evidence-based medicine & psychiatry


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(Updated 3/9/04)

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 Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients."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]

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]

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]

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]

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]

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]

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]

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]

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]

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Recent Evidence-Based Medicine & Psychiatry Research

1) Hibbard R, Barlow J, Macmillan H
Psychological Maltreatment.
Pediatrics. 2012 Jul 30;
Psychological or emotional maltreatment of children may be the most challenging and prevalent form of child abuse and neglect. Caregiver behaviors include acts of omission (ignoring need for social interactions) or commission (spurning, terrorizing); may be verbal or nonverbal, active or passive, and with or without intent to harm; and negatively affect the child's cognitive, social, emotional, and/or physical development. Psychological maltreatment has been linked with disorders of attachment, developmental and educational problems, socialization problems, disruptive behavior, and later psychopathology. Although no evidence-based interventions that can prevent psychological maltreatment have been identified to date, it is possible that interventions shown to be effective in reducing overall types of child maltreatment, such as the Nurse Family Partnership, may have a role to play. Furthermore, prevention before occurrence will require both the use of universal interventions aimed at promoting the type of parenting that is now recognized to be necessary for optimal child development, alongside the use of targeted interventions directed at improving parental sensitivity to a child's cues during infancy and later parent-child interactions. Intervention should, first and foremost, focus on a thorough assessment and ensuring the child's safety. Potentially effective treatments include cognitive behavioral parenting programs and other psychotherapeutic interventions. The high prevalence of psychological abuse in advanced Western societies, along with the serious consequences, point to the importance of effective management. Pediatricians should be alert to the occurrence of psychological maltreatment and identify ways to support families who have risk indicators for, or evidence of, this problem. [PubMed Citation] [Order full text from Infotrieve]

2) Fishbain DA, Cole B, Lewis JE, Gao J
Is Smoking Associated with Alcohol-Drug Dependence in Patients with Pain and Chronic Pain Patients? An Evidence-Based Structured Review.
Pain Med. 2012 Jul 30;
Objective.? The objective of this study was to determine if there is consistent evidence for smoking to be considered a red flag for development of opioid dependence during opioid exposure in patients with pain and chronic pain patients (CPPs). Methods.? Six hundred and twenty-three references were found that addressed the areas of smoking, pain, and drug-alcohol dependence. Fifteen studies remained after exclusion criteria were applied and sorted into four groupings addressing four hypotheses: patients with pain and CPPs who smoke are more likely than their nonsmoking counterparts to use opioids, require higher opioid doses, be drug-alcohol dependent, and demonstrate aberrant drug-taking behaviors (ADTBs). Each study was characterized by the type of study it represented according to the Agency for Health Care Policy and Research (AHCPR) guidelines and independently rated by two raters according to 13 quality criteria to generate a quality score. The percentage of studies in each grouping supporting/not supporting each hypothesis was calculated. The strength and consistency of the evidence in each grouping was rated by the AHCPR guidelines. Results.? In each grouping, 100% of the studies supported the hypothesis for that grouping. The strength and consistency of the evidence was rated as A (consistent multiple studies) for the first hypothesis and as B (generally consistent) for the other. Conclusions.? There is limited consistent indirect evidence that smoking status in patients with pain and CPPs is associated with alcohol-drug and opioid dependence. Smoking status could be a red flag for opioid-dependence development on opioid exposure. [PubMed Citation] [Order full text from Infotrieve]

3) Schoenwald SK, Chapman JE, Henry DB, Sheidow AJ
Taking Effective Treatments to Scale: Organizational Effects on Outcomes of Multisystemic Therapy for Youth with Co-occurring Substance Use.
J Child Adolesc Subst Abuse. 2012 1;21(1):1-31.
A prospective multi-site study examined organizational climate and structure effects on the behavior and functioning of delinquent youth with and without co-occurring substance treated with an evidence-based treatment for serious antisocial behavior (i.e., Multisystemic Therapy). Participants were 1979 youth treated by 429 therapists across 45 provider organizations in North America. Results of Mixed Effects Regression Models showed some aspects of climate and structure had no effects, some had similar effects, and some had slightly differential and sometimes counter-intuitive effects on the outcomes of these youth. Implications are considered for research to increase the array and availability of effective treatments for youth with co-occurring substance use across service sectors. [PubMed Citation] [Order full text from Infotrieve]

