| Abstract|| |
Methodology: An online survey was received by 3475 psychiatrist, of whom 608 (17.5%) participants completed the survey.
Results: Almost all (93.8%) of the psychiatrists agreed that there should be separate CPGs for Indian setting. In terms of problems with the previous version of the CPGs, this survey shows that the previous version of guidelines was used in making clinical decisions by only one-third (31.25%) of the participating psychiatrists. The major limitations of the previous version of CPGs which were pointed out included the lack of consideration of socio-cultural issues (33.2%), lack of recommendations for many clinical situations that are encountered in clinical practice (43.15) and poor dissemination (35.2%). In terms of expectations, the membership expects the society to come up with guidelines, which are shorter in length (82.2%), has significant proportion of information in the form of tables and flow diagrams (58.7%), besides the evidence base must also take expert opinions into account (84.7%), must be circulated before adopting (88.7%), must be disseminated by displaying the same on the website (72%), and also by sending the same by E-mails (62%). Further, the membership expects the IPS to design online continuing medical education program on CPGs (54.3%). The survey also suggests that it is feasible on the part of more than two-third of the psychiatrists to monitor the metabolic parameters in routine clinical practice and carryout various nonpharmacological treatments. Majority of the psychiatrist opined that polypharmacy is not used in more than 25% of patients with schizophrenia and depression and hence the use of polypharmacy should be recommended judiciously.
Conclusion: This survey shows that the membership of the IPS is interested in having own guidelines for the management of various psychiatric disorders in Indian setting. Further, the survey provides insights into why the previous versions of the guidelines were not very popular and what IPS should do improve the acceptability of guidelines in future.
Keywords: Clinical practice guidelines, guidelines, India, Indian Psychiatric Society
|How to cite this article:|
Grover S, Avasthi A. Indian Psychiatric Society Survey on Clinical Practice Guidelines. Indian J Psychiatry 2017;59, Suppl S1:10-8
| Introduction|| |
Indian Psychiatric Society (IPS), started publishing clinical practice guidelines (CPGs) for the management of various psychiatric disorders in the year 2005 and between the year 2005 and 2009, published five volumes of treatment practice guidelines, covering most of the psychiatric disorders. ,,,, A survey was conducted in the months of October-November 2008, to evaluate the usefulness, awareness, and implementation of IPS-CPGs. The survey was sent to 1100 psychiatrists, of whom 107 responded to the survey. Among the responders, only half of the responders were aware about the four published volumes of the guidelines at that time, and only 12.7% of the responders had read all the four volumes. About two-thirds of the responders had referred to these guidelines in their clinical practice, either occasionally (46.1%), often (16.7%), or always (2%). More than two-thirds of the responders considered these guidelines to be helpful in making day-to-day clinical decisions in their practice, either occasionally (48%), often (19.6%), or always (3.9%). In the open-ended questions, many of the responders discussed their dissatisfaction with these guidelines and gave suggestions as to how these guidelines could be improved. Some of the areas of dissatisfaction were the lack of uniformity, lack of consideration of local/cultural issues into account, not very useful, lengthy, not user friendly, poor quality of printing and typological errors. Some of the suggestions which emerged from this survey included, rather than having guidelines on the basis of evidence base only, guidelines may be drawn on the basis of consensus and may be field tested. Further, the IPS should try to focus on drawing guidelines only on few disorders, rather than having guidelines for everything. In terms of circulation, participants suggested that the guidelines should be sent to all the Indian psychiatrists, and must be made available on the society's website or on the website of the journal. 
| Methodology|| |
This survey was conducted by using Survey Monkey platform. Based on the E-mail address database of various members of the society and E-mail addresses of the trainee psychiatrist collected by the authors, the survey was sent to 4394 E-mail addresses. The survey was approved by the ethics committee of the research and training foundation of the IPS. The cover letter of the survey mentioned that the IPS has decided to revise CPGs for the management of schizophrenia, bipolar disorder, and depression, and the Executive Committee of IPS was seeking inputs from its membership prior to finalizing the CPGs. The participants were also informed that a symposium on the CPGs will be held during the ANCIPS-2016. The participation in the survey was voluntary and the participants had the option of "opt-out" from the survey. Completion of the survey implied informed consent. The survey was sent twice a week for 6 consecutive weeks. Those who responded to the survey or "opted out" were not sent the reminders. Those who completed the survey partially were also sent reminders in between to complete the survey. The survey questionnaire included 41 questions and required about 15-20 min to complete.
