How close is evidence to truth in evidence-based treatment of mental disorders?

Biological Reductionism as an Obstacle to the Advancement of the Biopsychosocial Concept of Mental Disorders

The substantial progress in neurobiological technologies has narrowed the horizons of many psychiatrists, ultimately leading them to focus exclusively on biomedical research, primarily aimed at studying the biological basis of mental illnesses. This has led to an unjustified dominance of the biomedical paradigm in understanding the nature of mental disorders, while virtually ignoring the study of other components of the disease related to the psychosocial maladjustment of patients. This trend, largely associated with advancements in neuroscience employing neuroimaging techniques to study the brain's activity as a biophysical object, has contributed to the development of such innovative field as evidence-based medicine. The methods of evidence-based medicine are seen as adequate in terms of determining the effectiveness of therapy for predominantly biologically determined components of mental illness (including the selection of medications) and only partially for psychological interventions. However, it seems that the predominant use of evidence-based medicine principles is insufficient for a holistic diagnostic approach, which includes a multilevel (diversified) representation of the criteria of effectiveness for pharmacological and psychological interventions. In this regard, it is promising to establish a scientifically and clinically productive combination of, on the one hand, the evidence-based concept of effectiveness assessments based on high-quality randomized scientific studies, and on the other, expert opinions of highly qualified scientific specialists, as well as practicing physicians with their personal professional experience in individualized therapy. This makes it reasonable to develop a personality-oriented personalized psychiatry, based on a biopsychosocial understanding of the nature of mental disorders, their holistic assessment, and the development of comprehensive therapeutic measures.

L’evidence-based medicine, un projet épistémologique et éthique en porte-à-faux avec la psychiatrie ?

Le discours psychiatrique contemporain dominant repose principalement sur un paradigme médico-technologique où la souffrance mentale est conceptualisée comme un « mécanisme défectueux » qui nécessite une « réparation » grâce à l’arsenal médical. Dans ce contexte, l’evidence-based medicine (EBM) a donc été largement adopté par la psychiatrie à la fin des années 90. L’EBM est une proposition qui vise à influencer et même légiférer la prise de décisions cliniques en mettant de l’avant l’idée d’une hiérarchie des évidences, où le savoir tiré d’essais contrôlés randomisés (ECR) et de méta-analyses a préséance sur les informations tirées d’autres sources. Ainsi, comme l’EBM favorise ces outils de création de savoir (ECRs et méta-analyses) il en découle que le savoir qui compte véritablement dans le paradigme EBM est celui qui est mesurable et spécifique ; deux conditions préalables nécessaires pour l’utilisation même de ces outils. En conséquence, l’EBM diminue la valeur et va même jusqu’à ignorer d’autres formes d’évidences, de savoir et de justifications pour la prise de décisions cliniques. Du point de vue éthique, le concept EBM soutient que la « bonne chose à faire » est d’appliquer le savoir produit par l’EBM dans le contexte clinique. Les autres formes de savoir pouvant être impliquées dans la prise de décisions cliniques, mais qui ne peuvent pas être étudiées via l’EBM, sont dévalorisées d’un point de vue éthique. La littérature révisée et explorée ici considère donc que l’EBM est mal adapté à la réalité de la pratique psychiatrique. L’EBM ne peut pas, par définition, prendre en compte les spécificités de la discipline, notamment pour ce qui est des diagnostics psychiatriques ; leur complexité rend les évidences produites par l’EBM d’une validité questionnable. Le concept ne peut pas non plus tenir compte des spécificités des thérapeutiques psychiatriques. Les facteurs thérapeutiques non spécifiques, ceux discrédités par l’EBM, sont cruciaux pour les soins de santé mentale. Également, les observations portant sur des aspects de l’esprit, sur des expériences subjectives, ne sont que bien incorrectement traduites en résultats statistiques, mesurables et spécifiques. Ces observations amènent le présent essai à considérer qu’il serait peut-être préférable pour la psychiatrie, de rejeter la « hiérarchie des évidences » de l’EBM, et de développer son propre « système des savoirs ». Celui-ci devrait prendre en compte la position épistémologique unique de la psychiatrie, où subjectivité, contextes, et valeurs pourraient occuper de façon légitime la place qui leur revient dans la prise de décisions cliniques en psychiatrie. Bien qu’une alternative à l’EBM en psychiatrie n’ait pas encore été établie, la littérature, et ce papier pointent vers l’idée d’un « système des savoirs » plus flexible que ce qu’offre l’EBM en termes épistémologiques, où les aspects éthiques reliés à la discipline, incluant l’éthique du savoir, l’éthique de « ce qui compte comme évidence », revêtent une importance cruciale.