4) Walpoth-Niederwanger M, Kemmler G, Grunze H, Wei U, Hörtnagl C, Strau R, Blasko I, Hausmann A
Treatment patterns in inpatients with bipolar disorder at a psychiatric university hospital over a 9-year period: focus on mood stabilizers.
Int Clin Psychopharmacol. 2012 Jul 26;
The increasing number of pharmacological treatment options for bipolar disorder seems to be paralleled by the number of evidence-based guidelines published previously. The aim of this study was to systematically examine the adherence to published guidelines and any change in prescription habits over time in a psychiatric hospital setting. This is a retrospective study of 531 bipolar in patients who were consecutively admitted to the Department for Psychiatry and Psychotherapy in Innsbruck. Their complete medical histories were evaluated for psychotropic medications, with a special focus on mood stabilizers (MSs). To compare the use of individual MSs or combinations with other psychotropic medications in two preselected observation periods (1999-2003 and 2004-2007), we used Fisher's exact test. Overall, the proportion of patients receiving at least one MS increased significantly from 1999-2003 to 2004-2007 (74.1 vs. 83.1%, P=0.011). Among the individual MSs, valproate was used most frequently in both time periods, showing a significant increase (P<0.001). Prescriptions of quetiapine (P<0.001) and lamotrigine (P=0.033) increased significantly, carbamazepine showed a significant decrease (P<0.001). Prescriptions of lithium and olanzapine decreased without reaching significance. The significant increase in the prescription of MS reflects the increasing awareness and implementation of recent evidence-based medicine guidelines into clinical practice. Clinical decision making, usually made on the basis of individual clinical experience, should always be reevaluated using periodically updated evidence-based medicine guidelines. [PubMed Citation] [Order full text from Infotrieve]

5) Witteveen AB, Bisson JI, Ajdukovic D, Arnberg FK, Bergh Johannesson K, Bolding HB, Elklit A, Jehel L, Johansen VA, Lis-Turlejska M, Nordanger DO, Orengo-García F, Polak AR, Punamaki RL, Schnyder U, Wittmann L, Olff M
Post-disaster psychosocial services across Europe: The TENTS project.
Soc Sci Med. 2012 Jul 14;
At present post-disaster activities and plans seem to vary widely. An adequate estimation of the availability of post-disaster psychosocial services across Europe is needed in order to compare them with recently developed evidence-informed psychosocial care guidelines. Here we report on the results of a cross-sectional web-based survey completed in 2008 by two hundred and eighty-six representatives of organizations involved in psychosocial responses to trauma and disaster from thirty-three different countries across Europe. The survey addressed planning and delivery of psychosocial care after disaster, methods of screening and diagnosis, types of interventions used, and other aspects of psychosocial care after trauma. The findings showed that planning and delivery of psychosocial care was inconsistent across Europe. Countries in East Europe seemed to have less central coordination of the post-disaster psychosocial response and fewer post-disaster guidelines that were integrated into specific disaster or contingency plans. Several forms of psychological debriefing, for which there is no evidence of efficacy to date, were still used in several areas particularly in North Europe. East European countries delivered evidence-based interventions for PTSD less frequently, whilst in South- and South-Eastern European countries anxiety suppressing medication such as benzodiazepines were prescribed more frequently to disaster victims than in other areas. Countries across Europe are currently providing sub-optimal psychosocial care for disaster victims. This short report shows that there is an urgent need for some countries to abandon non-effective interventions and others to develop more evidence based and effective services to facilitate the care of those involved in future disasters. [PubMed Citation] [Order full text from Infotrieve]

6) Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ
World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the acute treatment of schizophrenia and the management of treatment resistance.
World J Biol Psychiatry. 2012 Jul;13(5):318-378.
Abstract These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia. [PubMed Citation] [Order full text from Infotrieve]

7) Tsiouris JA, Kim SY, Brown WT, Pettinger J, Cohen IL
Prevalence of Psychotropic Drug Use in Adults with Intellectual Disability: Positive and Negative Findings from a Large Scale Study.
J Autism Dev Disord. 2012 Jul 25;
The use of psychotropics by categories and the reason for their prescription was investigated in a large scale study of 4,069 adults with ID, including those with autism spectrum disorder, in New York State. Similar to other studies it was found that 58 % (2,361/4,069) received one or more psychotropics. Six percent received typical, 6 % received typical, while 39 % received atypical antipsychotics. There was greater use of antidepressants (23 %), mood stabilizers (19 %), and antianxiety agents (16 %) relative to other studies. The use of anti-impulsives, stimulants and hypnotics was rare (1-2 %). Half of the psychotropics were prescribed for treatment of major psychiatric disorders, 13 % for control of challenging behaviors, and 38 % for both. Results indicated that the major psychiatric disorders, except anxiety disorder and autism, influenced the use of psychotropics and the number of medication used. These findings imply that although practitioners still rely too heavily on the use of antipsychotics in this population, there is a welcome shift in the prescription patterns relative to other studies. The practitioners appeared to use psychotropics primarily to treat diagnosed psychiatric disorders and not just to control aggressive behavior which suggests that evidence-based practice of psychiatry is playing an increasing role in the ID population. [PubMed Citation] [Order full text from Infotrieve]

