Psyber Psychiatry, Commentary
Online clinical resources: To pay or not to pay?
Free references invaluable in many clinical situations
Why pay for diagnostic, treatment, and research information when the Internet offers scores of free resources? Which free references are best, and when are they more clinically beneficial than paid information?
This article reviews select free online references and—where applicable—compares them with fee-based resources.
We often don’t look past DSM-IV-TR guidelines when forming a diagnosis. In such cases, BehaveNet’s simple yet comprehensive list of DSM-IV-TR criteria is handy (www.behavenet.com, click on “Diagnoses and criteria by category”).
For in-depth diagnostic guidelines, American Psychiatric Publishing (www.appi.org) offers its DSM-IV-TR Quick Reference for $29, and Skyscape (www.skyscape.com) offers the full DSM-IV-TR at $77. Both personal digital assistant (PDA)-based programs come in Palm OS and Pocket PC versions.
Treatment decision aids
Free drug information references such as PDR.net (www.pdr.net) and Epocrates (www.epocrates.com) can help with medication choices. Both services let you check interactions on several drugs at once, which is important when treating patients who are taking multiple medications.
PDR.net is free for U.S.-based physicians and prescribers and requires registration. Epocrates can be used without registering, but going through the free registration process will provide additional features such as medication cost estimates. For a fee, Epocrates will throw in premium features such as pill identification, clinical tables and guidelines, and medical calculators.
Both PDR.net and Epocrates offer free PDA versions (Epocrates started as a PDA-based service). Other PDA-based drug references charge for access, but in some cases the information is more comprehensive and accurate.
For cytochrome P-450 metabolism information, you could reference the metabolism sections of each drug information sheet. Alternatively:
- Indiana University offers a good free drug interaction table showing substrates, inhibitors, and inducers of CYP-450 isoenzymes (medicine.iupui.edu/flockhart).
- mhc.com/Cytochromes offers similar information and links to more CYP-450 resources.
Clinical trials. Numerous Web sites offer free access to evidence-based findings and randomized clinical trials. The National Institute of Mental Health, for example, offers free online information on:
- Sequenced Treatment Alternatives to Relieve Depression (STAR*D, www.nimh.nih.gov/healthinformation/stard.cfm)
- Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE, www.nimh.nih.gov/healthinformation/catie.cfm).
The sites describe these medication trials in a lucid question-and-answer format. Clinicians can use the study results to guide medication choices. The STAR*D site also lists percentages of treatment success and describes duration-of-treatment trials.
Online algorithms. Free drug treatment algorithms and guidelines based on literature reviews and expert consensus are available online:
- The Texas Medication Algorithm Project (www.dshs.state.tx.us/mhprograms/TMAPtoc.shtm) addresses depression, bipolar disorder, and schizophrenia treatment.
- The Harvard Psychopharmacology Algorithm Project (mhc.com/Algorithms) covers depression, schizophrenia, and anxiety in patients with substance abuse.
- The International Psychopharmacology Algorithm Project (www.ipap.org) covers schizophrenia, posttraumatic stress disorder, and generalized anxiety disorder.
Free psychiatric rating scales—such as the Patient Health Questionnaire-9 (PHQ-9, www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9)—can help you efficiently monitor the progress of patients who complete the self-report forms.
The Psychiatric Rating Scales Index (www.neurotransmitter.net/ratingscales.html) lists links to other rating scales and descriptions, and notes which scales are free and which must be purchased.
Access to clinical articles
Online abstracts. By subscribing to Medline services, academic institutions provide students and faculty access to journal articles.
If you don’t have Medline access, use the free National Institutes of Health PubMed database (www.pubmed.gov) to search for abstracts on a given topic. You can view abstracts to all types of articles or click on the “review” tab on the search results page to view only reviews.
Although abstracts are free, full-text access usually is not unless your institution has a site license for that journal or you have purchased online access to that publication. By reading the abstract, you often can tell whether the full article contains information relevant to your practice.
Evidence-based medicine. The Centre for Evidence Based Mental Health (www.cebmh.com, click on “Research”) lists links to reviews, clinical trial information, and resources for learning about evidence-based medicine. CEBMH posts references to articles but does not offer full-text access.
The Cochrane Collaboration (www.cochrane.org/reviews/en/topics/index.html) offers free online abstracts of systematic reviews of psychiatric treatments, but you need a paid subscription to access full articles.
News sites such as Psychiatric News (pn.psychiatryonline.org), Psychiatric Times (www.psychiatrictimes.com), Clinical Psychiatry News (www.clinicalpsychiatrynews.com), and Medscape Psychiatry (www.medscape.com/psychiatry) offer free full-text access to news updates and summaries of recent major papers and presentations. These summaries help you stay abreast of the literature, but they are not as detailed as the original sources.
You don’t need a subscription to request free electronic tables of contents (e-TOCs) from selected journals. Some e-TOCs list links to abstracts of all articles in the current issue.
Online clinical textbooks and journals. American Psychiatric Publishing’s online DSM Premium package (www.psychiatryonline.com) includes access to the Textbook of Clinical Psychiatry, 5 psychiatry journals, American Psychiatric Association (APA) practice guidelines, and the DSM Library. DSM Premium Plus also includes access to 3 PDA-based eBooks (DSM-IV-TR Quick Reference, DSM-IV-TR Differential Diagnosis, and APA Practice Guidelines Quick Reference). Packages cost $229 to $399 annually, depending on which package you choose and whether you are an APA member.
Open-source book technology allows users to contribute to and edit an online volume. Wikipedia (en.wikipedia.org), the prototypical open-source site, hosts a free online encyclopedia.
Giles1 in 2005 found the accuracy of science entries in Wikipedia comparable to similar entries in Encyclopaedia Britannica. Among 42 entries from both encyclopedias, researchers found on average 4 errors per entry with Wikipedia and 3 with Encyclopaedia Britannica.
One sister Wiki project, Wikibooks (en.wikibooks.org), is designed to encourage production of open-source textbooks. This has led to one fledgling psychiatry textbook (en.wikibooks.org/wiki/Psychiatry) and others soon could follow. The clinical accuracy of this Wiki-based psychiatry textbook is variable, though this could improve if more psychiatrists become involved with Wikibook peer review.
1. Giles J. Internet encyclopaedias go head to head. Nature 2005;438(7070):900-1. Available at: http://www.nature.com/news/2005/051212/full/438900a.html. Accessed February 14, 2007.