EKS® - Expert Consensus Guidelines®

How often have you wished that there was an expert on hand to advise you about how best to help a patient who is not responding well to treatment or is having a serious complication? Unfortunately, an expert is usually not at hand and, even if a consultation were available, how would you know that any one expert opinion represents the best judgment of our entire field? This is why we began the Expert Consensus Guidelines® Series. Our practical clinical guidelines for treating the major mental disorders are based on a wide survey of the best expert opinion and are meant to be of immediate help to you in your everyday clinical work.

How do the Expert Consensus Guidelines® relate to (and differ from) other guidelines that are already available?

Each of our guidelines builds upon existing guidelines but goes beyond them in a number of ways:

1. We focus our questions on the most specific and crucial treatment decisions for which detailed recommendations are usually not made in the more generic guidelines that are currently available.
2. We survey the opinions of a large number of the leading experts in each field and have achieved a remarkably high rate of survey response (at least over 85%), ensuring that our recommendations are authoritative and represent the best in current expert opinion.
3. We report the experts responses to each question in a detailed and quantified way (but one that is easy to understand) so that you can evaluate the relative strength of expert opinion supporting the guideline recommendations.
4. The guidelines are presented in a simple format. It is easy to find where each patient's problem fits in and what the experts would suggest you do next.

Why should we base treatment decisions on expert consensus instead of relevant treatment studies in the research literature and evidence-based guidelines?

There are three reasons why expert consensus remains an important addition:

1. Most research studies are difficult to generalize to everyday clinical practice. The typical patient who causes us the most concern usually presents with comorbid disorders, has not responded to previous treatment efforts, and/or requires a number of different treatments delivered in combination or sequentially. Such individuals are almost universally excluded from clinical trials. We need practice guidelines for help with those patients who would not meet the narrow selection criteria used in most research studies.
2. The available controlled research studies do not, and cannot possibly, address all the variations and contingencies that arise in clinical practice. Expert-generated guidelines are needed because clinical practice is so complicated that it is constantly generating far too many questions for the clinical research literature to ever answer comprehensively with systematic studies.
3. Changes in the accepted best clinical practice often occur at a much faster rate than the necessarily slower-paced research efforts that would eventually provide scientific documentation for the change. As new treatments become available, clinicians often find them to be superior for indications that go beyond the narrower indications supported by the available controlled research.

For all these reasons, the aggregation of expert opinion is a crucial bridge between the clinical research literature and clinical practice.

How valid are the expert opinions provided in these guidelines, and how much can I trust the recommendations?

We should be better able to answer this question when our current research projects on guideline implementation are completed.For now, the honest answer is that we simply don't know. Expert opinion must always be subject to the corrections provided by the advance of science. Moreover, precisely because we asked the experts about the most difficult questions facing you in clinical practice, many of their recommendations must inevitably be based on incomplete research information and may have to be revised as we learn more. Despite this, the aggregation of the universe of expert opinion is often the best tool we have to develop guideline recommendations. Certainly the quantification of the opinions of a large number of experts is likely to be much more trustworthy than the opinions of any small group of experts or of any single person.

Why should I use treatment guidelines?

First, no matter how skillful or artful any of us may be, there are frequent occasions when we feel the need for expert guidance and external validation of our clinical experience. Second, our field is becoming standardized at an ever more rapid pace. The only question is, who will be setting the standards? We believe that practice guidelines should be based on the very best in clinical and research opinion. Otherwise, they will be dominated by other less clinical and less scientific goals (e.g., pure cost reduction, bureaucratic simplicity). Third, it should be of some comfort to anyone concerned about losing clinical art under the avalanche of guidelines that the complex specificity of clinical practice will always require close attention to the individual clinical situation. Guidelines can provide useful information but are never a substitute for good clinical judgment and common sense.

Our guidelines are already being used throughout the country and seem to be helpful not only to clinicians but also to policy makers, administrators, case managers, mental health educators, patient advocates, and clinical and health services researchers. Ultimately, of course, the purpose of this whole enterprise is to do whatever we can to improve the lives of our patients. It is our hope that the expert advice provided in these guidelines will make our treatments ever more specific and effective.