A Focus On: Evidence-Based Psychiatry
Image: Ward in the Hospital in Arles, by Vincent van Gogh. Reproduced from http://commons.wikimedia.org/wiki/File:Ward_in_the_Hospital_in_Arles.jpg
Rated by the British Medical Journal as one of the top 15 breakthroughs in medicine over the last 150 years, evidence-based medicine (EBM) is an idea that has become highly influential in clinical practice. EBM promotes a seemingly irrefutable principle: that clinical decision-making should be based, as much as possible, on the most up-to-date research findings. Nowhere has this idea been more welcomed than in psychiatry, a field that continues to be dogged by a legacy of controversial clinical interventions.
Evidence-based psychiatry is simply the application of the rules of EBM to psychiatric practice. Many mental health experts believe that evidence-based psychiatry is the best way of safeguarding patients from unproven fads or dangerous interventions. Yet the kind of research favoured by EBM makes certain assumptions about the nature of disease and treatment that do not necessarily apply to psychiatric problems. By emphasizing research of treatment effects in large groups of patients, the rules of EBM assume that mental disorders reflect specific pathophysiological states that are relatively homogeneous across individuals. For example, while the pathophysiology coronary artery disease may be similar across individuals, it has not been established that the same applies to mental illnesses. This means that group-derived data may be of very limited utility in individual clinical decision-making. Furthermore, EBM’s emphasis on group-derived data may discourage rigorous and systematic investigation of the particulars of individual psychiatric problems, dismissing them as part of the ill-defined ‘art’ of medicine.
Rather than allowing EBM to define what counts as the best evidence for their field, psychiatrists need to specify the circumstances in which evidence-based psychiatry can contribute usefully to the problems faced in actual practice. Once undertaken, they can then better identify the research questions and investigations needed to address the areas of practice lying beyond the reach of EBM.
Mona Gupta is Assistant Professor in the Department of Psychiatry at the University of Montreal. She holds an MDCM (McGill) in medicine and a PhD (Toronto) in Bioethics. Her area of expertise lies in psychiatric ethics and qualitative methods.
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