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David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian
Haynes, W Scott Richardson
Evidence based medicine: what it is and
what it isn't
BMJ 1996;312:71-72
"Evidence based
medicine is the conscientious, explicit, and judicious use of current best evidence
in making decisions about the care of individual patients. The practice of evidence
based medicine means integrating individual clinical expertise with the best available
external clinical evidence from systematic research. By individual clinical expertise
we mean the proficiency and judgment that individual clinicians acquire through
clinical experience and clinical practice. Increased expertise is reflected in
many ways, but especially in more effective and efficient diagnosis and in the
more thoughtful identification and compassionate use of individual patients' predicaments,
rights, and preferences in making clinical decisions about their care. By best
available external clinical evidence we mean clinically relevant research, often
from the basic sciences of medicine, but especially from patient centred clinical
research into the accuracy and precision of diagnostic tests (including the clinical
examination), the power of prognostic markers, and the efficacy and safety of
therapeutic, rehabilitative, and preventive regimens. External clinical evidence
both invalidates previously accepted diagnostic tests and treatments and replaces
them with new ones that are more powerful, more accurate, more efficacious, and
safer. Good doctors use both individual clinical
expertise and the best available external evidence, and neither alone is enough.
Without clinical expertise, practice risks becoming tyrannised by evidence, for
even excellent external evidence may be inapplicable to or inappropriate for an
individual patient. Without current best evidence, practice risks becoming rapidly
out of date, to the detriment of patients." [Full
Text]
R Brian Haynes
What
kind of evidence is it that Evidence-Based Medicine advocates want health care
providers and consumers to pay attention to?
BMC Health
Services Research 2002, 2:3
"BACKGROUND: In 1992, Evidence-Based Medicine
advocates proclaimed a "new paradigm", in which evidence from health
care research is the best basis for decisions for individual patients and health
systems. Hailed in New York Times Magazine in 2001 as one of the most influential
ideas of the year, this approach was initially and provocatively pitted against
the traditional teaching of medicine, in which the key elements of knowing for
clinical purposes are understanding of basic pathophysiologic mechanisms of disease
coupled with clinical experience. This paper reviews the origins, aspirations,
philosophical limitations, and practical challenges of evidence-based medicine.
DISCUSSION: EBM has long since evolved beyond its initial (mis)conception, that
EBM might replace traditional medicine. EBM is now attempting to augment rather
than replace individual clinical experience and understanding of basic disease
mechanisms. EBM must continue to evolve, however, to address a number of issues
including scientific underpinnings, moral stance and consequences, and practical
matters of dissemination and application. For example, accelerating the transfer
of research findings into clinical practice is often based on incomplete evidence
from selected groups of people, who experience a marginal benefit from an expensive
technology, raising issues of the generalizability of the findings, and increasing
problems with how many and who can afford the new innovations in care. SUMMARY:
Advocates of evidence-based medicine want clinicians and consumers to pay attention
to the best findings from health care research that are both valid and ready for
clinical application. Much remains to be done to reach this goal." [Full
Text] R Brian Haynes, P J Devereaux, Gordon H
Guyatt
Physicians' and patients' choices in evidence based practice
BMJ 2002;324:1350, doi:10.1136/bmj.324.7350.1350
"The
notion that decisions may vary from circumstance to circumstance, and from patient
to patient with the same circumstances, has received increasing attention. But
achieving the right balance among the factors that can affect a decision is not
necessarily easy. Indeed, providing evidence to patients in a way that allows
them to make an informed choice is challenging and in many cases beyond our current
knowledge of doctor-patient communicationvery much a problem awaiting the generation
of new evidence. The term evidence based medicine
was developed to encourage practitioners and patients to pay due respectno more,
no lessto current best evidence in making decisions. An alternative term that
some may find more appealing is research enhanced health care. Whichever term
is applied, one can be confident in making better use of research evidence in
clinical practice, especially if the wishes of the patient are taken into account."
[Full Text] S
E Straus, D L Sackett
Getting research findings into practice: Using
research findings in clinical practice
BMJ 1998;317:339-342
"Applying
the results of critical appraisals involves the essential second element of evidence
based medicine: integrating the evidence with clinical expertise and knowledge
of the unique features of patients and their situations, rights, and expectations.
