How to Determine the Best Evidence-based Treatment When no Clinical Practice Guideline Exists

PHCoE Psych Health Evidence Briefs thumbnails
PHCoE graphic
By Amanda Edwards-Stewart, Ph.D., ABPP
August 6, 2018

Let’s say you diagnosed your patient with a disorder that does not have a formal clinical practice guideline, and you want to make sure you are aware of the recommended evidence-based treatment(s) for this condition. Or, perhaps, you’d like to know if new treatments have emerged in recent years.

How can you find answers to these questions?

You could do a literature review. This, however, takes time and effort, especially if you have a high patient load and little time to dig through and evaluate a large quantity of research articles.

The good news is, there are many resources for busy providers that lessen the burden of answering these questions. Many groups summarize research, taking into account both the vast quantity and quality of published trials.

One of these resources includes clinical practice guidelines (CPG). These guidelines are created by a team of experts who review the literature (to include systematic reviews, meta-analyses, randomized trials, and observational studies) to determine what treatments (therapies and medications) are supported by evidence and can be recommended as first-line, second-line, and third-line treatments for a given disorder (both medical and psychological). The Department of Defense and Department of Veterans Affairs have CPGs for many mental health disorders, but not for every disorder.

When no CPG exists, what should you do?

Look around. Other groups outside of the military publish CPGs. They are generally produced by large health care systems. As with any research, CPGs can vary in their methodological rigor. Two groups that compile or create CPGs with consistent scientific quality are the Agency for Healthcare Research and Quality (AHRQ) and the National Institute for Health and Care Excellence (NICE).

Systematic reviews are another resource to consider, when no CPG is available. Systematic reviews are large literature reviews with systematic methods meant to answer a specific question, which tend to be focused on a treatment’s efficacy or effectiveness. Many systematic reviews digest both published and unpublished findings, determine the quality of each, and summarize this literature. Systematic reviews of specific disorders would likely tell us which intervention(s) have the most evidence. The authority for such reviews is Cochrane Library. They provide guidance that establishes the parameters of the applicable reviews. These reviews span evidence for both specific medications and psychological treatments.

A final resource is the Psychological Health Center of Excellence (PHCoE). PHCoE exists to support military behavioral health care providers. We publish systematic reviews, rapid reviews, and evidence briefs that answer questions related to the evidentiary support of psychological health treatments. PHCoE Psych Health Evidence Briefs are short summaries of research evidence on existing and novel treatments for psychological health conditions. The latest batch of briefs includes one on cognitive behavioral therapy for generalized anxiety disorder, a disorder which does not have a DoD/VA CPG. The brief states that, based on an established evidence base, cognitive behavioral therapy should be considered a front-line treatment. The brief explains it’s unclear which interventions, including psychosocial and medication treatments, are most effective for which patients, under which conditions, and in which combinations.

As a provider, consider consulting the resources listed above and review their guidance through the lens of your patient, before identifying which treatments you’ll use.

Once you’ve identified recommended first-line treatments, how do you learn to conduct treatment?

Excellent trainings are available from the Center for Deployment Psychology. Becoming familiar with the treatment via their published manuals (published by Oxford Clinical Psychology) can also be helpful.

Edwards-Stewart is a board certified, licensed, clinical psychologist with specialties in trauma and substance use disorders. She currently works as a research psychologist for the Psychological Health Center of Excellence.

 


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • You could also ask your friendly local Medical Librarian to perform a literature search for you or to set up a search alert for you to help you keep up with your topic of interest.

    In the MHS, we get the Cochrane Library content through our OvidSP subscription.

    You can find it at your Service Component's Virtual Medical Library portal. For Army, the AMEDD Virtual Library is at https://medlinet.amedd.army.mil/

    For the Air Force, the VML is on the Knowledge Exchange: https://kx2.afms.mil/

    The Navy Medical Electronic Library information for access is at https://www.med.navy.mil/sites/nmcp/Dept/SitePages/Library/NMeL.aspx

  • Should use of any modality not improve restful sleep in 7 to 21 days at the most, I argue that it is not a very effective modality. With over 100,000 clients who had compromised sleep co-morbid with a host of diagnosed symptoms, the sleep has been basic to their beginning healing journey. Lee

Add new comment

PHCoE welcomes your comments.

Please do not include personally identifiable information, such as Social Security numbers, phone numbers, addresses, or e-mail addresses in the body of your comment. Comments that include profanity, personal attacks, or any other material deemed inappropriate by site administrators will be removed. Your comments should be in accordance with our full comment policy regulations. Your participation indicates acceptance of these terms.

Please read our full Comment Policy.

You must have Javascript enabled to use this form.
You must have Javascript enabled to use this form.