Electronic Letters to:
|
|
eLetters: Electronic letters published:
-
![[Read eLetter]](/icons/misc/sectionDOWN.gif)
Nature of Evidence in Evidence-Based Medicine
- Prakash Gangdev, & Consultant Psychiatrist,, Regional Mental Health Centre, London ON, Canada (19 February 2009)
|
|
|||
|
Prakash Gangdev, Psychiatrist Associate Professor, Dept of Psychiatry, University of Western Ontario, & Consultant Psychiatrist,, Regional Mental Health Centre, London ON, Canada
Send letter to journal:
Prakash.Gangdev{at}sjhc.london.on.ca Prakash Gangdev, et al.
|
Professor Parker's editorial 1 not only argues against summary discrediting of the antidepressants, but also raises an important question. What is the nature of evidence that forms the basis for Evidence -Based Medicine? Randomized Controlled Trial (RCT), the gold standard for 'evidence’ is fraught with problems as discussed by Parker 1. If the broad DSM-based approach is uncritically used, it is likely to lead to a heterogeneous group of disorders with differing etiologies and treatment response. Thus, RCTs, at least in psychiatry, may enable us to do the things right, but not necessarily do the right thing. A number of confounders need to be addressed in patients with depression. The distinction of melancholic from non-melancholic depression is also, apart form being difficult, quite complex, in that a life event- induced non-melancholic depression may evolve into melancholic depression, and a melancholic depression may be accompanied by psychological sequel (read non-melancholic depression) arising form a) psychosocial stressors that may be a result of being depressed (melancholically) and b) the psychological meaning of having anhedonia and the loss of functioning. Furthermore, mild melancholic depression may be missed if it happens to co -exist with non-melancholic depression. The issue of spontaneous remission, and the unstated axiom that a patient with Bipolar Disorder can only have Bipolar Depression and no other, are additional problems. The presence of psychosocial determinants/consequences calls for appropriate psychosocial interventions, and may perhaps explain the prolonged/'treatment-refractory' depressions. In effect, it means that just like antidepressants, even psychosocial interventions could end up being discredited if applied as a matter of routine.. The converse may also be true both for pharmacotherapy and psychosocial interventions. For example, based on the axiom mentioned above, Milkowitz and colleagues2 concluded that Bipolar Depression responds to psychosocial interventions. Defining depression more clearly, and refining the manner in which depression is diagnosed, is more likely to lead to the development of reliable evidence that can guide our practice. Declaration of conflict of interest: None References 1 Parker G. Antidepressants on trial: how valid is the evidence? The British Journal of Psychiatry 2009; 194: 1-3 2 Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, et al. Psychosocial Treatments of Bipolar Depression. A 1-Year Randomized Trial From the Systematic Treatment Enhancement Program. Arch Gen Psychiatry. 2007;64(4):419-426 |
|||