Only after these things have been considered can we then decide whether and how
to incorporate the evidence into the care of a particular patient." [Full
Text] Brian Haynes, Andrew Haines
Getting
research findings into practice: Barriers and bridges to evidence based clinical
practice
BMJ 1998;317:273-276
"Clinicians and healthcare
planners who want to improve the quality and efficiency of healthcare services
will find help in research evidence. This evidence is increasingly accessible
through information services that combine high quality evidence with information
technology. However, there are several barriers to the successful application
of research evidence to health care. We discuss both the prospects for harnessing
evidence to improve health care and the problems that readersclinicians, planners,
and patientswill need to overcome to enjoy the benefits of research." [Full
Text]
LAWRIE, STEPHEN M., SCOTT, ALLAN
I.F., SHARPE, MICHAEL C.
Implementing evidence-based psychiatry:
whose responsibility?
Br J Psychiatry 2001 178: 195-196
"Evidence-based
medicine is fine in principle, but needs to demonstrate tangible benefits to clinicians
and their patients in practice. The main obstacles to its implementation are:
(a) identifying information needs; (b) delivering reliable and clinically useful
information to the ward/clinic; and (c) ensuring the information is regularly
updated. How can this be achieved in psychiatry?" [Full
Text] Palmer, Claire, Lelliott, Paul
Encouraging
the implementation of clinical standards into practice
Psychiatr
Bull 2000 24: 90-93
"Implementing clinical standards is not a linear process
of ‘information provision=implementation’. It is not even as simple
as ‘information+training+resources=implementation’. It is a complex
and ‘messy’ process. An individual implementation method, or even combination
of methods, may work for one individual or group but not another. It appears from
the research in this area that the best implementation strategy is one which uses
a wide range of different approaches in the hope that it will provide something
which works for the maximum number of people." [Full
Text] Ted J Kaptchuk
Effect of interpretive
bias on research evidence
BMJ 2003;326:1453-1455, doi:10.1136/bmj.326.7404.1453
"Doctors
are being encouraged to improve their critical appraisal skills to make better
use of medical research. But when using these skills, it is important to remember
that interpretation of data is inevitably subjective and can itself result in
bias." [Full
Text] A C Freeman, K Sweeney
Why
general practitioners do not implement evidence: qualitative study
BMJ
2001;323:1100, doi:10.1136/bmj.323.7321.1100
"This study suggests that
the general practitioner acts as a conduit in consultations in which clinical
evidence is one commodity. For some doctors the evidence had clarified practice,
focused clinical effort, and sometimes radically altered practice. But a stronger
theme from our data is that doctors are shaping the square peg of the evidence
to fit the round hole of the patient's life. The nature of the conduit is determined
partly by the doctors' previous experiences and feelings. These feelings can be
about the patient, the evidence itself, or where the evidence has come from (the
hospital setting). The conduit is also influenced by the doctor-patient relationship.
The precise words used by practitioners in their role as conduit can affect how
evidence is implemented. In some settings, logistical problems will diminish the
effectiveness of the conduit." [Full
Text] Ian Kerridge, Michael Lowe, David Henry
Personal paper: Ethics and evidence based medicine
BMJ
1998;316:1151-1153
"However, the presence of reliable evidence does not
ensure that better decisions will be made. Claims that evidence based medicine
offers an improved method of decision making are difficult to evaluate because
current practice is so poorly defined. Medical decision making draws upon a broad
spectrum of knowledgeincluding scientific evidence, personal experience, personal
biases and values, economic and political considerations, and philosophical principles
(such as concern for justice). It is not always clear how practitioners integrate
these factors into a final decision, but it seems unlikely that medicine can ever
be entirely free of value judgments." [Full
Text] Goldman, Howard H., Ganju, Vijay, Drake,
Robert E., Gorman, Paul, Hogan, Michael, Hyde, Pamela S., Morgan, Oscar
Policy
Implications for Implementing Evidence-Based Practices
Psychiatric
Services 2001 52: 1591-1597
"The authors describe the policy and administrative-practice
implications of implementing evidence-based services, particularly in public-sector
settings. They review the observations of the contributors to the evidence-based
practices series published throughout 2001 in Psychiatric Services. Quality and
accountability have become the watchwords of health and mental health services;
evidence-based practices are a means to both ends. If the objective of accountable,
high-quality services is to be achieved by implementing evidence-based practices,
the right incentives must be put in place, and systemic barriers must be overcome.