The data were analyzed by SPSS (SPSS for Windows, Version 14.0. Chicago, SPSS Inc.). Continuous variables were analyzed in the form of mean, standard deviation, median, and range. Categorical variables were analyzed as frequency and percentages.
| Results|| |
Of the 4394 E-mail addresses, the invitation to participate "bouched-back" for 712 E-mail addresses and for 207 E-mail addresses, people opted out to participate in the survey. Out of the eligible, 3475 participants, 608 (17.5%) of the participants completed the survey. The mean age of the participants was 41 (standard deviation [SD] 11.78) years, with a range of 26-79 years and a median of 38 years. As is evident from [Table 1], about 80% of the participants were ≤50 years with majority of the participants were in the age range of 31-40 years. Four-fifth of the participants were males and about one-fifth were females. More than three-fourth (77.5%) of the participants had done MD only or had done MD along with an additional degree. The mean total experience in psychiatry, including the training period was 14.22 (SD - 10.89) years, with a median of 10 years and range of 1-53 years. Three-fifth of the participants were in the government jobs (either fulltime government job only or government job with private practice) and two-fifth were in full-time private practice only. In terms of place of work, one-fourth were in full-time private practice, one-fifth were in the government medical colleges (without any private practice). About one-sixth were in central institutes [Table 1]. In terms of location, about three-fourth of the psychiatrist were practicing in the heart of the large city or in the suburbs of a large city. One-fifth were practicing in a town and very few were practicing in villages. On an average, a psychiatrist was seeing 30 (SD 26.2) patients a day with a median of 25 patients a day and a range of 2-200. The mean duration of time spent in consultation for a new patient was 27.9 (SD - 16.3; median 25) min and that for an old follow-up patient was 11.91 (SD - 6.94; median 10) min. Only a small proportion (7.4%) of the participants had been part of the IPS CPG formulation groups in the past.
Views about guidelines
A majority (81.6%) of the participants reported that they do follow some treatment guidelines for the management of patients with severe mental disorders such as schizophrenia, bipolar disorder, or depression. Among those who were using guidelines, in terms of most commonly followed guidelines for the management of patients with severe mental disorders, about two-fifth (41%) were following Maudsley Prescribing Guidelines and about one-fourth (28.65%) were following American Psychiatric Association guidelines. About one-seventh (14.3%) were following National Institute of Clinical Excellence (NICE) guidelines and another one-seventh (14.63%) were following IPS guidelines [Table 2]. Majority (82.24%) of those who were using various guidelines reported that they were able to use the guidelines only partially.
When enquired about having separate CPGs for Indian setting majority (93.8%) of the participants answered in affirmation. When asked about earlier IPS guidelines, 83.3% of the participants were aware about the same and about half (52.1%) had used the IPS guidelines. Those who used the same had most often used the same to update their knowledge (43.5%). About one-third (31.25%) used the same for taking day to day clinical decisions and one-fourth (25.65%) used it for teaching and few (11%) had used the same for defending themselves in the court of law. When asked to report about the problems with the earlier version of the guidelines, the most commonly reported problem was that these do not address many clinical situations that are encountered (43.1%), followed by problems in dissemination (35.2%), do not address the socio-cultural issues encountered in practice (33.2%), and not evidence based (20.2%). Other details are shown in [Table 2].
Expectations from the revised clinical practice guidelines
When asked about their expectations from the upcoming CPGs, most of the participants expected that the guidelines should be at best of <5 pages (45.8%) or 5-10 pages (36.4%) of Indian Journal of Psychiatry (IJP) [Table 3]. More than half of the participants expected the CPGs to be presented in the form of tables and flow diagram format. Majority of the participants expected that the guidelines must be based on evidence base along with expert opinion (84.7%), must be circulated before being adopted (88.7%) and having a symposium in ANCIPS would be beneficial (91.4%). When asked about how to improve the use of CPGs, majority of the participants expected that the guidelines must be made available on the IPS website (72%) and this was followed by the expectation of receiving the softcopy of guidelines by E-mail (62%) and presenting major parts of the guidelines in the form of flow charts and tables (58.7%) and by conducting online continuing medical education (CME) programs on the CPGs (54.3%) and least proportion of the participants (47.4%) considered sending parts of guidelines in the form of small educational capsules through E-mail on regular basis would be of benefit. About half (48.6%) of the participants considered that the society should not make it mandatory for its membership to follow the CPGs and very few (5.6%) considered that it should definitely be made mandatory.
