Practice-Based Evidence Rather Than Evidence-Based Practice in Psychiatry

David J. Hellerstein, MD


June 16, 2008


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Physicians are barraged with demands to implement evidence-based practices (EBP).[1] Hesitate and you risk being labeled as part of the medical axis of evil. Some resisters may favor "superstition-based practice." Not me. But, I do believe that the evidence that evidence-based practice works in actual practice often isn't good enough.

Some EBP recommendations make good sense. Give depressed patients a full trial of antidepressant medication -- OK, I can do that. Others are difficult to impossible. How do I find a local practitioner of interpersonal psychotherapy? It may work, but hardly anyone does it. The same for many psychiatric EBP recommendations, such as frequently measuring BMI and lipids in schizophrenics.[2]

Efficacy studies supporting such recommendations are often done in academic settings, then extended in real-world "effectiveness" trials. Unfortunately, much such work is shelved, or done halfheartedly. Often EBPs contain unfunded mandates -- great ideas requiring resources you don't have. Practitioners may be justified in skepticism.

Rather than more EBP, what we really need is what has been called PBE -- practice-based evidence.[3] High-quality scientific evidence that is developed, refined, and implemented first in a variety of real-world settings.

My recommendations:

  1. Use real-world practices as laboratories for developing effective treatments.

  2. Revive quality improvement as an academic discipline[4] since QI projects are perfect models for PBE.

  3. Develop modular treatments that can be incorporated into existing practices.

  4. Use online technologies to the fullest -- for collecting effectiveness data; training providers; educating patients; and for testing, monitoring, and rewarding effectiveness.

Eventually we will have PBE -- practice-based evidence. I'll be first in line to apply it!

That's my opinion. I'm Dr. David Hellerstein, Associate Professor of Clinical Psychiatry at Columbia University in New York.




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