The authors use the framework from the U.S. Surgeon General's 1999 report on mental
health to describe eight courses of action for addressing the gap between science
and practice: continue to build the science base; overcome stigma; improve public
awareness of effective treatments; ensure the supply of mental health services
and providers; ensure delivery of state-of-the-art treatments; tailor treatment
to age, sex, race, and culture; facilitate entry into treatment; and reduce financial
barriers to treatment." [Full
Text] Schoenwald, Sonja K., Hoagwood, Kimberly
Effectiveness,
Transportability, and Dissemination of Interventions: What Matters When?
Psychiatric
Services 2001 52: 1190-1197
"The authors identify and define key aspects
of the progression from research on the efficacy of a new intervention to its
dissemination. They highlight the role of transportability questions that arise
in that progression and illustrate key conceptual and design features that differentiate
efficacy, effectiveness, and dissemination research. An ongoing study of the transportability
of multisystemic therapy is used to illustrate independent and interdependent
aspects of effectiveness, transportability, and dissemination studies. Variables
relevant to the progression from treatment efficacy to dissemination include features
of the intervention itself as well as variables pertaining to the practitioner,
client, model of service delivery, organization, and service system. The authors
provide examples of how some of these variables are relevant to the transportability
of different types of interventions. They also discuss sample research questions,
study designs, and challenges to be anticipated in the arena of transportability
research." [Full
Text] GILBODY, SIMON M., HOUSE, ALLAN O., SHELDON,
TREVOR A.
Outcomes research in mental health: Systematic review
Br
J Psychiatry 2002 181: 8-16
"BACKGROUND: Outcomes research involves the
secondary analysis of data collected routinely by clinical services, in order
to judge the effectiveness of interventions and policy initiatives. It permits
the study of large databases of patients who are representative of 'real world'
practice. However, there are potential problems with this observational design.
AIMS: To establish the strengths and limitations of outcomes research when applied
in mental health. METHOD: A systematic review was made of the application of outcomes
research in mental health services research. RESULTS: Nine examples of outcomes
research in mental health services were found. Those that used insurance claims
data have information on large numbers of patients but use surrogate outcomes
that are of questionable value to clinicians and patients. Problems arise when
attempting to adjust for important confounding variables using routinely collected
claims data, making results difficult to interpret. CONCLUSIONS: Outcomes research
is unlikely to be a quick or cheap means of establishing evidence for the effectiveness
of mental health practice and policy." [Full
Text] MARGISON, FRANK R., McGRATH, GRAEME, BARKHAM,
MICHAEL, CLARK, JOHN MELLOR, AUDIN, KERRY, CONNELL, JANICE, EVANS, CHRIS
Measurement
and psychotherapy: Evidence-based practice and practice-based evidence
Br
J Psychiatry 2000 177: 123-130
"BACKGROUND: Measurement is the foundation
of evidence-based practice. Advances in measurement procedures should extend to
psychotherapy practice. AIMS: To review the developments in measurement relevant
to psychotherapy. METHOD: Domains reviewed are: (a) interventions; (b) case formulation;
(c) treatment integrity; (d) performance (including adherence, competence and
skillfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine
outcome measurement. RESULTS: Modern methods of measurement can support 'evidence-based
practice' for psychological treatments. They also support 'practice-based evidence',
a complementary paradigm to improve clinical effectiveness in routine practice
via the infrastructure of Practice Research Networks (PRNs). CONCLUSIONS: Advances
in measurement derived from psychotherapy research support a model of professional
self-management (practice-based evidence) which is widely applicable in psychiatry
and medicine." [Full
Text] Roberts, Glenn A.
Narrative
and severe mental illness: what place do stories have in an evidence-based world?
Adv
Psychiatr Treat 2000 6: 432-441
"Science and narrative, the quantitative
and qualitative, are not competitors but represent a complementary duality, as
intimately connected as the two sides of the cerebral cortex. Narrative preserves
individuality, distinctiveness and context, whereas quantitative methods and evidence-based
guidelines offer a solid foundation for what is reliably and generally correct.
