From the Editor
Are psychiatrists more evidence-based than psychologists?
One survey found that only 15% of respondents with serious mental illness received care that was considered at least minimally adequate
A recent psychology journal article lambasted clinical psychologists for not using evidence-based psychotherapeutic modalities when treating their patients.1 The authors pointed out that many psychologists were ignoring efficacious and cost-effective psychotherapy interventions or using approaches that lack sufficient evidence.
An accompanying editorial2 was equally scathing—calling the disconnect between clinical psychology practice and advances in psychological science “an unconscionable embarrassment”—and warned that the profession “will increasingly discredit and marginalize itself” if it persists in neglecting evidence-based practices. The author quoted the respected late psychologist Paul Meehl as saying “most clinical psychologists select their methods like kids make choices in a candy store” and added that the comment is heart-breaking because it is true. A Newsweek column—“Ignoring the evidence: Why do psychologists reject science?”3—elicited little agreement and mostly howls of protest from psychologists.
So, are psychiatrists more evidence-based than psychologists? We manage patients who are more severely ill than those seen by psychologists, and we use both pharmacotherapy and psychotherapy to stabilize neurobiologic disorders. Because only 15% of DSM-IV-TR diagnostic categories have an evidence-based, FDA-approved drug treatment,4 we practice by necessity a substantial amount of non-evidenced-based (off-label) pharmacotherapy. But what about psychiatric conditions for which evidence-based treatments exist? Do studies show that we follow the evidence?
Psychiatrists’ track record
The Schizophrenia Patient Outcomes Research Team5 assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.
A study using data from the National Comorbidity Survey6 found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.
Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia7 showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.
Who is evidence-based: A self-assessment
Are YOU an evidence-based psychiatric clinician? Ask yourself:
- Can I correctly define evidence-based psychopharmacology?
- Do I regularly read systematic reviews (such as Cochrane reviews) or meta-analytic articles about the medications I prescribe?
- Can I cite at least 1 randomized controlled trial supporting my use of each medication I prescribe?
- Do I know what “effect size” means?
- Do I usually or sometimes select a psychotherapeutic agent based on number needed to treat (NNT) or number needed to harm (NNH)?
- Do I routinely use clinical rating scales employed in FDA controlled trials to quantify the severity of my patients’ illness and determine whether they achieve “remission” or just a “response”?
Psychiatric practice should be evidence-based and continuously adapt to incorporate the wealth of evidence being generated. Psychiatrists who do not keep up with the evidence run the risk of practicing psychopharmacology of the previous millennium.
1. Baker TB, McFall RM, Shoham V. Current status and future prospects of clinical psychology: toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest. 2009;9(2):67-103. Available at: http://www.psychologicalscience.org/journals/pspi/inpress/baker.pdf. Accessed November 10, 2009.
2. Mischel W. Connecting clinical practice with scientific progress. Psychological Science in the Public Interest. 2009;9(2). Available at: http://www.psychologicalscience.org/journals/pspi/inpress/baker.pdf. Accessed November 10, 2009.
3. Begley S. Ignoring the evidence: why do psychologists reject science? Newsweek. October 12, 2009. Available at: http://www.newsweek.com/id/216506. Accessed November 10, 2009.
4. Devalupalli KK, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian Journal of Psychiatry. 2009;2(1):29-36.
5. Lehman AF, Steinwachs DM. Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Schizophr Bull. 1998;24(1):11-20.
6. Wang PS, Delmer O, Kessler RC. Adequacy of treatment for serious mental illness in the United States. Am J Public Health. 2002;92(1):92-98.
7. Young GJ, Mohr DC, Meterko M, et al. Psychiatrists’ self-reported adherence to evidence-based prescribing practices in the treatment of schizophrenia. Psychiatr Serv. 2006;57(1):130-132.