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 1 Sackett, 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