The Maudsley Prescribing Guidelines in Psychiatry, 12th ed

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The Maudsley Prescribing Guidelines in Psychiatry, 12th ed

edited by David Taylor, Carol Paton, and Shitij Kapur. Wiley Blackwell, Oxford, UK, 2015, 741 pages, $90.00 (paper).

The Maudsley Prescribing Guidelines in Psychiatry began in 1994 as an effort to guide the prescribing practices of psychiatrists at the Maudsley Hospital in London. The first production for general distribution came in its fifth edition (1999), and now, in its twelfth edition, the Guidelines has, quite intentionally, readied itself for adaptation outside of the United Kingdom. Whether the broader prescribing community will embrace the Guidelines will depend on whether it is ready for the distinctive approach taken by the Guidelines, one that is without the usual heuristics or anecdote found in the psychopharmacology literature. It purports to provide “just the facts, ma’ am.”

In its introduction, the Guidelines summarizes its aims as to “provide clinicians with practical and useful advice on the prescribing of psychotropic agents in commonly encountered clinical situations” (p xiii). The Guidelines is also explicitly avoidant of theories and models in its approach to psychopharmacology. The atheoretical stance of the book is evident beginning with the table of contents, where one finds that the chapters are not organized by patient demographics, medication class, or even consistently by diagnosis: the chapter “Plasma Level Monitoring of Psychotropic Drugs” is followed by the chapter “Schizophrenia.”

In lieu of theory, Guidelines is structured on a system of pragmatic empiricism. Moving through the chapters, recommendations are based on results from large meta-analyses, randomized controlled trials (RCTs), and consensus guidelines. The consensus guideline portion of the text has a heavy reliance on the National Institute for Health and Care Excellence (NICE) guidelines, a not-so-subtle nod to the origins of the book in the United Kingdom’s national health care system. True to its pragmatic nature, Guidelines also examines the less rigorous tiers of the evidence-based medicine hierarchy, including the case report level, for situations that are insufficiently better-studied (eg, alternatives to oral antidepressant delivery), contentious (eg, herbal and vitamin-based remedies), or frequently treatment refractory (eg, tardive dyskinesia). This literature simply does not figure as heavily as RCTs and the like in the text’s algorithms and summative statements.

Although Guidelines does not claim to be a psychopharmacology textbook, one cannot help but make comparisons. Other popular texts are (often helpfully) guided by mechanistic neurotransmitter schemata, but sometimes take liberties in leaping from what drugs do to how they work and, from there, to how to choose between them. No such attempts are made here. Generally, specific drugs are not matched with subtle phenomenological differences in a particular disorder (eg, atypical depression and melancholic depression are not mentioned). That is to say, there is no “art” of prescribing to be found in the Guidelines. The “science” (more accurately, the practical rules) of prescribing, however, is present in abundance. This is the resource to turn to when trying to determine how, for example, to restart clozapine after missed doses, to convert from oral antipsychotic to long-acting injectables, or to adjust for renal or hepatic impairment.

With its approach, the Guidelines proves to be clinically useful and also accomplishes something larger. It lays out the ground rules for psychotropic prescribing without taking liberties that obfuscate the limits of our evidence. Where the book really excels is not in its distillation of the psychiatric evidence base, but in its ability to maintain a dialectical stance between evidence-based and clinical judgment—even going as far as to suggest that discussion of patients’ preferences is equally essential to responsible medical decision-making as is the use of rigorous empirical methodology. Thus, the Guidelines offers a different and refreshing perspective on prescribing, one that suggests that evidence-based, sometimes algorithmic, practices are possible, but that in situations within, and especially outside, those algorithms, decision-making is in the hands of the provider, sensitive to the patient’s needs and values. It also suggests a more conservative, and perhaps realistic, approach to prescribing than the rampant polyprescribing of today seems to reflect.

James A. Jenkins, MD

Nicholas Kontos, MD

nkontos@partners.org

Author affiliation: Harvard Medical School, Boston, Massachusetts.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2016;77(4):e469

dx.doi.org/10.4088/JCP.16bk10716

© Copyright 2016 Physicians Postgraduate Press, Inc.