At Issue

Cochrane, Early Intervention, and Mental Health Reform

Analysis, Paralysis, or Evidence-informed Progress?

Patrick McGorry


Schizophr Bull. 2012;38(2):221-224. 

In This Article

Evidence-based Health Care

Evidence-based medicine (EBM) originally referred to "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."[4] However, it was soon widened to apply to population health and health care systems. "We call the new approach EBM when applied by individual clinicians to individual patients and evidence-based health care (EBHC) when applied by public health professionals to groups of patients and populations."[5] This is a crucial distinction. The Cochrane collaboration is the principal database for EBM, producing reviews of randomized clinical trials (RCTs). The RCT, developed to judge the efficacy of individual treatments, remains, despite its limitations, an essential element in clinical research strategy. Its inherent conservatism provides a reassuring antidote to the potential in psychiatry for pursuing "great and desperate cures"[6] that prove to be useless or harmful, though excessive conservatism may also have negative effects. The RCT also has a place, though inevitably much less central, in health services research and EBHC. Crucially, however, the same design standards that were derived for RCTs of individual treatments cannot be simply translated to service level trials, though this is routinely done, including in the Cochrane EIP review. Furthermore, a key question we must answer is what is a valid yet realistic basis for making decisions in mental health reform, in a context of widespread gaps, poor access, and poor quality of care? And where should the onus of proof lie? Should substantially higher standards be applied to proposals for change than for continuing an evidence-poor status quo, when the latter is performing poorly or failing?