8) Davey Z, Schifano F, Corazza O, Deluca P
e-Psychonauts: Conducting research in online drug forum communities.
J Ment Health. 2012 Aug;21(4):386-394.
Background "Legal highs" are becoming increasingly common features of the recreational drug market. The Internet has emerged as an important resource for technical and pharmacological knowledge in the absence of evidence-based literature, and for identifying emerging trends. Self-established drug-related Internet forums have emerged as particularly useful sources of information. Aims It was the aim of this study to explore the key features of drug-related Internet forums and the drug forum communities. Methods Within the framework of the larger Psychonaut Web Mapping project, eight English-language drug forums were assessed, and key features, categories, themes and attributions were identified. Results The results are reported taking into account ethical issues, such as anonymity and confidentiality, associated with research in online communities. Conclusions This study identified strong, unified and unique communities of recreational drug users that can provide an insight into the growing market in new drugs and drug compounds, and may be key components in future research, harm reduction and prevention strategies. [PubMed Citation] [Order full text from Infotrieve]

9) Lu YY, Wei IH, Huang CC
Dental health - a challenging problem for a patient with autism spectrum disorder.
Gen Hosp Psychiatry. 2012 Jul 19;
Patients with autism spectrum disorders (ASDs) are at an increased risk for many diseases. However, little has been published about the dental health of patients with ASDs. Here, we describe the clinical presentations in a 28-year-old woman with autistic disorder. The most striking finding was the severe dental problems which had been neglected for several years. Our patient exhibited a combination of several factors that may have increased the risk of development of severe dental problem. The early recognition is still challenging to managing this unusual condition in patients with ASDs. From the experience of caring for this patient, a team of parents or caregivers, psychiatrist and dentist should be involved in maintaining oral health care of such patients with early intervention and long-term follow-up. Evidence-based behavioral management approaches for patients with ASD need to be developed to improve compliance with oral care procedures. [PubMed Citation] [Order full text from Infotrieve]

10) Fava GA
Clinical judgment in psychiatry. Requiem or reveille?
Nord J Psychiatry. 2012 Jul 23;
Background: There is increasing awareness of a crisis in psychiatric research and practice. Psychopathology and clinical judgment are often discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions. Aim: The aim of this review was to examine the clinical judgment in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy. Methods: A MEDLINE search from inception to August 2011 using the keywords "clinical judgment" and "clinimetric" in relation to psychiatric illness for articles in English language was performed. It was supplemented by a manual search of the literature. Choice of items was based on their established or potential incremental increase in clinical information compared with use of standard diagnostic criteria. The most representative examples were selected. Results: Research on clinical judgment has disclosed several innovative assessment strategies: the use of diagnostic transfer stations instead of diagnostic endpoints using repeated assessments, subtyping versus integration of different diagnostic categories, staging, macro-analysis, extension of clinical information beyond symptomatic features. Evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment. Conclusions. A renewed interest in clinical judgment may yield substantial advances in clinical assessment and treatment. A different clinical psychiatry is available and can be practiced now. [PubMed Citation] [Order full text from Infotrieve]

11) Thornicroft G
Evidence-based mental health care and implementation science in low- and middle-income countries.
Epidemiol Psychiatr Sci. 2012 May 28;:1-4.
Although the evidence base for what to do about the mental health gap in low- and middle-income countries (LAMICs) has improved significantly over the last decade, mental health care in LAMICs still provide services to only a small minority of people with mental disorders. The problem is how to translate the relevant body of scientific knowledge into routine practice. It is clear from over two decades of research that the creation of evidence-based guidelines is necessary but not sufficient for evidence-based practice, whether in high- or low-income settings. In this Editorial, I discuss whether the recent development of 'implementation science' may offer an opportunity towards effective guideline implementation in low- and medium-income settings, so that clinical practice is more often based on evidence that does lead to patient benefit. [PubMed Citation] [Order full text from Infotrieve]