Feasibility of investigations
In terms of feasibility of carrying out investigations, for majority of the participants (>75%), it was feasible to order and get reports of hemogram, fasting blood glucose levels, serum electrolytes, liver function test, renal function test, lipid profile, thyroid function test, ultrasound of abdomen and pelvis, electroencephalogram, computerized tomography of brain, X-ray chest, and electrocardiogram. More than two-third of the participants also had access to serum lithium levels and magnetic resonance imaging. More than half had access to Vitamin B12 and Vitamin D levels. Only two-fifth (42.6%) had access to serum valproate levels and urine drug screen (40.6%). However, very few had access to positron-emission tomography and serum clozapine levels [Table 4]. For at least two-third of the psychiatrists, it was possible to measure height, weight, blood pressure, fasting blood glucose levels, and the lipid profile. More than half (55.3%) also reported that it was feasible to measure waist circumference of their patients.
Investigations carried out routinely prior to starting of various psychotropic medications
In terms of current practice, in general, more investigations were being done prior to starting of antipsychotics and mood stabilizers, when compared to the use of antidepressants. Investigations done prior to starting of antipsychotics by more than half of the psychiatrists included hemogram, fasting blood glucose levels, and lipid profile. Further more than half of the psychiatrists also monitored the same while using antipsychotics [Table 5] and [Table 6]. Investigations done by about half or more psychiatrists, prior to starting of mood stabilizers included hemogram, fasting blood glucose levels, liver function test, renal function test, and thyroid function test. Of these, only liver function tests, renal function tests, and thyroid function tests were being monitored while using mood stabilizers. In general, fewer psychiatrists carried out investigations prior to starting and while using various antidepressants. The most commonly carried out investigations included hemogram, fasting blood glucose level, and thyroid function test.
|Table 5: Investigations carried out routinely prior to starting of various psychotropic medications |
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|Table 6: Investigations carried out while monitoring patients on various psychotropic medications |
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In terms of option given for other investigations, few reported evaluating serum drug levels (lithium and valproate) (5.9%) and serum prolactin (3.8%), while monitoring patients on various psychotropic medications.
Majority of the psychiatrists were carrying out renal function test (84.9%), thyroid function test (78%), and serum electrolytes prior to starting of lithium. However, very few psychiatrists reported evaluating 24 h urine osmolality and 24 h proteins prior to starting of lithium. Very few (5.6%) of psychiatrist reported not carrying out any investigations prior to starting of lithium.
When asked about polypharmacy, 26.8-32.37% of the participants reported using combination of antipsychotic continuously for more than 2 weeks to manage acute phase of illness of patients with schizophrenia, depression, or bipolar disorder [Table 7]. Combinations of antidepressants were used by 23% of participants in the management of acute phase depression. Combinations of two classical mood stabilizers (i.e., lithium, valproate, lamotrigine, carbamazepine, etc.,) were used by 18.63% only for the management of mania. However, combination of mood stabilizer (i.e., lithium, valproate, lamotrigine, carbamazepine, etc.,) and an antipsychotic medication were used for the management of acute phase of mania by 58.3% of the participants.
About one-fourth (24.12%) of the participants, reported using the combination of antipsychotics in the stabilization/stable phase of schizophrenia. In terms of management of bipolar disorder in the maintenance phase, combination of a classical mood stabilizer and antipsychotic medication was used in about 40.5% of patients and this was followed by the use of a combination of two classical mood stabilizers (21.04%) or combination of two classical mood stabilizers and an antipsychotic medication (14.71%).
Competence in nonpharmacological interventions
Majority of the psychiatrist (>80%) considered their competence to carry out psychoeducation, cognitive behavior therapy, behavior therapy, family intervention, and relaxation exercises as "average" or "above average" or "excellent." However, for psychoeducation, only 64.4% considered their competence as "average" or "above average". In terms of carrying out cognitive remediation therapy, only about half of the participants reported their own competence as average or above average [Table 8].
| Discussion|| |
This survey intended to have basic information about the dissatisfaction and utility of previous version of CPGs of IPS and to understand the expectations of the membership with regard to the revised CPGs. In addition, the Task force of IPS on CPGs was also interested in understanding the feasibility of making certain recommendations such as carrying out investigations for the evaluation of metabolic syndrome and various nonpharmacological treatments.
