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Intellectuals have a choice to make…: they can either become demagogues and treat ideas as “swords against enemies,” or they can be teachers and use ideas as “plowshares to loosen the soil of contemplative thought.” - Max Weber (in Science as Vocation, 1946)
The appellation “evidence-based” is fast becoming de rigueur in any discussion on mental health care. Judging from the variety of uses to which it is put, however, one could be excused for mistaking it as simply a way to win an argument by intimidation (“I have read the evidence, which you clearly have not!”). I was attracted to the evidence-based medicine (EBM) approach as a medical student because of the explicit and transparent approach it offered toward clinical ignorance (my own) and uncertainty (in the available knowledge base) and the relief it offered in being able to tell the 2 apart! Since then I have turned to this approach often in my practice of clinical psychiatry, both as a way to make decisions in the face of considerable uncertainty and as a framework to teach about how to use population data for individual patient care. In this latter task, I have found Evidence-based mental health care to be an excellent resource.
This book is based on the authors’ course for mental health clinicians at the University of Auckland. This is a “How to do EBM” book pitched at clinicians from various professional backgrounds (eg, nursing, social work) in addition to traditional psychiatry and psychology trainees. Despite this introductory intent, however, I have found it to be a useful supplement for a course I teach to US psychiatry residents. Other useful books in this category include the deceptively titled Concise guide to evidence-based psychiatry (GE Gray. American Psychiatric Association, 2003), which is better suited as a reference, and Practising evidence-based mental health (J Geddes et al. Radcliffe Medical Press, 1999), which is a collection of worked through examples of appraisal that can serve as a companion to this book.
The introductory chapter takes a clear-headed approach to making the case for learning the skills for “research-enhanced health care,” the authors’ preferred term for EBM. The authors highlight the value of these skills for a process of transparent decision making, which sets the tone for the rest of the book.
The chapters follow the overall structure of previous classic EBM manuals by Sackett et al and Guyatt & Rennie, with examples drawn from psychiatric practice. Chapters on formulating questions and searching the mental health literature are followed by several chapters devoted to appraising various study designs for questions about treatment, prognosis, and risk. The chapter on appraisal would have benefited from tools to calculate confidence intervals when these are not reported in the paper to be appraised. For example, I recommend Rod Jackson’s GATE spreadsheets (www.epiq.co.nz) or the JAMA users’ guide website (http://pubs.ama-assn.org/misc/usersguides.dtl) to trainees. Notable additions to the usual format are chapters on appraisal of diagnostic scales in psychiatry and qualitative research.
Two chapters are notable strengths of this book. The first titled “What to do if there is no evidence” starts by acknowledging what most clinicians turn to in this situation (experience, instinct, or pathophysiological theory), offers a concise discussion on the risks of common heuristics that are most likely to get us in trouble when left unexamined (the EBM equivalent of the Freudian “unconscious”?), and launches into a detailed discussion of 2 possible approaches to this conundrum: n of 1 randomized trials and decision analysis. While the first has limited applicability in psychiatric conditions (the authors use methylphenidate in the treatment of ADHD as 1 example) and the second is a Herculean task of its own, the exercise of working through the examples in the book is valuable instruction in the process of transparent decision making.
The final chapter titled “Putting it all together—practicing evidence-based mental health care” is one I have come to rely on in presenting to trainees on continuing professional development or—as the authors like to put it—a SMART (Specific, Measurable, Achievable, Realistic, and Timely) way to keep up to date. Practical suggestions, based on tactics used in behavioural therapies, are offered to help practitioners develop and sustain a reading habit that is also humane. Notable omissions from this chapter and the chapter on searching the literature are the secondary journal Evidence-Based Mental Health (EBMH—http://ebmh.bmj.com/) and the e-mail alerting service BMJupdates+ (http://bmjupdates.mcmaster.ca/index.asp) that can help practitioners keep up with the avalanche of clinical publications.
This book succeeds remarkably at conveying the process of EBM guided decision making in a deceptively slim volume of 156 pages that can be read from cover to cover or dipped into selectively. The primary focus of this book is to introduce EBM to trainees, and it is probably best used as a supplement to a workshop, journal club, or other didactic activity that includes active participation in clinical problem solving. The book also serves as a clear introduction for more experienced mental health clinicians from various disciplines who wish to apply EBM principles in their clinical practice.
Brevity is an important accomplishment in such a manual. Packed in are useful tables and graphics (eg, a nifty visual tool for understanding and communicating numbers needed to treat) and targeted references. The tone is pragmatic but refreshingly irreverent with historical examples of past excesses in the field (eg, the notion of “schizophrenogenic mother” and prefrontal lobotomies). This book is a welcome tonic for evidence-based sword-brandishing and provides many ideas worthy of contemplation by teachers and their students.
Clinical usefulness ★★★★★
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