Published: 20/06/2002, Volume II2, No.5810 Page 24 25

Evidence? NICE is all for it - That is exactly why It is provided

You suggest (comment, 7 June) that National Institute for Clinical Excellence guidance should contain an audit trail so that those who use it can see how our independent advisory committees reach their conclusions. I agree, which is why each of our technology appraisals sets out a clear summary of the evidence and contains a consideration section that explains how the evidence has been interpreted.

In addition we publish on our website the independent assessment made of the worldwide literature, which is prepared by an academic group commissioned by NHS Research and Development.

This assessment report, combined with submissions from professionals and patient groups and the results of consultation, are used to inform the committee's decisions.

Our appraisal of the atypical antipsychotics, used in the treatment of schizophrenia (news, page 4) is a balanced assessment of the therapeutic value of these medicines and positions their use carefully in the management of this condition.

They are more expensive than the existing 'typical' antipsychotics, but for patients in whom these older drugs produce unacceptable sideeffects, they are an alternative which the NHS should offer.

It takes us about a year to complete our appraisals. We spend about eight months gathering and assembling the evidence and the remaining four months interpreting it and consulting on our conclusions. It is a good process, supported by a sound methodology. Those wishing to follow and provide comment on appraisals in progress can do so through our website. And we are always willing to listen to suggestions as to how the way we work can be improved.

Andrew Dillon Chief executive National Institute for Clinical Excellence andrew. dillon@nice. nhs. uk

Right decision that took too long

I never thought I would jump to the defence of NICE (comment, 7 June). This issue is one of the most pressing on its agenda, and I would criticise it only for taking so long to come up with the recommendations, which have been obvious for the past five years to all who work in mental health. The only factor that has delayed this guidance is money.

The evidence is not 'thin'.

Hundreds of thousands of service users out there will tell you which drugs they think are most effective and best tolerated.

I accept that this is not goldstandard randomised controlled trial (RCT) evidence, but there is evidence that RCT methodology does not suit research into mental health, where outcomes are less clear cut and assessments more likely to be skewed by subjective, rather intangible, factors.

Mental health is one area of research where the user voice must prevail. Give a room full of health economic decisionmakers the choice between a dose of haloperidol (traditional) and a dose of olanzapine (atypical): you'll be killed in the rush for the latter.

Gary Sweeney GP and mental health and clinical governance lead Tendring primary care trust

Shakes, spasms and other side-effects are good enough reason for newer treatment

I am delighted that the atypical antipsychotic drugs have the NICE green light. It means that we in the community mental health teams have a stronger mandate to tackle the difficult seriously mentally ill and their problems in the community.

We stand a better chance of keeping them away from the wards and relapse, avoiding the deterioration that often happens with that process. We stand a better chance of 'selling' these drugs as a going concern to our clients. They may be ill but they are not stupid, and clients have always been reticent about taking the older drugs, with their shakes, spasms and other horrible side-effects. Would you commit yourself to a drug on a long-term basis that could easily ruin your successful sex life?

The other point not to miss is the importance of trained community staff, especially community psychiatric nurses, who are equipped to tackle the challenge presented in the national service framework. The newer methods of treating the severely mentally ill in the community, especially the psychosocial interventions model, enable a more caring approach. But be under no illusions: it will be more labourintensive. The preponderance of the older drug use was in depot injection form, often meaning that the nurse contact would be short and two to four-weekly.

We should anticipate care being more intensive and frequent.

The other big challenge is compliance. Even with better drugs uniformly available, this is a major issue with the severely mentally ill. With the old drugs often used in depot form, compliance was easier to affirm.

So far none of the new drugs is in depot form, leaving compliance more fluid. Patients could change their minds and seriously affect the therapeutic levels of the drug in their system within days.

If changing to a more labourintensive system achieves a more humane and caring consensual management of the illnesses of this sector of society, I am for it.

Depots have always been blunt instruments, and there has always been a feeling of enforcing 'stability' upon the client.

The care of the severely mentally ill is in a period of massive change, and we should be aware of the ramifications for the staffing levels in community mental health teams. We should address staff levels and retraining in an essentially different approach to treating our clients.

Terry Cawser, Leicester