The development of multidisciplinary guidelines was triggered by the observation that monodisciplinary guidelines disagree on essential features of the treatment of patients with a depressive disorder.
The disciplines decided to bring together their bodies of knowledge in the hope of developing an integrated guideline. The traditional consensus-based methodology seemed inappropriate to bridge the gap between the disciplines. The more recent evidence-based methodology of developing guidelines offered one important advantage: it created the possibility to compare interventions using an independent and objective vocabulary. The different levels of evidence were used as a first criterion, suggesting that the results of scientific research could solve old controversies. This, of course, was naive.
The recognition of different goals
The problem with monodisciplinary guidelines has moved the discussion to what disciplines have in common. Indeed psychiatrists, psychotherapists, GPs, psychologists, social workers and social psychiatric nurses sometimes offer the same interventions, such as brief psychotherapy, problem solving, bibliotherapy, counselling, etc. Even if drug treatment is reserved to doctors, other disciplines also have some knowledge about it. All these interventions are aimed at reducing complaints and are most likely prescribed in the first or second phase of the treatment process. The monodisciplinary guidelines focused on that phase and those interventions, and it was there that disagreement came to light. Because all those interventions more or less shared the same objectives, it was clear that research outcomes could help in solving the controversies. The EBM paradigm offered a useful basis for the development of new multidisciplinary guidelines.
Disciplines in mental health care, however, do more than reduce complaints. Many interventions have other goals. For example, psychiatric nurses who support the patient during admission carry out interventions directed towards the creation of a context in which improvement becomes possible: helping the patient to get up in the morning, to have his breakfast, to attend different therapies, to resolve conflicts with his family, to realise how his behaviour is reinforcing feelings of misery, etc. In general, it is safe to say that as the psychopathology becomes more complex, so does the care process. Accordingly, that process gradually loses its firm orientation towards symptom reduction.
The recognition of different goals sheds another light on the problems mentioned earlier. The best method to achieve more order in the amalgam of interventions is not to compare interventions as regards their level of evidence but, first and foremost, to compare their goals. This first step seems easy to realise: if disciplines know what they are doing, they can describe why they are doing so. Unfortunately, professional work is not always as transparent as that. Reflective practitioners are needed to draw up guidelines [22
]. Moreover, it should be noted that setting intervention objectives can be a highly complex process. The more discretely an intervention can be described, the easier it is to identify and define its purpose. However, as mentioned earlier, many activities in mental health care cannot easily be described as discrete interventions. Clinical care comprises a variety of activities; at first glance the grouping of activities into interventions seems more or less arbitrary. It emerges that disciplines differ considerably in their experience and tradition of describing interventions and setting goals. Disciplines that mainly involve diagnostic and healing tasks generally have fewer problems in defining their goals then disciplines that involve more care tasks. Similar differences exist between the more medical and the more social disciplines. Psychiatric nurses have more experience with this process than social workers or group leaders (pedagogic workers).
The next step in guideline development should be to establish a taxonomy of goals. Interventions should be catalogued: for each intervention goals should be made more explicit. As most interventions can probably be used to reach several goals, a distinction should be made between primary and secondary goals. The challenge then is to construct a taxonomy of goals that is independent of the specific vocabularies of disciplines. It is not clear whether such a taxonomy exists, or indeed whether it can be developed. Goals are related to the way problems are perceived and defined. The literature shows that definitions of problems are essential features of the specific disciplinary bodies of knowledge [23
]. As long as disciplines, in the process of making care objectives explicit, adhere only to their own bodies of knowledge, the development of a multidisciplinary guideline will remain difficult. Even so, this does not preclude a multidisciplinary taxonomy. Multidisciplinary taxonomies do exist; one example is the DSM. It is unlikely, however, that the DSM could also be used for the classification of goals, because it has the disadvantage of reducing problems to complaints and disorders. As a result, goals would then too easily be reduced to symptom reduction.
Let us consider in more detail the possibilities of international classification as proposed by the WHO.
The International Classification of Functioning
In 2002, the World Health Organization (WHO) published an International Classification of Functioning, Disability and Health (ICF) [24
]. The ICF is not a ready-made instrument to classify disorders, but it can help to describe human functioning and health problems in relation to external and personal factors. The ICF offers possibilities for combining taxonomies of disorders, such as the DSM, with taxonomies of disabilities, levels of social functioning, etc.
The anxiety disorders working group has applied the ICF to the care process for patients that suffer from anxiety disorders, and has described the various goals of that process [13
]. Four different components are distinguished: disorder, disability, participation, and inhibiting factors. Within each component, different categories are identified. The ‘disorder’ component is divided into mental functions, psychomotor functions and cognitive functions. The ‘disability’ component comprises four categories: communication, self-care, housekeeping, interactions, and social relations. Next, the working group fixed the desired results (intervention objectives) for each component or category. The objective for the ‘disorder’ component, for instance, is to reduce symptoms, the objective for the ‘self-care’ category is to achieve an adequate level of daily self-care. Finally, the working group identified the interventions that claim to lead to the attainment of such goals. For example, for symptom reduction they identified the following interventions: psycho-education, cognitive behavioural therapy, drug treatment, combination treatment, supportive interventions, relaxation therapy and, finally, movement therapy. Sociotherapy is mentioned for adequate daily self-care.