As there are no such surveys which have looked into these aspects of practice of psychiatry, it would be difficult to compare the findings of the present survey with existing literature. Hence, we would discuss the findings of this survey in the context of formulation of newer guidelines.
The present survey suggests that in Indian setting, majority of the psychiatrists follow one or other treatment guidelines for the management of their patients with severe mental disorders. This finding is very similar to the previous survey in which only 8.8% of psychiatrists had reported not following any specific treatment guidelines in managing their patients.  In terms of preference, a large proportion of psychiatrists was following treatment guidelines issued by other associations, i.e., Maudsley Prescribing Guidelines, American Psychiatric Association, and NICE and only a very small proportion of psychiatrists based their day to day clinical decisions based on IPS guidelines. This finding can be interpreted as possible lack of satisfaction with the IPS guidelines. This lower reliance on IPS guidelines also can be due to the lack of awareness about these guidelines in about one-sixth of the participants.
In terms of applicability, majority of the participants reported that they were able to use guidelines of different associations only partially in their clinical practice. This suggests that guidelines issued by various associations probably are not in tune with the real life situations faced by the psychiatrists and hence any new guidelines must take these situations into account while making recommendations.
When asked about the need for separate CPGs for Indian setting, almost all (93.8%) of the participants expressed the need to have separate treatment guidelines for Indian setting. This finding clearly reflects that there is a need for development of treatment guidelines by the IPS. Hence, it can be said that decision of IPS to revise these guidelines is in the right direction. In terms of using the previous version of guidelines only 52.1% of psychiatrists reported ever using the IPS guidelines. Only one-third of the psychiatrists, who used the IPS guidelines, reported that these were useful in making day to day clinical decisions. In terms of implementation of treatment guidelines, studies from other parts of the world show that the barriers to implementation to various treatment guidelines include organizational resources, health care professional's own characteristics, and perception of guidelines and implementation strategies.  Accordingly, it is important for the IPS to keep these facts in mind to reduce the barriers in implementation of treatment guidelines.
In terms of expectations, majority of the participants expressed the need to have shorter documents, with lot of information being provided in the form of flow diagrams and tables and drawing the recommendations based on the evidence base and expert opinion. In addition, the membership expects that the society should make these guidelines available to them electronically through various resources. In addition, a significant proportion of the members expect that having online CME program on guidelines could be of help IPS must take these views into account while circulating the revised guidelines.
In terms of problems with the existing guidelines, a significant proportion of participants reported that the guidelines do not take into consideration various socio-cultural issues encountered in practice, do not address many clinical situations that are encountered, are not evidence based and there is too much emphasis on pharmacotherapy. In addition, about one-third of the participants also pointed out the issue of poor dissemination of these guidelines. This again suggest that revised version of guidelines must focus on these issues and must be disseminated properly.
IPS Task force on formulation of treatment guidelines must take these insights in terms of problems with earlier version of the guidelines and expectations of the membership in formulation of future CPGs. Some of the issues like making the recommendations on the basis of current evidence base can easily be done by carrying out proper review of the existing literature and drawing recommendations based on the same. The newer guidelines should provide adequate information about the nonpharmacological treatments, so that these can be easily incorporated into clinical practice and emphasis on the use of only pharmacological measures must be reduced. Problem of dissemination must be addressed by publishing the guidelines as part of the IJP and possibly making the guidelines available at the IJP website and sending the guidelines to the membership by E-mail. IPS must look at developing online CME program for improving the acceptability of CPGs. This can be done probably by having CME program which can evaluate the knowledge of the participant about the content of IPS guidelines. This program can also possibly help in evaluating specific dissatisfactions with the guidelines. In future, there is a need to carry out a survey to understand the socio-cultural aspects and the clinical situations, which clinicians feel that the guidelines do not address.
Members of all the societies expect their leaders to fulfill their demands and aspirations. In the survey, a very large proportion of the psychiatrists expressed that having a symposium in ANCIPS is going to help in formulation of guidelines. The Task force on the formulation of treatment guidelines organized a symposium on the revised CPGs in ANCIPS 2016. The attendance in this symposium was far less than expected. This possibly reflects the apathy of the membership on this issue. Till the membership does not take up their own responsibility sincerely, just blaming the leadership and people involved in the task of formulation would be unfair. Accordingly, the membership should take up their own responsibility more sincerely and provide their inputs on this endeavor so that a collective effort can result in the formulation of CPGs which are practical and can be used.