12) Aakhus E, Flottorp SA, Oxman AD
Implementing evidence-based guidelines for managing depression in elderly patients: a Norwegian perspective.
Epidemiol Psychiatr Sci. 2012 May 22;:1-4.
Depression in the elderly is common and exhibits a distinctive phenomenology, due to neurobiological, physiological, psychological and social changes related to ageing. Most elderly with depression are managed in primary health care. Although the number of scientific publications related to geriatric psychiatry has increased, there are still important gaps. Implementation of evidence-based guidelines for managing depression in primary care has had limited success, but has led to improvements compared to standard care. It is logical that the determinants (barriers and enablers) of implementing depression guidelines can be identified and can guide the selection of more effective implementation strategies that are tailored to address those determinants. We are testing that logic as part of a multinational implementation research project called 'Tailored Implementation for Chronic Diseases' (TICD). Our focus in Norway is on the management of depression in the elderly in primary care. We will identify the determinants of implementing evidence-based recommendations using various methods and comparing those methods. We will then use different methods to match the implementation interventions to the identified determinants and compare those methods. Finally, we will evaluate the resulting tailored implementation strategy in a randomized trial. [PubMed Citation] [Order full text from Infotrieve]

13) Li Shen Ooi J
WINNER of YOUNG WRITER'S COMPETITION: How loud is the unquiet mind? William Sargant (1907-88) and British psychiatry in the mid-20th century.
J Med Biogr. 2012 May;20(2):71-8.
William Walters Sargant (1907-1988) is credited, for better or for worse, with putting physicalist psychiatry on the map - at the expense of the dictum primum non nocere (first do no harm). He was an outspoken supporter and practitioner of what he termed the 'practical rather than philosophical approaches' to the treatment of mental illness. This paper examines Sargant's fascinating career, beginning with the reasons behind lifelong passion for radical psychiatry, then discusses the various physical treatments he pioneered and publicized during his three decades at St Thomas' including prolonged electroconvulsive therapy, insulin coma therapy, dangerous combinations of antidepressants and, most notably, prefrontal leucotomy. His heady mix of dogma and charisma enabled him to get away with flying in the face of evidence-based medicine - but not without courting the considerable controversy and contempt that was to so blacken his reputation posthumously. This paper ends with comments on misguided and misplaced enthusiasm in the history of therapeutics, acknowledgement of Sargant's positive contributions to psychiatry and finally a reminder not to be tempted to pass post hoc judgement on the man or his legacy all too quickly. [PubMed Citation] [Order full text from Infotrieve]

14) Leentjens AF, Rundell J, Rummans T, Shim JJ, Oldham R, Peterson L, Philbrick K, Soellner W, Wolcott D, Freudenreich O
Delirium: An evidence-based medicine (EBM) monograph for psychosomatic medicine practice, comissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP).
J Psychosom Res. 2012 Aug;73(2):149-52.
[PubMed Citation] [Order full text from Infotrieve]

15) Cipriani A, Barbui C, Rizzo C, Salanti G
What is a multiple treatments meta-analysis?
Epidemiol Psychiatr Sci. 2012 Jun;21(2):151-3.
Standard meta-analyses are an effective tool in evidence-based medicine, but one of their main drawbacks is that they can compare only two alternative treatments at a time. Moreover, if no trials exist which directly compare two interventions, it is not possible to estimate their relative efficacy. Multiple treatments meta-analyses use a meta-analytical technique that allows the incorporation of evidence from both direct and indirect comparisons from a network of trials of different interventions to estimate summary treatment effects as comprehensively and precisely as possible. [PubMed Citation] [Order full text from Infotrieve]

16) Franke AG, Lieb K, Hildt E
What Users Think about the Differences between Caffeine and Illicit/Prescription Stimulants for Cognitive Enhancement.
PLoS One. 2012;7(6):e40047.
Pharmacological cognitive enhancement (CE) is a topic of increasing public awareness. In the scientific literature on student use of CE as a study aid for academic performance enhancement, there are high prevalence rates regarding the use of caffeinated substances (coffee, caffeinated drinks, caffeine tablets) but remarkably lower prevalence rates regarding the use of illicit/prescription stimulants such as amphetamines or methylphenidate. While the literature considers the reasons and mechanisms for these different prevalence rates from a theoretical standpoint, it lacks empirical data to account for healthy students who use both, caffeine and illicit/prescription stimulants, exclusively for the purpose of CE. Therefore, we extensively interviewed a sample of 18 healthy university students reporting non-medical use of caffeine as well as illicit/prescription stimulants for the purpose of CE in a face-to-face setting about their opinions regarding differences in general and morally-relevant differences between caffeine and stimulant use for CE. 44% of all participants answered that there is a general difference between the use of caffeine and illicit/prescription stimulants for CE, 28% did not differentiate, 28% could not decide. Furthermore, 39% stated that there is a moral difference, 56% answered that there is no moral difference and one participant was not able to comment on moral aspects. Participants came to their judgements by applying three dimensions: medical, ethical and legal. Weighing the medical, ethical and legal aspects corresponded to the students' individual preferences of substances used for CE. However, their views only partly depicted evidence-based medical aspects and the ethical issues involved. This result shows the need for well-directed and differentiated information to prevent the potentially harmful use of illicit or prescription stimulants for CE. [PubMed Citation] [Order full text from Infotrieve]