Palmer (2000) has argued that it is clinicians who need to bridge the gap, if
they are to be able both to appraise evidence and appreciate the meaningful experience
of their patients: "It may be uncomfortable to ride the twin horses of rigour
and richness, of general scepticism and particular enthusiasm, but the clinician
has to try to do so". Narrative is endemic to
medicine, but has been excluded in the rise of EBM. It remains to be seen whether
narrative's ecumenicalism will be rebuffed or reconciled with EBM's fundamentalism,
but there are signs of convergence. A recent issue of the Journal of Evidence-Based
Health Care (October, 1999) began by declaring that "This issue of Bandolier
is mostly about updating stories from previous months and years", and went
on to state that "reviews are also beginning to concentrate more on outcomes
that are important to patients and practitioners, rather than just on outcomes
that are measurable". There is an emerging image
of the mature and experienced clinician of the future, who will have the capacity
to integrate narrative- and evidence-based perspectives, quantitative and qualitative
methods, and have a balanced awareness of the contributions and limitations of
both as a sound basis for clinical judgements. However, if this is to be more
than a heroic ideal, our initial training and continuing professional development
will need to encourage the simultaneous development of both the art and science
of our subject, reconciling probabilistic P-values with personalistic ‘P-values’."
[Full Text] Roberts,
Glenn, Wolfson, Paul
The rediscovery of recovery: open to all
Adv
Psychiatr Treat 2004 10: 37-48
"‘Recovery’ is usually taken
as broadly equivalent to ‘getting back to normal’ or ‘cure’,
and by these standards few people with severe mental illness recover. At the heart
of the growing interest in recovery is a radical redefinition of what recovery
means to those with severe mental health problems. Redefinition of recovery as
a process of personal discovery, of how to live (and to live well) with enduring
symptoms and vulnerabilities opens the possibility of recovery to all. The ‘recovery
movement’ argues that this reconceptualisation is personally empowering,
raising realistic hope for a better life alongside whatever remains of illness
and vulnerability. This paper explores the background and defining features of
the international recovery movement, its influence and impact on contemporary
psychiatric practice, and steps towards developing recovery-based practice and
services." [Abstract] Frese,
Frederick J., III, Stanley, Jonathan, Kress, Ken, Vogel-Scibilia, Suzanne
Integrating
Evidence-Based Practices and the Recovery Model
Psychiatric
Services 2001 52: 1462-1468
"Consumer advocacy has emerged as an important
factor in mental health policy during the past few decades. Winning consumer support
for evidence-based practices requires recognition that consumers' desires and
needs for various types of treatments and services differ significantly. The authors
suggest that the degree of support for evidence-based practices by consumer advocates
depends largely on the degree of disability of the persons for whom they are advocating.
Advocates such as members of the National Alliance for the Mentally Ill, who focus
on the needs of the most seriously disabled consumers, are most likely to be highly
supportive of research that is grounded in evidence-based practices. On the other
hand, advocates who focus more on the needs of consumers who are further along
their road to recovery are more likely to be attracted to the recovery model.
Garnering the support of this latter group entails ensuring that consumers, as
they recover, are given increasing autonomy and greater input about the types
of treatments and services they receive. The authors suggest ways to integrate
evidence-based practices with the recovery model and then suggest a hybrid theory
that maximizes the virtues and minimizes the weaknesses of each model." [Full
Text] Fisher, Daniel B., Ahern, Laurie
Evidence-Based
Practices and Recovery
Psychiatric Services 2002 53: 632-a-633
[Full Text]
MARKS,
ISAAC M.
