1. Evidence-Based Psychiatry in clinical care and community health programs and policies Misconceptions, achievements and future directions Milos Jenicek XLIII National Congress of the Italian Society of Psychiatry Bologna, October 19-24, 2003

2. Medicine may be Belief - based (BBM)Subjective experience Claim-based (CBM)Authority-enforced (Serious MDs, most of ACMs) Understanding-based Laboratory, (UBM) paraclinical world (mechanisms) Reality-based (RBM)Epidemiology and also Evidence-based (EBM)

3. Evidence-Based Medicine (EBM) is the integration of l best research evidence with l clinical expertise and l patient values

4. Evidence-based Medicine and Evidence-based Public Health ‘… a way to obtain the best evidence, knowledge and experience, and to apply them to clinical and community health problems in conjecture with patient and community preferences and values...’

5. An evidence-useful question Intervention:Does the bupropion therapy Outcomes:diminish the yearly frequency and severity of clinically important depression episodes Population setting:in older patients Condition suffering from a bipolar of interest:affective disorder?

6. An evidence-nebulous question ‘ What is the role of tricyclic and clinically similar compounds in the treatment of mood disorders?’

7. Hard and soft data in psychiatry l Soft data:Symptoms (mood), findings from qualitative research, psychoanalytical observations l Hard data:Paraclinical findings (serum lithium levels), any other measurable and quantifiable findings

8. Steps in evidence-based process l Evidence retrieval l Evidence evaluation l Application to a particular patient in a specific clinical setting l Evidence implementation and uses in daily practice l Evaluation of the evidence-based psychiatric care itself

9. Cause-effect link oversimplifications l P-values as substitute for causation. l Biological plausibility as substitute for causation. l Singular case or case series experience. l Any other case of unspecified experience. l Authoritarian raising the voice in a clinical argument.

10. Attention to logic and critical thinking in psychiatry l Obtaining good evidence does not mean yet using it properly l Logical uses of evidence are essential in daily practice (e.g., assessment of patient structure of thought) l Research discussion and results interpretation rely on flawless reasoning

11. Logic in medicine ‘System of thought and reasoning that governs understanding and decisions in clinical and community care.’ It defines valid reasoning, which helps us understand the meaning of medical phenomena and leads us to the justification of the choice of clinical and paraclinical decisions about how to act upon such phenomena.

12. Critical thinking ‘A process, the goal of which is to make reasonable decisions about what to believe and what to do.’ Or: ‘The ability to solve problem by making sense of information using creative, intuitive, logical and analytical mental process.’

13. Priorities for health programs and community interventions Health problem must be- frequent - serious - controllable Intervention must be- feasible

14. Priority of any health program is a product of Disease occurrence (incidence,prevalence, duration) Clinical importance (disease severity, i.e. gradient and spectrum) Controllability (effectiveness of intervention) and Operational considerations (population proportion which can be reached by the program)

15. Information necessary for primary prevention l Risk factors as causes l Data on risk factors and disease occurrence available before and after intervention l Disease natural history and course l Effective intervention as prevention modality l Program effectiveness confirmed by a systematic review of evidence l Program choice confirmed by decision analysis

16. Information necessary for secondary prevention The same as for primary prevention, plus: l Risk markers l Prognostic markers and factors l Natural history of the disease l Clinical course of the disease l Effective outcome modifying intervention (continued)

17. Information necessary for secondary prevention The same as for primary prevention, plus: l Baseline clinical data l Outcome data l Program effectiveness confirmed by a systematic review of evidence (meta-analysis) l Program choice confirmed by decision analysis (end)

18. Information necessary for tertiary prevention Same as for the secondary prevention plus: l Disease auxometry (measured by the evolution of disease gradient and spectrum) is known and available for the program l Program effectiveness confirmed by a systematic review of evidence (meta- analysis) l Program choice confirmed by decision analysis

19. Achievements of psychiatry from the EBP view l Psychiatric fundamental and clinical epidemiology as reality of life l Refinement of soft and hard data in diagnosis (DSM IV - TR) l Controlled clinical trials overcoming challenges of soft data

20. Future directions for psychiatry from the EBM point of view l Be broad-minded in judging evidence l Get the best evidence available l Use it l Evaluate the effectiveness of EBP l Train others how to do it l Improve your logic and critical thinking in clinical practice and community mental health

21. Do we have other alternatives than EBP? ‘It has been said that Evidence-based Psychiatry is the worst form of approach to mental health problem-solving except all those other alternatives that have been tried from time to time.’ ‘Two cheers for Evidence-based Psychiatry: one because it admits variety and two because it admits criticism.’