The relevance of EPA guidance papers in the framework of the European Psychiatric Association

The role of the European Psychiatric Association is to improve the quality of psychiatric services for patients with mental disorders in Europe, in particular in the European Union, and beyond. To achieve this aim, the EPA supports the integration of national services, clinical research and psychiatric education. In support of this endeavour, Wolfgang Gaebel and Hans-Juergen Möller started an initiative to develop clinical guidance papers [3]. These papers were meant to provide guidance especially for the management and treatment of clinical conditions and related problems that may not yet have received the necessary attention in research and/or meta-analyses.

Two series of guidance papers have been published in special issues of European Psychiatry in 2013 and 2014. They included papers on the quality of mental health services [4], conflict of interest [8], suicide prevention [15], the importance and development of trust of patients and the public in mental health services [5]. All guidance papers are freely available on the EPA website. They have been read and welcomed by many European and international psychiatrists. The third series is published in this issue and include the following guidance papers:

• EPA guidance on the early detection of clinical high-risk states of psychoses;

• European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare;

• EPA guidance on cultural competence training;

• EPA guidance on the early intervention in clinical high-risk states of psychoses;

• EPA guidance on the role and responsibilities of psychiatrists;

• EPA guidance on how to improve the image of psychiatry and of the psychiatrist.

Further issues are planned and will be published under the leadership of the EPA guidance committee, which was selected by the president and the president-elect of the EPA and was confirmed by its board. The plan will be to publish one issue of guidance papers per year on the occasion of the annual EPA congress.

The guidance papers will have relevance for the continuous development of European gold standards in care, prevention, education and ethics. These documents can be locally adapted and take into consideration the geographical, cultural and economic specificities of the European region. Thirty-six European National Psychiatric Associations (NPAs), which represent over 77,000 psychiatrists, are an important target group for the EPAs guidance papers.

They should be systematically disseminated and used in different educational activities. The systematic use of the guidance papers, translated into local languages by National Psychiatric Associations, will contribute to the further progress in clinical practice, research, education and uphold to the proud traditions of European Psychiatry.

To improve the quality and relevance of future guidance papers the EPA guidance committee has developed the following recommendations:

• the proposed topic of a guidance document must be approved by the EPA guidance committee and the EPA board;

• guidance papers should be prepared by collaboration of all authors and should be agreed and supported by all relevant stakeholders including the EPA board and the guidance committee;

• the authorship should be a reasonable representation of European psychiatric experts in the area – psychiatrists and experts from relevant disciplines from inside and outside the EPA membership. It is advisable to get the support of the EPA Council of National Psychiatric Associations (NPA) to identify national experts;

• the authors of guidance papers should be experts in their field, they should represent the variety of psychiatric services in Europe, and should be supported by a relevant number of European NPAs;

• depending on the topic, relevant European stakeholders and patient organisations should be actively involved in the development of the guidance recommendations;

• there may be two types of authors:

  • ○ principal authors who worked to produce the guidance paper and made the most significant direct contribution to the production of the guidance manuscript,

  • ○ contributing authors who are members of the guidance group and will have provided significant comments and approval (which is important in these type of documents). The latter should be listed in the authors list as “EPA guidance group on <guidance name>” (e.g. EPA guidance group on ethics in publishing) under the manuscript title and their individual names and affiliations should appear in full in the acknowledgments;

• all authors must be actively involved in the guidance development from the start. All authors must disclose potential conflicts of interest;

• the paper must be structured in the form of a review, with abstract, keywords, introduction, methods, results, and discussion. All methods used to develop the guidance paper including the literature research, the literature extraction, the grading, evaluation and interpretation of information, the development of the agreed guidance and the procedures to reach consent within the group of authors must be comprehensively and transparently described in the paper;

• guidance papers should be evidence-based on a systematic review or meta-analysis of the available and relevant literature. The extraction of information from the literature must be systematic, transparent and comprehensively documented. The results of the literature search, extraction and evidence grading should be presented in tabular form;

• the methods used to develop and grade guidance recommendations must be clear, reasonable and reproducible and must follow international guidelines:

  • ○ it is recommended that the guidance development group uses published guidelines/recommendations for the development of guidance papers such as SIGN [13] or AMWF [6],

  • ○ we are aware that there are other published recommendations that may be equally suited for the development of individual guidance papers. However, we are not aware about any type of guideline for the development of clinical guidance which has shown its superiority over all others, consequently, this leaves some freedom of choice by the authors to select the most appropriate one for their specific needs;

• the grading of evidence must follow international rules. The consensus finding on grading the evidence among the authors should be systematic and follow international rules (e.g. [13]);

• gaps in the availability of the relevant literature must be addressed;

• systematic consents may replace the lack of the available evidence basis;

• the final version of the guidance document must be supported by the EPA guidance committee and the EPA board before being externally reviewed;

• finally, all guidance papers will be submitted to the usual comprehensive external review process as all papers published in European Psychiatry. The guidance document must be successfully reviewed in line with the usual procedures of European Psychiatry.

Recent recommendations for the development of evidence-based guidelines have focused on the quality of the review recommendations and stressed the importance that reviews and meta-analyses should be based on high quality assessment of the literature to avoid different types of bias [1]. As a consequence quality criteria for reviews and meta-analyses have been developed, e.g. Assessment of Multiple Systematic Reviews (AMSTAR) [9,14], Expanding the Grading of Recommendations Assessment, Development, and Evaluation for Evidence-Based Clinical Recommendations (Ex-GRADE) [11], and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [10]. Authors may thus find it helpful to refer to these criteria.

There is sufficient evidence to assume that guidance based on systematic analysis of the literature is of superior quality in comparison with narrative based reviews based on selected papers only, as the comprehensive selection and information extraction of all relevant papers reduces the risk of a selection and awareness bias [2]. Saltman et al. [12] emphasize the importance of distillation, interpretation and synthesis of information to assist clinicians, they underscore the importance of standardised approaches to include adverse events, incidence of harm, patient's needs and preferences and clinician's expertise and discretion in reviews. However, they question the utility of evidence-based approaches as a uni-dimensional approach to improving clinical care. In agreement, Greenhalgh et al. [7] raise relevant criticism about the failures and more importantly about the limitations of evidence-based medicine.

Best clinical practice is based on evidence as well as experience. Consequently, guidance should be based on systematic reviews and meta-analyses, but it may also be necessary to go beyond what the current evidence-base can provide. If there is no published evidence for any literature-based recommendations, other experience based information may be used providing that the methods to reach the guidance is well documented and follows common recommendations (e.g. [6,13]).

Consequently, the final EPA guidance papers should follow the guideline development recommendations as much as possible, but should also keep their originality and their focus on new questions and new answers at the forefront of scientific research and clinical practice, but must make sure that the development of their guidance is comprehensive, open and transparent.