[The use of evidence-based medicine in psychotherapeutic medicine]

[On the present situation in psychotherapy and its implications - A critical analysis of the facts]

The currently dominating research paradigm in evidence-based medicine is expounded and discussed regarding the problems deduced from so-called empirically supported treatments (EST) in psychology and psychotherapy. Prevalent political and economic as well as ideological backgrounds influence the present dominance of the medical model in psychotherapy by implementing the randomized-controlled research design as the standard in the field. It has been demonstrated that randomized controlled trials (RCTs) are inadequate in psychotherapy research, not the least because of the high complexity of the psychotherapy and the relatively weak role of the treatment concept in the change process itself. All major meta-analyses show that the Dodo bird verdict is still alive, thereby demonstrating that the medical model in psychotherapy with its RCT paradigm cannot explain the equivalence paradox. The medical model is inappropriate, so that the contextual model is proposed as an alternative. Extensive process-outcome research is suggested as the only viable and reasonable way to identify highly complex interactions between the many factors regularly involved in change processes in psychotherapy.

The Task before Psychiatry Today Redux: STSPIR*

This paper outlines six important tasks for psychiatry today, which can be put in short as:

Spread and scale up services;

Talk;

Science,

Psychotherapy;

Integrate; and

Research excellence.

As an acronym, STSPIR.

Spread and scale up services: Spreading mental health services to uncovered areas, and increasing facilities in covered areas:

Mental disorders are leading cause of ill health but bottom of health agenda;

Patients face widespread discrimination, human rights violations and lack of facilities;

Need to stem the brain drain from developing countries;

At any given point, 10% of the adult population report having some mental or behavioural disorder;

In India, serious mental disorders affect nearly 80 million people, i.e. combined population of the northern top of India, including Punjab, Haryana, Jammu and Kashmir, Uttarakhand and Himachal Pradesh;

Combating imbalance between burden of demand and supply of efficient psychiatric services in all countries, especially in developing ones like India, is the first task before psychiatry today. If ever a greater role for activism were needed, this is the field;

The need is to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Talk: Speaking to a wider audience about positive contributions of psychiatry:

Being aware of, understanding, and countering, the massive anti-psychiatry propaganda online and elsewhere;

Giving a firm answer to anti-psychiatry even while understanding its transformation into mental health consumerism and opposition to reckless medicalisation;

Defining normality and abnormality;

Bringing about greater precision in diagnosis and care;

Motivating those helped by psychiatry to speak up;

Setting up informative websites and organising programmes to reduce stigma and spread mental health awareness;

Setting up regular columns in psychiatry journals around the globe, called ‘Patients Speak’, or something similar, wherein those who have been helped get a chance to voice their stories.

Science: Shrugging ambivalence and disagreement and searching for commonalities in psychiatric phenomena;

An idiographic orientation which stresses individuality cannot, and should not, preclude the nomothetic or norm laying thrust that is the crux of scientific progress.

The major contribution of science has been to recognize such commonalities so they can be researched, categorized and used for human welfare.

It is a mistake to stress individuality so much that commonalities are obliterated.

While the purpose and approach of psychiatry, as of all medicine, has to be humane and caring, therapeutic advancements and aetiologic understandings are going to result only from a scientific methodology.

Just caring is not enough, if you have not mastered the methods of care, which only science can supply.

Psychotherapy: Psychiatrists continuing to do psychotherapy:

Psychotherapy must be clearly defined, its parameters and methods firmly delineated, its proof of effectiveness convincingly demonstrated by evidence based and controlled trials;

Psychotherapy research suffers from neglect by the mainstream at present, because of the ascendancy of biological psychiatry;

It suffers resource constraints as major sponsors like pharma not interested;

Needs funding from some sincere researcher organisations and altruistic sponsors, as also professional societies and governments;

Psychotherapy research will have to provide enough irrefutable evidence that it works, with replicable studies that prove it across geographical areas;

It will not do for psychiatrists to hand over psychotherapy to clinical psychologists and others.

Integrate approaches: Welcoming biological breakthroughs, while supplying psychosocial insights:

Experimental breakthroughs, both in aetiology and therapeutics, will come mainly from biology, but the insights and leads can hopefully come from many other fields, especially the psychosocial and philosophical;

The biological and the psychological are not exclusive but complementary approaches;

Both integration and reductionism are valid. Integration is necessary as an attitude, reductionism is necessary as an approach. Both the biological and the psychosocial must co-exist in the individual psychiatrist, as much as the branch itself.

