Persons AND colleagues1 have raised some intriguing, provocative, and clinically important issues in their review and critique of two clinical practice guidelines: one by the Agency for Health Care Policy and Research (AHCPR),2, 3 aimed at primary care (PC) practitioners, and the second by the American Psychiatric Association (APA),4 directed toward psychiatrists. In essence, Persons et al find a greater basis for recommending psychotherapy alone as a treatment for major depressive disorder, and they view the stronger call for combined treatment (medication and psychotherapy) by the APA as lacking empirical support. They make several recommendations for subsequent guideline development (eg, multidisciplinary panels, comments on cost, highest reliance on randomized controlled trials [RCTs], periodic revisions, etc).
The following comments, intended to be explanatory rather than in defense of, in particular, the AHCPR guidelines, focus on the philosophical basis underpinning the development and use of clinical practice guidelines. Assumptions made