psychologists (EQIP) *fee/registration required for some resources
  https://eqip.psychology.org.au/
• British Psychological Society
  http://www.bps.org.uk/publications/policy-and-guidelines/practice-guidelines-policy-documents/practice-guidelines-poli
• Society of Behavioural Medicine – Evidence-Based Behavioral Practice
  http://www.ebbp.org/
• Society of Clinical Child & Adolescent Psychology
  http://www.effectivechildtherapy.com
• Society of Clinical Psychology
  http://www.div12.org/psychological-treatments
• University of Ottawa’s Psychotherapy and Practice Research Network
  http://www.med.uottawa.ca/pprnet/eng/resources.html
• Ken Pope – Articles, Research and Resources in Psychology
  http://www.kspope.com

The Institute of Medicine published a report titled “Clinical Practice Guidelines We Can Trust” in 2011 (find the full report here). They suggest several things that clinicians should look for when evaluating CPGs, including:

• Is there an explicit description of development and funding processes that is publicly accessible?
• Do the authors follow a transparent process that aims to minimize bias, distortion, and conflicts of interest?
• Were the guidelines developed by a multidisciplinary panel comprising clinicians, methodological experts, and representatives, including a patient or consumer, of populations expected to be affected by the guideline?
• Does it use a rigorous systematic evidence review and consider quality, quantity, and consistency of the aggregate of available evidence?
• Does it summarize evidence (and evidentiary gaps) about potential benefits and harms relevant to each recommendation?
• Does it explain the parts that values, opinion, theory, and clinical experience play in deriving recommendations?
• Does it provide a rating of the level of confidence in the evidence underpinning each recommendation and a rating of the strength of each recommendation?
• Has it undergone extensive external review that includes an open period for public comment?
• Is there a mechanism for revision when new evidence becomes available?

(questions adapted from IOM report and overview from UptoDate)

There are several instruments that have been developed to help individuals and groups assess the quality of CPGs. We have included links to two of the most commonly used below.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
http://www.gradeworkinggroup.org/

The Appraisal of Guidelines, Research & Evaluation (AGREE) scale
http://www.agreetrust.org/

Up to Date has a helpful summary/overview of issues relating to CPGs
https://www.uptodate.com/contents/overview-of-clinical-practice-guidelines

The American Psychological Association has developed some criteria for evaluating treatment guidelines, including a checklist practitioners can use. You can find it here:
http://www.apa.org/practice/guidelines/evaluating.aspx. APA is also working on developing their own CPGs.

The Guidelines International Network (http://www.g-i-n.net/) is currently working on developing consensus around minimal standards for guideline development.