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

The Role of Cochrane in Evidence-informed Health Services Reform

Cochrane is Cochrane, a fact that is understood by academic researchers. However, in the wider society and the media, these inevitably conservative findings that fail to draw on the complete body of evidence may be misconstrued. This could undermine public confidence in the value of urgently needed policy reforms and put them, and consequently large numbers of young patients, at continued risk of delayed and substandard care as offered by the status quo.[22] Just as there are risks of impulsive policy decisions, there are also risks of extreme conservatism. Lack of sufficient scientific evidence can facilitate poor clinical practice; however, excessive conservatism contributes to the long delays in implementing evidence in clinical practice. While different views must always be heard and typically be respected, we now know that some scientific colleagues are willing to misuse the EBM paradigm and spread doubt where it should not exist.[23] We must be vigilant to identify this phenomenon when it is occurring in psychiatry.

Finally, a recent Cochrane review on the effects of dietary salt intake[24] produced negative conclusions, which have been challenged by many other experts and policy makers, as revealed in a compelling recent BBC radio debate.[25] The lead author of the salt review, Professor Rod Taylor, subsequently qualified the negative review's conclusions. His reasons? The review excluded evidence, and when the full body of evidence was considered a quite different, conclusion was the only reasonable one to embrace. In fact, Cochrane methodology had forced a prematurely negative conclusion. The Cochrane EIP reviewers may be thinking the same way as Professor Taylor because the conclusions of their commentary reveals as much support for the future of EIP as they could manage within the Cochrane constraints. Cochrane clearly still has substantial value, especially in the evaluation of individual treatments; however, it should not address itself to policy decisions on health system reform unless it finds a way to include other forms of relevant evidence. In applying an evidence-based approach in the here and now of policy-making, the jury on health services reform should consider its verdict based on the balance of probabilities and informed by the best available evidence from all sources and not require a unanimous, beyond all reasonable doubt verdict, based on an excessively narrow band of admissible evidence. This is the only feasible approach to EBHC and progress in mental health reform. The alternative is paralysis or impulsive and desultory "reform."