Disparities in the development and implementation ofguidelines for the management of depression in adults

A systematic review of evidence from high- vs. low- and middle-income countries

Yena Leeon behalf of the GACD Mental Health Guidelines Working Group:

Elisa Brietzke, Bing Cao, Yan Chen, Outi Linnaranta, Rodrigo B. Mansur, Paulina Cortes, Markus Kosters, Amna Majeed,Jocelyn K. Tamura, Leanna M. W. Lui, Maj Vinberg, Jaakko Keinanen, Steve Kisely, Sadiq Naveed, Corrado Barbui,

Mayowa Owolabi, Daisuke Nishi, JungGoo Lee, Manit Srisurapanont, Hartej Gill, Lan Guo, Vicent Balanza-Martınez, TimoPartonen, Willem A. Nolen, Jae-Hon Lee, Ji Hwan Kim, Niels H. Chavannes, Tatjana Ewais, Beatriz Atienza-Carbonell,Anna V. Silven, Naonori Yasuma, Andrey Novikov, Artyom Gil, Cameron Lacey, Anke Versluis, Sofia von Malortie, Lai

Fong Chan, Ahmed Waqas, Marianna Purgato, Jiska Aardoom, Josefina T. Ly-Uson, Kang Sim, Maria Tuineag, Riannevan der Kleij, Sanne van Luenen, Sirijit Suttajit, Tomas Hajek, Yu Wei Lee, Gary Parker, Richard J. Porter, Mohammad

Alsuwaidan, Roger S. McIntyre

Institute of Medical Science, University of Toronto;Mood Disorders Psychopharmacology Unit, Toronto Western Hospital,

University Health Network, Toronto, ON, Canada

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 1 / 10

About the Working Group (Nov. 2018 – Present)

>50 collaborators in 30 countries (>25 languages)

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 2 / 10

Project Objectives

Clinical practice guidelines (CPGs) aim to support clinical decision making,standardize care, improve health outcomes, and reduce cost.

To characterize the development and implementation of

CPGs for the management of depressionin adults with major depressive or bipolar disorder.

To compare CPGs from high- and low/middle-income countries onmeasures of:

Guideline availabilityDevelopment process qualityTranslatabilityImplementabilityApplication monitoring

Systematic review registration: PROSPERO CRD42019124759Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 3 / 10

Availability of CPGs for Depression

94 national and international CPGs in 26 languages from 82 countries

Many LMICs, especially in Africa, lack CPGs

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 4 / 10

Target Populations and Users

51 MDD, 33 BD

Most CPGs target psychiatrists (81%) or primary care providers (68%)

Fewer CPGs target policymakers (20%) or payers (14%)

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Psychiatrists

PrimaryCare

Providers

OtherSpecialists

Psychologists

Nurses

Patients

PolicyMakers

Payers

0 20 40 60

# of Guidelines

Income Classification

HIC

UMIC

LM/LIC

International

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 5 / 10

Guideline Scope and Intent

15 CPGs provide work-related decision support: continue workingunless otherwise indicated, measure impairment, consult resources

50 CPGs recommend and 6 recommend against depression screening

CardiometabolicComorbidities

PsychiatricComorbidities

Screening

PrimaryPrevention

Work−relatedDecisionSupport

0 25 50 75 100

% of Guidelines

Income Classification

HIC

UMIC

LM/LIC

International

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 6 / 10

Quality of Guideline Development Processes

26% of CPGs for depression developed by multidisciplinary group

vs 64% in diabetes mellitus, 52% in hypertension (Owolabi et al., 2016; 2018)

54% openly declared funding sources and COIs

0

2

4

6

8

40 60 80

Healthcare Access and Quality Index [Median]

# o

f Io

M S

tandard

s M

et [M

edia

n]

Income Classification HIC UMIC LM/LIC

Transparency*, 60%

COI Management*, 62%

Multidisciplinary* DG, 38%

Systematic Review*, 71%

Grading Strength*, 47%

Clarity, 76%

External Review*, 50%Updating, 48%

27%27%

9%

41%

23%

59%

23%

36%33%33%

0%0%0%

33%

0%0%

HICsHICsHICsHICsHICsHICsHICsHICs UMICsUMICsUMICsUMICsUMICsUMICsUMICsUMICs LM/LICsLM/LICsLM/LICsLM/LICsLM/LICsLM/LICsLM/LICsLM/LICs

0

20

40

60

80

% o

f G

uid

elin

es

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Guideline Translatability and Implementability

66% of CPGs informed by systematic review of intervention efficacyonly 26% evaluated enablers and barriers to CPG implementation22% evaluated patient preferences

35% operationalized criteria for monitoring CPG application

16% plan to assess CPG adherence and/or quality indicators

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0

20

40

60

AuthorCredibility

Implem−entation

Tool

Ethical SocialLegal EconomicEaseof

Use

ResourceImplications

PatientPref−

erences

Enablers&

Barriers

Effect−iveness

Surv−eillance

# o

f G

uid

elin

es

HIC

UMIC

LM/LIC

International

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Conclusions

Globally, the implementation of CPGs is inadequately planned,reported, and measured.

To what extent CPGs are acceptable to patients and target users,feasible, and cost-effective and improve health outcomes remainsunknown.

Refinement of decision support processes in depression is a criticalfirst step towards the aim of reducing morbidity, especially in low- andmiddle-income countries.

Future guidelines should present strategies to implementrecommendations and measure feasibility, cost-effectiveness, andimpact on health outcomes, co-designed by stakeholders andexperiential knowledge experts from low- and middle-income

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Acknowledgements

GACD Mental Health Guidelines Working Group: Elisa Brietzke, Bing Cao,Yan Chen, Outi Linnaranta, Rodrigo B. Mansur, Paulina Cortes, MarkusKosters, Amna Majeed, Jocelyn K. Tamura, Leanna M. W. Lui, MajVinberg, Jaakko Keinanen, Steve Kisely, Sadiq Naveed, Corrado Barbui,Mayowa Owolabi, Daisuke Nishi, JungGoo Lee, Manit Srisurapanont,Hartej Gill, Lan Guo, Vicent Balanza-Martınez, Timo Partonen, Willem A.Nolen, Jae-Hon Lee, Ji Hwan Kim, Niels H. Chavannes, Tatjana Ewais,Beatriz Atienza-Carbonell, Anna V. Silven, Naonori Yasuma, AndreyNovikov, Artyom Gil, Cameron Lacey, Anke Versluis, Sofia von Malortie,Lai Fong Chan, Ahmed Waqas, Marianna Purgato, Jiska Aardoom,Josefina T. Ly-Uson, Kang Sim, Maria Tuineag, Rianne van der Kleij,Sanne van Luenen, Sirijit Suttajit, Tomas Hajek, Yu Wei Lee, Gary Parker,Richard J. Porter, Mohammad Alsuwaidan, Roger S. McIntyre

Yena Lee Mental Health Guidelines Working Group GACD Annual Meeting 10 / 10