Clinical Wisdom Versus Evidence-based Treatment
Developments in translational neuroscience offer hope for the future, but psychiatry still relies more on skilled clinical observations than laboratory tests.
Richard J. Metzner, M.D.
Clinical Professor
Semel Institute for Neuroscience and Human Behavior at UCLA
Founder, DepressionConsultant.com
The MRIs, CAT scans and lab studies that guide so many other treatments are of benefit in psychiatry mainly to confirm that the services of other specialties are required. The listening and watching skills that must be honed in psychiatric training are necessary to gather our most essential data: the verbal and non-verbal behaviors of patients. Clinical wisdom in psychiatry consists of matching what we see and hear with what we know and then using our own verbal and non-verbal skills to implement and manage effective pharmacological and psychotherapeutic treatments.
The quest to find out what treatments works best has given rise in psychiatry to the pursuit of evidence-based treatments. To qualify as evidence-based, a treatment must prove effective in placebo-controlled, double-blind studies, where the biases of practitioners and patients have minimal influence over outcomes. To be optimally useful such studies must replicate naturalistic clinical settings and determine objectively which interventions are most effective in those settings. Unfortunately, the purely scientific values that could produce studies of this kind are severely compromised by the limitations of real world research. Most of the evidence about pharmacological treatment has been derived from studies funded by the pharmaceutical industry. It falls upon the U.S. Food and Drug Administration to regulate the drug industry and ensure the safety and effectiveness of its products. Yet while the research protocols mandated for bringing medications to market may have protected against the biases of practitioners and patients, they have enabled the more insidious biases of the companies paying for the studies to influence published results.
A corrupted evidence base poses serious problems. While her own biases against psychiatry are no secret, Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine stated credibly: "I have spent most of my professional life evaluating the quality of clinical research, and I believe it is especially poor in psychiatry." It may be that until the psychiatric research establishment finds ways to fund its pharmacological studies without corrupting or corrupted influences, clinicians are going to have to depend on some of the conclusions that derive from empirical observation and logical deduction in real world psychiatric settings.
As clinicians, our brains may not have the power of computers to crunch numbers, but they are perfectly matched to the brains of the patients we are treating. Mirror neurons give us an unbeatable edge in apprehending what our patients are feeling. Years of experience matching medications to what we observe may constitute an evidence base lacking in rigorous controls, but it offers some advantages to patients. The evidence-based remission rate for initial antidepressant treatment with citalopram in the STAR*D Study was 27.5% (HDRS). Clinicians matching antidepressants to patients (TTDI Study) showed a superior initial remission rate of 65.2% (convergent validity with HDRS= P<.01).
In the long run clinical wisdom will always be subject to confounding biases that require validation by objective scientific research. Without randomized controlled studies we can never know with certainty what is and is not effective for our patients. Nonetheless, until those studies are done as they should be, the wisdom of the concerned clinician armed with the best treatments at hand is all that may transform relentless depression into lasting recovery.
Copyright 2012, Scaled Psychiatric Systems, Inc. All rights reserved