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.’