The maturing of therapy: Some brief psychotherapies help
anxiety/depressive disorders but mechanisms of action are unclear
Br
J Psychiatry 2002 180: 200-204
"BACKGROUND: Psychiatric therapy needs
assessment regarding its maturation as a therapeutic science. AIMS: Judgement
of whether such a science is emerging. METHOD: Four criteria are used: efficacy;
identification of responsible treatment components; knowledge of their mechanisms
of action; and elucidation of why they act only in some sufferers. RESULTS: Brief
behavioural, interpersonal, cognitive, problem-solving and other psychotherapies
have a mature ability to improve anxiety and depressive disorders reliably and
enduringly, often only with instruction from a manual or a computer. Therapy's
cost-effectiveness and acceptability deserve more attention. We know little about
which treatment components produce improvement, how they do so and why they do
not help all sufferers. CONCLUSIONS: Therapy is coming of age regarding efficacy
for anxiety and depression, but is only a toddler regarding the scientific principles
to explain its effects." [Full
Text] |
Sensky, Tom
Knowledge management
Adv
Psychiatr Treat 2002 8: 387-395
"More generally, the need for personal
knowledge management skills underlies the widespread acknowledgement that now,
more than ever before, it is impossible for a clinician to acquire sufficient
knowledge during training to equip him or her for the duration of a professional
career. This is reflected not only in the importance attached to continuing professional
development, but also in the change in emphasis during undergraduate medical training
from the acquisition of facts to the development of skills needed for lifelong
learning." [Full
Text] Stuart Barton
Which clinical
studies provide the best evidence?
BMJ 2000;321:255-256,
doi:10.1136/bmj.321.7256.255
"The new studies do not justify a major revision
of the hierarchy of evidence, but they do support a flexible approach in which
randomised controlled trials and observational studies have complementary roles.
High quality observational studies may extend evidence over a wider population
and are likely to be dominant in the identification of harms and when randomised
controlled trials would be unethical or impractical." [Full
Text] Hoagwood, Kimberly, Burns, Barbara J., Kiser,
Laurel, Ringeisen, Heather, Schoenwald, Sonja K.
Evidence-Based Practice
in Child and Adolescent Mental Health Services
Psychiatric
Services 2001 52: 1179-1189
"The authors review the status, strength,
and quality of evidence-based practice in child and adolescent mental health services.
The definitional criteria that have been applied to the evidence base differ considerably
across treatments, and these definitions circumscribe the range, depth, and extensionality
of the evidence. The authors describe major dimensions that differentiate evidence-based
practices for children from those for adults and summarize the status of the scientific
literature on a range of service practices. The readiness of the child and adolescent
evidence base for large-scale dissemination should be viewed with healthy skepticism
until studies of the fit between empirically based treatments and the context
of service delivery have been undertaken. Acceleration of the pace at which evidence-based
practices can be more readily disseminated will require new models of development
of clinical services that consider the practice setting in which the service is
ultimately to be delivered." [Full
Text]
Hoagwood, Kimberly
Making
the Translation from Research to Its Application: The Je Ne Sais Pas of Evidence-Based
Practices
Clin. Psychol. 2002 9: 210-213
"Moving
evidence-based treatments into practice settings is an important new direction
for the field of children's mental health., but is fraught with many unknowns.
This commentary discusses scientific conundrums that surround that transportability
of research-based interventions, including issues of definition (e.g., differences
among treatments, preventive interventions, services); diagnostic reification
and the absence of markers; the value and status of combination treatments (including
pharmacologic) for conceptualizing the evidence base; and differences between
evidence-based practices and evidence-based treatments. Suggestions are made for
a disciplined approach to advancing a yoked research and policy agenda for children's
mental health." [Abstract]
GEDDES,
JOHN, GOODWIN, GUY
Bipolar disorder: clinical uncertainty, evidence-based
medicine and large-scale randomised trials
Br J Psychiatry
2001 178: 191s-194
"BACKGROUND: The increasing use of the methods of evidence-based
medicine to keep up-to-date with the research literature highlights the absence
of high-quality evidence in many areas in psychiatry. AIMS: To outline current
uncertainties in the maintenance treatment of bipolar disorder and to describe
some of the decisions involved in designing a large simple trial. METHOD: We describe
some of the strategies of evidence-based medicine, and how they can be applied
in practice, focusing specifically on the area of bipolar disorder. RESULTS: One
of the key clinical uncertainties in the treatment of bipolar disorder is the
place of maintenance drug treatments and their relative efficacy. A large-scale
study, the Bipolar Affective Disorder: Lithium Anticonvulsant Evaluation (BALANCE)
trial, is proposed to compare the effectiveness of lithium, valproate and the
combination of lithium and valproate. CONCLUSIONS: Providing reliable answers
to key clinical questions in psychiatry will require new approaches to clinical
trials. These will need to be far larger than previously appreciated and will
therefore need to be collaborative ventures involving front-line clinicians."
