Practice Guidelines

Comprehensive Guidelines for Treating PANS/PANDAS

An expert panel of clinicians and researchers has published comprehensive guidelines for treatment of Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS).  PANS/PANDAS is characterized by an unusually abrupt onset of obsessive-compulsive disorder (OCD) symptoms and/or severe eating restrictions in children, along with secondary behavioral, cognitive, and/or neurological symptoms. This syndrome is believed to result from a range of triggers, though studies have shown that autoimmune problems and/or neuroinflammation drive the illness in most cases.

Accordingly, the treatment guidelines, published in the Journal of Child and Adolescent Psychopharmacology, are divided into three clinical focus areas:

  1. Psychiatric and behavioral interventions to address obsessive-compulsive symptoms, eating restrictions, anxiety, irritability, and more.
  2. Immunomodulatory therapies that target the neuroinflammation and post-infectious autoimmunity commonly seen in PANS/PANDAS.
  3. Treatment and prevention of the streptococcal and other infections that underlie these neuropsychiatric conditions.

Clinical evidence suggests that depression, anxiety, OCD, and other behavioral symptoms of PANS/PANDAS respond to the same medications used to treat these disorders in the general population. However, some reports also suggest that PANS/PANDAS patients may be more sensitive to adverse effects of psychotropic medications such as agitation or dystonia, the authors noted in the psychiatric guidelines (part I).  Therefore, clinicians are advised to initiate with dosages no more than one-quarter the normal amount and slowly titer upwards. Benzodiazepines are also considered first-line treatments for PANS/PANDAS as anxiety, agitation, aggression, and insomnia are common symptoms, but clinicians and parents should be aware of the risk of disinhibition following benzodiazepine treatment in pediatric patients.

From July 24, 2017 Psychiatric News Alert

Updated Quality Care Measures for Dementia

A joint work group of the APA and the American Academy of Neurology has updated the quality measures for the care of patients with dementia to encourage physicians to disclose the diagnosis to patients and their caregivers. The updated quality care measures were published online May 1 in the American Journal of Psychiatry.  A summary is also available.

Guideline on Pharmacologic Treatment for Insomnia

This American Academy of Sleep Medicine clinical practice guideline published in 2017 reflects a comprehensive, evidence-based analysis of individual pharmacotherapy commonly used to treat people experiencing persistent trouble falling asleep and staying asleep.   The guideline offers recommendations on whether clinicians should or should not use specific medications for sleep-onset insomnia and/or sleep maintenance insomnia in adults versus no treatment, based on current published evidence.

New Practice Guidelines on the Use of Antipsychotics in Patients with Dementia

In May 2016, the APA released new evidence-based guidelines on the use of antipsychotics to treat agitation or psychosis in patients with dementia. The guidelines include recommendations for assessment of dementia, development of a comprehensive treatment plan, assessment of the benefits and risks of antipsychotics, and judicious use of antipsychotics, including specifics for dosing, duration and monitoring. See the Executive Summary in the May issue of The American Journal of Psychiatry and the full guideline.

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Announced in March 2016, this guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy.  The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use.  The CDC also provided a checklist for prescribing opioids for chronic pain, as well as a website with additional tools to guide clinicians in implementing the recommendations.

In February 2016, the American College of Physicians released a new clinical practice guideline on the treatment of depression.

New Practice Guideline on Opioid Use Disorders

The American Society of Addiction Medicine has released a national practice guideline on the use of medications to treat opioid use disorders. The guideline was created in response to the rapid increase in recent years in the number of people misusing and overdosing on morphine and other opioids (both prescription and non-prescription).  The guideline provides specific and evidence-based guidance on selecting the best treatments for opioid use disorders. It also discusses the importance of pairing any pharmacological treatment of opioid use disorder with psychosocial treatment and includes recommendations for patient populations with special needs, such as those with comorbid psychiatric disorders.  The APA’s Practice Guideline on Substance Use Disorders also includes a section on managing opioid use disorders.

New Edition of APA Practice Guidelines for Evaluation of Adults

Published in late July 2015, these guidelines address nine topics, in the context of an initial psychiatric evaluation: review of psychiatric symptoms, trauma history, and treatment history, substance use assessment, assessment of suicide risk, assessment for risk of aggressive behaviors, assessment of cultural factors, assessment of medical health, quantitative assessment, involvement of the patient in treatment decision making, and documentation of the psychiatric evaluation.  Each guideline suggests topics to include during an initial psychiatric evaluation and provides guidance on enhancing patient care.  An expert opinion survey and available evidence on psychiatric evaluation were considered in development.  The guidelines are available online, as well as for sale in print.  Visit http://psychiatryonline.org/guidelines.

APA Guideline Watch for Alzheimer’s and Other Dementias

The APA has released a Guideline Watch for the 2007 “Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias.” The guideline watch summarizes new evidence and developments since the publication of the practice guideline.  The reviewers of the latest clinical research in the field found that “new studies have changed the strength of evidence supporting some of the recommendations in the 2007 guideline; however, … the recommendations remain substantially correct and current.” The new information highlighted in the watch better defines the risks and adverse effects of some medications used in treatment, which will help clinicians make better decisions for individual patients.

For more information on APA practice guidelines please click here.