1/ Since "evidence-based medicine" is not uncommonly used as a weapon to dismiss clinical experience (including patient experiences) and is used to maintain a hyper-skeptical attitude that in the absence of well-designed RCTs no judgment can be formed, it is helpful to...
2/ ... revisit the words of David Sackett, one of the fathers of EBM, who offers a very different picture:
"The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research...."
3/ "Good doctors use both individual clinical expertise & the best available external evidence & neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for>>
4/ "... an individual patient... Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions... some questions about therapy do not require randomised trials..."
5/ "... (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external evidence and work from there."
6/ Source: Sackett et al. Evidence based medicine: what it is and what it isn't. BMJ. 1996
2/ It's remarkable that we have 20 yr follow-up data! This is extremely valuable for anyone interested in longitudinal course. It is important to however realize that it is a naturalistic study; subjects were not randomized to receive or not receive antipsychotics.
3/ This was a decision made by subjects/families/doctors in the course of their care (or lack of care) for a variety of possible reasons. These reasons are not known to us. Harrow et al are following the individuals and tracking the treatment they have received & their outcomes.
1/ I do think a lot of problems with current practices in psychiatry have to be do with system issues, however, these system issues have been synergistic with a variety of conceptual, scientific, & ethical problems that have to do with reductionism, diagnostic reification...
2/ ... eclecticism, manipulation of "evidence-based" medicine, neglect of phenomenology, lack of attention to power imbalances and systemic coercion, neglect of iatrogenic harm, & unreflective reliance on medicalization as the default for mental health care.
3/ An examination of these issues is not about blaming individual clinicians or researchers, or even about blaming psychiatry as a medical profession isolated from other disciplines, law, and society. These are larger forces that transcend any single individual or profession.
1/ "it is overwhelmingly likely that the differences in symptomatology which the DSM taxonomy captures reflect the contribution of the neural, neurochemical, and genetic differences, *plus* differences in higher-level factors: broadly, social and cultural factors." Neil Levy
2/ "These include (but are not limited to) the ways in which different mental illnesses are conceptualized in a society, the ways in which social roles are assigned & understood,...
3/ "... and perhaps idiosyncratic facts about the individual and her history which result in her having beliefs that modulate the form that her illness takes."
1/ "Whereas symptomatology is strictly illness oriented, psychopathology is also person oriented, since it attempts to describe the patient’s experience and her relationship to herself & to the world."
2/ "The patient is an active partner in the diagnostic process, capable of interpreting her own complaints. Symptoms are conceptualised as the outcome of a mediation between a vulnerable self and the sick person trying to cope with and make sense of her complaints."
3/ "The existing classifications of mental illnesses are merely provisional diagnostic conventions... if psychopathology is conflated with nosography, only those symptoms that are supposed to have diagnostic value will be investigated,...
1. Great paper by @HengartnerMP & @Altostrata, based on quantitative analysis of a case series. Given the paucity of previously published literature on this, this is an important contribution. Some thoughts and questions that come to my mind:
2. Chouinard & Chouinard criteria also specify criteria related to reversibility of symptoms & partial/total response to reintroduction of discontinued drug. It is unclear if these criteria were also applied as selection criteria.
3. To the best of our knowledge, unless future studies show otherwise, PWS appears to be a rare occurrence, but even rare occurrences can become common if the number of people being treated is large enough, & this is no reason to disqualify the suffering of those afflicted.
Some weeks back I had asked for articles on how to best understand & approach "treatment resistance" in psychiatry. I was preparing for a talk & wanted to see what ppl thought. It was interesting to see the mere mention of TR provoke some emotionally-charged responses! /1
Anyway, here are 3 articles I really enjoyed and found very useful on the topic of "treatment resistance" in psychiatry (mostly focused on depression) which offer a non-mainstream, critical view of the concept. /2
i) Treatment-resistant depression: problematic illness or a problem in our approach?
Malhi, et al. British Journal of Psychiatry. /3