[Full Text]
Drake, Robert E., Goldman, Howard H., Leff, H.
Stephen, Lehman, Anthony F., Dixon, Lisa, Mueser, Kim T., Torrey, William C.
Implementing
Evidence-Based Practices in Routine Mental Health Service Settings
Psychiatric
Services 2001 52: 179-182
"The authors describe the rationale for implementing
evidence-based practices in routine mental health service settings. Evidence-based
practices are interventions for which there is scientific evidence consistently
showing that they improve client outcomes. Despite extensive evidence and agreement
on effective mental health practices for persons with severe mental illness, research
shows that routine mental health programs do not provide evidence-based practices
to the great majority of their clients with these illnesses. The authors define
the differences between evidence-based practices and related concepts, such as
guidelines and algorithms. They discuss common concerns about the use of evidence-based
practices, such as whether ethical values have a role in shaping such practices
and how to deal with clinical situations for which no scientific evidence exists."
[Full Text]
Torrey,
William C., Drake, Robert E., Dixon, Lisa, Burns, Barbara J., Flynn, Laurie, Rush,
A. John, Clark, Robin E., Klatzker, Dale
Implementing Evidence-Based
Practices for Persons With Severe Mental Illnesses
Psychiatric
Services 2001 52: 45-50
"Extensive empirical research, summarized in several
reviews and codified in practice guidelines, recommendations, and algorithms,
demonstrates that several pharmacological and psychosocial interventions are effective
in improving the lives of persons with severe mental illnesses. Yet the practices
validated by research are not widely offered in routine mental health practice
settings. As part of an effort to promote the implementation of evidence-based
practice, the authors summarize perspectives on how best to change and sustain
effective practice from the research literature and from the experiences of administrators,
clinicians, family advocates, and services researchers. They describe an implementation
plan for evidence-based practices based on the use of toolkits to promote the
consistent delivery of such practices. The toolkits will include integrated written
material, Web-based resources, training experiences, and consultation opportunities.
Special materials will address the concerns of mental health authorities (funders),
administrators of provider organizations, clinicians, and consumers and their
families." [Full
Text] Cruz, Mario, Pincus, Harold Alan
Research
on the Influence That Communication in Psychiatric Encounters Has on Treatment
Psychiatric
Services 2002 53: 1253-1265
"OBJECTIVE: The purpose of this article is
to inform mental health professionals about the empirical literature on medical
and psychiatric encounters and the influence of communicative behaviors on specific
encounter outputs and treatment outcomes. METHODS: A comprehensive review of the
health communications literature from 1950 to 2001, using MEDLINE and PsycINFO,
was conducted to identify relevant articles on the communication skills of psychiatrists
and other physicians. These searches were augmented by personal correspondence
with experts on changes in practice patterns in psychiatry and on medical and
psychiatric communications research. A review of references within each article
and information from the experts identified other relevant articles. Selection
was then narrowed to include reports of studies that used structured written instruments
that captured relevant physician and patient perceptions of the physician-patient
relationship, content analysis of audio- or videotapes of communication in medical
or psychiatric encounters, or interaction analysis systems used to categorize
audio- or videotaped communicative behaviors in medical or psychiatric encounters.
RESULTS AND CONCLUSIONS: Twenty-five articles in medicine and 34 articles in psychiatry
were selected. Medical communication researchers have observed associations between
physicians' communicative skills and patients' satisfaction, patients' adherence
to treatment recommendations, treatment outputs, and patients' willingness to
file malpractice claims. The research has also shown that primary care physicians
can be more responsive to patients' concerns without lengthening visits. In psychiatry,
the literature can be organized into four discrete categories of research: negotiated
treatment and the customer approach, therapeutic alliance, Gottschalk-Gleser content
analysis of patients' speech, and content analysis of psychiatric interviews."