17) Epperson CN, Steiner M, Hartlage SA, Eriksson E, Schmidt PJ, Jones I, Yonkers KA
Premenstrual dysphoric disorder: evidence for a new category for DSM-5.
Am J Psychiatry. 2012 May;169(5):465-75.
Premenstrual dysphoric disorder, which affects 2%?5% of premenopausal women, was included in Appendix B of DSMIV, "Criterion Sets and Axes Provided for Further Study." Since then, aided by the inclusion of specific and rigorous criteria in DSM-IV, there has been an explosion of research on the epidemiology, phenomenology, pathogenesis, and treatment of the disorder. In 2009, the Mood Disorders Work Group for DSM-5 convened a group of experts to examine the literature on premenstrual dysphoric disorder and provide recommendations regarding the appropriate criteria and placement for the disorder in DSM-5. Based on thorough review and lengthy discussion, the work group proposed that the information on the diagnosis, treatment, and validation of the disorder has matured sufficiently for it to qualify as a full category in DSM-5. A move to the position of category, rather than a criterion set in need of further study, will provide greater legitimacy for the disorder and encourage the growth of evidence-based research, ultimately leading to new treatments. [PubMed Citation] [Order full text from Infotrieve]

18) Shear MK
Grief and mourning gone awry: pathway and course of complicated grief.
Dialogues Clin Neurosci. 2012 Jun;14(2):119-28.
Complicated grief is a recently recognized condition that occurs in about 7% of bereaved people. People with this condition are caught up in rumination about the circumstances of the death, worry about its consequences, or excessive avoidance of reminders of the loss. Unable to comprehend the finality and consequences of the loss, they resort to excessive avoidance of reminders of the loss as they are tossed helplessly on waves of intense emotion. People with complicated grief need help, and clinicians need to know how to recognize the symptoms and how to provide help. This paper provides a framework to help clinicans understand bereavement, grief, and mourning. Evidence-based diagnostic criteria are provided to help clinicians recognize complicated grief, and differentiate it from depression as well as anxiety disorder. We provide an overview of risk factors and basic assumptions and principles that can guide treatment. [PubMed Citation] [Order full text from Infotrieve]

19) Laborde DJ, Magruder K, Caye J, Parrish T
Feasibility of Disaster Mental Health Preparedness Training for Black Communities.
Disaster Med Public Health Prep. 2012 Jun 29;
Objectives:  To test the feasibility of developing evidence-based mental health training to build capacity to respond to natural disasters in black communities and the adaptation of a train-the-trainer (TTT) model for black community leaders and clinical providers in distressed areas at risk of natural disasters. Methods:  A core curriculum was developed based on a training needs assessment and resource review. Participants were recruited using network sampling in eastern North Carolina. The core curriculum was tested for usability, revised, and then pilot tested among five mental health providers. Three of the five were trained to lead one-day workshops tailored for black community leaders and clinical providers. Process data were collected, and workshop participants completed posttraining knowledge tests, evaluation forms, and debriefing focus groups. Results:  Ten providers and 13 community leaders pilot tested the training. Posttest knowledge scores were generally higher among clinical providers. Perceived effectiveness of training was higher among community-based organization leaders than clinical providers. Evaluations indicated that the workshop components were culturally relevant and well received by all participants. We identified ways to facilitate recruitment, provide optional e-learning, evaluate effectiveness, and extend trainer support in future field trials. Conclusion:  The curriculum and TTT model provide culturally competent disaster mental health preparedness training for black communities. [PubMed Citation] [Order full text from Infotrieve]

20) Cohen JA, Mannarino AP, Kliethermes M, Murray LA
Trauma-focused CBT for youth with complex trauma.
Child Abuse Negl. 2012 Jun;36(6):528-41.
[PubMed Citation] [Order full text from Infotrieve]