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Centre for Evidence-
Based Medicine

Introduction to evidence-based mental health

Evidence based practice in mental health

Why has it proved so difficult to narrow the gap between research and practice in psychiatry and mental health? The provision of mental health services is determined by many factors, including government policy, public demand, the behaviour of general practitioners and mental health professionals, and the financial pressures under which purchasers and providers of services work. These groups often have widely disparate views about the nature of mental disorder and the most appropriate services, and many forces exist to keep their views apart. Now is the time for a different approach based on the optimum application of the available evidence-heralded by the publication early next year of a new journal, Evidence- Based Mental Health. This approach will not provide easy answers and there will still be room for discussion about interpretation of even the very best evidence. Nevertheless, an approach that, firstly, acknowledges that mental health services should be fundamentally evidence based and, secondly, helps define what constitutes the best available evidence should clarify decision making.

The task is formidable. The public view depression as being mainly caused by life events, may be reluctant to consult their general practitioner, and believe that counselling is more effective than antidepressant drugs, which they consider to be addictive.1 Differences also exist between the views of all the disciplines working with people with mental health problems. General practitioners, psychiatrists, clinical psychologists, and mental health nurses are educated and trained in unidisciplinary structures and organisations. These professional organisations often sustain interdisciplinary rivalries. Even within the single discipline of psychiatry considerable differences exist between clinicians who subscribe to different (and often competing) schools of thought.

How much evidence is available on which to base mental health services? In fact, there is much evidence, which, although often difficult to find, is gradually being systematically reviewed by organisations such as the Cochrane Collaboration.2, 3 Psychiatry was one of the first medical specialties to use extensively the randomised controlled trial, and one of the founding principles of the profession of clinical psychology in the 1950s was that practice should be based on the results of experimental comparisons of treatment methods. Multicentre randomised controlled trials showed the effectiveness of antidepressant and antipsychotic drugs in the 1960s.4, 5 The recognition of international variations in diagnostic practice led to the development of explicit diagnostic criteria such as the Diagnostic and Statistical Manual, third edition, of the American Psychiatric Association.6, 7 Methodological innovations such as meta-analysis were first used in health care by psychologists in psychotherapy.8 Despite these undoubted advances, however, a considerable gap remains between research and practice. For example, important variations exist in the treatment of depression, in the use of electroconvulsive therapy, and in the use of stimulant medication for attention deficit hyperactivity disorder.9, 10, 11 In mental health nursing the recent increase in the amount of published research has rarely been reflected by changes in practice.12, 13 In clinical psychology it has been asserted that "in clinical practice empirically supported methods are routinely ignored in favour of intuition and clinical experience."14 Moreover, the public perception of mental health services has not kept up with advances in research and practice.1, 9 Others have argued that mental health policy has usually been influenced more by political values than evidence.15

As elsewhere, one essential ingredient required to make mental health services clinically effective is to ensure that clinicians know how to use evidence. There are many workshops aimed at helping mental health clinicians of all disciplines acquire the skills required for evidence based practice. Clinicians also need easy access to high quality evidence.16 In addition to the problems of keeping up to date common to all clinicians,17 mental health practitioners are often geographically isolated from information resources. Each discipline has its own journals which, even if read, may not contain the most important research. To improve access to the best evidence as it is published the BMJ is starting a new journal, Evidence-Based Mental Health, in collaboration with the Royal College of Psychiatrists, the British Psychological Society, and the Royal College of Nursing. Evidence-Based Mental Health will be a sister journal to Evidence-Based Medicine and Evidence-Based Nursing, and ACP Journal Club, using the same methods and the same editorial office in the health information research unit at McMaster University. The aim of the journal will be to provide all mental health clinicians with the very best information about mental health care in the form of "value added" abstracts. The first issue will be in published in February 1998 and a launch conference will be held in London on 16 February 1998.

Evidence based practice offers a way of making sure that clinical practice is based on the best available evidence. But we also need a culture change with better integration of patient values into the implementation of research and a need to go beyond professional rivalries and other barriers to provide the best available care for patients.

John Geddes, Senior clinical research fellow Centre for Evidence Based Mental Health Department of Psychiatry University of Oxford, Oxford OX3 7JX john.geddes@psychiatry.ox.ac.uk

Shirley Reynolds, Academic Course Organise Clinical Psychology Doctorate Programme School of Health Policy and Practice University of East Anglia Norwich NR4 7TJ

David Streiner, Professor Departments of Clinical Epidemiology and Biostatistics and Psychiatry McMaster University, Hamilton, Ontario, Canada Department of Psychiatry McMaster University and Center for the Study of Children at Risk Hamilton, Ontario, Canada

Peter Szatmari, Professor Departments of Clinical Epidemiology and Biostatistics and Psychiatry McMaster University, Hamilton, Ontario, Canada Department of Psychiatry McMaster University and Center for the Study of Children at Risk Hamilton, Ontario, Canada

References

  1. Priest RG, Vize C, Roberts A, Roberts M, Tylee A. Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313:858-9.
  2. Geddes JR, Game D, Jenkins NE, Petersen LA, Pottinger GR, Sackett DL. What proportion of primary psychiatric interventions are based on randomised evidence? Quality in Health Care 1996;5:215-7.
  3. The Cochrane Library [database on disk and CD ROM]. Cochrane Collaboration. Oxford: Update Software; 1997. Updated quarterly.
  4. National Institute of Mental Health Psychopharmacology Service Center Collaborative Study Group. Phenothiazine treatment in acute schizophrenia. Arch Gen Psychiatry 1964;10:246-61.
  5. Clinical Medical Research Council. Clinical trial of the treatment of depressive illness. BMJ 1965;i:881-6.
  6. Cooper JE, Kendell RE, Gurland BJ, Sharpe L, Copeland JRM, Simon R, et al. Psychiatric diagnoses in New York and London. London: Oxford University Press, 1972 Maudsley Monograph No 20).
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 3rd ed. Washington, DC: APA, 1980.
  8. Smith ML, Glass GV. Meta-analysis of psychotherapy outcome studies. American Psychologist 1977;32:752-60.
  9. Hirschfeld RM, Keller MB, Panico S, Arons BS, Barlow D, Davidoff F, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 1997;277:333-40.
  10. Pippard J. Audit of electroconvulsive treatment in two national health service regions. Br J Psychiatry 1992;160:621-37.
  11. Valentine J, Zubrick S, Sly P. National trends in the use of stimulant medication for attention deficit hyperactivity disorder. J Paediatr Child Health 1996;32:223-7.
  12. Yonge O, Austin W, Zhou Qiuping P, Wacko M, Wilson S, Zaleski J, et al. A systematic review of the psychiatric/mental health nursing research literature 1982-1992. Journal of Psychiatric and Mental Health Nursing 1997;4:171-7.
  13. McKenna HP. Dissemination and application of mental health nursing research. British Journal of Nursing 1995;4:1257-63.
  14. Wilson GT. Treatment manuals in clinical practice. Behav Res Ther 1997;35:205-10.
  15. Ham C, Hunter DJ, Robinson R. Evidence based policymaking. BMJ 1995;310:71-2.
  16. Smith, R. What clinical information do doctors need? BMJ 1996;313:1062-8.
  17. Mulrow CD. Rationale for systematic reviews. BMJ 1994;309:597-9.