Transcript Evidence-Based Psychiatry in clinical care and community

Evidence-Based Psychiatry
in clinical care
and community health
programs and policies
Misconceptions, achievements and future directions
Milos Jenicek
XLIII National Congress
of the Italian Society of Psychiatry
Bologna, October 19-24, 2003
Medicine may be
Belief - based (BBM)
Claim-based (CBM)
Understanding-based
(UBM)
Reality-based (RBM)
Subjective experience
Authority-enforced
(Serious MDs, most of
ACMs)
Laboratory,
paraclinical world
(mechanisms)
Epidemiology
and also Evidence-based (EBM)
Evidence-Based Medicine
(EBM)
is the integration of
 best
research evidence with
 clinical expertise and
 patient values
Evidence-based Medicine
and Evidence-based Public Health
‘… a way to obtain the best evidence, knowledge
and experience, and to apply them to clinical
and community health problems in conjecture
with patient and community preferences and
values. ..’
An evidence-useful question
Intervention:
Does the bupropion
therapy
Outcomes:
diminish the yearly
frequency and severity
of clinically important
depression episodes
Population setting: in older patients
Condition
suffering from a bipolar
of interest:
affective disorder?
An evidence-nebulous question
‘What is the role of tricyclic and clinically
similar compounds in the treatment of
mood disorders?’
Hard and soft data
in psychiatry

Soft data:
Symptoms (mood), findings
from qualitative research,
psychoanalytical observations
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Hard data:
Paraclinical findings (serum
lithium levels), any other
measurable and quantifiable
findings
Steps in evidence-based
process
Evidence retrieval
 Evidence evaluation
 Application to a particular patient in a
specific clinical setting
 Evidence implementation and uses in daily
practice
 Evaluation of the evidence-based
psychiatric care itself

Cause-effect link
oversimplifications
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P-values as substitute for causation.
Biological plausibility as substitute for
causation.
Singular case or case series experience.
Any other case of unspecified experience.
Authoritarian raising the voice in a clinical
argument.
Attention to logic
and critical thinking
in psychiatry
Obtaining good evidence does not mean yet
using it properly
 Logical uses of evidence are essential in
daily practice (e.g., assessment of patient
structure of thought)
 Research discussion and results
interpretation rely on flawless reasoning

Logic in medicine
‘System of thought and reasoning that governs
understanding and decisions in clinical and
community care.’
It defines valid reasoning, which helps us
understand the meaning of medical phenomena
and leads us to the justification of the choice of
clinical and paraclinical decisions about how to
act upon such phenomena.
Critical thinking
‘A process, the goal of which is to make
reasonable decisions about what to believe
and what to do.’
Or:
‘The ability to solve problem by making
sense of information using creative, intuitive,
logical and analytical mental process.’
Priorities for health programs
and community interventions
Health problem must be
- frequent
- serious
- controllable
Intervention must be
- feasible
Priority of any health program is
a product of
Disease occurrence (incidence,prevalence,
duration)
Clinical importance (disease severity, i.e.
gradient and spectrum)
Controllability
(effectiveness of
intervention) and
Operational considerations (population
proportion which can be
reached by the program)
Information necessary for
primary prevention
Risk factors as causes
 Data on risk factors and disease occurrence
available before and after intervention
 Disease natural history and course
 Effective intervention as prevention modality
 Program effectiveness confirmed by a
systematic review of evidence
 Program choice confirmed by decision analysis

Information necessary for secondary
prevention
The same as for primary prevention, plus:
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Risk markers
Prognostic markers and factors
Natural history of the disease
Clinical course of the disease
Effective outcome modifying intervention
(continued)
Information necessary for
secondary prevention
The same as for primary prevention, plus:
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Baseline clinical data
Outcome data
Program effectiveness confirmed by a
systematic review of evidence (meta-analysis)
Program choice confirmed by decision
analysis
(end)
Information necessary for
tertiary prevention
Same as for the secondary prevention plus:
 Disease auxometry (measured by the
evolution of disease gradient and spectrum)
is known and available for the program
 Program effectiveness confirmed by a
systematic review of evidence (metaanalysis)
 Program choice confirmed by decision
analysis
Achievements of psychiatry
from the EBP view
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Psychiatric fundamental and clinical
epidemiology as reality of life
Refinement of soft and hard data in
diagnosis (DSM IV - TR)
Controlled clinical trials overcoming
challenges of soft data
Future directions
for psychiatry
from the EBM point of view
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Be broad-minded in judging evidence
Get the best evidence available
Use it
Evaluate the effectiveness of EBP
Train others how to do it
Improve your logic and critical thinking in
clinical practice and community mental
health
Do we have other alternatives
than EBP?
‘It has been said that Evidence-based
Psychiatry is the worst form of approach to
mental health problem-solving except all those
other alternatives that have been tried from
time to time.’
‘Two cheers for Evidence-based Psychiatry:
one because it admits variety and two because
it admits criticism.’