Letters to the Editor
Re: Case Reports as Letters Should Stay in The Canadian Journal of Psychiatry
Dear Editor: The debate on the subject of publishing case reports, initiated by Dr Margolese (1) with the editor-in-chief of our Journal, Dr Paris (2), deserves attention. I agree with Dr Paris’s concern about reinforcing the Journal’s impact by revising the publication criteria and methods. However, I support Dr Margolese in his concern that the case reports category will eventually disappear, even as letters to the editor. His argument is well presented. I would like to point out that eliminating case reports does not render any service to research or to practice; rather, it dispossesses a clinical knowledge that contrasts with the evidence-based medicine design currently used. Those of us in psychiatry claim that our knowledge is solid because it is based on evidence-based medicine. Nonetheless, we are not rich enough in our knowledge to discard case reports. Unless I do not read the same literature as today’s psychiatrists, all our knowledge on clinical and therapeutic data is fragile: antipsychotics, antidepressants, cognitive-behavioral therapies, lithium, and cholinesterase inhibitors have not drastically improved the destinies of our patients. Metaanalyses dictate their effectiveness or their efficiency, which in general ranges from weak to moderate (3,4). The more one deals with long-course diseases, the more the data are far from convincing. As for side effects, the literature is close to “evidence-biased” medicine (5). Thus, the single case report is often the first sign of alarm, for example, in reported cases of agranulocytosis, ablastic anemia, and hepatic failure. In addition, a well-established epistemology of single cases is already used in neuropsychology and cognitive neurosciences. These case reports, validated with the “single case study methodology,” produced major successive publications that our psychiatric discipline could not possibly be indifferent to. It would have been regrettable had Paul Broca’s case presenting Tan Tan, which revolutionized neurology, not been accepted for publication (6), or had Brenda Milner’s case reports with HM, which revolutionized neuropsychology of the memory and learning, not been published (7). The diagnoses of Capgras or Asperger syndromes, for instance, began with case reports, not as de novo classified syndromes. I personally believe that the CJP would not lose prestige if such cases were published. In addition, I believe that in Canada we have many clinicians like Broca and Milner who could make outstanding findings using single-case methodology. This argument is on especially firm ground for rare cases. Worth mentioning, the DSM-IV did not succeed in eliminating rare cases, nor has the DSM-V prelude project (www.dsm5.org). The idiosyncrasy is to psychiatry what a diamond is to geology.
References
1. Margolese H. Case reports as letters should stay in The Canadian Journal of Psychiatry. Can J Psychiatry 2005;50:370.
2. Paris J. Canadian Journal of Psychiatry: new editor and new policies [editorial]. Can J Psychiatry 2005;50:1.
3. Lesage AD, Stip E, Grunberg F. “What’s up, doc?” The context, limitations, and issues for clinicians in evidence-based medicine. Can J Psychiatry 2001;46:396–402.
4. Stip E. Happy birthday neuroleptics! 50 years later: la folie du doute. Eur Psychiatry 2002;17:115–9.
5. Melander H, Ahlqvist-Rastad J, Meijer G, Beermann B. Evidence b(i)ased medicine—selective reporting from studies sponsored by pharmaceutical industry: review of studies in new drug applications. BMJ 2003;326:1171–3.
6. Broca P. Localisations des fonctions cérébrales. Siège de la faculté du langage articulé. Bulletin de la Société d’Anthropologie 1863. Paris tome IV : 200–8.
7. Milner B, Corkin S, Teuber H-L. Further analysis of the hippocampal syndrome: 14-year follow-up study of HM. Neuropsychologia 1968;6:215–34.
Emmanuel Stip, MD, MSc, CSPQ
Montreal, Quebec
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