Introduction to Evidence Based Psychiatry. Chapters 1 and 2.

1. INTRODUCTION TO EVIDENCE BASED PSYCHIATRY
CHAPTERS 1 & 2
SIU-School of Medicine
Franklin Alier, MD
PGY-2, Psychiatry

2. INTRODUCTION TO EVIDENCE-BASED MEDICINE (CHAPTER 1)
 The phrase “Evidence Based” has appeared with increased frequency in psychiatric literature.
 Despite the increased use of the term, even leaders of American psychiatry appear unfamiliar with the
methods and philosophy of Evidence-Based Medicine.
 They may believe it is associated with “cost-cutting” or “cookbook medicine”.
 So what is it?

3. INTRODUCTION TO EVIDENCE-BASED MEDICINE
 Over the past few years evidence has suggested, that there is a significant gap between the knowledge
acquired from clinical trials regarding effective treatments for mental disorders and the actual treatment
of patients in clinical practice.
 This occurs in other specialties as well where clinical practice often lags behind research findings.
 40% of clinical decisions were unsupported by evidence from the research literature.

4. WHAT PROBLEMS LEAD TO SUBOPTIMAL CARE
 Information overload: Clinicians want to determine which treatments are truly most effective. There are
thousands of medical journals and millions of articles. This means that nobody (providers) can expect to
keep up with all of the developments in their field.
 Textbooks being out of date: Leads to clinical practice lagging behind the research.
 When reviewing results of research studies, information can appear contradicting (false positive results,
false negative results, consulting a review article which is subject to the author’s bias)
 Uncritical acceptance of available information: Over-reliance on one’s own clinical experiences,
excessive influence of pharmaceutical companies etc.
 Critics of evidence based medicine: State that EBM devalues clinical judgement as well as the “art” of
medicine.

5. PHILOSOPHY OF EVIDENCE BASED MEDICINE
 Evidence based medicine is “Partly a philosophy, partly a skill, and partly the application of a set of
tools.”
 It’s been defined as: The application of a knowledge of medical informatics and clinical epidemiology to
the treatment of individual patients.
 Involves the integration of best research evidence with clinical expertise and patient values.
 EBM allows the clinician to integrate research evidence, patient preferences and clinical state in making
decisions about patient care.
 Rather than being “cookbook medicine” it empowers the clinician to make their own decisions, guided
by the best evidence to support those decisions.
 EBM also places emphasis on patient preferences and values, and encourages patient-centered care.

6. DEVELOPMENT OF EBM AND PSYCHIATRY
 In this new philosophy of EBM, clinicians would rely heavily on the medical research literature rather than
textbooks and tradition. (Published in journal of the AMA, ACP Journal Club, Journal of American Board
of Family Practice)
 Issues with Psychiatry: Misunderstanding of EBM by mental health professionals and the belief that their
patients’ individuality and the non-quantifiable aspects of psychotherapy would preclude the application
of EBM to psychotherapeutic interventions.

7. THE 5-STEP EBM MODEL (CHAPTER 2)
 Step 1: Formulate the Question.
 Question may involve the issues related to the diagnosis, treatment, prognosis or etiology of the illness.
 Question is formatted to include a patient problem, diagnosis, treatment, diagnostic test, risk factor,
prognostic factor and outcome of interest.
 Step 2: Search for Answers
 Find an answer in the literature. Assessment of the type of evidence that is most appropriate for
answering the questions as well as the actual search for the evidence.

8. THE 5-STEP EBM MODEL
 Step 3: Appraise the Evidence
 After you find the article, appraise its validity and importance before applying the results.
 Decide whether the results can be applied to your particular patient in your setting.
 Step 4: Apply the results to your patient
 Assuming the evidence is valid, important and applicable, and feasible in your setting, the next step is to
apply the care of your patient which is where clinical expertise is most important.

9. THE 5-STEP EBM MODEL
 Step 5: Assess the Outcome
 Evaluation of your performance in searching the literature, finding an answer, an assessment of the
patient’s response to your treatment.

10. SHORTCUTS
 You do not need to go through the entire 5 step process for every patient encounter.
 The answer found for one patient can be applied to other similar patients.
 Will usually be the exceptional patient that triggers application of the full 5 step process.