【医脉通-指南】2015+APA实践指南：成人精神病学评估

APAOFFICIALACTIONS

TheAmericanPsychiatricAssociationPracticeGuidelinesforthePsychiatricEvaluationofAdults

JoelJ.Silverman,M.D.,MarcGalanter,M.D.,MagaJackson-Triche,M.D.,M.S.H.S.,DouglasG.Jacobs,M.D.,JamesW.LomaxII,M.D.,MichelleB.Riba,M.D.,LowellD.Tong,M.D.,KatherineE.Watkins,M.D.,M.S.H.S.,LauraJ.Fochtmann,M.D.,M.B.I.,RichardS.Rhoads,M.D.,JoelYager,M.D.

AtitsDecembermeeting,TheAPABoardofTrusteesap-provedtheAPAWorkGrouponPsychiatricEvaluation’sPracticeGuidelinesforthePsychiatricEvaluationofAdults.[Thefullguidelineisavailableathttp:///doi/book/10.1176/appi.books.9780890426760].BACKGROUNDANDDEVELOPMENTPROCESSThesePracticeGuidelinesforthePsychiatricEvaluationofAdultsmarkatransitionintheAmericanPsychiatricAsso-ciation’sPracticeGuidelines.Sincethepublicationofthe2011InstituteofMedicinereportClinicalPracticeGuidelinesWeCanTrust,therehasbeenanincreasingfocusonusingclearlyde ned,transparentprocessesforratingthequalityofevi-denceandthestrengthoftheoverallbodyofevidenceinsystematicreviewsofthescienti cliterature.Theseguide-linesweredevelopedusingaprocessintendedtobeconsistentwiththerecommendationsoftheInstituteofMedicine(2011),thePrinciplesfortheDevelopmentofSpecialtySocietyClinicalGuidelinesoftheCouncilofMedicalSpecialtySocieties(2012),andtherequirementsoftheAgencyforHealthcareResearchandQuality(AHRQ)forinclusionofaguidelineintheNationalGuidelineClearinghouse.Parametersusedfortheguidelines’systematicreviewareincludedwiththefulltextoftheguidelines;thedevelopmentprocessisfullydescribedinadocumentavailableontheAPAwebsite:http:///File%20Library/Practice/APA-Guideline-Development-Process–updated-2011-.pdf.Tosupplementtheexpertiseofmembersoftheguidelineworkgroup,weuseda“snowball”surveymethodologytoidentifyexpertsonpsychiatricevaluationandsolicittheirinputonaspectsofthepsychiatricevaluationthattheysawaslikelytoimprovespeci cpatientoutcomes(Yager2014).Resultsofthisexpertsurveyareincludedwiththefulltextofthepracticeguideline.

Ratingthestrengthofresearchevidenceandrecommendations

ThenewguidelinerecommendationsareratedusingGRADE(GradingofRecommendationsAssessment,DevelopmentandEvaluation),anapproachadoptedbymultipleprofessionalorganizationsaroundtheworldtodeveloppracticeguidelinerecommendations(Guyattetal.,2013).WiththeGRADE

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approach,thestrengthofaguidelinestatementre ectsthelevelofcon dencethatpotentialbene tsofaninterventionoutweighthepotentialharms(Andrewsetal.,2013).Thislevelofcon denceisinformedbyavailableevidence,whichincludesevidencefromclinicaltrialsaswellasexpertopinionandpatientvaluesandpreferences.Evidenceforthebene tofaparticularinterventionwithinaspeci cclinicalcontextisidenti edthroughsystematicreviewandisthenbalancedagainsttheevidenceforharms.Inthisregard,harmsarebroadlyde nedandmightincludedirectandindirectcostsoftheintervention(includingopportunitycosts)aswellaspo-tentialforadverseeffectsfromtheintervention.Wheneverpossible,wehavefollowedtheadmonitiontocurrentguidelinedevelopmentgroupstoavoidusingwordssuchas“might”or“consider”indraftingtheserecommendationsastheycanbedif cultforclinicianstointerpret(Shiffmanetal.,2005).

Asdescribedunder“GuidelineDevelopmentProcess,”each nalratingisaconsensusjudgmentoftheauthorsoftheguidelinesandisendorsedbytheAPABoardofTrustees.A“recommendation”(denotedbythenumeral1aftertheguidelinestatement)indicatescon dencethatthebene tsoftheinterventionclearlyoutweighharms.A“suggestion”(denotedbythenumeral2aftertheguidelinestatement)indicatesuncertainty(i.e.,thebalanceofbene tsandharmsisdif culttojudge,oreitherthebene tsortheharmsareunclear).Eachguidelinestatementalsohasanassociatedratingforthe“strengthofsupportingresearchevidence.”Threeratingsareused:high,moderate,orlow(denotedbythelettersA,BandC,respectively)andre ectthelevelofcon dencethattheevidencere ectsatrueeffectbasedonconsistencyof ndingsacrossstudies,directnessoftheeffectonaspeci chealthoutcome,andprecisionoftheestimateofeffectandriskofbiasinavailablestudies(AHRQ2014;Balshemetal.2011;Guyattetal.2006).

Itiswellrecognizedthatthereareguidelinetopicsandclinicalcircumstancesforwhichhighqualityevidencefromclinicaltrialsisnotpossibleorisunethicaltoobtain(CouncilofMedicalSpecialtySocieties,2012).Forexample,itwouldnotbeethicaltorandomlyassignonlyhalfofpatientswithdepressiontobeaskedaboutsuicidalideas.Manyquestionsneedtobeaskedaspartoftheassessment,andinquiringaboutaparticularsymptomorelementofthehistorycannot

AmJPsychiatry172:8,August2015

beseparatedoutforstudyasadiscreteintervention.Itwouldalsobeimpossibletoseparatechangesinoutcomeduetoas-sessmentfromchangesinoutcomesduetoensuingtreatment.Researchonpsychiatricassessmentisalsocomplicatedbymultipleconfoundingfactorssuchastheinteractionbetweentheclinicianandthepatientorthepatient’suniquecircum-stancesandexperiences.Fortheseandotherreasons,thevastmajorityoftopicscoveredintheseguidelinesonpsychiatricevaluationhavereliedonformsofevidencesuchasconsensusopinionsofexperiencedcliniciansorindirect ndingsfromobservationalstudiesratherthanbeingbasedonresearchfromrandomizedtrials.TheGRADEworkinggroupandguidelinesdevelopedbyotherprofessionalorganizationshavenotedthatastrongrecommendationmaybeappro-priateevenintheabsenceofresearchevidencewhensensiblealternativesdonotexist(Andrewsetal.2013;Britoetal.2013;Djulbegovicetal.2009;Hazlehurstetal.2013).

Goalsandscopeofguidelinesforthepsychiatricevaluationofadults

Despitethedif cultiesinobtainingquantitativeevidencefromrandomizedtrialsforpracticeguidelinessuchaspsy-chiatricevaluation,guidancetoclinicianscanstillbebene- cialinenhancingcaretopatients.Thus,inthecontextofaninitialpsychiatricevaluation,amajorgoaloftheseguidelinesistoimprovetheidenti cationofpsychiatricsignsandsymptoms,psychiatricdisorders(includingsubstanceusedisorders),othermedicalconditions(thatcouldaffecttheaccuracyofapsychiatricdiagnosis),andpatientswhoareatincreasedriskforsuicidaloraggressivebehaviors.Additionalgoalsrelatetoidentifyingfactorstha …… 此处隐藏：19475字，全部文档内容请下载后查看。喜欢就下载吧 ……