In recent years new methodologies for developing treatment recommendations that give consideration to evidence, values, preferences and feasibility issues have been developed. One of the most well-developed approaches is the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. This article briefly presents how this methodology may be employed to develop treatment recommendations that might constitute a permanent infrastructure between primary research and everyday clinical practice.
"One of these tools is the GRADE methodology (Grading of Recommendations Assessment, Development and Evaluation) [4-6]. This methodology has already been used to produce guidelines for several fields of medicine, including mental health care . For example, WHO developed a model intervention guide within the mental health Gap Action Programme (mhGAP) , which provides recommendations to facilitate care at first and second level facilities by the non-specialist health care providers in low and middle income countries. "
[Show abstract][Hide abstract] ABSTRACT: Introduction
In recent years the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology has often been used by international or national health authorities, or scientific societies, for developing evidence-based treatment recommendations. However, the GRADE approach has never been used by practicing physicians who aim at harmonizing their prescribing behaviours paying due attention to the best available evidence. This paper describes the experience of a working group of psychiatrists who adopted the GRADE approach to develop clinical recommendations on the use of psychotropic drugs in specialist mental healthcare.
The project was conducted in the Department of Mental Health of Verona, Italy, a city located in the north of Italy. At the beginning of 2012, psychiatrists with a specific interest in the rational use of psychotropic drugs were identified and appointed as members of a Guideline Development Group (GDG). The first task of the GDG was the identification of controversial areas in the use of psychotropic drugs, the definition of scoping questions, and the identification of outcomes of interest. The GDG was supported by a scientific secretariat, who searched the evidence, identified one or more systematic reviews matching the scoping questions, and drafted GRADE tables.
Discussion and evaluation
On the basis of efficacy, acceptability, tolerability and safety data, considering the risk of bias and confidence in estimates, and taking also into consideration preferences, values and practical aspects in favour and against the intervention under scrutiny, a draft recommendation with its strength was formulated and agreed by GDG members. Recommendations were submitted for consideration to all specialists of the Department, discussed in two plenary sessions open to the whole staff, and finally approved at the end of 2012.
The present project of guideline development raised several challenging and innovating aspects, including a “bottom-up” approach, as it was motivated by reasons that found agreement among specialists, those who developed the recommendations were those who were supposed to follow them, and values, preferences and feasibility issues were considered paying due attention to local context variables.
International Journal of Mental Health Systems 05/2013; 7(1):14. DOI:10.1186/1752-4458-7-14 · 1.06 Impact Factor
"This implies the production of a very diverse range of recommendations, including clinical practice guidelines (individual level) and health systems guidance (policy level). At both these levels scientific evidence is considered an extremely valuable tool, but it cannot be the only consideration [5,6]. This seems particularly relevant in the field of mental health, where value-based decisions together with resource and feasibility considerations may be unavoidable . "
[Show abstract][Hide abstract] ABSTRACT: A new resolution on mental, neurological and substance use disorders was adopted in January 2012 by the World Health Organization (WHO) Executive Board. The resolution urges WHO and Member States to collaborate in the development of a comprehensive mental health action plan, to be submitted for discussion and approval to the WHO World Health Assembly. This commentary aims at rising awareness on the risk that this resolution may not fulfil its potential.
Lack of political awareness and visibility of the resolution is a first major issue. Theoretically, Member States should be aware of the resolution and support its implementation at their respective national level, but in practice political commitment may not be high enough, and technical and financial resources made available may be limited. A second challenge is that the resolution suggests to work with Member States and technical agencies to promote academic exchange through which to contribute to policy-making in mental health. It is not straightforward, however, how such a statement may be effectively translated into action. A third key methodological aspect is how scientific evidence and factors other than scientific evidence will be handled. This seems particularly relevant in the field of mental health, where value-based decisions together with resource and feasibility considerations may be unavoidable.
We argue that WHO and Member States should work together to increase the visibility of the resolution, ensuring that Ministries of Health and other relevant components of the health systems are aware of the resolution and its implications. As the resolution urges for academic exchange, WHO should develop a plan for an explicit, inclusive and open call for support and collaboration, so that partners willing to contribute are not kept out from the process. The production of an action plan for mental disorders should be based on scientifically sound methodology. Such a methodology should be transparently described, for example in a WHO process document, to make it clear how individual-level recommendations and policy-level guidance are developed. WHO should establish and maintain an open forum of experts, scientists, health officials and user groups worldwide to interact and agree on values, preferences, feasibility, acceptability, implementability, equity and economic issues that should inform the action plan.
International Journal of Mental Health Systems 06/2012; 6(1):6. DOI:10.1186/1752-4458-6-6 · 1.06 Impact Factor
"complexity of analyses that underpin clinical guidelines and health technology appraisals (Barbui & Cipriani, 2011). Expert statistical support, as well as subject expertise, is required for carrying out and interpreting MTM results. "
[Show abstract][Hide abstract] ABSTRACT: Standard meta-analyses are an effective tool in evidence-based medicine, but one of their main drawbacks is that they can compare only two alternative treatments at a time. Moreover, if no trials exist which directly compare two interventions, it is not possible to estimate their relative efficacy. Multiple treatments meta-analyses use a meta-analytical technique that allows the incorporation of evidence from both direct and indirect comparisons from a network of trials of different interventions to estimate summary treatment effects as comprehensively and precisely as possible.
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