[Full Text]
Mike
Shooter
The patient's perspective on medicines in mental illness
BMJ
2003;327:824-826, doi:10.1136/bmj.327.7419.824
"Worldwide 40 antipsychotic
preparations are available and twice as many antidepressants. As a patient with
a recurrent depressive disorder myself it would be comforting to think that choice
of treatment is based on a concordance between the patient's wishes and the doctor's
advice. In reality it will reflect the many factors that affect their relationship—medical
attitudes; the way information is presented; the capacity of patients to understand
this information and to relate it to their condition; health service, social,
and commercial pressures. Not surprisingly, Cochrane reviews of interventions
to improve "adherence" show findings that are inconsistent or complex.
Adherence can only be improved by mutual respect." [Full
Text] Eysenbach G, Jadad AR.
Evidence-based
patient choice and consumer health informatics in the Internet age.
J
Med Internet Res. 2001 Apr-Jun;3(2):E19.
"In this paper we explore current
access to and barriers to health information for consumers. We discuss how computers
and other developments in information technology are ushering in the era of consumer
health informatics, and the potential that lies ahead. It is clear that we witness
a period in which the public will have unprecedented ability to access information
and to participate actively in evidence-based health care. We propose that consumer
health informatics be regarded as a whole new academic discipline, one that should
be devoted to the exploration of the new possibilities that informatics is creating
for consumers in relation to health and health care issues." [Full
Text] Gunther Eysenbach
Recent advances:
Consumer health informatics
BMJ 2000;320:1713-1716, doi:10.1136/bmj.320.7251.1713
"Medical
informatics has expanded rapidly over the past couple of years. After decades
of development of information systems designed primarily for physicians and other
healthcare managers and professionals, there is an increasing interest in reaching
consumers and patients directly through computers and telecommunications systems.
Consumer health informatics is the branch of medical informatics that analyses
consumers' needs for information; studies and implements methods of making information
accessible to consumers; and models and integrates consumers' preferences into
medical information systems. Consumer informatics stands at the crossroads of
other disciplines, such as nursing informatics, public health, health promotion,
health education, library science, and communication science, and is perhaps the
most challenging and rapidly expanding field in medical informatics; it is paving
the way for health care in the information age." [Full
Text] Gunther Eysenbach, Eun Ryoung Sa, Thomas
L Diepgen
Shopping around the internet today and tomorrow: towards
the millennium of cybermedicine
BMJ 1999;319:1294
"The
fact that patients have access to the same databases as clinicians leads to increased
consumer knowledge, which is pushing clinicians to higher quality standards and
evidence based medicine." [Full
Text]
Beveridge, Allan
Time
to abandon the subjective--objective divide?
Psychiatr Bull
2002 26: 101-103
"In the mental state examination, a standard method of
describing the clinical encounter is to contrast the patient's supposedly ‘subjective’
account with the doctor's ‘objective’ description. In this model, the
doctor is granted a privileged position: the clinician's perspective is taken
to be superior to that of the patient. The doctor's objective approach is considered
neutral, scientific and representing the truth of the matter. In contrast, the
patient's subjective report is regarded as unreliable, distorted and potentially
false. The lowly status of the subjective perspective is further emphasised by
the frequent use of the accompanying prefix, merely. On
reflection, this dichotomy is an extraordinary one. It is held that the doctor
is an authority on the patient's inner experiences. The doctor knows more about
how the patient is thinking and feeling than the patient him-/herself. This belief
ignores the preconceptions and prejudices that the clinician brings to the interview.
It ignores the impact that the interview has on how the doctor perceives the patient,
and how the patient responds. In the physical sciences, it has long been recognised
that the observer has an influence on what is being observed." [Full
Text] Saunders, John
The practice
of clinical medicine as an art and as a science
Medical
Humanities 2000 26: 18-22
"The practice of modern medicine is the application
of science, the ideal of which has the objective of value-neutral truth. The reality
is different: practice varies widely between and within national medical communities.
Neither evidence from randomised controlled trials nor observational methods can
dictate action in particular circumstances. Their conclusions are applied by value
judgments that may be impossible to specify in "focal particulars".
Herein lies the art which is integral to the practice of medicine as applied science."
[Full Text]
Summerfield,
D.
Culture-specific psychiatric illness?
