March 26, 2013

The public needs to know, and to demand change

There is an enormous conflict going on in the therapy world and the public needs to know.

More effective methods exist for depression and anxiety and eating disorders but the public isn't sophisticated enough to know the difference and they are unlikely to be told this by the very people they consult.

We need to support the clinicians who ARE offering evidence-based approaches. We need to find ways to make sure patients have access to those clinicians who understand that "evidence-based" is NOT a cookie-cutter attitude. Those who criticize the call for evidence are, in my experience, the ones most likely to simply not understand the difference.

It is time to call this out, to speak plainly.

Harriet Brown's piece in yesterday's New York Times is an important one, and I applaud her and the Times and all those quoted for bringing uncomfortable stuff into the light. I know some folks (read the comments) will be unable to understand and will do so with great vehemence but if the public knows the difference and clinicians start holding colleagues accountable we can really move forward.

8 comments:

  1. Thanks, Laura! I respect you, Harriet, and everyone who takes this important issue on, you are very brave. Of course, it helps to remember that what we are really after here is to demand effective treatment for our loved ones, who (so often) cannot demand it for themselves.

    I wanted to bring your attention to this recent study in The Lancet. This is what RCT looks like when it is done well- randomization, in a primary care setting, with good adherence and retention across the groups. Still not perfect, the study lacked a blinded control intervention; subjects knew which group they were in and this could have influenced their responses to the questionnaires. Nevertheless, we should demand more of this kind of study for eating disorders and all mental illnesses. We also should demand effective training for practitioners so they know how to use this information for the benefit of their patients. Hopefully the English NHS will use these results to make good on their promise: "no health without mental health".

    Lancet. 2013 Feb 2;381(9864):375-84. doi: 10.1016/S0140-6736(12)61552-9.
    Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial.

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  2. I'm a little confused by Harriet's piece - I think she does wonderful work in general, but the article seems a bit short-sighted. In all areas of medicine, mental health or no, it is well-known that RCTs deal with idealized patient populations (usually), and medicine does involve a large amount of art in determining what exactly a particular patient needs and integrating the various RCTs to come up with recommendations for a particular patient. I don't think having an "eclectic" approach means anything - it could signify a clinician with excellent training in many evidence-based modalities or a clinical with no training at all. For a patient with borderline personality disorder, generalized anxiety disorder, OCD, and anorexia (not at all an impossible combination), a combination of DBT, CBT, EXRP, and FBT seems entirely appropriate to me, even though it is somewhat "eclectic" and combines various therapies. There is also a large amount of art in performing a particular therapy well, and there is lots of evidence showing that the relationship does indeed matter. I guess what I am saying is that even for someone who believes fully in the important of evidence-based practice in mental healthy, the article came off as maybe a bit narrow-minded. Which I don't think Harriet is, but somehow the article just didn't seem to pull together in the right way, and I understand why some of the comments are there.

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  3. It's all about context, here.

    The context of a piece like that, in my opinion, is that the public has NO IDEA what they are being offered or why. Patients and their families can't be expected to realize that what they are offered may be based on something solid or something completely inappropriate.

    I don't think the article is saying, nor would I, that treatment for individuals should be done out of books and limited to only what has been studied and supported by the literature. The idea is that if you are treating mental illness you should be able to offer evidence-based approaches and be skilled at knowing when and how to innovate. Most of the psych field isn't doing that, and resists it.

    The opposite of evidence-based decision-making is myth-based decision making. It's about having a compass, not a rigid path.

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  4. I agree with the second anonymous... while I fully agree with the intention of the article, I think maybe it did not explain what an evidenced based approach means very well and I think it reads very one-dimensional. I have now re-read the article several times, trying to get a different feel for it, but it keeps leaving me with a bad feeling. Now, I actually think I agree whole heartedly with what HB means, but I don't think the article explains it very well

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  5. What the...? According to the film, 'Miss Representation,' 65% of women have an ED? Even with EDNOS (sorry, can't stomach the acronym, "FEDNEC") and BED that is crazy! I heard someone quote 25% - possibly not including BED but maybe she was including it - and thought THAT was nuts. Where are they getting these stats?

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  6. Weather, I'm with you in apoplexy about the inflated stats. Why do people think EDs need high rates, or growing rates, to be urgent? I don't need that: I don't want ONE patient to be unwell and I think the anguish of an eating disorder is worth caring about no matter what the prevalence.

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