A non-linear dynamical approach to belief revision in cognitive behavioral therapy

Belief revision is the key change mechanism underlying the psychological intervention known as cognitive behavioral therapy (CBT). It both motivates and reinforces new behavior. In this review we analyze and apply a novel approach to this process based on AGM theory of belief revision, named after its proponents, Carlos Alchourrón, Peter Gärdenfors and David Makinson. AGM is a set-theoretical model. We reconceptualize it as describing a non-linear, dynamical system that occurs within a semantic space, which can be represented as a phase plane comprising all of the brain's attentional, cognitive, affective and physiological resources. Triggering events, such as anxiety-producing or depressing situations in the real world, or their imaginal equivalents, mobilize these assets so they converge on an equilibrium point. A preference function then evaluates and integrates evidentiary data associated with individual beliefs, selecting some of them and comprising them into a belief set, which is a metastable state. Belief sets evolve in time from one metastable state to another. In the phase space, this evolution creates a heteroclinic channel. AGM regulates this process and characterizes the outcome at each equilibrium point. Its objective is to define the necessary and sufficient conditions for belief revision by simultaneously minimizing the set of new beliefs that have to be adopted, and the set of old beliefs that have to be discarded or reformulated. Using AGM, belief revision can be modeled using three (and only three) fundamental syntactical operations performed on belief sets, which are expansion; revision; and contraction. Expansion is like adding a new belief without changing any old ones. Revision is like adding a new belief and changing old, inconsistent ones. Contraction is like changing an old belief without adding any new ones. We provide operationalized examples of this process in action.

Influence of sociodemographic and socioeconomic features on treatment outcome in RCTs versus daily psychiatric practice

PURPOSE

Sociodemographic and socioeconomic characteristics of participants in antidepressant and psychotherapy efficacy trials (AETs and PETs) for major depressive disorder (MDD) may limit the generalizability of the results. We compared trial participants with daily practice patients. We subsequently assessed the influence of socio-demographic and socioeconomic status on treatment outcome in daily practice.

METHODS

Data on daily practice patients were derived through routine outcome monitoring (ROM). We included 626 patients with MDD according to the MINIplus. Distributions of age, gender, race, marital status and employment status were compared with participants in 63 selected AETs and PETs. Influence of these features on treatment outcome was explored through multivariate regression analysis.

RESULTS

Trial participants were older, more often male (diff. 4 %, p = 0.05), white (diff. 4 %, p < 0.001) and not married (diff. 7 %, p = 0.003). Although significant, most differences were relatively small. However, the difference in employment status was striking: 34 % of the ROM patients were currently working versus 68 % of the trial participants (diff. 34 %, p < 0.001). Being employed contributed to a positive treatment outcome: OR 1.8 for response [50 % reduction of Montgomery Asberg Rating Scale for Depression (MADRS)], OR 1.9 for remission (MADRS ≤10).

CONCLUSIONS

Employment status should be taken into account while interpreting results from randomized controlled trials and as predictor of treatment success in daily practice.

The psychiatric interview: validity, structure, and subjectivity

There is a glaring gap in the psychiatric literature concerning the nature of psychiatric symptoms and signs, and a corresponding lack of epistemological discussion of psycho-diagnostic interviewing. Contemporary clinical neuroscience heavily relies on the use of fully structured interviews that are historically rooted in logical positivism and behaviorism. These theoretical approaches marked decisively the so-called "operational revolution in psychiatry" leading to the creation of DSM-III. This paper attempts to examine the theoretical assumptions that underlie the use of a fully structured psychiatric interview. We address the ontological status of pathological experience, the notions of symptom, sign, prototype and Gestalt, and the necessary second-person processes which are involved in converting the patient's experience (originally lived in the first-person perspective) into an "objective" (third person), actionable format, used for classification, treatment, and research. Our central thesis is that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects. We claim that in order to perform faithful distinctions in this particular domain, we need a more adequate approach, that is, an approach that is guided by phenomenologically informed considerations. Our theoretical discussion draws upon clinical examples derived from structured and semi-structured interviews. We conclude that fully structured interview is neither theoretically adequate nor practically valid in obtaining psycho-diagnostic information. Failure to address these basic issues may have contributed to the current state of malaise in the study of psychopathology.