The ICF taxonomy elaborated by the anxiety disorders working group seems promising. It offers a framework for the classification of interventions, with reference mainly to goals, and also offers perspectives for the development of guidelines. But, the proof of the pudding is in the eating. Other working groups are likely to opt for different frameworks. In each case a framework is needed to determine the intervention objectives. Classification is necessary in order to compare interventions. In the development of guidelines, it is only in this phase that a comparison between interventions becomes fruitful. Once agreement has been reached on a taxonomy of goals and interventions have been classified, it is possible to proceed to comparing interventions that share the same goals. Obviously, in that phase levels of evidence can be used as a standard for comparison.
Towards a hierarchy of goals
Guidelines should describe interventions and their goals, and indicate which interventions are suitable for achieving a specific goal. In this paragraph, we will argue that guidelines should also deal with the question of how to determine appropriate goals during the treatment process.
Why not leave the choice to the patient himself? After a diagnosis, caregivers could present a taxonomy of goals and explain to the patient how these different goals could be realised. The patient could then opt for a specific goal, and the guideline would prescribe the appropriate interventions to achieve it. Even if this idea sounds sympathetic to the patient, it is slightly nanve. Some goals are inherently difficult to achieve, others are only attainable after other goals have been achieved. This means that at least some professional knowledge is required. Caregivers and patients should jointly select the goals for treatment. Given that professionals always have the final responsibility for the treatment they offer, it is their task to determine the treatment goals together with their patients. However, this is not to say that the guidelines should leave the selection of goals totally open. Guidelines should support professionals and patients in their selection of specific goals.
Other solutions are conceivable. For instance, multidisciplinary guidelines could leave room for regional or institutional preferences. Another possibility is to leave the job to monodisciplinary guidelines. However, these solutions, too, would fail to incorporate the real choices into the guidelines. What is needed, therefore, is a hierarchy of goals.
A vision of the care process
Multidisciplinary guidelines should combine the evidence, the collective sense of profession and a vision of the care process, i.e. a hierarchy of goals. A guideline should indicate which goals need to be realised first, what comes next, and how to handle complex interactions between different interventions.
Although several models for the care process are available, in the Dutch mental health care sector we see an increasing interest in the principles of stepped care. Stepped care provides a framework for the care of patients that uses limited resources to their greatest effect on a population basis. In stepped care, the intensity of professional care is augmented for patients who do not achieve an acceptable outcome with lower levels of care [25
]. Stepped care proposes to opt first for the less intrusive forms of care that offer a chance of success. Only if these do not lead to improvement, more intrusive care is prescribed. In other words: the first step is to choose the intervention that is most effective in facilitating the patient's capacity to cope. Stepped care maximises the patient's autonomy and empowerment.
The stepped care model offers several advantages. First, it provides clear criteria for choosing among interventions that are equally effective. Second, it can be used to construct a hierarchy of goals. presents an example of such a hierarchy.
A stepped care model for mental health care.
The hierarchy proposed is constructed on the basis of evidence in combination with a judgement on the level of intrusiveness. In the absence of clear-cut contraindications (crisis, psychosis, etc.), the first step is a psychosocial intervention (re-labelling the context, problem solving psycho-education, watchful waiting, etc.), which should take no more than a few weeks. If after this period no amelioration can be observed, the patient is guided towards the second step, which focuses on the reduction of symptoms. Common methods are drug treatment, cognitive behavioural therapy, interpersonal therapy, etc. The second step takes three months or less, and after this period the complaints should have subsided. If the problems persist, the patient is referred to the third step, where the interventions are directed towards the transformation of adaptation mechanisms. Psychodynamic psychotherapy, partner relation therapy and experiential therapy are examples of this type of intervention. The third step tends to take a fair amount of time. The fourth step provides a combination of the first three steps, and is generally offered in specialised transmural care centres. These centres have two points of entry: from the third step, or from a crisis intervention stage. If the fourth step is not successful either, it is sometimes possible to refer the patient to a fifth step in the form of specialised top referent care.
Each step is characterised by a unique set of goals, to be realised by several interventions. These interventions can subsequently be compared as regards their level of evidence. Sometimes we do have some additional evidence concerning their order in the treatment process (within the same step). For example, drug treatment should precede cognitive behavioural therapy. A guideline based on the principle of stepped care should first present diagnostic criteria for inclusion (What kinds of patients?) and exclusion (Which patients should be directly referred to crisis intervention or specialised care?). Next, the guideline should present the main goals of each step and describe the interventions needed to realise these goals. This should be followed by a description of the available evidence for each intervention, as well as of possible contraindications and (adverse) side effects. Finally, the guideline should give information on how these interventions interrelate. By linking this information to the course of the disease, the guideline can be given the characteristics of a disease management system.