Post on 03-Jan-2016
Evidence-Based PsychiatryEvidence-Based Psychiatryin clinical carein clinical care
and community health and community health programs and policiesprograms and policies
Misconceptions, achievements and future directionsMisconceptions, achievements and future directions
Milos JenicekXLIII National Congress
of the Italian Society of Psychiatry
Bologna, October 19-24, 2003
Medicine may beMedicine may beBelief - based (BBM) Subjective experience
Claim-based (CBM) Authority-enforced
(Serious MDs, most ofACMs)
Understanding-based Laboratory,
(UBM) paraclinical world
(mechanisms)
Reality-based (RBM) Epidemiology
and also Evidence-based (EBM)
Evidence-Based Medicine Evidence-Based Medicine (EBM)(EBM)
is the integration of
best research evidence withclinical expertise and
patient values
Evidence-based MedicineEvidence-based Medicineand Evidence-based Public Healthand 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 questionAn evidence-useful question
Intervention: Does the bupropion therapy
Outcomes: diminish the yearly frequency and severityof clinically important
depression episodes
Population setting: in older patients
Condition suffering from a bipolar
of interest: affective disorder?
An evidence-nebulous questionAn evidence-nebulous question
‘What is the role of tricyclic and clinically
similar compounds in the treatment of
mood disorders?’
Hard and soft data Hard and soft data in psychiatryin psychiatry
Soft data: Symptoms (mood), findings
from qualitative research,
psychoanalytical observations
Hard data: Paraclinical findings (serum
lithium levels), any other measurable and quantifiable findings
Steps in evidence-based Steps in evidence-based processprocess
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 Cause-effect link oversimplificationsoversimplifications
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 Attention to logic and critical thinking and critical thinking
in psychiatryin 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 medicineLogic 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 thinkingCritical 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 programsPriorities for health programsand community interventionsand community interventions
Health problem must be - frequent
- serious
- controllable
Intervention must be - feasible
Priority of any health program is Priority of any health program is a product ofa 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 Information necessary for primary preventionprimary 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 Information necessary for secondary preventionprevention
The same as for primary prevention, plus:
Risk markers Prognostic markers and factors Natural history of the disease Clinical course of the disease Effective outcome modifying intervention
(continued)
Information necessary for Information necessary for secondary prevention secondary prevention
The same as for primary prevention, plus:
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 Information necessary for tertiary preventiontertiary 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 (meta-analysis)
Program choice confirmed by decision analysis
Achievements of psychiatry Achievements of psychiatry from the EBP viewfrom the EBP view
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 Future directions for psychiatry for psychiatry
from the EBM point of viewfrom the EBM point of view 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 Do we have other alternatives than EBP?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.’