Recent Advances in Evidence-Based Psychiatry
John Geddes, MD, FRCPsych1, Stuart Carney, MB, ChB2
Background: There is increasing interest in the potential contribution of evidence-based
medicine to clinical decision making in psychiatry. In this article, we describe
some of the recent advances in evidence-based psychiatry and outline future
Method: Narrative review
Content: The successful introduction of evidence-based practice into psychiatry requires the acquisition of new skills by clinicians. It is also important that policy statements that aim to be evidence-based, such as clinical practice guidelines, use rigorous methods to synthesize the primary evidence and do not overlook its limitations. One result of the systematic reviewing of evidence is the identification of important residual clinical uncertainties. Primary research can then be focused on these questions. For questions regarding therapy in psychiatry, it will be necessary to undertake some large, simple randomized trials. Making the best available evidence readily accessible in a clinical setting, however, remains a significant challenge.
Conclusions: Collaboration between clinicians, researchers, policy-makers, and those involved in information technology is required to optimize the contribution of evidence-based medicine in psychiatry.
(Can J Psychiatry 2001;46:403-406)
Key Words: clinical medicine, evidence-based medicine, guidelines, medical informatics, information systems
One of the first contributions to the literature on evidence-based psychiatry was published in the Canadian Journal of Psychiatry in 1995 by Elliot Goldner and Dan Bilsker (1). They highlighted a particular challenge in the implementation of evidence-based psychiatry: the evidence-based approach is fundamentally empirical—in contrast to the still-prevalent schools of psychiatry or to particular ideologies, such as the biological or psychosocial approaches. Just as the principal architects of the DSM-III-R adopted an atheoretical approach to the development of classification (2), so evidence-based psychiatry requires that clinicians place at least as much (and often more) emphasis on the use of high-quality research evidence as on theoretical formulations in their diagnostic, treatment, and prognostic decision making (3). The first article from the Evidence-Based Medicine Working Group recognized that evidence-based practice required this paradigm shift in the epistemic approach to clinical practice (3), but Goldner and Bilsker were surely correct to emphasize its particular relevance to psychiatry.
received and accepted April 2001.
It is important to keep this rather radical paradigm shift in mind, because it might explain the reluctance of some clinicians to adopt an evidence-based approach to their practice. Evidence-based medicine (EBM) is, however, first and foremost a practical, problem-based method that allows clinicians to keep up with the ever-increasing research literature and to ensure that important research findings can be integrated into clinical practice so that patients benefit from the best possible care (4,5). One of the key practical difficulties in making EBM a reality is the shortage of time. How can the busy clinician realistically be expected to look up the evidence for each and every clinical decision for which there was the least hint of uncertainty? Developments in evidence-based psychiatry have focused on making this feasible—by improving the standards of the evidence and by increasing clinicians’ access to the evidence in real-life clinical practice. In this article, we review some of the recent advances in evidence-based psychiatry and outline future challenges.
A Cultural Shift
As we described above, the acceptance of the need for evidence-based practice requires accepting that research findings should inform practice, rather than viewing research as a separate activity taking place alongside clinical practice—interesting when it agrees with clinical experience, but ignored when it does not (6).