Br
J Psychiatry 2001 179: 460-
"All of psychiatry is culture-bounded, not
just a few syndromes in the DSM or ICD: even presentations by patients with organic
disorders are embedded in particular ‘lifeworlds’ and local forms of
knowledge. Western psychiatry is but one among many ethnopsychiatries." [Abstract] EISENBERG,
LEON
Is psychiatry more mindful or brainier than it was a decade
ago?
Br J Psychiatry 2000 176: 1-5
"Nature and nurture
stand in reciprocity, not opposition. Children inherit - along with their parents'
genes - their parents, their peers and the places they inhabit. Neighbourhood
and neighbours matter, as do parents and siblings. The distribution of health
and disease in human populations reflects environmental factors (where people
live, what they eat, the work they do, the air and water they consume, their degree
of connection with others, and the status they occupy in the social order) as
well as what they inherit, namely their relative vulnerabilities and resistances
to environmental pathogens. Biomedical knowledge
is essential for providing sound medical care but it is not sufficient; the doctor's
transactions with the patient must also be informed by psychosocial understanding.
Neither mindlessness nor brainlessness can be tolerated in medicine. The unique
role of psychiatry will be its contribution to a new paradigm: brain/mindfulness,
integrating neurobiology with behaviour in its social context. That is the intellectual
challenge ahead." [Full
Text]
HOLMES, JEREMY
Fitting the
biopsychosocial jigsaw together
Br J Psychiatry 2000 177:
93-94 [Full Text] Patrick
Bracken, Philip Thomas
Postpsychiatry: a new direction for mental
health
BMJ 2001;322:724-727, doi:10.1136/bmj.322.7288.724
[Full Text]
[Be sure to read the rapid responses.] Duncan
Double
The limits of psychiatry
BMJ 2002;324:900-904,
doi:10.1136/bmj.324.7342.900
"Much of the expansion of psychiatry in the
past few decades has been based on a biomedical model that encourages drug treatment
to be seen as a panacea for multiple problems. Psychiatrist Duncan Double is sceptical
of this approach and suggests that psychiatry should temper and complement a biological
view with psychological and social understanding, thus recognising the uncertainties
of clinical practice." [Full
Text] COOPER, BRIAN
Evidence-based
mental health policy: a critical appraisal
Br J Psychiatry
2003 183: 105-113
"BACKGROUND: Arguments for and against evidence-based
psychiatry have mostly centred on its value for clinical practice and teaching.
Now, however, use of the same paradigm in evaluating health care has generated
new problems. AIMS: To outline the development of evidence-based health care;
to summarise the main critiques of this approach; to review the evidence now being
employed to evaluate mental health care; and to consider how the evidence base
might be improved. METHOD: The following sources were monitored: publications
on evidence-based psychiatry and health care since 1990; reports of randomised
trials and meta-analytic reviews to the end of 2002; and official British publications
on mental health policy. RESULTS: Although evidence-based health care is now being
promulgated as a rational basis for mental health planning in Britain, its contributions
to service evaluation have been distinctly modest. Only 10% of clinical trials
and meta-analyses have been focused on effectiveness of services, and many reviews
proved inconclusive. CONCLUSIONS: The current evidence-based approach is overly
reliant on meta-analytic reviews, and is more applicable to specific treatments
than to the care agencies that control their delivery. A much broader evidence
base is called for, extending to studies in primary health care and the evaluation
of preventive techniques." [Abstract] Healy,
David
Evidence biased psychiatry?
Psychiatr
Bull 2001 25: 290-291
"The majority of recent psychotropic drug trials
are business rather than scientific exercises, constructed for the purposes of
achieving regulatory approval and thereafter market penetration. In the case of
regulatory applications for the newer antipsychotics, adopting the null hypothesis
for the data leaves fair-minded observers unable to maintain the position that
these drugs are without effect. Some recent studies have included comparator arms,
using haloperidol in particular. But none of these studies have led to a regulatory
labelling of the newer agents as superior to or preferable to haloperidol. In
the absence of regulatory indications that the null hypothesis has not been shown
to hold when new and older agents are compared, it is difficult to see how the
makers of guidelines can make many statements comparing agents. It also becomes
possible to see why those who might frame guidelines leave themselves open to
a legal challenge from pharmaceutical companies, as has happened in other areas
of medicine." [Full
Text] |
