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Mental Health
Treating schizophrenia: the quality of evidence behind treatment recommendations and how it can improve
  1. Greg Aran1,2,
  2. Chandler Hicks1,2,
  3. Alexander Demand1,2,
  4. Austin L Johnson1,
  5. Jason Beaman2,3,
  6. Yakiji Bailey2,
  7. Melissa Haught2,
  8. Aaron Lane2,
  9. Philip Sinnett2,
  10. Matt Vassar1
  1. 1 Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
  2. 2 Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
  3. 3 Department of Psychiatry, Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
  1. Correspondence to Austin L Johnson, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA; austin.johnson14{at}


Objective To assess the methodological and reporting quality of systematic reviews that comprise the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients with Schizophrenia and to determine the extent to which results from Cochrane systematic reviews published after guideline development would alter or confirm current recommendations.

Participants Systematic reviews that underpinned recommendations in the APA guidelines and Cochrane systematic reviews.

Main outcome Three independent reviewers scored all systematic reviews referenced in the guideline for quality and reporting using AMSTAR and PRISMA checklist, respectively. Items in both tools were individually graded and compared to identify consistently low-performing areas within the systematic reviews. Post hoc analysis of the Cochrane systematic reviews since the latest revision of APA’s guidelines were performed to determine whether their findings were congruent with recent recommendations.

Results The mean score of the 57 reviews on the PRISMA checklist was 70%. The mean AMSTAR score was 6.8, correlating with a moderate quality score. Post hoc analysis revealed that 171 Cochrane reviews had been published since the APA guideline release. Only half of the reviews of pharmacological interventions confirmed current recommendations.

Conclusions and relevance The methodological quality of the systematic reviews included in the APA guideline was deficient in key areas. Our study brings to light the importance of using high-quality evidence in the development of clinical practice guidelines. An updated APA guideline (last updated in 2009) is necessary to provide the highest quality treatment recommendations for clinicians in the management of schizophrenia.

Trial registration number UMIN-CTR, UMIN000023099.

  • guidelines
  • schizophrenia
  • systematic reviews
  • cochrane
  • american psychiatry association

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  • Contributors GA: data curation, formal analysis, investigation, methodology, writing—original draft, writing—review and editing. CH: data curation, formal analysis, investigation, writing—review and editing. AD—data curation, formal analysis, investigation, writing—review and editing. ALJ: investigation, methodology, writing—review and editing, corresponding author. JB: conceptualisation, supervision, writing—review and editing. YB: data curation, formal analysis, investigation, writing—review and editing. MH: supervision, writing—review and editing. AL: supervision, writing—review and editing. PS—conceptualisation, investigation, writing—review and editing. MV: conceptualisation, project administration, supervision, writing—review and editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are publicly available on figshare.