Transcript Evidence-Based Psychiatry: An Introduction

John M. Diamond, MD
Professor and Head, Division of
Child and Adolescent Psychiatry
Brody School of Medicine at
East Carolina University
EBM is a term used and misused
Isn’t medical “science” all about evidence?
Why the controversy recently about
mammograms?
Example of treating corneal abrasion
Gap between knowledge from clinical trials and
actual treatment
Practice often lags years behind research
findings
Studies are in progress, results presented,
published, disseminated, but what causes a
change in practice?
Surveys in academic centers found up to 40% of
clinical decisions unsupported by research
evidence (power of “experience”)
Information overload, with thousands of
journals and millions of articles
Small studies are often contradictory
Many false positives and false negatives
Review articles are often narrative, and not
systematic
Over-reliance on experience, expert opinion,
and results from single studies
Excessive influence of pharmaceutical
companies
Partly a philosophy, partly a skill, partly the
application of a set of tools
“The conscientious, explicit, and judicious use
of current best evidence in making decisions
about the care of individual patients…involving
the integration of best research evidence with
clinical expertise and patient values.1
Emphasis on patient preferences and values
1Sackett, DL (2000): Often known as the “father” of EBM
Double blind placebo controlled studies
Appropriate dosing
Intention to treat
Random selection
Beware of bias of reporting only positive
results--need for good replications
There are levels of evidence, including
experience, but that is the lowest level
Diagnosis by symptoms: sadness; worries;
moodiness; activity level
Diagnosis by medication response
Polypharmacy: two meds of one class, multiple
meds focusing just on symptoms and side
effects
Reliance on expensive, new medications
Childhood Bipolar Disorder
Reactive Attachment Disorder
ADHD--Stimulants
OCD--SSRIs, clomipramine
Enuresis--imipramine, DDAVP
Depression—fluoxetine, escitalopram
Tourette’s Disorder--pimozide, haloperidol
Bipolar Disorder--risperidone (10-17), aripiprazole
Psychotic Disorder--risperidone, aripiprazole,
haloperidol
Autism--risperidone
Cognitive-Behavioral Therapy for Depression,
Anxiety, OCD
Parent Training/Education for disruptive
behaviors
Stimulant medication for ADHD