Over the last 1-2 decades, development of metabolic syndrome with the use of psychotropics has become an important issue. Various associations have issued guidelines for monitoring of metabolic syndrome. This survey clearly shows that it is feasible for majority of the psychiatrists to carry out most of the routine investigations in their clinical practice. Further, it was also feasible to carryout anthropometric evaluation on part of majority of psychiatrists. In terms of current practice too, it was evident that a significant proportion of psychiatrists were already carrying out baseline investigations and also were ordering for investigations while using psychotropics in long run. Accordingly, the recommendations of guidelines in terms of carrying out baseline investigations and anthrometric evaluation must take these into account. Accordingly, the guidelines may recommend monitoring of metabolic parameters for patients recommended antipsychotic and mood stabilizers. If in future, these recommendations are followed by the practicing psychiatrists in routine clinical practice, this could possibly help in detecting metabolic abnormalities at early stages and prevention of development of chronic physical illnesses such as diabetes mellitus and hypertension. This all can probably also help in reduction in premature cardiovascular mortality. The findings of this survey also shows that majority of the psychiatrists follow the basic recommendations for prelithium investigations. Accordingly, future guidelines must make recommendations of this with ease.
There is a general perception that there is high rate of polypharmacy in routine clinical practice. Some of the psychiatrists argue about this issue and give this as an excuse for not following treatment guidelines. Some claim that most patients require polypharmacy and it is not possible to manage patients with monotherapy during the acute and maintenance phase. Keeping these views in mind, there is always a pressure of recommending polypharmacy as part of CPGs. However, findings of the current survey clearly shows that in general, polypharmacy is not practiced for significant proportion of patients with schizophrenia and depressive disorders. However, a significant proportion of patients with bipolar disorder receive polypharmacy during the acute and maintenance phase treatment. Accordingly, it can be said that guidelines should judiciously recommend the use of polypharmacy.
In terms of nonpharmacological treatment, more than half of the psychiatrists reported average or above average competence in carrying out nonpharmacological treatments such as psychoeducation, cognitive behavior therapy, behavior therapies, family interventions, and relaxation exercises. These findings suggest that future guidelines must provide more information about the role of these interventions in management of various psychiatric disorders. Further, the findings also suggest that a significant proportion of psychiatrists are not very well versed with cognitive remediation therapy. Accordingly, as capacity building measure, IPS must hold workshops and symposiums on cognitive remediation therapy, so that these can be practiced more often by its membership.
This survey has certain limitations. The survey did not evaluate the specific level of dissatisfaction among the psychiatrists with regard to the existing guidelines. Further the survey did not evaluate the specific expectations of the psychiatrists from the newer guidelines. This survey did not endeavor to assess the barriers to the implementation of treatment guidelines in clinical practice. Only about one-sixth of the membership participated in this survey. Due to this, generalizability of this survey can be questioned.
| Conclusion|| |
The present survey shows that the majority of the psychiatrists are interested in having own CPGs and at present follow one or other treatment guidelines for the management of patients. In terms of problems with the previous version of the CPGs, this survey shows that the previous version of guidelines were used for making clinical decisions by a very small proportion of psychiatrists only. The major limitations of the previous versions which were pointed out included the lack of consideration of socio-cultural issues, lack of recommendations for many clinical situations that are encountered in clinical practice and poor dissemination. In terms of expectations, the membership expects the society to come up with guidelines, which are shorter in length, has more information in the form of tables and flow diagrams, should take expert opinions into account, must be circulated before adopting, must be disseminated by displaying the same on the website, and also by sending the same by E-mails. Further, the membership expects the organization to design online CME program on CPGs. The survey also suggests that it is feasible to monitor the metabolic parameters in routine clinical practice and carryout various nonpharmacological treatments. In addition, the survey suggests that polypharmacy is not used much; hence its use should be recommended judiciously.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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Grover S, Avasthi A. Views about clinical practice guidelines of the Indian Psychiatric Society: A survey of psychiatrists in India. Indian J Psychiatry 2009;51:127-33.
Forsner T, Hansson J, Brommels M, Wistedt AA, Forsell Y. Implementing clinical guidelines in psychiatry: A qualitative study of perceived facilitators and barriers. BMC Psychiatry 2010;10:8.
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]