Evidence vs experience
Concerning the role of “evidence” in psychiatric practice (“Are psychiatrists more evidence-based than psychologists?” From the Editor, Current Psychiatry, December 2009,), my question is whether psychiatrists who consider themselves evidence-based achieve better clinical results than those who do not. I suspect there is no significant difference. Of course, this question will never be answered to Dr. Nasrallah’s standards. No pharmaceutical or insurance companies are interested enough because, with the mediation of psychiatric thought leaders, they have succeeded in redefining the nature of and criteria for evidence. They now own it. To what degree it strongly pertains to the real world is an open question.
As a psychiatrist with several decades of experience who works on the front lines, I am leery of the growing biomedical depersonalization and algorithmic regimentation of treatment. I am less optimistic about the kind of progress implied in Dr. Nasrallah’s editorial. I do not believe it is his place to tell colleagues how they should practice. Psychiatric treatment mostly occurs in the context of a one-to-one relationship, and evidence generated by the research industry must be scrutinized according to the individual patient’s exigencies and factors affecting the patient’s life and clinical condition. This is a process of clinical judgment, which integrates not only the narrowly defined, research-based evidence Dr. Nasrallah mentioned but also a psychiatrist’s experience, which there appears to be little place for in psychiatry’s brave new world. It may be that psychologists maintain a certain clinical advantage over psychiatrists in this regard.
Edmond Zeldin, MD
Dr. Nasrallah responds
I welcome Dr. Zeldin’s critical remarks. As a clinician, I too value my more than 3 decades of clinical experience, but as a researcher I also recognize that it is insufficient to provide optimal care. On the first page of Dr. Gregory Gray’s book Evidence-based psychiatry,1 the first heading states “Clinical practice is not always evidence-based.” Dr. Gray says that evidence-based medicine (EBM) is “the application of a knowledge of medical informatics and clinical epidemiology to the treatment of individual patients and involves the integration of the best research evidence with clinical expertise and patient values.”
The EBM concept was initiated by D.L. Sackett et al in 1996,2 not by pharmaceutical companies. However, all drug companies must conduct strictly evidence-based clinical trials (double-blind, placebo-controlled, and sufficiently powered sample size) on experimental drugs before these agents can be approved by the FDA. The large FDA studies conducted by industry are part of EBM that are adopted in clinical practice. However, some non-FDA drug company studies are self-serving and not evidence-based.3
I recently reviewed 237 meta-analytic studies in schizophrenia,4 and only 30 of those studies address pharmacology. Other meta-analyses included: genetics (58 studies), cognition (38), neuroimaging (23), psychopathology (22), psychosocial therapies (19), neurophysiology (13), epidemiology (12), neurochemistry (8), development (7), and post-mortem (3). Those meta-analytic studies sift through thousands of published papers and help provide part of the “evidence” in schizophrenia. Similar meta-analyses are conducted for all psychiatric disorders.
Finally, I did not instruct readers that they must practice in an evidence-based manner. However, I implied that many patients are not receiving effective evidence-based care in both psychotherapy (by psychologists) and psychopharmacology (by psychiatrists). Many clinicians practice “experience-based medicine” or “eminence-based medicine,” but I believe EBM should be the basic framework into which we integrate our clinical experience or expert opinions to provide optimal care for our patients.
Henry A. Nasrallah, MD
1. Gray GE. Concise guide to evidence-based psychiatry. Arlington, VA: American Psychiatric Publishing, Inc; 2004.
2. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.
3. Heres S, Davis J, Maino K, et al. Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics. Am J Psychiatry. 2006;163:185-194.
4. Nasrallah HA. Meta-analysis trends in schizophrenia over three decades. Schizophr Res. 2009;108:1-2.