Guidelines, Tramlines, and Faultlines

It would be irrational to want our health care providers to practice in accordance with anything other than the best possible evidence. Given this, it seems entirely sensible to have expert panels regularly assess the current state of the controlled trial evidence for particular treatment options and codify these assessments in guidelines. If these panels are independent, this is surely a good mechanism to ensure that clinicians' practice will be relatively independent of drug company blandishments. We might be able to depend on such a bolster against commercial pressure-if the clinical trials being conducted were genuine scientific exercises and were being reported transparently and honestly. However, recent developments in even independent guidelines raise the prospect that the pharmaceutical industry has captured the guideline process and is using it as a mechanism to gain and control markets. This article aims at bringing out the key issues by considering recent National Institute of Clinical Excellence (NICE) guidelines for pediatric depression and bipolar disorder, and the difficulties such guidelines can pose in certain settings.