["What's up, doc?" The context, limitations, and issues for clinicians in evidence-based medicine]

[Programs for first onset psychosis and evidence-based medicine: a case of the syndrome of the emperor's new clothes]

In this essay, the author states that the first onset psychoses clinics described in many articles of this special issue of Santé mentale au Québec are not as evidence-based than the enthusiasm of its promoters would lend to believe. Using three stories based on observations made recently in Quebec where the argument of evidence-based support was brought, it will be illustrated how groups, their interventions and programs positioned themselves to their advantage.. These promoters in the health care system aim at better care, but they are also motivated by their own professional, departmental and research agendas ; they are supported by other logics and stakeholders like pharmaceutical firms, consumers and relatives; but can be slowed down by decision-makers and planners querying the ressources required, the efficiency, the accessibility, the training and the impact on other programs in a balanced mental health care system. This essay also briefly review the definitions, the limits of an evidence-based approach, and its origins from clinical epidemiology and public health. It does not consist solely of evidence drawn from randomised clinical trials and quantitative research designs, but also from qualitative and mixed designs, that have been developed by human sciences. The practice and application of evidence is not mastered in mental health systems, but the author hopes that with increased training by all stakeholders in its use, it will introduce a continuous evaluation at the individual clinical level, at the program and system levels. A continuous questioning that signals quality in clinical practices and services.

Développer de meilleures pratiques

Cet éditorial consiste en une recension des écrits décrivant le développement du mouvement des « meilleures pratiques ». Encore en partie méconnu dans le milieu de la pratique, ce mouvement est suffisamment important pour qu’une recension des écrits lui soit consacrée, d’autant plus que la littérature de langue française à ce sujet est pratiquement inexistante. Après avoir formulé une hypothèse économico-politique explicative à propos de leur émergence, l’article décrit les principaux modèles sous-jacents à leur développement : evidence-based model et expert-consensus model. Il suggère ensuite deux manières de présenter les meilleures pratiques pour faciliter leur utilisation : les lignes directrices et les algorithmes, de même que les interventions propres à favoriser leur dissémination auprès des praticiens et des administrateurs. L’article conclut par une analyse critique de cette approche.