Research excellence: Promoting genuine research alone, and working towards an Indian Nobel Laureate in psychiatry by 2020:

To stop promoting poor quality research and researchers, and to stop encouraging sycophants and ladder climbers. To pick up and hone genuine research talent from among faculty and students;

Developing consistent quality environs in departments and having Heads of Units who recognize, hone and nurture talent. And who never give in to pessimism and cynicism;

Stop being satisfied with the money, power and prestige that comes by wheeling-dealing, groupism and politicking;

Infinite vistas of opportunity wait in the wings to unfold and offer opportunities for unravelling the mysteries of the ‘mind’ to the earnest seeker. Provided he is ready to seek the valuable. Provided he stops holding on to the artificial and the superfluous.

Evidenzbasierte Psychotherapie und Therapie-Ressourcen

Zusammenfassung. Theoretischer Hintergrund: In der Methodologie der klinisch-psychologischen Forschung steht nach dem Konzept der evidenzbasierten Psychotherapie das aus der pharmakologischen Forschung und evidenzbasierten Medizin adaptierte 4-Phasen-Prüfmodell im Vordergrund. Empirisch fundierte Psychotherapie ist die Basis von Therapie-Ressourcen wie Behandlungs-Leitlinien und -Manualen sowie Patientenratgebern. Fragestellung: Auf welchen der Prüfphasen liegen die Schwerpunkte der klinisch-psychologischen Forschung, wie viele Therapie-Ressourcen sind aus ihr resultiert, zeigen sich seit 1977 Veränderungen in den Schwerpunkten? Methode: Alle in der Fachliteraturdatenbank PSYNDEX dokumentierten Beiträge zur klinisch-psychologischen Interventionsforschung wurden nach einem erweiterten 4-Phasen-Prüfmodell und nach der Art der Therapie-Ressourcen klassifiziert. Ergebnisse: Zwischen 1977 und 2006 wurden im deutschsprachigen Bereich 16.467 empirische Beiträge zu klinisch-psychologischen Interventionen publiziert. Die Mehrheit ist den Phasen 0 (Entwicklungsphase: 55%), 1 (Erkundungsphase: 23%), 4 (Praxiskontrolle: 12%) und 5 (Prävention, Rehabilitation und Persönlichkeitsentwicklung: 22%) zugeordnet. Befunde zur Phase 2 (Randomisierte Studien: 2.2%) und Phase 3 [Testphase mit Multicenter-Studien (1.5%) und Metaanalysen (1.0%)] wurden seltener publiziert, weisen aber in den letzten zehn Jahren eine ansteigende Tendenz auf. Bei den Therapie-Ressourcen dominieren Patientenratgeber (61%) im Vergleich zu Behandlungs-Manualen (32%) und -Leitlinien (9%). Schlussfolgerungen: Aus der klinisch-psychologischen Forschung im deutschsprachigen Bereich liegt ein umfangreiches Reservoir von Publikationen zur empirisch fundierten Psychotherapie und zu Therapie-Ressourcen vor. Defizite bestehen bei Veröffentlichungen zu randomisierten Studien (Phasen 2 und 3), für die Ratgeber-Literatur ist inzwischen ein Überhang festzustellen.

Evidenzbasierung, Methodik, therapeutische Freiheit und Kreativität

Zusammenfassung: Von therapeutischen Interventionen jeder Art wird erwartet, dass sich die vorhergesagten Wirkungen nachweisen lassen. Die wissenschaftliche und politische Bewegung “Evidenzbasierte Medizin” (EbM) gibt dem seit der einflussreichen Publikation von Sackett (1996) Nachdruck. Sie hat methodische Standards aufgestellt, die zunächst vor allem für die Pharmawirkungsforschung gelten sollen. Kann sich die Neuropsychologie an dem Standard der “randomisiert-kontrollierten Studie” (RCT), mit Kontrollgruppen und Konstanthaltung von Störvariablen, orientieren? Die Untersuchung der Experimentalmethodik in der Neuropsychologie, die Probleme der Operationalisierung und der Störbedingungen sowie die Besonderheiten der neuropsychologischen Aufgabenstellungen in der Praxis sprechen dafür, dass die Therapieforschung nicht einfach das Paradigma der Pharmaforschung übernehmen kann, sondern an die klinische Praxis angepasste Methoden entwickelt werden sollten. Es wird dafür geworben, dass die Forschung im Zusammenwirken mit der klinischen Praxis geeignete Methoden weiterentwickelt, die für die Arbeit mit dem Patienten geeignet sind.